37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 188674 |
Time | |
Date | 199109 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : yqt |
State Reference | ON |
Altitude | msl bound lower : 9000 msl bound upper : 9900 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : yqt |
Operator | general aviation : instructional |
Make Model Name | Small Transport, Low Wing, 2 Recip Eng |
Flight Phase | descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 5000 flight time type : 10 |
ASRS Report | 188674 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This was only my second trip in an small transport. This was a different model than the one flown 2 yrs previous. As an airline pilot I thought I had it all covered. My chkout was 1.1 hours the day before. VFR T and G and single engine. Very quick briefing on xx model autoplt. Approaching yqt I was under high task loading, getting ATIS, balancing fuel, switching frequencys, navigating, interruptions by non-pilot passenger. The autoplt (while listening to ATIS) did an unexpected 30 degree turn, so I turned it off, checked the navigation and turned it back on. Shortly thereafter I noticed that I was up 300 ft. I turned off the autoplt again and analyzed that I had touched altitude hold but not autoplt on, oops, so I turned on the autoplt. I went back to checking ATIS, approach called for me to 'identify' a second time, oh no! I was 900 ft high. I 'fessed up' that I had autoplt problems. I got a descent clearance and descended manually. On further analysis, I found that I had incorrectly activated the autoplt modes. When the xx model is turned on (all push buttons) it is automatically in heading (heading) and att (attitude). I correctly selected 'navigation' instead of heading but did not select 'altitude' altitude hold. Thus I kept climbing in 'att', despite 2 mode annunciator panels. Having 2 mode switches next to each other so close in name 'att', 'altitude' is a poor design, but, my overconfidence exacerbated the problem!
Original NASA ASRS Text
Title: PLT NEWLY CHKED OUT IN EQUIP OPERATES AUTOPLT INCORRECTLY. ALT DEV.
Narrative: THIS WAS ONLY MY SECOND TRIP IN AN SMT. THIS WAS A DIFFERENT MODEL THAN THE ONE FLOWN 2 YRS PREVIOUS. AS AN AIRLINE PLT I THOUGHT I HAD IT ALL COVERED. MY CHKOUT WAS 1.1 HRS THE DAY BEFORE. VFR T AND G AND SINGLE ENG. VERY QUICK BRIEFING ON XX MODEL AUTOPLT. APCHING YQT I WAS UNDER HIGH TASK LOADING, GETTING ATIS, BALANCING FUEL, SWITCHING FREQS, NAVIGATING, INTERRUPTIONS BY NON-PLT PAX. THE AUTOPLT (WHILE LISTENING TO ATIS) DID AN UNEXPECTED 30 DEG TURN, SO I TURNED IT OFF, CHKED THE NAV AND TURNED IT BACK ON. SHORTLY THEREAFTER I NOTICED THAT I WAS UP 300 FT. I TURNED OFF THE AUTOPLT AGAIN AND ANALYZED THAT I HAD TOUCHED ALT HOLD BUT NOT AUTOPLT ON, OOPS, SO I TURNED ON THE AUTOPLT. I WENT BACK TO CHKING ATIS, APCH CALLED FOR ME TO 'IDENT' A SECOND TIME, OH NO! I WAS 900 FT HIGH. I 'FESSED UP' THAT I HAD AUTOPLT PROBLEMS. I GOT A DSCNT CLRNC AND DSNDED MANUALLY. ON FURTHER ANALYSIS, I FOUND THAT I HAD INCORRECTLY ACTIVATED THE AUTOPLT MODES. WHEN THE XX MODEL IS TURNED ON (ALL PUSH BUTTONS) IT IS AUTOMATICALLY IN HDG (HEADING) AND ATT (ATTITUDE). I CORRECTLY SELECTED 'NAV' INSTEAD OF HDG BUT DID NOT SELECT 'ALT' ALT HOLD. THUS I KEPT CLBING IN 'ATT', DESPITE 2 MODE ANNUNCIATOR PANELS. HAVING 2 MODE SWITCHES NEXT TO EACH OTHER SO CLOSE IN NAME 'ATT', 'ALT' IS A POOR DESIGN, BUT, MY OVERCONFIDENCE EXACERBATED THE PROBLEM!
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.