37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 271535 |
Time | |
Date | 199405 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : pxr airport : phx |
State Reference | AZ |
Altitude | msl bound lower : 11000 msl bound upper : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | cruise other descent other |
Route In Use | arrival other arrival star : star enroute airway : phx |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 14500 flight time type : 1500 |
ASRS Report | 271535 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 14000 flight time type : 1300 |
ASRS Report | 271536 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I set wrong altitude in FCU (11000 ft), but set correct altitude in mcdu of 12000 ft. Descended in open descent instead of managed mode on descent. I feel problem arose out of being tired and not cross checking the altitude set. We noticed altitude of 11000 ft and ATC asked when we checked on we told him we were at 11000 ft. The main contributing factor 'fatigue.' working 5 day trip with 2 days on training prior to that with just 24 hours off in 7 days. Working night trips 'all night' then last day of trip switches to a.M. Trip. My body did not adjust on last day, only slept 2 hours prior to trip on last day. Got up in ord at 4 a.M. Solution: better crew rest and regulations to prevent companies from flying crews too many hours and days. All night trips need more regulated rules. Also, flaw in altitude setting system in aircraft, a 100 ft selection and 1000 ft selection. I may have used the 1000 ft setting and 1 little turn could have caused miss setting. I'm not sure. Supplemental information from acn 271536: the first officer was flying and set 12000/250 at tonto on the CDU, I confirmed the setting with him, but missed the fact that he set 11000 oh and the altitude selector. In discussion with the first officer, we believe the error may have also been because of the altitude selector was mis- adjusted to 1000 increments and 1 notch will set it off 1000 ft.
Original NASA ASRS Text
Title: ALT RESTR NOT MET BY DSNDING TFC.
Narrative: I SET WRONG ALT IN FCU (11000 FT), BUT SET CORRECT ALT IN MCDU OF 12000 FT. DSNDED IN OPEN DSCNT INSTEAD OF MANAGED MODE ON DSCNT. I FEEL PROB AROSE OUT OF BEING TIRED AND NOT CROSS CHKING THE ALT SET. WE NOTICED ALT OF 11000 FT AND ATC ASKED WHEN WE CHKED ON WE TOLD HIM WE WERE AT 11000 FT. THE MAIN CONTRIBUTING FACTOR 'FATIGUE.' WORKING 5 DAY TRIP WITH 2 DAYS ON TRAINING PRIOR TO THAT WITH JUST 24 HRS OFF IN 7 DAYS. WORKING NIGHT TRIPS 'ALL NIGHT' THEN LAST DAY OF TRIP SWITCHES TO A.M. TRIP. MY BODY DID NOT ADJUST ON LAST DAY, ONLY SLEPT 2 HRS PRIOR TO TRIP ON LAST DAY. GOT UP IN ORD AT 4 A.M. SOLUTION: BETTER CREW REST AND REGS TO PREVENT COMPANIES FROM FLYING CREWS TOO MANY HRS AND DAYS. ALL NIGHT TRIPS NEED MORE REGULATED RULES. ALSO, FLAW IN ALT SETTING SYS IN ACFT, A 100 FT SELECTION AND 1000 FT SELECTION. I MAY HAVE USED THE 1000 FT SETTING AND 1 LITTLE TURN COULD HAVE CAUSED MISS SETTING. I'M NOT SURE. SUPPLEMENTAL INFO FROM ACN 271536: THE FO WAS FLYING AND SET 12000/250 AT TONTO ON THE CDU, I CONFIRMED THE SETTING WITH HIM, BUT MISSED THE FACT THAT HE SET 11000 OH AND THE ALT SELECTOR. IN DISCUSSION WITH THE FO, WE BELIEVE THE ERROR MAY HAVE ALSO BEEN BECAUSE OF THE ALT SELECTOR WAS MIS- ADJUSTED TO 1000 INCREMENTS AND 1 NOTCH WILL SET IT OFF 1000 FT.
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.