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|
Attributes | |
ACN | 224759 |
Time | |
Date | 199210 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : den |
State Reference | CO |
Altitude | msl bound lower : 23000 msl bound upper : 23500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdv tower : olm |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | enroute airway : zdv |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : flight engineer pilot : instrument pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 7500 flight time type : 400 |
ASRS Report | 224759 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 12000 flight time type : 150 |
ASRS Report | 224358 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
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:
The captain was flying. We were cleared from FL200 to FL230. The aircraft was very light and the climb rate very high, about 2500-3000 FPM. With the altitude change clearance we were also given a frequency change. The new frequency was very busy. Center had to repeat instructions 3 times to an aircraft with receiver problems. This distracted both the captain and me. A jump seat rider (omc) caught the altitude deviation at FL233 and the aircraft climbed to FL235 before being brought immediately back to FL230. I can say without doubt that fatigue was the single largest factor in the cause of this incident. Our day began with an XA00 eastern time wake-up. We are a west coast based crew who had operated the previous 3 days on the west coast. So in effect our wake up was really XZ00. Our first leg was ewr-den. In denver, den-sfo, we had about a 1 1/2 hour delay. 1 hour of that was taken in the holding area, waiting for takeoff. The extremely early start, combined with a long ground delay, combined to make you far less mentally sharp than you would normally be. Thank goodness for the omc! This is an example of how valuable that extra person can be. Supplemental information from acn 224358: WX was several layers of clouds with cap cloud over mt range. I was attempting to not fly through cap cloud. Jump seat rider yelled, 'level at 230' as I was passing through it.
Original NASA ASRS Text
Title: WDB FLC CLBS ABOVE ASSIGNED ALT.
Narrative: THE CAPT WAS FLYING. WE WERE CLRED FROM FL200 TO FL230. THE ACFT WAS VERY LIGHT AND THE CLB RATE VERY HIGH, ABOUT 2500-3000 FPM. WITH THE ALT CHANGE CLRNC WE WERE ALSO GIVEN A FREQ CHANGE. THE NEW FREQ WAS VERY BUSY. CTR HAD TO REPEAT INSTRUCTIONS 3 TIMES TO AN ACFT WITH RECEIVER PROBLEMS. THIS DISTRACTED BOTH THE CAPT AND ME. A JUMP SEAT RIDER (OMC) CAUGHT THE ALTDEV AT FL233 AND THE ACFT CLBED TO FL235 BEFORE BEING BROUGHT IMMEDIATELY BACK TO FL230. I CAN SAY WITHOUT DOUBT THAT FATIGUE WAS THE SINGLE LARGEST FACTOR IN THE CAUSE OF THIS INCIDENT. OUR DAY BEGAN WITH AN XA00 EASTERN TIME WAKE-UP. WE ARE A W COAST BASED CREW WHO HAD OPERATED THE PREVIOUS 3 DAYS ON THE W COAST. SO IN EFFECT OUR WAKE UP WAS REALLY XZ00. OUR FIRST LEG WAS EWR-DEN. IN DENVER, DEN-SFO, WE HAD ABOUT A 1 1/2 HR DELAY. 1 HR OF THAT WAS TAKEN IN THE HOLDING AREA, WAITING FOR TKOF. THE EXTREMELY EARLY START, COMBINED WITH A LONG GND DELAY, COMBINED TO MAKE YOU FAR LESS MENTALLY SHARP THAN YOU WOULD NORMALLY BE. THANK GOODNESS FOR THE OMC! THIS IS AN EXAMPLE OF HOW VALUABLE THAT EXTRA PERSON CAN BE. SUPPLEMENTAL INFO FROM ACN 224358: WX WAS SEVERAL LAYERS OF CLOUDS WITH CAP CLOUD OVER MT RANGE. I WAS ATTEMPTING TO NOT FLY THROUGH CAP CLOUD. JUMP SEAT RIDER YELLED, 'LEVEL AT 230' AS I WAS PASSING THROUGH IT.
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.