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|
Attributes | |
ACN | 153262 |
Time | |
Date | 199008 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : atl |
State Reference | GA |
Altitude | msl bound lower : 10500 msl bound upper : 12000 |
Environment | |
Flight Conditions | Marginal |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : atl tower : ind |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent other |
Route In Use | arrival star : star |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft |
Flight Phase | cruise other |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 17000 flight time type : 1000 |
ASRS Report | 153262 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : instrument pilot : atp pilot : commercial |
Experience | flight time last 90 days : 300 flight time total : 13000 flight time type : 2100 |
ASRS Report | 152900 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | Other |
Miss Distance | horizontal : 500 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
My first flight was delayed over 1 1/2 hours for WX. The WX was poor. When I got to my aircraft there was a problem with the comparator system and it was out. However the warning light was left on and bright which makes it difficult when flying at night. As we rotated and lifted off another problem was obvious. The whole front of the airplane vibrated. This is usually due to flat spots on the nose tires or they are out of balance. Returning to atl the public address system began to squeal. This is a challenging problem because with the telephone type transmitter, it squeals directly in the captain's ear and makes it difficult to communication with his passenger. At atl, maintenance signed off the PA as ground checked ok. We arrived at our layover station pbi late and I'm very tired and so is my crew. My concern is for the WX the next day and the very long on duty day of 13 hours and 53 min if all goes perfect. We are now down to a 9 hour and 25 min layover. So I call crew schedule and tell them we need to set the take off time back 1 1/2 to 2 hours. They share with me that that much of a delay makes them uncomfortable and suggest 30 mins would be better. So we get 30 minutes. By the time the F/a's finish their work and the van delivers us to the hotel we are down to a minimum layover. The next morning we take flight to atl. After takeoff the tower reports traffic ahead 5 to 6 miles. Then a GA airplane passes a couple of hundred feet off our right side. I was going to call the close proximity of the plane to the tower, but I don't remember if I did. Because the F/a came up and showed me there was smoke in the cabin. There was also a hot smell in the plane. The smoke was condensation that was filling the plane. This can happen when the water separator bag on the air conditioning system gets dirty and needs to be changed. Ice can form in the system and cause the system to get hot. So you can get condensation smoke and smell of burning. My first officer, a very experienced pilot takes over the flying of the airplane and he begins to warm up the air condition system which will reduce the condensation. Meanwhile I am trying to comfort my passenger and tell them that we have no fire on the airplane but an air condition system that is putting condensation into the plane and that as soon as we get the air conditioning a little warmer it will go away. I am doing this while all the time the PA is squealing in my ear! Then the PA on off blue light fails so I had a hard time telling if the PA was on or off to the passenger. At the very best it was distracting and irritating. Then we had the #2 engine fire detection system fail so we went through the abnormal procedures for that problem and secured that system. As we were making our descent into atl I had my captain gyro fail, so my attitude indicator was not good. There was no backup gyro. Since we were making our descent we were going to have to cool the cabin a little so I told my first officer that I would be talking to the passenger and atl. I talked to my passenger and told them we were landing and there may be a little condensation but nothing to be alarmed about. Then I called atl and got a gate etc. Then I called atl maintenance and told them of my problem. When I got back I noticed that we were leveling 17000'. So I asked first officer if he knew what altitude we were descending to. He decisively said 10000' so I set that in the indicator. I don't know if he took the altitude call or if I did. We were pretty busy. At 10500' approach control asked me our altitude. I told them 10500'. They then asked me to maintain 12000'. The controller proceeded as usual and never changed his pace or indicated an urgency. Just business as usual. We continued to atl. If we were out of our altitude, I am certainly responsible and accountable. I don't remember taking a call for lower altitude and we were very busy. My first officer is as good as they come and more than capable of being a captain himself. The contributing factor from my perspective are: mechanic problems, deferred maintenance, and crew rest. A couple of personal observations. I can fly over 8 hours schedule and still be safe with adequate rest. But that's not legal. I can fly over 30 hours in 7 days and still be safe, but that is not legal. I can fly long on duty day of 14+ hours with min layover and it is at best marginal safety, but is legal!! It also bothers me that if I were out of my altitude for over a minute and if I were off altitude by 1500' in the atl area and a controller would be so slow to let me know and not have a concern in his voice. I count on them to help me keep my passenger safe. They are an extremely important resource to the captain. Callback conversation with reporter revealed the following: reporter described all the events of the previous day that contributed to fatigue. He said that the smoke (condensation) was dense and restr visibility in the cabin to the point that he could not see the galley when he looked aft. He is not sure if he had an altitude deviation or not. He may be using the report as a vehicle to air his concerns about min rest time requirements.
Original NASA ASRS Text
Title: ALT OVERSHOT ON DESCENT.
Narrative: MY FIRST FLT WAS DELAYED OVER 1 1/2 HRS FOR WX. THE WX WAS POOR. WHEN I GOT TO MY ACFT THERE WAS A PROB WITH THE COMPARATOR SYS AND IT WAS OUT. HOWEVER THE WARNING LIGHT WAS LEFT ON AND BRIGHT WHICH MAKES IT DIFFICULT WHEN FLYING AT NIGHT. AS WE ROTATED AND LIFTED OFF ANOTHER PROB WAS OBVIOUS. THE WHOLE FRONT OF THE AIRPLANE VIBRATED. THIS IS USUALLY DUE TO FLAT SPOTS ON THE NOSE TIRES OR THEY ARE OUT OF BAL. RETURNING TO ATL THE PUBLIC ADDRESS SYS BEGAN TO SQUEAL. THIS IS A CHALLENGING PROB BECAUSE WITH THE TELEPHONE TYPE TRANSMITTER, IT SQUEALS DIRECTLY IN THE CAPT'S EAR AND MAKES IT DIFFICULT TO COM WITH HIS PAX. AT ATL, MAINT SIGNED OFF THE PA AS GND CHKED OK. WE ARRIVED AT OUR LAYOVER STATION PBI LATE AND I'M VERY TIRED AND SO IS MY CREW. MY CONCERN IS FOR THE WX THE NEXT DAY AND THE VERY LONG ON DUTY DAY OF 13 HRS AND 53 MIN IF ALL GOES PERFECT. WE ARE NOW DOWN TO A 9 HR AND 25 MIN LAYOVER. SO I CALL CREW SCHEDULE AND TELL THEM WE NEED TO SET THE TAKE OFF TIME BACK 1 1/2 TO 2 HRS. THEY SHARE WITH ME THAT THAT MUCH OF A DELAY MAKES THEM UNCOMFORTABLE AND SUGGEST 30 MINS WOULD BE BETTER. SO WE GET 30 MINUTES. BY THE TIME THE F/A'S FINISH THEIR WORK AND THE VAN DELIVERS US TO THE HOTEL WE ARE DOWN TO A MINIMUM LAYOVER. THE NEXT MORNING WE TAKE FLT TO ATL. AFTER TKOF THE TWR RPTS TFC AHEAD 5 TO 6 MILES. THEN A GA AIRPLANE PASSES A COUPLE OF HUNDRED FEET OFF OUR RIGHT SIDE. I WAS GOING TO CALL THE CLOSE PROX OF THE PLANE TO THE TWR, BUT I DON'T REMEMBER IF I DID. BECAUSE THE F/A CAME UP AND SHOWED ME THERE WAS SMOKE IN THE CABIN. THERE WAS ALSO A HOT SMELL IN THE PLANE. THE SMOKE WAS CONDENSATION THAT WAS FILLING THE PLANE. THIS CAN HAPPEN WHEN THE WATER SEPARATOR BAG ON THE AIR CONDITIONING SYS GETS DIRTY AND NEEDS TO BE CHANGED. ICE CAN FORM IN THE SYS AND CAUSE THE SYS TO GET HOT. SO YOU CAN GET CONDENSATION SMOKE AND SMELL OF BURNING. MY F/O, A VERY EXPERIENCED PLT TAKES OVER THE FLYING OF THE AIRPLANE AND HE BEGINS TO WARM UP THE AIR CONDITION SYS WHICH WILL REDUCE THE CONDENSATION. MEANWHILE I AM TRYING TO COMFORT MY PAX AND TELL THEM THAT WE HAVE NO FIRE ON THE AIRPLANE BUT AN AIR CONDITION SYS THAT IS PUTTING CONDENSATION INTO THE PLANE AND THAT AS SOON AS WE GET THE AIR CONDITIONING A LITTLE WARMER IT WILL GO AWAY. I AM DOING THIS WHILE ALL THE TIME THE PA IS SQUEALING IN MY EAR! THEN THE PA ON OFF BLUE LIGHT FAILS SO I HAD A HARD TIME TELLING IF THE PA WAS ON OR OFF TO THE PAX. AT THE VERY BEST IT WAS DISTRACTING AND IRRITATING. THEN WE HAD THE #2 ENG FIRE DETECTION SYS FAIL SO WE WENT THROUGH THE ABNORMAL PROCS FOR THAT PROB AND SECURED THAT SYS. AS WE WERE MAKING OUR DSNT INTO ATL I HAD MY CAPT GYRO FAIL, SO MY ATTITUDE INDICATOR WAS NOT GOOD. THERE WAS NO BACKUP GYRO. SINCE WE WERE MAKING OUR DSNT WE WERE GOING TO HAVE TO COOL THE CABIN A LITTLE SO I TOLD MY F/O THAT I WOULD BE TALKING TO THE PAX AND ATL. I TALKED TO MY PAX AND TOLD THEM WE WERE LNDG AND THERE MAY BE A LITTLE CONDENSATION BUT NOTHING TO BE ALARMED ABOUT. THEN I CALLED ATL AND GOT A GATE ETC. THEN I CALLED ATL MAINT AND TOLD THEM OF MY PROB. WHEN I GOT BACK I NOTICED THAT WE WERE LEVELING 17000'. SO I ASKED F/O IF HE KNEW WHAT ALT WE WERE DSNDING TO. HE DECISIVELY SAID 10000' SO I SET THAT IN THE INDICATOR. I DON'T KNOW IF HE TOOK THE ALT CALL OR IF I DID. WE WERE PRETTY BUSY. AT 10500' APCH CTL ASKED ME OUR ALT. I TOLD THEM 10500'. THEY THEN ASKED ME TO MAINTAIN 12000'. THE CTLR PROCEEDED AS USUAL AND NEVER CHANGED HIS PACE OR INDICATED AN URGENCY. JUST BUSINESS AS USUAL. WE CONTINUED TO ATL. IF WE WERE OUT OF OUR ALT, I AM CERTAINLY RESPONSIBLE AND ACCOUNTABLE. I DON'T REMEMBER TAKING A CALL FOR LOWER ALT AND WE WERE VERY BUSY. MY F/O IS AS GOOD AS THEY COME AND MORE THAN CAPABLE OF BEING A CAPT HIMSELF. THE CONTRIBUTING FACTOR FROM MY PERSPECTIVE ARE: MECH PROBS, DEFERRED MAINT, AND CREW REST. A COUPLE OF PERSONAL OBSERVATIONS. I CAN FLY OVER 8 HRS SCHEDULE AND STILL BE SAFE WITH ADEQUATE REST. BUT THAT'S NOT LEGAL. I CAN FLY OVER 30 HRS IN 7 DAYS AND STILL BE SAFE, BUT THAT IS NOT LEGAL. I CAN FLY LONG ON DUTY DAY OF 14+ HRS WITH MIN LAYOVER AND IT IS AT BEST MARGINAL SAFETY, BUT IS LEGAL!! IT ALSO BOTHERS ME THAT IF I WERE OUT OF MY ALT FOR OVER A MINUTE AND IF I WERE OFF ALT BY 1500' IN THE ATL AREA AND A CTLR WOULD BE SO SLOW TO LET ME KNOW AND NOT HAVE A CONCERN IN HIS VOICE. I COUNT ON THEM TO HELP ME KEEP MY PAX SAFE. THEY ARE AN EXTREMELY IMPORTANT RESOURCE TO THE CAPT. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: RPTR DESCRIBED ALL THE EVENTS OF THE PREVIOUS DAY THAT CONTRIBUTED TO FATIGUE. HE SAID THAT THE SMOKE (CONDENSATION) WAS DENSE AND RESTR VISIBILITY IN THE CABIN TO THE POINT THAT HE COULD NOT SEE THE GALLEY WHEN HE LOOKED AFT. HE IS NOT SURE IF HE HAD AN ALT DEVIATION OR NOT. HE MAY BE USING THE RPT AS A VEHICLE TO AIR HIS CONCERNS ABOUT MIN REST TIME REQUIREMENTS.
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.