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|
Attributes | |
ACN | 145696 |
Time | |
Date | 199005 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : tys |
State Reference | TN |
Altitude | msl bound lower : 15500 msl bound upper : 16000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : dfw |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise other descent other |
Route In Use | enroute airway : ztl |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain observation : company check pilot oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 155 flight time total : 15000 flight time type : 11000 |
ASRS Report | 145696 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 70 flight time total : 6800 flight time type : 35 |
ASRS Report | 145700 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : required legal separation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Last day of 3-DAY trip. Training new medium large transport first officer (from lga first officer). Early departure, short overnight -- somewhat fatigued. First officer was doing all flying so as to gain experience in -10 -30 -50 degrees. I was teaching 6-1 2-1 3-1 power off dscnts during the two 3-DAY trips we flew because of fuel economy. He had been doing fine even though he was used to only 3-1 dscnts on large transport. Mem-tys left 290 and cleared to 160. Out of 180 got ATIS and doing approach check. ATIS reported severe turbulence 10000 to ground. Out of 180 told first officer 2000' to level off. Opened cockpit door to tell lead F/a to pick up and be seated because of possible turbulence. Alerter went off and I said one to go. As I was closing door and the alerter went off at 15800' and I grabbed yoke and disengaged autoplt, aircraft went to 15600'. Immediately went back to 16000'. Atlanta center said nothing about altitude or traffic. Few mins later he gave us a new frequency and said there was a possible altitude deviation and please call atl center. Talked to supervisor. He said computer indicated aircraft descended to 15500' then back to 16000'. We were west to east. He said there was traffic in the area north to south at 15000'. First officer said he was worried about getting down because he had had trouble the previous week and was fixed on 30 mi out at 10000' and 250 KTS. Have no idea why he did not heed either my calls or altitude alerter. Conclusions: I should have not had him fly all the legs. He may have been more tired than I could detect. He hand flew aircraft too much causing more fatigue. Company procedures are good in that PNF makes altitude calls at 2000' and one to go, but PF is not required to acknowledge either one. In this case I may have detected something had he been required to respond to my altitude calls. (Will pursue this with flight standard.) supplemental information from acn 145700: we learned that the company had decided to issue descent computers of the round, slide rule type, to all medium large transport pilots -- something that would have lowered my mental workload had one been available.
Original NASA ASRS Text
Title: ACR MLG ALT DEVIATION OVERSHOT DURING DESCENT RESULTS IN LESS THAN STANDARD SEPARATION WITH ACFT ON CROSSING AIRWAY TRACK.
Narrative: LAST DAY OF 3-DAY TRIP. TRAINING NEW MLG F/O (FROM LGA F/O). EARLY DEP, SHORT OVERNIGHT -- SOMEWHAT FATIGUED. F/O WAS DOING ALL FLYING SO AS TO GAIN EXPERIENCE IN -10 -30 -50 DEGS. I WAS TEACHING 6-1 2-1 3-1 POWER OFF DSCNTS DURING THE TWO 3-DAY TRIPS WE FLEW BECAUSE OF FUEL ECONOMY. HE HAD BEEN DOING FINE EVEN THOUGH HE WAS USED TO ONLY 3-1 DSCNTS ON LGT. MEM-TYS LEFT 290 AND CLRED TO 160. OUT OF 180 GOT ATIS AND DOING APCH CHECK. ATIS REPORTED SEVERE TURBULENCE 10000 TO GND. OUT OF 180 TOLD F/O 2000' TO LEVEL OFF. OPENED COCKPIT DOOR TO TELL LEAD F/A TO PICK UP AND BE SEATED BECAUSE OF POSSIBLE TURBULENCE. ALERTER WENT OFF AND I SAID ONE TO GO. AS I WAS CLOSING DOOR AND THE ALERTER WENT OFF AT 15800' AND I GRABBED YOKE AND DISENGAGED AUTOPLT, ACFT WENT TO 15600'. IMMEDIATELY WENT BACK TO 16000'. ATLANTA CENTER SAID NOTHING ABOUT ALT OR TFC. FEW MINS LATER HE GAVE US A NEW FREQ AND SAID THERE WAS A POSSIBLE ALT DEVIATION AND PLEASE CALL ATL CENTER. TALKED TO SUPVR. HE SAID COMPUTER INDICATED ACFT DESCENDED TO 15500' THEN BACK TO 16000'. WE WERE W TO E. HE SAID THERE WAS TFC IN THE AREA N TO S AT 15000'. F/O SAID HE WAS WORRIED ABOUT GETTING DOWN BECAUSE HE HAD HAD TROUBLE THE PREVIOUS WEEK AND WAS FIXED ON 30 MI OUT AT 10000' AND 250 KTS. HAVE NO IDEA WHY HE DID NOT HEED EITHER MY CALLS OR ALT ALERTER. CONCLUSIONS: I SHOULD HAVE NOT HAD HIM FLY ALL THE LEGS. HE MAY HAVE BEEN MORE TIRED THAN I COULD DETECT. HE HAND FLEW ACFT TOO MUCH CAUSING MORE FATIGUE. COMPANY PROCS ARE GOOD IN THAT PNF MAKES ALT CALLS AT 2000' AND ONE TO GO, BUT PF IS NOT REQUIRED TO ACKNOWLEDGE EITHER ONE. IN THIS CASE I MAY HAVE DETECTED SOMETHING HAD HE BEEN REQUIRED TO RESPOND TO MY ALT CALLS. (WILL PURSUE THIS WITH FLT STANDARD.) SUPPLEMENTAL INFORMATION FROM ACN 145700: WE LEARNED THAT THE COMPANY HAD DECIDED TO ISSUE DSNT COMPUTERS OF THE ROUND, SLIDE RULE TYPE, TO ALL MLG PLTS -- SOMETHING THAT WOULD HAVE LOWERED MY MENTAL WORKLOAD HAD ONE BEEN AVAILABLE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.