37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 250355 |
Time | |
Date | 199308 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : bur |
State Reference | CA |
Altitude | msl bound lower : 24000 msl bound upper : 24300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla tower : stl |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 181 flight time total : 17000 flight time type : 2430 |
ASRS Report | 250355 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Climbing through FL243, the first officer pointed to the altitude reminder and said '24000 ft.' the main cause of this mistake was acute fatigue. I had trouble sleeping the previous 2 nights. The first one was due to a late arrival at the layover point, coupled with a disturbance in the parking lot outside my room at XA50 am. The second night I just couldn't get to sleep until XA00 am and then had to get up at XF30. Prior to going to work on the second day, I rented a bicycle and rode for approximately 20 mi, far beyond what I should have done in my state of physical fitness. The end result was I was very tired and made the mistake of not leveling off at the assigned altitude. In fact, I misinterpreted the altitude warning when I passed FL240. I thought it was the 'almost 1000 ft to go' warning when in fact it was the 'you just passed your altitude' warning. There's no question, I would have leveled off at FL250. I don't know what happened to the '23000 ft for 24000 ft' callout that should have taken place 1000 ft before the assigned altitude. I am very religious in following that SOP and insist my coplts do so too. If it was given, it didn't register in my conscious mind. If it wasn't given, I didn't detect that either. We all have heard that pilots are not to fly when too tired. In my 26 yrs with the airlines I have only heard of 1 pilot that actually took himself off a trip due to excess fatigue. He was put on a without pay status for the remainder of the trip. I have known many, many others who have admitted to being too tired to fly and did so anyway, because of not wanting to lose the pay or not wanting to appear to not have the 'right stuff.' it would be nice if that could change. If I ever get this tired again, I will join the 1 courageous guy I mentioned and just say no.
Original NASA ASRS Text
Title: ACR PIC CITES FLC BEHAVIOR FATIGUE AS REASON FOR ALT DEV ALT OVERSHOT IN CLBING TFC.
Narrative: CLBING THROUGH FL243, THE FO POINTED TO THE ALT REMINDER AND SAID '24000 FT.' THE MAIN CAUSE OF THIS MISTAKE WAS ACUTE FATIGUE. I HAD TROUBLE SLEEPING THE PREVIOUS 2 NIGHTS. THE FIRST ONE WAS DUE TO A LATE ARR AT THE LAYOVER POINT, COUPLED WITH A DISTURBANCE IN THE PARKING LOT OUTSIDE MY ROOM AT XA50 AM. THE SECOND NIGHT I JUST COULDN'T GET TO SLEEP UNTIL XA00 AM AND THEN HAD TO GET UP AT XF30. PRIOR TO GOING TO WORK ON THE SECOND DAY, I RENTED A BICYCLE AND RODE FOR APPROX 20 MI, FAR BEYOND WHAT I SHOULD HAVE DONE IN MY STATE OF PHYSICAL FITNESS. THE END RESULT WAS I WAS VERY TIRED AND MADE THE MISTAKE OF NOT LEVELING OFF AT THE ASSIGNED ALT. IN FACT, I MISINTERPRETED THE ALT WARNING WHEN I PASSED FL240. I THOUGHT IT WAS THE 'ALMOST 1000 FT TO GO' WARNING WHEN IN FACT IT WAS THE 'YOU JUST PASSED YOUR ALT' WARNING. THERE'S NO QUESTION, I WOULD HAVE LEVELED OFF AT FL250. I DON'T KNOW WHAT HAPPENED TO THE '23000 FT FOR 24000 FT' CALLOUT THAT SHOULD HAVE TAKEN PLACE 1000 FT BEFORE THE ASSIGNED ALT. I AM VERY RELIGIOUS IN FOLLOWING THAT SOP AND INSIST MY COPLTS DO SO TOO. IF IT WAS GIVEN, IT DIDN'T REGISTER IN MY CONSCIOUS MIND. IF IT WASN'T GIVEN, I DIDN'T DETECT THAT EITHER. WE ALL HAVE HEARD THAT PLTS ARE NOT TO FLY WHEN TOO TIRED. IN MY 26 YRS WITH THE AIRLINES I HAVE ONLY HEARD OF 1 PLT THAT ACTUALLY TOOK HIMSELF OFF A TRIP DUE TO EXCESS FATIGUE. HE WAS PUT ON A WITHOUT PAY STATUS FOR THE REMAINDER OF THE TRIP. I HAVE KNOWN MANY, MANY OTHERS WHO HAVE ADMITTED TO BEING TOO TIRED TO FLY AND DID SO ANYWAY, BECAUSE OF NOT WANTING TO LOSE THE PAY OR NOT WANTING TO APPEAR TO NOT HAVE THE 'RIGHT STUFF.' IT WOULD BE NICE IF THAT COULD CHANGE. IF I EVER GET THIS TIRED AGAIN, I WILL JOIN THE 1 COURAGEOUS GUY I MENTIONED AND JUST SAY NO.
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.