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|
Attributes | |
ACN | 269190 |
Time | |
Date | 199404 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : atl |
State Reference | GA |
Altitude | msl bound lower : 11500 msl bound upper : 11500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : cvg |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 135 |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | enroute airway : ztl |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 6000 flight time type : 4500 |
ASRS Report | 269190 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 270 flight time total : 2000 flight time type : 600 |
ASRS Report | 269575 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence other |
Independent Detector | other controllera |
Resolutory Action | 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:
The incident occurred at the end of 5 consecutive days of flying which included a reduced rest, check ride (6 months) and 4 normal rest respectively. The total flight time at the incident for the 5 days was 27 hours and approximately 28 takeoffs and lndgs. This was flown in a noisy, vibrating turbo propeller. The last leg was the end of a very long 2 day trip which had 5 takeoffs and lndgs each day, had a block time of 13:45 and was away from base for 31:19 hours. The overnight was for 10 hours where I personally was without a room and had to be relocated to another hotel which shortened my night and added unwanted stress. Our clearance was descend from FL230 to cross 10 southwest of homie intersection at 12000 with the altimeter setting given. The first issuance was partially blocked so I had it repeated. The clearance was out of the norm as when arriving from the west into atl, we normally are cleared to 11000 when landing west as we were. Between determining the exact fix, the unfamiliar clearance and the restating of the blocked clearance, I set 10000 into the altitude alerter while still thinking about the 10 southwest of home crossing fix. As we descended through 12000 we were reminded of our altitude twice before we were back at 12000. Within 30 second of level off, we were handed off to atl approach and cleared down to 11000 as was the norm. Fortunately there was no other traffic and the controller wasn't yelling at us. On behalf of part 135 pilots, our lives and our passenger lives are worth getting rid of the ridiculous fatigue generating inadequate rest requirements. If I didn't see it and hear it from every pilot I work with, I would think it was just me, but it isn't. We are tired of flying tired because it might cost someone a few dollars to ensure flight crew's of 135 operations get enough rest to be alert in the cockpit. It is unfortunate that it is virtually impossible to medically diagnose fatigue. We will never know how many deaths have been contributed to by fatigued crews. Pilots get fatigued the same as the aircraft they fly. The difference is it impairs our judgement and after we crash there isn't enough left to determine much of anything. I hope reports like this and not more deaths will help to provide 1 level of safety for the flying public, the crews and their families. With so much flying, inconsistent sleep, and cycles of takeoff and lndgs in a very noisy environment, it is fatiguing to all, including myself. Supplemental information from acn 269575: normally when we get an altitude clearance the PNF puts the new altitude in the altitude alerter and says that altitude out loud, and the PF repeats or confirms it. In this case that was not done, because we had gotten a clearance we were not used to getting, the first thing I did was confirm where the altitude restr was and never confirmed the altitude.
Original NASA ASRS Text
Title: ALT BUST IN DSCNT.
Narrative: THE INCIDENT OCCURRED AT THE END OF 5 CONSECUTIVE DAYS OF FLYING WHICH INCLUDED A REDUCED REST, CHK RIDE (6 MONTHS) AND 4 NORMAL REST RESPECTIVELY. THE TOTAL FLT TIME AT THE INCIDENT FOR THE 5 DAYS WAS 27 HRS AND APPROX 28 TKOFS AND LNDGS. THIS WAS FLOWN IN A NOISY, VIBRATING TURBO PROP. THE LAST LEG WAS THE END OF A VERY LONG 2 DAY TRIP WHICH HAD 5 TKOFS AND LNDGS EACH DAY, HAD A BLOCK TIME OF 13:45 AND WAS AWAY FROM BASE FOR 31:19 HRS. THE OVERNIGHT WAS FOR 10 HRS WHERE I PERSONALLY WAS WITHOUT A ROOM AND HAD TO BE RELOCATED TO ANOTHER HOTEL WHICH SHORTENED MY NIGHT AND ADDED UNWANTED STRESS. OUR CLRNC WAS DSND FROM FL230 TO CROSS 10 SW OF HOMIE INTXN AT 12000 WITH THE ALTIMETER SETTING GIVEN. THE FIRST ISSUANCE WAS PARTIALLY BLOCKED SO I HAD IT REPEATED. THE CLRNC WAS OUT OF THE NORM AS WHEN ARRIVING FROM THE W INTO ATL, WE NORMALLY ARE CLRED TO 11000 WHEN LNDG W AS WE WERE. BTWN DETERMINING THE EXACT FIX, THE UNFAMILIAR CLRNC AND THE RESTATING OF THE BLOCKED CLRNC, I SET 10000 INTO THE ALT ALERTER WHILE STILL THINKING ABOUT THE 10 SW OF HOME XING FIX. AS WE DSNDED THROUGH 12000 WE WERE REMINDED OF OUR ALT TWICE BEFORE WE WERE BACK AT 12000. WITHIN 30 SEC OF LEVEL OFF, WE WERE HANDED OFF TO ATL APCH AND CLRED DOWN TO 11000 AS WAS THE NORM. FORTUNATELY THERE WAS NO OTHER TFC AND THE CTLR WASN'T YELLING AT US. ON BEHALF OF PART 135 PLTS, OUR LIVES AND OUR PAX LIVES ARE WORTH GETTING RID OF THE RIDICULOUS FATIGUE GENERATING INADEQUATE REST REQUIREMENTS. IF I DIDN'T SEE IT AND HEAR IT FROM EVERY PLT I WORK WITH, I WOULD THINK IT WAS JUST ME, BUT IT ISN'T. WE ARE TIRED OF FLYING TIRED BECAUSE IT MIGHT COST SOMEONE A FEW DOLLARS TO ENSURE FLC'S OF 135 OPS GET ENOUGH REST TO BE ALERT IN THE COCKPIT. IT IS UNFORTUNATE THAT IT IS VIRTUALLY IMPOSSIBLE TO MEDICALLY DIAGNOSE FATIGUE. WE WILL NEVER KNOW HOW MANY DEATHS HAVE BEEN CONTRIBUTED TO BY FATIGUED CREWS. PLTS GET FATIGUED THE SAME AS THE ACFT THEY FLY. THE DIFFERENCE IS IT IMPAIRS OUR JUDGEMENT AND AFTER WE CRASH THERE ISN'T ENOUGH LEFT TO DETERMINE MUCH OF ANYTHING. I HOPE RPTS LIKE THIS AND NOT MORE DEATHS WILL HELP TO PROVIDE 1 LEVEL OF SAFETY FOR THE FLYING PUBLIC, THE CREWS AND THEIR FAMILIES. WITH SO MUCH FLYING, INCONSISTENT SLEEP, AND CYCLES OF TKOF AND LNDGS IN A VERY NOISY ENVIRONMENT, IT IS FATIGUING TO ALL, INCLUDING MYSELF. SUPPLEMENTAL INFO FROM ACN 269575: NORMALLY WHEN WE GET AN ALT CLRNC THE PNF PUTS THE NEW ALT IN THE ALT ALERTER AND SAYS THAT ALT OUT LOUD, AND THE PF REPEATS OR CONFIRMS IT. IN THIS CASE THAT WAS NOT DONE, BECAUSE WE HAD GOTTEN A CLRNC WE WERE NOT USED TO GETTING, THE FIRST THING I DID WAS CONFIRM WHERE THE ALT RESTR WAS AND NEVER CONFIRMED THE ALT.
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.