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|
Attributes | |
ACN | 149135 |
Time | |
Date | 199006 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : yng |
State Reference | OH |
Altitude | msl bound lower : 15000 msl bound upper : 24000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : pit |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute airway : zob |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 10000 |
ASRS Report | 149135 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 100 flight time total : 7000 |
ASRS Report | 149401 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight was cleared from FL350 to FL240 at 15 mi east of the youngstown VOR while westbound on a routing from ewr to cle. As the captain, I worked the radios and the first officer was flying the aircraft. This aircraft is an medium large transport with an automated MCP and inertial reference system navigation (IRS). I acknowledged the clearance and the first officer began a 6000 FPM descent, as we were in moderate turbulence and desired the smoother altitude below. I diverted my attention to the approach plate book for cle information and reference. The problem in this situation was that the first officer placed 15000' in the altitude alerter on he MCP instead of 24000' as required by the clearance. I didn't notice this and hwile my attention was diverted away from the first officer's actions, he descended through FL240 and ZOB noted this when he reached FL210. We were then cleared to FL220 with a 20 degree heading change to the right. No further problems arose. In retrospect, in my opinion, the first officer heard the 15 mi east of yng, but programmed 15000' in his thoughts instead of the 24000'. I should have observed and x-chked his actions, but failed to do so by attending to other nonessential details at the time. It cannot be stressed enough to be always vigilant--'copy, confirm and x-chk.'
Original NASA ASRS Text
Title: ACR CREW MISINTERPRETS CLRNC, DESCENDS BELOW ASSIGNED ALT.
Narrative: FLT WAS CLRED FROM FL350 TO FL240 AT 15 MI E OF THE YOUNGSTOWN VOR WHILE WBND ON A RTING FROM EWR TO CLE. AS THE CAPT, I WORKED THE RADIOS AND THE F/O WAS FLYING THE ACFT. THIS ACFT IS AN MLG WITH AN AUTOMATED MCP AND INERTIAL REF SYS NAV (IRS). I ACKNOWLEDGED THE CLRNC AND THE F/O BEGAN A 6000 FPM DSNT, AS WE WERE IN MODERATE TURB AND DESIRED THE SMOOTHER ALT BELOW. I DIVERTED MY ATTN TO THE APCH PLATE BOOK FOR CLE INFO AND REF. THE PROB IN THIS SITUATION WAS THAT THE F/O PLACED 15000' IN THE ALT ALERTER ON HE MCP INSTEAD OF 24000' AS REQUIRED BY THE CLRNC. I DIDN'T NOTICE THIS AND HWILE MY ATTN WAS DIVERTED AWAY FROM THE F/O'S ACTIONS, HE DSNDED THROUGH FL240 AND ZOB NOTED THIS WHEN HE REACHED FL210. WE WERE THEN CLRED TO FL220 WITH A 20 DEG HDG CHANGE TO THE RIGHT. NO FURTHER PROBS AROSE. IN RETROSPECT, IN MY OPINION, THE F/O HEARD THE 15 MI E OF YNG, BUT PROGRAMMED 15000' IN HIS THOUGHTS INSTEAD OF THE 24000'. I SHOULD HAVE OBSERVED AND X-CHKED HIS ACTIONS, BUT FAILED TO DO SO BY ATTENDING TO OTHER NONESSENTIAL DETAILS AT THE TIME. IT CANNOT BE STRESSED ENOUGH TO BE ALWAYS VIGILANT--'COPY, CONFIRM AND X-CHK.'
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.