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|
Attributes | |
ACN | 250047 |
Time | |
Date | 199308 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : sby |
State Reference | MD |
Altitude | msl bound lower : 28000 msl bound upper : 28400 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zdc |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise other |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : atp pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 190 flight time total : 7000 flight time type : 4200 |
ASRS Report | 250047 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 190 flight time total : 10000 flight time type : 7500 |
ASRS Report | 249894 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : required legal separation non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
As the captain slowed his rate of climb passing FL270 to level off at FL280, ZDC called to ask if we were on an assigned heading. This confused us as we thought we were heading outbound from sby on J79. As we were checking our course and realized the captain was flying outbound on the 205 degree radial vice 225 degree radial, center gave us direct to kinston (iso). During this confusion, the captain rotated the autoplt thumb wheel to level off at FL280. At this time, both of us had our heads in the charts, looking up iso. The next thing we knew, the altitude alert went off. This surprised us both as we were sure we had leveled off. The autoplt was just barely out of the level position and had a slight climb going. The captain immediately disengaged autoplt and began a manual descent. Just as the captain disengaged the autoplt, we received an RA on our TCASII. This was the first and only warning we received on TCASII. No TA. We had already begun the descent back to FL280 and we had visual acquisition of the traffic, so we made no evasive maneuver. We also had a little over 100 ft difference in the 2 altimeters, so the first officer showed maximum altitude at 28400 ft while the captain indicated just under 28300 ft. The other traffic reported an RA also. When center asked us to check our altitude, we were already back level at FL280, and so stated. This incident was initially caused by poor cockpit lighting resulting in reading the wrong radial. The copilot should always verify that the PF has the appropriate navaids set correctly. This was a case of poor crew coordination. Supplemental information from acn 249894: original navigation mistake was caused by misreading my own handwriting on the chart holder note pad in a dark cockpit. I should have monitored the level off at FL280 until completed rather than placing so much trust in the autoplt.
Original NASA ASRS Text
Title: AN ACR MLG HAD A NAV ERROR AND DSNDED IN RESPONSE TO A TCASII COMMAND.
Narrative: AS THE CAPT SLOWED HIS RATE OF CLB PASSING FL270 TO LEVEL OFF AT FL280, ZDC CALLED TO ASK IF WE WERE ON AN ASSIGNED HDG. THIS CONFUSED US AS WE THOUGHT WE WERE HDG OUTBOUND FROM SBY ON J79. AS WE WERE CHKING OUR COURSE AND REALIZED THE CAPT WAS FLYING OUTBOUND ON THE 205 DEG RADIAL VICE 225 DEG RADIAL, CTR GAVE US DIRECT TO KINSTON (ISO). DURING THIS CONFUSION, THE CAPT ROTATED THE AUTOPLT THUMB WHEEL TO LEVEL OFF AT FL280. AT THIS TIME, BOTH OF US HAD OUR HEADS IN THE CHARTS, LOOKING UP ISO. THE NEXT THING WE KNEW, THE ALT ALERT WENT OFF. THIS SURPRISED US BOTH AS WE WERE SURE WE HAD LEVELED OFF. THE AUTOPLT WAS JUST BARELY OUT OF THE LEVEL POS AND HAD A SLIGHT CLB GOING. THE CAPT IMMEDIATELY DISENGAGED AUTOPLT AND BEGAN A MANUAL DSCNT. JUST AS THE CAPT DISENGAGED THE AUTOPLT, WE RECEIVED AN RA ON OUR TCASII. THIS WAS THE FIRST AND ONLY WARNING WE RECEIVED ON TCASII. NO TA. WE HAD ALREADY BEGUN THE DSCNT BACK TO FL280 AND WE HAD VISUAL ACQUISITION OF THE TFC, SO WE MADE NO EVASIVE MANEUVER. WE ALSO HAD A LITTLE OVER 100 FT DIFFERENCE IN THE 2 ALTIMETERS, SO THE FO SHOWED MAX ALT AT 28400 FT WHILE THE CAPT INDICATED JUST UNDER 28300 FT. THE OTHER TFC RPTED AN RA ALSO. WHEN CTR ASKED US TO CHK OUR ALT, WE WERE ALREADY BACK LEVEL AT FL280, AND SO STATED. THIS INCIDENT WAS INITIALLY CAUSED BY POOR COCKPIT LIGHTING RESULTING IN READING THE WRONG RADIAL. THE COPLT SHOULD ALWAYS VERIFY THAT THE PF HAS THE APPROPRIATE NAVAIDS SET CORRECTLY. THIS WAS A CASE OF POOR CREW COORD. SUPPLEMENTAL INFORMATION FROM ACN 249894: ORIGINAL NAV MISTAKE WAS CAUSED BY MISREADING MY OWN HANDWRITING ON THE CHART HOLDER NOTE PAD IN A DARK COCKPIT. I SHOULD HAVE MONITORED THE LEVEL OFF AT FL280 UNTIL COMPLETED RATHER THAN PLACING SO MUCH TRUST IN THE AUTOPLT.
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.