37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 246676 |
Time | |
Date | 199307 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : swf |
State Reference | NY |
Altitude | msl bound lower : 5500 msl bound upper : 6000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zny |
Operator | common carrier : air carrier |
Make Model Name | Medium Transport, High Wing, 2 Turboprop Eng |
Navigation In Use | Other Other |
Flight Phase | descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 184 flight time total : 7511 flight time type : 831 |
ASRS Report | 246676 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 3800 flight time type : 80 |
ASRS Report | 246123 |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : weather non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During our arrival into newburgh, ny (swf), ZNY gave us a descent clearance to 6000 ft. I was the PF, and the flight director and autoplt were in use at the time. Passing 7000 ft, I chose to maintain our 1000 FPM rate of descent (rather than decrease it to a normal 500 FPM) in order to get more quickly below a broken cloud layer that was providing light to moderate turbulence. As we proceeded through our arrival checklist, ATC suddenly alerted us to 'maintain 6000 ft.' as my first officer acknowledged, I realized we were descending through 5600 ft. I immediately disconnected the autoplt and returned the aircraft to 6000 ft. We achieved a minimum altitude of 5500 ft. Assuming the autoplt did not malfunction, I apparently had failed to select the altitude select mode on the flight controller (or had selected it twice, causing the mode to be cancelled), resulting in a failure to capture the selected altitude. Factors that may have contributed to the incident include: 1) the turbulence we experienced may have caused me to fail to press the altitude select button hard enough to engage it, or may have caused me to inadvertently press it twice, thereby cancelling the mode. 2) both pilots were occupied with execution of the arrival checklist at the time. 3) both pilots were tired and fatigued. It was the 5TH leg of the day, our originating flight had been delayed 30 mins, and we had been playing catch up all day with no breaks. 4) the first officer had been making required altitude callouts only intermittently during the day, and in order to avoid conflict, I had not demanded that he begin consistently making them. Supplemental information from acn 246123: radio call from ATC and then altitude select was not pressed. Aircraft descended to 5600 ft when ATC reminded us of our altitude. That radio call from ATC which led to other conversations between captain and myself which led to the altitude select not being pushed.
Original NASA ASRS Text
Title: ALTDEV ALT OVERSHOT IN DSCNT.
Narrative: DURING OUR ARR INTO NEWBURGH, NY (SWF), ZNY GAVE US A DSCNT CLRNC TO 6000 FT. I WAS THE PF, AND THE FLT DIRECTOR AND AUTOPLT WERE IN USE AT THE TIME. PASSING 7000 FT, I CHOSE TO MAINTAIN OUR 1000 FPM RATE OF DSCNT (RATHER THAN DECREASE IT TO A NORMAL 500 FPM) IN ORDER TO GET MORE QUICKLY BELOW A BROKEN CLOUD LAYER THAT WAS PROVIDING LIGHT TO MODERATE TURB. AS WE PROCEEDED THROUGH OUR ARR CHKLIST, ATC SUDDENLY ALERTED US TO 'MAINTAIN 6000 FT.' AS MY FO ACKNOWLEDGED, I REALIZED WE WERE DSNDING THROUGH 5600 FT. I IMMEDIATELY DISCONNECTED THE AUTOPLT AND RETURNED THE ACFT TO 6000 FT. WE ACHIEVED A MINIMUM ALT OF 5500 FT. ASSUMING THE AUTOPLT DID NOT MALFUNCTION, I APPARENTLY HAD FAILED TO SELECT THE ALT SELECT MODE ON THE FLT CTLR (OR HAD SELECTED IT TWICE, CAUSING THE MODE TO BE CANCELLED), RESULTING IN A FAILURE TO CAPTURE THE SELECTED ALT. FACTORS THAT MAY HAVE CONTRIBUTED TO THE INCIDENT INCLUDE: 1) THE TURB WE EXPERIENCED MAY HAVE CAUSED ME TO FAIL TO PRESS THE ALT SELECT BUTTON HARD ENOUGH TO ENGAGE IT, OR MAY HAVE CAUSED ME TO INADVERTENTLY PRESS IT TWICE, THEREBY CANCELLING THE MODE. 2) BOTH PLTS WERE OCCUPIED WITH EXECUTION OF THE ARR CHKLIST AT THE TIME. 3) BOTH PLTS WERE TIRED AND FATIGUED. IT WAS THE 5TH LEG OF THE DAY, OUR ORIGINATING FLT HAD BEEN DELAYED 30 MINS, AND WE HAD BEEN PLAYING CATCH UP ALL DAY WITH NO BREAKS. 4) THE FO HAD BEEN MAKING REQUIRED ALT CALLOUTS ONLY INTERMITTENTLY DURING THE DAY, AND IN ORDER TO AVOID CONFLICT, I HAD NOT DEMANDED THAT HE BEGIN CONSISTENTLY MAKING THEM. SUPPLEMENTAL INFO FROM ACN 246123: RADIO CALL FROM ATC AND THEN ALT SELECT WAS NOT PRESSED. ACFT DSNDED TO 5600 FT WHEN ATC REMINDED US OF OUR ALT. THAT RADIO CALL FROM ATC WHICH LED TO OTHER CONVERSATIONS BTWN CAPT AND MYSELF WHICH LED TO THE ALT SELECT NOT BEING PUSHED.
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.