37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 242865 |
Time | |
Date | 199306 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : yyz |
State Reference | ON |
Altitude | msl bound lower : 3000 msl bound upper : 3500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : yyz |
Operator | common carrier : air carrier |
Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 8000 flight time type : 900 |
ASRS Report | 242865 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 5000 flight time type : 3000 |
ASRS Report | 242793 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On departure passing 3500 ft PNF contacted departure. Stated 3500 ft for 4000 ft. Controller asked what altitude cleared, responded 4000 ft. Controller stated confusion that turboprops usually cleared to 3000 ft. Altitude preset for 4000 ft. Controller stated we were cleared to 3000 ft and then cleared us to 15000 ft. Problem arose because of cockpit mistake of not resetting altitude select to 3000 ft as in clearance. It was left at last assigned before landing. Captain briefed departure as indicating 4000 ft after first officer was off line briefing passenger. Reduced rest overnight with little sleep. Canadian procedures different than united states, i.e., contact departure when airborne not when switched by tower as is united states procedure. If initial contact had been when airborne controller would have caught the missetting of altitude select when 4000 ft stated by PNF. Altitude used was different than SID of 5000 ft so confusion, coupled with high workload and cockpit resource management breakdown and fatigue added to the problem. Supplemental information from acn 242793: I waited for tower to clear us over to departure but in canada unlike united states PIC must make the change without being told. Thus, after passing 3500 ft then con tacting departure it was too late to get an altitude confirmation.
Original NASA ASRS Text
Title: ALTDEV ALT OVERSHOT DURING SID DEP PROC. CLRNC INTERP PROB.
Narrative: ON DEP PASSING 3500 FT PNF CONTACTED DEP. STATED 3500 FT FOR 4000 FT. CTLR ASKED WHAT ALT CLRED, RESPONDED 4000 FT. CTLR STATED CONFUSION THAT TURBOPROPS USUALLY CLRED TO 3000 FT. ALT PRESET FOR 4000 FT. CTLR STATED WE WERE CLRED TO 3000 FT AND THEN CLRED US TO 15000 FT. PROB AROSE BECAUSE OF COCKPIT MISTAKE OF NOT RESETTING ALT SELECT TO 3000 FT AS IN CLRNC. IT WAS LEFT AT LAST ASSIGNED BEFORE LNDG. CAPT BRIEFED DEP AS INDICATING 4000 FT AFTER FO WAS OFF LINE BRIEFING PAX. REDUCED REST OVERNIGHT WITH LITTLE SLEEP. CANADIAN PROCS DIFFERENT THAN UNITED STATES, I.E., CONTACT DEP WHEN AIRBORNE NOT WHEN SWITCHED BY TWR AS IS UNITED STATES PROC. IF INITIAL CONTACT HAD BEEN WHEN AIRBORNE CTLR WOULD HAVE CAUGHT THE MISSETTING OF ALT SELECT WHEN 4000 FT STATED BY PNF. ALT USED WAS DIFFERENT THAN SID OF 5000 FT SO CONFUSION, COUPLED WITH HIGH WORKLOAD AND COCKPIT RESOURCE MGMNT BREAKDOWN AND FATIGUE ADDED TO THE PROB. SUPPLEMENTAL INFO FROM ACN 242793: I WAITED FOR TWR TO CLR US OVER TO DEP BUT IN CANADA UNLIKE UNITED STATES PIC MUST MAKE THE CHANGE WITHOUT BEING TOLD. THUS, AFTER PASSING 3500 FT THEN CON TACTING DEP IT WAS TOO LATE TO GET AN ALT CONFIRMATION.
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.