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Flight crew of an medium large transport overshot assigned altitude and failed to follow the correct course due to a last min ATC altitude and airspeed amendment and the first officer's error in setting the wrong fix in the FMC.
| Attributes | |
| ACN | 296312 |
| Time | |
| Date | 199502 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : sky |
| State Reference | OH |
| Altitude | msl bound lower : 22000 msl bound upper : 23000 |
| Environment | |
| Flight Conditions | Mixed |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zob tower : pdx |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | enroute : direct enroute : on vectors |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : flight engineer |
| Experience | flight time last 90 days : 220 flight time total : 11000 flight time type : 300 |
| ASRS Report | 296312 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 6000 flight time type : 2000 |
| ASRS Report | 296089 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance other spatial deviation |
| Independent Detector | other controllera 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:
Climbing through FL200 when cleared to FL280, center amended clearance to FL240 and told us to slow to 270 KTS. (We were climbing at 320 KTS). 270 was entered into the FMC climb page. Climb rate increased to slow the aircraft. Passing FL220 at better than 5000 FPM climb rate. Center again amended our climb limit to FL220. As we had already passed FL220, the aircraft peaked out at FL230 before a descent could be started. Concurrently, we were now overhead sky VOR with clearance to waterville (vwv) VOR. During preflight, the first officer had mistakenly entered the route as sky-vxv (volunteer) instead of sky-vwv. So in trying to comply with ATC clearance and get back down to FL220 and slow to 270 KTS, the turn south was not caught until the aircraft had rolled out headed to vxv. As we started a turn back to vwv, center told us to turn right to vwv and handed us off to the next center frequency who gave us a heading to intercept J-60 to gsh. Supplemental information from acn 296089: our route of flight was radar vectors until we were able, r-nav direct vwv VOR. Vxv VOR was inadvertently typed in the FMC which caused our course deviation. The rapid multiple altitude, airspeed, heading changes all contributed to the wrong VOR being typed into the FMC.
Original NASA ASRS Text
Title: FLC OF AN MLG OVERSHOT ASSIGNED ALT AND FAILED TO FOLLOW THE CORRECT COURSE DUE TO A LAST MIN ATC ALT AND AIRSPD AMENDMENT AND THE FO'S ERROR IN SETTING THE WRONG FIX IN THE FMC.
Narrative: CLBING THROUGH FL200 WHEN CLRED TO FL280, CTR AMENDED CLRNC TO FL240 AND TOLD US TO SLOW TO 270 KTS. (WE WERE CLBING AT 320 KTS). 270 WAS ENTERED INTO THE FMC CLB PAGE. CLB RATE INCREASED TO SLOW THE ACFT. PASSING FL220 AT BETTER THAN 5000 FPM CLB RATE. CTR AGAIN AMENDED OUR CLB LIMIT TO FL220. AS WE HAD ALREADY PASSED FL220, THE ACFT PEAKED OUT AT FL230 BEFORE A DSCNT COULD BE STARTED. CONCURRENTLY, WE WERE NOW OVERHEAD SKY VOR WITH CLRNC TO WATERVILLE (VWV) VOR. DURING PREFLT, THE FO HAD MISTAKENLY ENTERED THE RTE AS SKY-VXV (VOLUNTEER) INSTEAD OF SKY-VWV. SO IN TRYING TO COMPLY WITH ATC CLRNC AND GET BACK DOWN TO FL220 AND SLOW TO 270 KTS, THE TURN S WAS NOT CAUGHT UNTIL THE ACFT HAD ROLLED OUT HEADED TO VXV. AS WE STARTED A TURN BACK TO VWV, CTR TOLD US TO TURN R TO VWV AND HANDED US OFF TO THE NEXT CTR FREQ WHO GAVE US A HDG TO INTERCEPT J-60 TO GSH. SUPPLEMENTAL INFO FROM ACN 296089: OUR RTE OF FLT WAS RADAR VECTORS UNTIL WE WERE ABLE, R-NAV DIRECT VWV VOR. VXV VOR WAS INADVERTENTLY TYPED IN THE FMC WHICH CAUSED OUR COURSE DEV. THE RAPID MULTIPLE ALT, AIRSPD, HDG CHANGES ALL CONTRIBUTED TO THE WRONG VOR BEING TYPED INTO THE FMC.
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.