37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 158729 |
Time | |
Date | 199010 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : roa |
State Reference | VA |
Altitude | msl bound lower : 5000 msl bound upper : 6000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : roa |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors enroute airway : roa |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 175 flight time total : 6500 flight time type : 1500 |
ASRS Report | 158729 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On departure from roa we were given a clearance to maintain a heading of 235 degree and an altitude of 5000'. Shortly after takeoff ATC asked us to turn on our transponder. We found that it was on, but was not working, so we switched to the other one. At 4000' I looked at the altitude alerter and saw that it read 10000 so I continued the climb, thinking that the captain had received a clearance while I was diverted with the transponder. As we were passing 6000 the ctrl cleared us to 10000 and then asked us if we had climbed above 5000 before receiving further clearance. The captain told the controller that he (the controller) must be mistaken that we had already received the further climb clearance. There are 3 possibilities for how this occurred: we had received further climb and the controller was mistaken (this is the least likely scenario); this possibly was another case of the well documented occurrence of an uncommanded change of altitude on the altitude alert installed in medium large transport aircraft; we never set 5000' to begin with. Contributing factors: the hotel van was late so we were in a hurry-up mode and possibly did not adhere to all procedures. The early hour precluded us being as sharp as usual. Summation. If we had followed the company's newly established altitude awareness program we would not have had a problem. Callback conversation with reporter revealed the following: participated in the boeing study. Advised the company has changed SOP reference to altitude excursions by having both crew members confirming the assigned altitude at all times. Modification is in the process reference the altitude alert failing to 10000 with electrical interruption.
Original NASA ASRS Text
Title: ALT OVERSHOT ON CLIMBOUT.
Narrative: ON DEP FROM ROA WE WERE GIVEN A CLRNC TO MAINTAIN A HDG OF 235 DEG AND AN ALT OF 5000'. SHORTLY AFTER TKOF ATC ASKED US TO TURN ON OUR XPONDER. WE FOUND THAT IT WAS ON, BUT WAS NOT WORKING, SO WE SWITCHED TO THE OTHER ONE. AT 4000' I LOOKED AT THE ALT ALERTER AND SAW THAT IT READ 10000 SO I CONTINUED THE CLB, THINKING THAT THE CAPT HAD RECEIVED A CLRNC WHILE I WAS DIVERTED WITH THE XPONDER. AS WE WERE PASSING 6000 THE CTRL CLRED US TO 10000 AND THEN ASKED US IF WE HAD CLBED ABOVE 5000 BEFORE RECEIVING FURTHER CLRNC. THE CAPT TOLD THE CTLR THAT HE (THE CTLR) MUST BE MISTAKEN THAT WE HAD ALREADY RECEIVED THE FURTHER CLB CLRNC. THERE ARE 3 POSSIBILITIES FOR HOW THIS OCCURRED: WE HAD RECEIVED FURTHER CLB AND THE CTLR WAS MISTAKEN (THIS IS THE LEAST LIKELY SCENARIO); THIS POSSIBLY WAS ANOTHER CASE OF THE WELL DOCUMENTED OCCURRENCE OF AN UNCOMMANDED CHANGE OF ALT ON THE ALT ALERT INSTALLED IN MLG ACFT; WE NEVER SET 5000' TO BEGIN WITH. CONTRIBUTING FACTORS: THE HOTEL VAN WAS LATE SO WE WERE IN A HURRY-UP MODE AND POSSIBLY DID NOT ADHERE TO ALL PROCS. THE EARLY HOUR PRECLUDED US BEING AS SHARP AS USUAL. SUMMATION. IF WE HAD FOLLOWED THE COMPANY'S NEWLY ESTABLISHED ALT AWARENESS PROGRAM WE WOULD NOT HAVE HAD A PROB. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: PARTICIPATED IN THE BOEING STUDY. ADVISED THE COMPANY HAS CHANGED SOP REFERENCE TO ALT EXCURSIONS BY HAVING BOTH CREW MEMBERS CONFIRMING THE ASSIGNED ALT AT ALL TIMES. MODIFICATION IS IN THE PROCESS REFERENCE THE ALT ALERT FAILING TO 10000 WITH ELECTRICAL INTERRUPTION.
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.