Narrative:

We departed VFR from an uncontrolled airport. We climbed above a scattered layer to clear conditions. We then contacted center at about 5000 ft and requested our IFR clearance to the destination. Center cleared us as filed, but to maintain 9000 ft instead of the FL190 we had requested. I was sitting in the left seat as PIC, with a qualified second-in-command hand flying the airplane from the right seat. I was handling the checklists, running the radios, checking with the nurses (we were a lifeguard flight), etc. Everything seemed in order, and I decided to put on my sunglasses. That was a mistake! I had allowed myself to become distracted I assumed that the copilot was going to level off at 9000 ft. Before I could get my glasses out of their case I heard my copilot say something about 9100 ft. I immediately stopped what I was doing, looked up, and saw us going through 9200 ft. I did not take time to put on the glasses. Instead, I immediately reduced power and pushed my yoke forward. Our altitude was between 930 0 ft and 9400 ft before we began our descent down to 9000 ft. After we were level at 9000 ft, center asked us to say our altitude. We were in fact level at 9000 ft. The controller did not seem satisfied. He asked if we had been above 9000 ft at any time before our level off, and if so, how far had we gone? I confessed that we had overshot our altitude by 300-400 ft. We were informed that we had triggered some sort of alarm, and were given a phone number to call when we were back on the ground. Needless to say, the trip home was pretty quiet. I cannot say why the copilot did not level off at 9000 ft, and it doesn't really matter. The fact is, that I allowed myself to be distracted during a crucial phase of the flight, assuming the copilot was going to level the airplane at 9000 ft. I knew he understood the clearance, but that does not relieve me from making sure we adhere to our clearance. I should not have allowed myself to be distracted. I think there was another factor that contributed to this incident. The manner in which we, as pilots, become accustomed to routine procedures seems to create habit patterns that can lead to danger. We were climbing in excellent VFR conditions from a small, remote, uncontrolled airport, planning to go on up to FL190. The WX and our location had established a mindset that allowed me to become distracted, and perhaps allowed the copilot to become complacent about monitoring our altitude. We were passing through our assigned altitude much quicker than either of us realized. Also, because we were in good VFR conditions, I think we became complacent and did not continue to discuss our IFR clearance limits as diligently as if we were IMC. In order to prevent a recurrence of this incident, I think that, as flcs, we need to realize that our full attention is needed during all phases of flight, and that we must learn to recognize the traps that can be set when we find ourselves doing the ordinary and routine. We must also be always vigilant about the activities we find ourselves doing during crucial phases of flight. Callback conversation with reporter revealed the following information: captain reporter stated their altitude deviation 'triggered' alarm at center. ATC reported that there was another aircraft at 10000 ft MSL and 3 mi. Reporter stated that they never had visual contact. Reporter stated he saw this as no major conflict. Supplemental information from acn 213214: being in VFR conditions, I didn't scan the altimeter frequently enough. After making a heading change, and setting my HSI course, I heard the altitude alert bell thinking it was warning me of being within 1000 ft of assigned altitude. To my horror, I glanced at the altitude, and realized I had just flown through my altitude. I believe this situation can be avoided by not allowing clear conditions to make you complacent about altitude scan. Callback conversation with reporter revealed the following information: first officer reporter stated that FAA did contact pilots. FAA has decided not to pursue further. Reporter states that contributor to error was that both pilots were wearing headsets and did not hear audible alert at 1000 ft from assigned. There was no cockpit callout by captain. Reporter states that audible alerts should be audible through intercom also. The visual (light) alert in this aircraft was placed low on panel between pilot's seats. Company mechanic has since re-positioned the light on the forward panel.

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Original NASA ASRS Text

Title: ALTDEV ALT OVERSHOT IN CLB.

Narrative: WE DEPARTED VFR FROM AN UNCTLED ARPT. WE CLBED ABOVE A SCATTERED LAYER TO CLR CONDITIONS. WE THEN CONTACTED CTR AT ABOUT 5000 FT AND REQUESTED OUR IFR CLRNC TO THE DEST. CTR CLRED US AS FILED, BUT TO MAINTAIN 9000 FT INSTEAD OF THE FL190 WE HAD REQUESTED. I WAS SITTING IN THE L SEAT AS PIC, WITH A QUALIFIED SECOND-IN-COMMAND HAND FLYING THE AIRPLANE FROM THE R SEAT. I WAS HANDLING THE CHKLISTS, RUNNING THE RADIOS, CHKING WITH THE NURSES (WE WERE A LIFEGUARD FLT), ETC. EVERYTHING SEEMED IN ORDER, AND I DECIDED TO PUT ON MY SUNGLASSES. THAT WAS A MISTAKE! I HAD ALLOWED MYSELF TO BECOME DISTRACTED I ASSUMED THAT THE COPLT WAS GOING TO LEVEL OFF AT 9000 FT. BEFORE I COULD GET MY GLASSES OUT OF THEIR CASE I HEARD MY COPLT SAY SOMETHING ABOUT 9100 FT. I IMMEDIATELY STOPPED WHAT I WAS DOING, LOOKED UP, AND SAW US GOING THROUGH 9200 FT. I DID NOT TAKE TIME TO PUT ON THE GLASSES. INSTEAD, I IMMEDIATELY REDUCED PWR AND PUSHED MY YOKE FORWARD. OUR ALT WAS BTWN 930 0 FT AND 9400 FT BEFORE WE BEGAN OUR DSCNT DOWN TO 9000 FT. AFTER WE WERE LEVEL AT 9000 FT, CTR ASKED US TO SAY OUR ALT. WE WERE IN FACT LEVEL AT 9000 FT. THE CTLR DID NOT SEEM SATISFIED. HE ASKED IF WE HAD BEEN ABOVE 9000 FT AT ANY TIME BEFORE OUR LEVEL OFF, AND IF SO, HOW FAR HAD WE GONE? I CONFESSED THAT WE HAD OVERSHOT OUR ALT BY 300-400 FT. WE WERE INFORMED THAT WE HAD TRIGGERED SOME SORT OF ALARM, AND WERE GIVEN A PHONE NUMBER TO CALL WHEN WE WERE BACK ON THE GND. NEEDLESS TO SAY, THE TRIP HOME WAS PRETTY QUIET. I CANNOT SAY WHY THE COPLT DID NOT LEVEL OFF AT 9000 FT, AND IT DOESN'T REALLY MATTER. THE FACT IS, THAT I ALLOWED MYSELF TO BE DISTRACTED DURING A CRUCIAL PHASE OF THE FLT, ASSUMING THE COPLT WAS GOING TO LEVEL THE AIRPLANE AT 9000 FT. I KNEW HE UNDERSTOOD THE CLRNC, BUT THAT DOES NOT RELIEVE ME FROM MAKING SURE WE ADHERE TO OUR CLRNC. I SHOULD NOT HAVE ALLOWED MYSELF TO BE DISTRACTED. I THINK THERE WAS ANOTHER FACTOR THAT CONTRIBUTED TO THIS INCIDENT. THE MANNER IN WHICH WE, AS PLTS, BECOME ACCUSTOMED TO ROUTINE PROCS SEEMS TO CREATE HABIT PATTERNS THAT CAN LEAD TO DANGER. WE WERE CLBING IN EXCELLENT VFR CONDITIONS FROM A SMALL, REMOTE, UNCTLED ARPT, PLANNING TO GO ON UP TO FL190. THE WX AND OUR LOCATION HAD ESTABLISHED A MINDSET THAT ALLOWED ME TO BECOME DISTRACTED, AND PERHAPS ALLOWED THE COPLT TO BECOME COMPLACENT ABOUT MONITORING OUR ALT. WE WERE PASSING THROUGH OUR ASSIGNED ALT MUCH QUICKER THAN EITHER OF US REALIZED. ALSO, BECAUSE WE WERE IN GOOD VFR CONDITIONS, I THINK WE BECAME COMPLACENT AND DID NOT CONTINUE TO DISCUSS OUR IFR CLRNC LIMITS AS DILIGENTLY AS IF WE WERE IMC. IN ORDER TO PREVENT A RECURRENCE OF THIS INCIDENT, I THINK THAT, AS FLCS, WE NEED TO REALIZE THAT OUR FULL ATTN IS NEEDED DURING ALL PHASES OF FLT, AND THAT WE MUST LEARN TO RECOGNIZE THE TRAPS THAT CAN BE SET WHEN WE FIND OURSELVES DOING THE ORDINARY AND ROUTINE. WE MUST ALSO BE ALWAYS VIGILANT ABOUT THE ACTIVITIES WE FIND OURSELVES DOING DURING CRUCIAL PHASES OF FLT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: CAPT RPTR STATED THEIR ALTDEV 'TRIGGERED' ALARM AT CTR. ATC RPTED THAT THERE WAS ANOTHER ACFT AT 10000 FT MSL AND 3 MI. RPTR STATED THAT THEY NEVER HAD VISUAL CONTACT. RPTR STATED HE SAW THIS AS NO MAJOR CONFLICT. SUPPLEMENTAL INFO FROM ACN 213214: BEING IN VFR CONDITIONS, I DIDN'T SCAN THE ALTIMETER FREQUENTLY ENOUGH. AFTER MAKING A HDG CHANGE, AND SETTING MY HSI COURSE, I HEARD THE ALT ALERT BELL THINKING IT WAS WARNING ME OF BEING WITHIN 1000 FT OF ASSIGNED ALT. TO MY HORROR, I GLANCED AT THE ALT, AND REALIZED I HAD JUST FLOWN THROUGH MY ALT. I BELIEVE THIS SITUATION CAN BE AVOIDED BY NOT ALLOWING CLR CONDITIONS TO MAKE YOU COMPLACENT ABOUT ALT SCAN. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: FO RPTR STATED THAT FAA DID CONTACT PLTS. FAA HAS DECIDED NOT TO PURSUE FURTHER. RPTR STATES THAT CONTRIBUTOR TO ERROR WAS THAT BOTH PLTS WERE WEARING HEADSETS AND DID NOT HEAR AUDIBLE ALERT AT 1000 FT FROM ASSIGNED. THERE WAS NO COCKPIT CALLOUT BY CAPT. RPTR STATES THAT AUDIBLE ALERTS SHOULD BE AUDIBLE THROUGH INTERCOM ALSO. THE VISUAL (LIGHT) ALERT IN THIS ACFT WAS PLACED LOW ON PANEL BTWN PLT'S SEATS. COMPANY MECH HAS SINCE RE-POSITIONED THE LIGHT ON THE FORWARD PANEL.

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.