 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Altitude deviaton. PF, captain, turns altitude select knob when given a heading change and during the distraction overshoots his assigned altitude. Aircraft on autoplt.
| Attributes | |
| ACN | 149128 |
| Time | |
| Date | 199006 |
| Day | Tue |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : lax |
| State Reference | CA |
| Altitude | msl bound lower : 13000 msl bound upper : 13400 |
| Environment | |
| Flight Conditions | VMC |
| Light | Dusk |
| Aircraft 1 | |
| Controlling Facilities | tracon : lax |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other Other |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | departure other departure sid : sid |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : commercial |
| Experience | flight time last 90 days : 15 flight time total : 10000 flight time type : 15 |
| ASRS Report | 149128 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument |
| Experience | flight time last 90 days : 150 flight time total : 6000 flight time type : 150 |
| ASRS Report | 149131 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : returned to intended course or assigned course |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation other |
Narrative:
On climb out with captain flying aircraft out of about 11000', lax departure gave a heading change as aircraft was on radar vector. Captain reached up for the heading knob, since aircraft was on autoplt, but turned the altitude alert knob instead. The altitude was set for 13000' and was the last in a series of altitude changes. When the heading curser on the HSI did not move, the captain checked the MCP and noticed that the altitude rather than heading had been changed. A conversation with the first officer then ensued, but there was only vague recollection of the cleared altitude. ATC was immediately called. He confirmed a clearance to only 13000'. A high rate of climb allowed a level-off at about 13400' with an immediate descent to 13000'. No mention of the deviation was made by approach control. I believe the close proximity and similar feel of the heading and altitude alert knobs was a contributing factor to this particular situation.
Original NASA ASRS Text
Title: ALT DEVIATON. PF, CAPT, TURNS ALT SELECT KNOB WHEN GIVEN A HEADING CHANGE AND DURING THE DISTR OVERSHOOTS HIS ASSIGNED ALT. ACFT ON AUTOPLT.
Narrative: ON CLBOUT WITH CAPT FLYING ACFT OUT OF ABOUT 11000', LAX DEP GAVE A HDG CHANGE AS ACFT WAS ON RADAR VECTOR. CAPT REACHED UP FOR THE HDG KNOB, SINCE ACFT WAS ON AUTOPLT, BUT TURNED THE ALT ALERT KNOB INSTEAD. THE ALT WAS SET FOR 13000' AND WAS THE LAST IN A SERIES OF ALT CHANGES. WHEN THE HDG CURSER ON THE HSI DID NOT MOVE, THE CAPT CHKED THE MCP AND NOTICED THAT THE ALT RATHER THAN HDG HAD BEEN CHANGED. A CONVERSATION WITH THE F/O THEN ENSUED, BUT THERE WAS ONLY VAGUE RECOLLECTION OF THE CLRED ALT. ATC WAS IMMEDIATELY CALLED. HE CONFIRMED A CLRNC TO ONLY 13000'. A HIGH RATE OF CLB ALLOWED A LEVEL-OFF AT ABOUT 13400' WITH AN IMMEDIATE DSNT TO 13000'. NO MENTION OF THE DEVIATION WAS MADE BY APCH CTL. I BELIEVE THE CLOSE PROX AND SIMILAR FEEL OF THE HDG AND ALT ALERT KNOBS WAS A CONTRIBUTING FACTOR TO THIS PARTICULAR SITUATION.
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.