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Potential conflict less than standard separation occurs when air carrier medium large transport experiences an altitude deviation altitude overshot in descent with opposite direction traffic.
| Attributes | |
| ACN | 184162 |
| Time | |
| Date | 199107 |
| Day | Tue |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | atc facility : hnl |
| State Reference | HI |
| Altitude | msl bound lower : 13200 msl bound upper : 14000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Flight Phase | cruise other descent other |
| Route In Use | enroute airway : zhn |
| Flight Plan | IFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Flight Phase | cruise other |
| 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 |
| Experience | flight time last 90 days : 140 flight time total : 6500 |
| ASRS Report | 184162 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| ASRS Report | 185206 |
| Events | |
| Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : clearance |
| Independent Detector | other controllera other flight crewa |
| Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course other |
| Consequence | faa : investigated |
| Miss Distance | horizontal : 12000 vertical : 200 |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
While flying the last trip of the evening, center cleared us down from FL250 to 14000 ft. We descended 800 ft below assigned altitude before we realized this. An immediate climb back to 14000 ft was established. There was opposite direction traffic at 13000 ft which we had in sight and presented no factor. The primary reason for this occurrence was crew exhaustion. Crew day began at pm:20 hours until am:20 hours. Shorter crew day would help prevent this. Supplemental information from acn 185206. We were cleared to 14000 ft and given TA of 11 O'clock at 13000 ft. We reported the traffic in sight. As we descended I engaged the captain in some conversation that detracted his attention from the altitude. Shortly hereafter, we simultaneously noticed our aircraft approaching 13200 ft. We applied power and quickly returned to 14000 ft. The controller also acknowledged the altitude deviation and issued an order to maintain 14000 ft. That was acknowledged on the way back up. Callback conversation with reporter revealed the following information. Reporter stated that, while watching the opposite direction traffic that had been pointed out, the flight crew just forgot to cross check their altimeter during the final phase of level-off. The fact that the aircraft Y had all of it's lights on and being so well lit up possibly created an over-fixation that was all absorbing to the crew.
Original NASA ASRS Text
Title: POTENTIAL CONFLICT LTSS OCCURS WHEN ACR MLG EXPERIENCES AN ALT DEV ALT OVERSHOT IN DSCNT WITH OPPOSITE DIRECTION TFC.
Narrative: WHILE FLYING THE LAST TRIP OF THE EVENING, CTR CLRED US DOWN FROM FL250 TO 14000 FT. WE DSNDED 800 FT BELOW ASSIGNED ALT BEFORE WE REALIZED THIS. AN IMMEDIATE CLB BACK TO 14000 FT WAS ESTABLISHED. THERE WAS OPPOSITE DIRECTION TFC AT 13000 FT WHICH WE HAD IN SIGHT AND PRESENTED NO FACTOR. THE PRIMARY REASON FOR THIS OCCURRENCE WAS CREW EXHAUSTION. CREW DAY BEGAN AT PM:20 HRS UNTIL AM:20 HRS. SHORTER CREW DAY WOULD HELP PREVENT THIS. SUPPLEMENTAL INFO FROM ACN 185206. WE WERE CLRED TO 14000 FT AND GIVEN TA OF 11 O'CLOCK AT 13000 FT. WE RPTED THE TFC IN SIGHT. AS WE DSNDED I ENGAGED THE CAPT IN SOME CONVERSATION THAT DETRACTED HIS ATTN FROM THE ALT. SHORTLY HEREAFTER, WE SIMULTANEOUSLY NOTICED OUR ACFT APCHING 13200 FT. WE APPLIED PWR AND QUICKLY RETURNED TO 14000 FT. THE CTLR ALSO ACKNOWLEDGED THE ALT DEV AND ISSUED AN ORDER TO MAINTAIN 14000 FT. THAT WAS ACKNOWLEDGED ON THE WAY BACK UP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO. RPTR STATED THAT, WHILE WATCHING THE OPPOSITE DIRECTION TFC THAT HAD BEEN POINTED OUT, THE FLC JUST FORGOT TO CROSS CHK THEIR ALTIMETER DURING THE FINAL PHASE OF LEVEL-OFF. THE FACT THAT THE ACFT Y HAD ALL OF IT'S LIGHTS ON AND BEING SO WELL LIT UP POSSIBLY CREATED AN OVER-FIXATION THAT WAS ALL ABSORBING TO THE CREW.
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.