37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 192637 |
Time | |
Date | 199110 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : oak |
State Reference | CA |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
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 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 190 flight time total : 11000 flight time type : 7500 |
ASRS Report | 192637 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 8000 |
ASRS Report | 192639 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : clearance |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Miss Distance | horizontal : 30000 vertical : 0 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After departure from oak for san, initial clearance was to 2000 ft. Prior to leveling at 2000 ft, clearance was received to 10000 ft. First officer (PNF) set 10000 ft in altitude alert, but somehow in the following 2-3 mins, 11000 ft appeared in window. We continued our climb through 10000 ft after hearing 1000 ft alert. At approximately 10500 ft, the controller (in a normal voice) notified us that there was inbound traffic at 2 O'clock at 11000 ft. I looked at the altitude alert setting (11000 ft) and was subconsciously wondering why we would have been cleared to the conflicting altitude. The TCASII was set on 10 mi range, and the traffic conflict was at approximately 6 mi. The RA portion indicated 'monitor vertical speed.' we leveled at 11000 ft (the first officer sincerely believed that was the altitude cleared to), the controller called to ask our altitude and the traffic passed well clear at 6 O'clock at 5 mi. I think a different TCASII design would help here. Our TCASII screen presented a potential conflicts with an altitude difference. That information is harder to mentally track than it would be if I could continually see his actual altitude, since that would have been a constant in this case. Noting that the altitude in my alerter (11000 ft) was the same as his on the TCASII screen at 8-9000 ft would have alerted me to question my clearance. Supplemental information from acn 192639. I thought I dialed in 10000 ft on the autoplt, but I either mistakenly dialed in 11000 ft or the autoplt controller changed. It was the older system (every click is 1000 ft, not like the newer one of 100 ft) and occasionally it happens.
Original NASA ASRS Text
Title: ACR MLG ALTDEV OVERSHOT DURING CLB OUT FROM OAK. TCASII INDICATED TA BUT TFC WAS SIGHTED AND REMAINED OVER 5 NM AWAY AT SAME ALT.
Narrative: AFTER DEP FROM OAK FOR SAN, INITIAL CLRNC WAS TO 2000 FT. PRIOR TO LEVELING AT 2000 FT, CLRNC WAS RECEIVED TO 10000 FT. FO (PNF) SET 10000 FT IN ALT ALERT, BUT SOMEHOW IN THE FOLLOWING 2-3 MINS, 11000 FT APPEARED IN WINDOW. WE CONTINUED OUR CLB THROUGH 10000 FT AFTER HEARING 1000 FT ALERT. AT APPROX 10500 FT, THE CTLR (IN A NORMAL VOICE) NOTIFIED US THAT THERE WAS INBOUND TFC AT 2 O'CLOCK AT 11000 FT. I LOOKED AT THE ALT ALERT SETTING (11000 FT) AND WAS SUBCONSCIOUSLY WONDERING WHY WE WOULD HAVE BEEN CLRED TO THE CONFLICTING ALT. THE TCASII WAS SET ON 10 MI RANGE, AND THE TFC CONFLICT WAS AT APPROX 6 MI. THE RA PORTION INDICATED 'MONITOR VERT SPD.' WE LEVELED AT 11000 FT (THE FO SINCERELY BELIEVED THAT WAS THE ALT CLRED TO), THE CTLR CALLED TO ASK OUR ALT AND THE TFC PASSED WELL CLR AT 6 O'CLOCK AT 5 MI. I THINK A DIFFERENT TCASII DESIGN WOULD HELP HERE. OUR TCASII SCREEN PRESENTED A POTENTIAL CONFLICTS WITH AN ALT DIFFERENCE. THAT INFO IS HARDER TO MENTALLY TRACK THAN IT WOULD BE IF I COULD CONTINUALLY SEE HIS ACTUAL ALT, SINCE THAT WOULD HAVE BEEN A CONSTANT IN THIS CASE. NOTING THAT THE ALT IN MY ALERTER (11000 FT) WAS THE SAME AS HIS ON THE TCASII SCREEN AT 8-9000 FT WOULD HAVE ALERTED ME TO QUESTION MY CLRNC. SUPPLEMENTAL INFO FROM ACN 192639. I THOUGHT I DIALED IN 10000 FT ON THE AUTOPLT, BUT I EITHER MISTAKENLY DIALED IN 11000 FT OR THE AUTOPLT CTLR CHANGED. IT WAS THE OLDER SYS (EVERY CLICK IS 1000 FT, NOT LIKE THE NEWER ONE OF 100 FT) AND OCCASIONALLY IT HAPPENS.
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.