37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 147339 |
Time | |
Date | 199006 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : rbs |
State Reference | IL |
Altitude | msl bound lower : 24000 msl bound upper : 24500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : corporate |
Make Model Name | Small Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute airway : zau |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 3000 flight time type : 75 |
ASRS Report | 143739 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : required legal separation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : took evasive action other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We called on center frequency level at FL230 and were cleared to FL240. As we passed FL245, center issued immediate turn and clearance to FL310, expedite through FL260. I heard center issue an immediate turn to another aircraft, apparently the one at FL250. This altitude deviation resulted from my failure as PIC to maintain coordination and discipline in the cockpit. Our normal company procedure is for the PNF to call out 1000' before assigned altitude. The PF is to respond with 'altitude select armed.' in this instance, I allowed the copilot to be distracted from his duties by a passenger who wished to place a phone call. As a result, no callout was made to compound the problem. I became involved in the relay of information between center and air carrier aircraft. This, along with the lack of a 1000' callout, resulted in my failure to arm the altitude select and my abandonment of INS xchk. As a result of these distrs, neither the copilot nor myself detected the altitude deviation. Situational awareness if the term used in the literature about cockpit resource management. This incident clearly resulted from a loss of situational awareness, created by a lack of adequate management.
Original NASA ASRS Text
Title: CORP FLT CREW ALT DEVIATION CREATES LESS THAN STANDARD SEPARATION WITH ANOTHER ACFT.
Narrative: WE CALLED ON CENTER FREQ LEVEL AT FL230 AND WERE CLRED TO FL240. AS WE PASSED FL245, CENTER ISSUED IMMEDIATE TURN AND CLRNC TO FL310, EXPEDITE THROUGH FL260. I HEARD CENTER ISSUE AN IMMEDIATE TURN TO ANOTHER ACFT, APPARENTLY THE ONE AT FL250. THIS ALT DEVIATION RESULTED FROM MY FAILURE AS PIC TO MAINTAIN COORD AND DISCIPLINE IN THE COCKPIT. OUR NORMAL COMPANY PROC IS FOR THE PNF TO CALL OUT 1000' BEFORE ASSIGNED ALT. THE PF IS TO RESPOND WITH 'ALT SELECT ARMED.' IN THIS INSTANCE, I ALLOWED THE COPLT TO BE DISTRACTED FROM HIS DUTIES BY A PAX WHO WISHED TO PLACE A PHONE CALL. AS A RESULT, NO CALLOUT WAS MADE TO COMPOUND THE PROB. I BECAME INVOLVED IN THE RELAY OF INFO BTWN CENTER AND ACR ACFT. THIS, ALONG WITH THE LACK OF A 1000' CALLOUT, RESULTED IN MY FAILURE TO ARM THE ALT SELECT AND MY ABANDONMENT OF INS XCHK. AS A RESULT OF THESE DISTRS, NEITHER THE COPLT NOR MYSELF DETECTED THE ALT DEVIATION. SITUATIONAL AWARENESS IF THE TERM USED IN THE LITERATURE ABOUT COCKPIT RESOURCE MGMNT. THIS INCIDENT CLEARLY RESULTED FROM A LOSS OF SITUATIONAL AWARENESS, CREATED BY A LACK OF ADEQUATE MGMNT.
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.