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|
Attributes | |
ACN | 278694 |
Time | |
Date | 199408 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : aco |
State Reference | OH |
Altitude | msl bound lower : 19000 msl bound upper : 20000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zob |
Operator | general aviation : corporate |
Make Model Name | Beechjet 400 |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : first officer |
Experience | flight time last 90 days : 90 flight time total : 2100 |
ASRS Report | 278694 |
Person 2 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 80 flight time total : 10245 |
ASRS Report | 278696 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : far other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I called center 'climbing to 11000 ft MSL.' both the captain and I heard climb to FL200. I reset the altitude alerter to FL200. We were in a be-400A all glass cockpit which has the selected altitude on both the captain and first officer flight displays. At FL180 we accomplished company required 'climb check' and shortly thereafter leveled off at FL200. Approximately 2 mins at FL200, we asked for higher altitude. The controller response was you 'have traffic at 12 O'clock and 8 mi at FL200, contact ZOB on (don't recall frequency) for higher.' I called the next sector controller and reported level at FL200. The controller's response was for us to climb to FL230, expedite through FL210. Traffic is at 12 O'clock and 4 mi. As we reported leaving FL210, center said traffic was at 12 O'clock and 1 mi at FL200. His next question was 'who cleared us to FL200. The last controller said he gave you FL190 and that they would look into the incident.' rest of flight was uneventful. After landing at bkw, the captain placed a phone call to ZOB at XA30 EDT and spoke with the supervisor. He indicated that we were given FL190 not FL200 as an altitude. He also said that an incident had occurred and he must report it to the cleveland FSDO. He thanked my captain for being concerned enough to call. I believe that the factors which contributed to this occurrence were: certain frequency was very busy. There were thunderstorms in the area and many aircraft were needing deviations around WX. We had a minor avionic problem with our automatic-slave compass that demanded attention every so often. I believe that this situation occurred as a result of several factors: kcgf to kbkw is a routine flight for our department and maybe we fall into a very complacent mode with our attention maybe not totally on what it should have been on. Although the captain and I are very regimented in standard call outs and crew coordination, I have never seen the captain make any errors and vice versa, and after deep discussion we both agreed that we were very comfortable flying with one another and had no reason to think that the other might make a mistake. This we are sure contributed to this incident. I think the only way to prevent this type of re-occurrence is to make sure that both pilots are in the 'loop' and in total agreement with ATC clrncs and instructions. We came of with the idea of having the PF visually verify that the altitude alerter was set properly and that the PF also verbally callout the new altitude assignment. Supplemental information from acn 278696: we were under the impression that if an aircraft deviated by more than 300 ft of assigned altitude, 'horns and whistles would go off to alert the ATC controller? If in fact that's true, from 19300 ft to FL200 and level would be approximately 2-4 mins. We were never asked about our altitude.
Original NASA ASRS Text
Title: A CPR LTT LEVELED AT THE WRONG ALT.
Narrative: I CALLED CTR 'CLBING TO 11000 FT MSL.' BOTH THE CAPT AND I HEARD CLB TO FL200. I RESET THE ALT ALERTER TO FL200. WE WERE IN A BE-400A ALL GLASS COCKPIT WHICH HAS THE SELECTED ALT ON BOTH THE CAPT AND FO FLT DISPLAYS. AT FL180 WE ACCOMPLISHED COMPANY REQUIRED 'CLB CHK' AND SHORTLY THEREAFTER LEVELED OFF AT FL200. APPROX 2 MINS AT FL200, WE ASKED FOR HIGHER ALT. THE CTLR RESPONSE WAS YOU 'HAVE TFC AT 12 O'CLOCK AND 8 MI AT FL200, CONTACT ZOB ON (DON'T RECALL FREQ) FOR HIGHER.' I CALLED THE NEXT SECTOR CTLR AND RPTED LEVEL AT FL200. THE CTLR'S RESPONSE WAS FOR US TO CLB TO FL230, EXPEDITE THROUGH FL210. TFC IS AT 12 O'CLOCK AND 4 MI. AS WE RPTED LEAVING FL210, CTR SAID TFC WAS AT 12 O'CLOCK AND 1 MI AT FL200. HIS NEXT QUESTION WAS 'WHO CLRED US TO FL200. THE LAST CTLR SAID HE GAVE YOU FL190 AND THAT THEY WOULD LOOK INTO THE INCIDENT.' REST OF FLT WAS UNEVENTFUL. AFTER LNDG AT BKW, THE CAPT PLACED A PHONE CALL TO ZOB AT XA30 EDT AND SPOKE WITH THE SUPVR. HE INDICATED THAT WE WERE GIVEN FL190 NOT FL200 AS AN ALT. HE ALSO SAID THAT AN INCIDENT HAD OCCURRED AND HE MUST RPT IT TO THE CLEVELAND FSDO. HE THANKED MY CAPT FOR BEING CONCERNED ENOUGH TO CALL. I BELIEVE THAT THE FACTORS WHICH CONTRIBUTED TO THIS OCCURRENCE WERE: CERTAIN FREQ WAS VERY BUSY. THERE WERE TSTMS IN THE AREA AND MANY ACFT WERE NEEDING DEVS AROUND WX. WE HAD A MINOR AVIONIC PROB WITH OUR AUTO-SLAVE COMPASS THAT DEMANDED ATTN EVERY SO OFTEN. I BELIEVE THAT THIS SIT OCCURRED AS A RESULT OF SEVERAL FACTORS: KCGF TO KBKW IS A ROUTINE FLT FOR OUR DEPT AND MAYBE WE FALL INTO A VERY COMPLACENT MODE WITH OUR ATTN MAYBE NOT TOTALLY ON WHAT IT SHOULD HAVE BEEN ON. ALTHOUGH THE CAPT AND I ARE VERY REGIMENTED IN STANDARD CALL OUTS AND CREW COORD, I HAVE NEVER SEEN THE CAPT MAKE ANY ERRORS AND VICE VERSA, AND AFTER DEEP DISCUSSION WE BOTH AGREED THAT WE WERE VERY COMFORTABLE FLYING WITH ONE ANOTHER AND HAD NO REASON TO THINK THAT THE OTHER MIGHT MAKE A MISTAKE. THIS WE ARE SURE CONTRIBUTED TO THIS INCIDENT. I THINK THE ONLY WAY TO PREVENT THIS TYPE OF RE-OCCURRENCE IS TO MAKE SURE THAT BOTH PLTS ARE IN THE 'LOOP' AND IN TOTAL AGREEMENT WITH ATC CLRNCS AND INSTRUCTIONS. WE CAME OF WITH THE IDEA OF HAVING THE PF VISUALLY VERIFY THAT THE ALT ALERTER WAS SET PROPERLY AND THAT THE PF ALSO VERBALLY CALLOUT THE NEW ALT ASSIGNMENT. SUPPLEMENTAL INFO FROM ACN 278696: WE WERE UNDER THE IMPRESSION THAT IF AN ACFT DEVIATED BY MORE THAN 300 FT OF ASSIGNED ALT, 'HORNS AND WHISTLES WOULD GO OFF TO ALERT THE ATC CTLR? IF IN FACT THAT'S TRUE, FROM 19300 FT TO FL200 AND LEVEL WOULD BE APPROX 2-4 MINS. WE WERE NEVER ASKED ABOUT OUR 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.