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|
Attributes | |
ACN | 201586 |
Time | |
Date | 199202 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : ord |
State Reference | IL |
Altitude | msl bound lower : 6000 msl bound upper : 6450 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : ord |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
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 |
Experience | flight time last 90 days : 125 flight time total : 6400 flight time type : 95 |
ASRS Report | 201586 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 220 flight time total : 6000 flight time type : 2500 |
ASRS Report | 201604 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation Intra Facility Coordination Failure |
Narrative:
Air carrier X on climb out from ord, we were on a heading of 040 degree and passing through approximately 4700 ft when we received clearance to climb to 6000 ft and turn to 140 degree heading. Rolling in 1000 FPM pitch on flight guidance panel we started a turn and a climb at approximately 5800 ft received a TA on TCASII and verbal traffic, traffic alert. Looking down at TCASII momentarily and then outside to see potential traffic conflict, aircraft passed through 6000 ft. After spotting traffic and returning to instruments, saw altitude was 6300 ft with approximately 600 ft rate of climb. Aural altitude warning was then heard. Safely but expeditiously pushed nose over without causing flight attendants to hit cabin ceiling. Aircraft reached approximately 6450 before actually descending to 6000 ft. Passing through 6300 ft and descending ATC advised our altitude clearance was 6000 ft. At this time we were going through 115 heading and was given a turn back to 100 degree never reaching the 140 degree heading that we were previously cleared to. Autoplt was off. I believe deviation was caused as a result of flight crew being distraction with TCASII alert within a couple of hundred ft to level off altitude. It was noticed a correction started seconds before receiving the aircraft altitude aural warning but climbing vector resulted in an approximately 450 ft high deviation. Supplemental information from acn 201594. This incident happened during a very busy departure as well as arrival rush into ord. Air carrier X, an medium large transport, had departed runway 32L on a 040 heading and was level at 5000 ft. Approximately 10 mi northeast of ord, air carrier X was cleared to 6000 ft and turned right to heading 090. A few seconds later, a fellow controller observed air carrier X climbing through 6400 ft. There was arrival traffic above at 8000 ft and off his left at 10000 ft. I immediately issued instructions for air carrier X to level at 7000 ft and issued the 8000 ft traffic. Air carrier X evidently realized his mistake as I issued the instructions to level at 7000 ft and he descended from 6600 ft back to 6000 ft in less then 2 sweeps (8 seconds). It was at this time he indicated to me that he had a TCASII alert. Upon further discussion with the pilot, he indicated his TCASII was giving him several alerts so both pilots went outside the cockpit for visual verification and they forgot to level at 6000 ft. In our environment, 7000 ft belongs to arrival and fortunately he had not descended his arrival from 8000 to 7000 ft. I feel that a TCASII distraction caused this pilot deviation from the most basic of piloting duties; 'fly the aircraft first.' this is another unfortunate occurrence where TCASII has become more of a distraction and hindrance in a high density terminal area.
Original NASA ASRS Text
Title: ACR X NON ADHERENCE TO ATC CLRNC CLB THROUGH ASSIGNED ALT. TCASII TA FLC DISTR. PLTDEV.
Narrative: ACR X ON CLBOUT FROM ORD, WE WERE ON A HDG OF 040 DEG AND PASSING THROUGH APPROX 4700 FT WHEN WE RECEIVED CLRNC TO CLB TO 6000 FT AND TURN TO 140 DEG HDG. ROLLING IN 1000 FPM PITCH ON FLT GUIDANCE PANEL WE STARTED A TURN AND A CLB AT APPROX 5800 FT RECEIVED A TA ON TCASII AND VERBAL TFC, TFC ALERT. LOOKING DOWN AT TCASII MOMENTARILY AND THEN OUTSIDE TO SEE POTENTIAL TFC CONFLICT, ACFT PASSED THROUGH 6000 FT. AFTER SPOTTING TFC AND RETURNING TO INSTS, SAW ALT WAS 6300 FT WITH APPROX 600 FT RATE OF CLB. AURAL ALT WARNING WAS THEN HEARD. SAFELY BUT EXPEDITIOUSLY PUSHED NOSE OVER WITHOUT CAUSING FLT ATTENDANTS TO HIT CABIN CEILING. ACFT REACHED APPROX 6450 BEFORE ACTUALLY DSNDING TO 6000 FT. PASSING THROUGH 6300 FT AND DSNDING ATC ADVISED OUR ALT CLRNC WAS 6000 FT. AT THIS TIME WE WERE GOING THROUGH 115 HDG AND WAS GIVEN A TURN BACK TO 100 DEG NEVER REACHING THE 140 DEG HDG THAT WE WERE PREVIOUSLY CLRED TO. AUTOPLT WAS OFF. I BELIEVE DEV WAS CAUSED AS A RESULT OF FLC BEING DISTR WITH TCASII ALERT WITHIN A COUPLE OF HUNDRED FT TO LEVEL OFF ALT. IT WAS NOTICED A CORRECTION STARTED SECONDS BEFORE RECEIVING THE ACFT ALT AURAL WARNING BUT CLBING VECTOR RESULTED IN AN APPROX 450 FT HIGH DEV. SUPPLEMENTAL INFO FROM ACN 201594. THIS INCIDENT HAPPENED DURING A VERY BUSY DEP AS WELL AS ARR RUSH INTO ORD. ACR X, AN MLG, HAD DEPARTED RWY 32L ON A 040 HDG AND WAS LEVEL AT 5000 FT. APPROX 10 MI NE OF ORD, ACR X WAS CLRED TO 6000 FT AND TURNED R TO HDG 090. A FEW SECONDS LATER, A FELLOW CTLR OBSERVED ACR X CLBING THROUGH 6400 FT. THERE WAS ARR TFC ABOVE AT 8000 FT AND OFF HIS L AT 10000 FT. I IMMEDIATELY ISSUED INSTRUCTIONS FOR ACR X TO LEVEL AT 7000 FT AND ISSUED THE 8000 FT TFC. ACR X EVIDENTLY REALIZED HIS MISTAKE AS I ISSUED THE INSTRUCTIONS TO LEVEL AT 7000 FT AND HE DSNDED FROM 6600 FT BACK TO 6000 FT IN LESS THEN 2 SWEEPS (8 SECONDS). IT WAS AT THIS TIME HE INDICATED TO ME THAT HE HAD A TCASII ALERT. UPON FURTHER DISCUSSION WITH THE PLT, HE INDICATED HIS TCASII WAS GIVING HIM SEVERAL ALERTS SO BOTH PLTS WENT OUTSIDE THE COCKPIT FOR VISUAL VERIFICATION AND THEY FORGOT TO LEVEL AT 6000 FT. IN OUR ENVIRONMENT, 7000 FT BELONGS TO ARR AND FORTUNATELY HE HAD NOT DSNDED HIS ARR FROM 8000 TO 7000 FT. I FEEL THAT A TCASII DISTR CAUSED THIS PLTDEV FROM THE MOST BASIC OF PILOTING DUTIES; 'FLY THE ACFT FIRST.' THIS IS ANOTHER UNFORTUNATE OCCURRENCE WHERE TCASII HAS BECOME MORE OF A DISTR AND HINDRANCE IN A HIGH DENSITY TERMINAL AREA.
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.