37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 291989 |
Time | |
Date | 199412 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : txk |
State Reference | AR |
Altitude | msl bound lower : 16000 msl bound upper : 16600 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Brasilia EMB-120 All Series |
Operating Under FAR Part | Part 135 |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute airway : zfw |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 12000 |
ASRS Report | 291989 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
In cruise flight at 16000 ft, first officer was flying. ZFW called with a pilot's discretion descent to 11000 ft and a new altimeter setting considerably higher than what was set. When I changed either the selected altitude or the altimeter, I do not know which one caused the problem -- the altitude hold mode on the autoplt disengaged. I went back to filling out the logbook and neither I nor the first officer, who was flying, noticed the aircraft begin to climb. When the altitude alerter sounded, we both disengaged the autoplt and nosed over, but the aircraft had already gone through 16600 ft, no doubt alerting the center controller who, although he did not request our altitude or mention it in any way, ordered an immediate descent to 16000 ft. This is a classic case of trust in aircraft system to the extent of not following through with a change of setting with observing that the system was performing properly before looking away from it. There was no excuse for me to not ensure that the altimeter and altitude settings did not affect -- as they sometimes do -- the autoplt and there was also no reason for us to not notice the aircraft beginning to climb.
Original NASA ASRS Text
Title: FLC OF AN LTT INADVERTENTLY CLBED ABOVE ASSIGNED ALT.
Narrative: IN CRUISE FLT AT 16000 FT, FO WAS FLYING. ZFW CALLED WITH A PLT'S DISCRETION DSCNT TO 11000 FT AND A NEW ALTIMETER SETTING CONSIDERABLY HIGHER THAN WHAT WAS SET. WHEN I CHANGED EITHER THE SELECTED ALT OR THE ALTIMETER, I DO NOT KNOW WHICH ONE CAUSED THE PROB -- THE ALT HOLD MODE ON THE AUTOPLT DISENGAGED. I WENT BACK TO FILLING OUT THE LOGBOOK AND NEITHER I NOR THE FO, WHO WAS FLYING, NOTICED THE ACFT BEGIN TO CLB. WHEN THE ALT ALERTER SOUNDED, WE BOTH DISENGAGED THE AUTOPLT AND NOSED OVER, BUT THE ACFT HAD ALREADY GONE THROUGH 16600 FT, NO DOUBT ALERTING THE CTR CTLR WHO, ALTHOUGH HE DID NOT REQUEST OUR ALT OR MENTION IT IN ANY WAY, ORDERED AN IMMEDIATE DSCNT TO 16000 FT. THIS IS A CLASSIC CASE OF TRUST IN ACFT SYS TO THE EXTENT OF NOT FOLLOWING THROUGH WITH A CHANGE OF SETTING WITH OBSERVING THAT THE SYS WAS PERFORMING PROPERLY BEFORE LOOKING AWAY FROM IT. THERE WAS NO EXCUSE FOR ME TO NOT ENSURE THAT THE ALTIMETER AND ALT SETTINGS DID NOT AFFECT -- AS THEY SOMETIMES DO -- THE AUTOPLT AND THERE WAS ALSO NO REASON FOR US TO NOT NOTICE THE ACFT BEGINNING TO CLB.
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.