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|
Attributes | |
ACN | 202303 |
Time | |
Date | 199202 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : dal |
State Reference | TX |
Altitude | msl bound lower : 23000 msl bound upper : 23500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zfw tracon : dal |
Operator | general aviation : corporate |
Make Model Name | Light Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 8000 flight time type : 2000 |
ASRS Report | 202303 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On the morning of feb/xx/92, departed dallas love airport runway 13L in small transport jet, ft worth 5 departure, millsap transition. Dfw departure cleared us to 16000 on assigned heading of 240 degrees, followed by later clearance of 270 degree heading direct millsap, climb to FL230. I turned to 270 and initiated climb, but mistakenly entered FL270 into the alerter, after passing FL225 was assigned frequency change to ft worth center. I called in climbing to FL270. The controller informed me to level at 230, which I attempted but reached FL235 before level off. This error was caused by a momentary distraction after receiving the clearance to FL230, then remembering the number 270 being said, felt sure that 270 was the assigned altitude. Callback conversation with reporter revealed the following information: reporter states he was very distracted at time of incident lecturing his first officer who had fallen well below standard. He takes full responsibility and knows he too fell below standard. Reversed heading and altitude numbers. Stated this is not the normal EMS operation. Company does not do as much 'trauma' work as long distance flts for patients who are stabilized and need transfer for further care or to home. Much work to canada due to numbers from there who vacation in florida. Much work with cruise lines who may have passenger ill or injured. Also frequently fly organs for transplant as in this incident. Usually have flts scheduled in advance and not last min rush calls. They work all over the north and south american continent.
Original NASA ASRS Text
Title: AIR AMBULANCE FLC REVERSES HDG AND ALT NUMBERS ASSIGNED. HDG DEV. ALTDEV.
Narrative: ON THE MORNING OF FEB/XX/92, DEPARTED DALLAS LOVE ARPT RWY 13L IN SMT JET, FT WORTH 5 DEP, MILLSAP TRANSITION. DFW DEP CLRED US TO 16000 ON ASSIGNED HDG OF 240 DEGS, FOLLOWED BY LATER CLRNC OF 270 DEG HDG DIRECT MILLSAP, CLB TO FL230. I TURNED TO 270 AND INITIATED CLB, BUT MISTAKENLY ENTERED FL270 INTO THE ALERTER, AFTER PASSING FL225 WAS ASSIGNED FREQ CHANGE TO FT WORTH CTR. I CALLED IN CLBING TO FL270. THE CTLR INFORMED ME TO LEVEL AT 230, WHICH I ATTEMPTED BUT REACHED FL235 BEFORE LEVEL OFF. THIS ERROR WAS CAUSED BY A MOMENTARY DISTR AFTER RECEIVING THE CLRNC TO FL230, THEN REMEMBERING THE NUMBER 270 BEING SAID, FELT SURE THAT 270 WAS THE ASSIGNED ALT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATES HE WAS VERY DISTRACTED AT TIME OF INCIDENT LECTURING HIS FO WHO HAD FALLEN WELL BELOW STANDARD. HE TAKES FULL RESPONSIBILITY AND KNOWS HE TOO FELL BELOW STANDARD. REVERSED HDG AND ALT NUMBERS. STATED THIS IS NOT THE NORMAL EMS OP. COMPANY DOES NOT DO AS MUCH 'TRAUMA' WORK AS LONG DISTANCE FLTS FOR PATIENTS WHO ARE STABILIZED AND NEED TRANSFER FOR FURTHER CARE OR TO HOME. MUCH WORK TO CANADA DUE TO NUMBERS FROM THERE WHO VACATION IN FLORIDA. MUCH WORK WITH CRUISE LINES WHO MAY HAVE PAX ILL OR INJURED. ALSO FREQUENTLY FLY ORGANS FOR TRANSPLANT AS IN THIS INCIDENT. USUALLY HAVE FLTS SCHEDULED IN ADVANCE AND NOT LAST MIN RUSH CALLS. THEY WORK ALL OVER THE N AND S AMERICAN CONTINENT.
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.