37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 209966 |
Time | |
Date | 199205 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : sie |
State Reference | NJ |
Altitude | msl bound lower : 14000 msl bound upper : 14800 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | artcc : zdc tower : fcm |
Operator | other |
Make Model Name | Military Transport |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure sid : sid enroute airway : v1 |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : military |
Function | other personnel other |
Qualification | pilot : atp pilot : military |
Experience | flight time last 90 days : 200 flight time total : 12000 flight time type : 3500 |
ASRS Report | 209966 |
Person 2 | |
Affiliation | government : military |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : military |
Experience | flight time last 90 days : 40 flight time total : 700 flight time type : 160 |
ASRS Report | 210256 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : required legal separation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course none taken : insufficient time |
Consequence | faa : investigated |
Miss Distance | vertical : 200 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was flying on the mlt, a military training flight as third pilot, in the cockpit jump seat. While on a published SID, the crew was cleared to climb to and maintain 14000 ft and advised of opposite direction traffic, 1 O'clock, 15000 ft. By ZDC. A few mins later, while I was scanning for the traffic, I heard ATC ask us to confirm our altitude was 14000 ft. I immediately looked down at the pilot's altitude and read 14800 ft. The pilot immediately started a rapid descent to 14000 ft. I immediately looked down at the pilot's altitude and read 14800 ft. The pilot immediately started a rapid descent to 14000 ft. The copilot confirmed with center that we were correcting back to 14000 ft. I never did spot the traffic, but the copilot said he saw it pass our 9 O'clock position at 2- 3 mi. ZDC advised the crew that an 'altitude deviation was noted.' at the time of the incident, the boom operator was sitting in his cockpit seat, out of view of flight instruments. The navigator was viewing his radar scope to check out a WX system to the west, and as it turns out, all 3 pilots were trying to find the reported traffic. The pilot later said he had engaged the autoplt altitude hold switch on the overhead panel, at 14000 ft and then began scanning outside for the traffic. I do remember him reaching up toward the autoplt panel. The autoplt had been operating and engaged. Whether the altitude hold function failed to engage or became disengaged, I don't know. Lessons learned: the pilot flying the airplane should do just that, and let other crew members scan for traffic -- particularly in dynamic phases of flight and when the called traffic is also in radar control, and positively separated. Secondly, pilots need to confirm that a control or switch is in fact positioned as we think and producing the desired results. Thirdly, the '1000 ft prior' to an assigned altitude callout should be a warning to all crew members to stop and confirm the airplane levels at the assigned altitude. It is incumbent on the PIC to fully use all resources available to back him up. Supplemental information from acn 210256: I was busy with the radios, running the checklists, keeping the navaids up with the SID -- basically navigating for the pilot. Since the navigator did not have the SID in the INS yet, we were flying VOR/TACAN. Even though the pilot has over 16 yrs of military flying experience. We (the crew) took his experience for granted and did not follow our crew concept SOP. A contributing factor was each crew members task saturation due to the mission change at the last min resulting in everyone being 'behind the jet.'
Original NASA ASRS Text
Title: FLC OF MLT HAS ALTDEV OF 800 FT IN CLB WHEN THEY BECOME DISTR WITH TFC WATCH AND OTHER COCKPIT TASKS.
Narrative: I WAS FLYING ON THE MLT, A MIL TRAINING FLT AS THIRD PLT, IN THE COCKPIT JUMP SEAT. WHILE ON A PUBLISHED SID, THE CREW WAS CLRED TO CLB TO AND MAINTAIN 14000 FT AND ADVISED OF OPPOSITE DIRECTION TFC, 1 O'CLOCK, 15000 FT. BY ZDC. A FEW MINS LATER, WHILE I WAS SCANNING FOR THE TFC, I HEARD ATC ASK US TO CONFIRM OUR ALT WAS 14000 FT. I IMMEDIATELY LOOKED DOWN AT THE PLT'S ALT AND READ 14800 FT. THE PLT IMMEDIATELY STARTED A RAPID DSCNT TO 14000 FT. I IMMEDIATELY LOOKED DOWN AT THE PLT'S ALT AND READ 14800 FT. THE PLT IMMEDIATELY STARTED A RAPID DSCNT TO 14000 FT. THE COPLT CONFIRMED WITH CTR THAT WE WERE CORRECTING BACK TO 14000 FT. I NEVER DID SPOT THE TFC, BUT THE COPLT SAID HE SAW IT PASS OUR 9 O'CLOCK POS AT 2- 3 MI. ZDC ADVISED THE CREW THAT AN 'ALT DEV WAS NOTED.' AT THE TIME OF THE INCIDENT, THE BOOM OPERATOR WAS SITTING IN HIS COCKPIT SEAT, OUT OF VIEW OF FLT INSTS. THE NAVIGATOR WAS VIEWING HIS RADAR SCOPE TO CHK OUT A WX SYS TO THE W, AND AS IT TURNS OUT, ALL 3 PLTS WERE TRYING TO FIND THE RPTED TFC. THE PLT LATER SAID HE HAD ENGAGED THE AUTOPLT ALT HOLD SWITCH ON THE OVERHEAD PANEL, AT 14000 FT AND THEN BEGAN SCANNING OUTSIDE FOR THE TFC. I DO REMEMBER HIM REACHING UP TOWARD THE AUTOPLT PANEL. THE AUTOPLT HAD BEEN OPERATING AND ENGAGED. WHETHER THE ALT HOLD FUNCTION FAILED TO ENGAGE OR BECAME DISENGAGED, I DON'T KNOW. LESSONS LEARNED: THE PLT FLYING THE AIRPLANE SHOULD DO JUST THAT, AND LET OTHER CREW MEMBERS SCAN FOR TFC -- PARTICULARLY IN DYNAMIC PHASES OF FLT AND WHEN THE CALLED TFC IS ALSO IN RADAR CTL, AND POSITIVELY SEPARATED. SECONDLY, PLTS NEED TO CONFIRM THAT A CTL OR SWITCH IS IN FACT POSITIONED AS WE THINK AND PRODUCING THE DESIRED RESULTS. THIRDLY, THE '1000 FT PRIOR' TO AN ASSIGNED ALT CALLOUT SHOULD BE A WARNING TO ALL CREW MEMBERS TO STOP AND CONFIRM THE AIRPLANE LEVELS AT THE ASSIGNED ALT. IT IS INCUMBENT ON THE PIC TO FULLY USE ALL RESOURCES AVAILABLE TO BACK HIM UP. SUPPLEMENTAL INFO FROM ACN 210256: I WAS BUSY WITH THE RADIOS, RUNNING THE CHKLISTS, KEEPING THE NAVAIDS UP WITH THE SID -- BASICALLY NAVIGATING FOR THE PLT. SINCE THE NAVIGATOR DID NOT HAVE THE SID IN THE INS YET, WE WERE FLYING VOR/TACAN. EVEN THOUGH THE PLT HAS OVER 16 YRS OF MIL FLYING EXPERIENCE. WE (THE CREW) TOOK HIS EXPERIENCE FOR GRANTED AND DID NOT FOLLOW OUR CREW CONCEPT SOP. A CONTRIBUTING FACTOR WAS EACH CREW MEMBERS TASK SATURATION DUE TO THE MISSION CHANGE AT THE LAST MIN RESULTING IN EVERYONE BEING 'BEHIND THE JET.'
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.