37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 297704 |
Time | |
Date | 199502 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : mth airport : mia |
State Reference | FL |
Altitude | msl bound lower : 16500 msl bound upper : 17000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zma |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | descent other |
Route In Use | arrival star : star enroute airway : zma |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 3500 flight time type : 900 |
ASRS Report | 297704 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Our aircraft was returning to mia at FL310. We were approaching mth NDB from the south to join the dolin 2 arrival into mia. We were initially cleared to descend to FL200 at pilots discretion. Sometime after beginning our descent, we received clearance to continue our descent. I thought we were cleared to descend to cross wever at 14000 ft and 250 KTS in accordance with the arrival. However, we were cleared only to 17000 ft. As we descended through 17000 ft, we received the aural signal from the altitude alerter. At this time I asked the captain and flight engineer if we had indeed been cleared to 14000 ft. In the absence of a conclusive response, I arrested the descent at approximately 16500 ft. Almost simultaneously ATC cleared us to cross wever at 14000 ft and 250 KTS. The flight continued normally from this point on. I am convinced this altitude deviation would not have occurred if the crew had not been so fatigued. All 3 of the crew members had been awake for over 24 hours. We had shown for duty approximately 18 hours prior to the altitude deviation. This was an international flight and therefore we were not subject to a duty time limitation. When the crew arrived at the airport for the trip, operations informed us that there would be a slight delay due to aircraft maintenance. After approximately 4 1/2 hours, we requested a replacement crew for the trip. This request was denied and after nearly 6 hours the aircraft was ready. The trip consisted of 4 legs. There were no facilities for crew rest in between legs. On the final leg, all of crew remarked how tired we were and we hoped we did not have to fly anywhere else upon our arrival into mia. We had accumulated only about 7 1/2 hours of flight time and would have been perfectly legal to fly another 4 1/2 hours. We all realized that our performance was not as sharp as usual due to our fatigue with the end result being an altitude deviation. Of course, better cockpit resource management could have prevented this altitude deviation. Both pilots should respond to a clearance altitude, 1 pilot over the radio and the other out loud to confirm the clearance and acknowledge its receipt. The bigger issue is the fatigue issue. I believe there is a real need to establish duty time limitations for international flts.
Original NASA ASRS Text
Title: ALTDEV ALT OVERSHOT -- DSCNT THROUGH THE CLRNC ALT BY ACR FLC.
Narrative: OUR ACFT WAS RETURNING TO MIA AT FL310. WE WERE APCHING MTH NDB FROM THE S TO JOIN THE DOLIN 2 ARR INTO MIA. WE WERE INITIALLY CLRED TO DSND TO FL200 AT PLTS DISCRETION. SOMETIME AFTER BEGINNING OUR DSCNT, WE RECEIVED CLRNC TO CONTINUE OUR DSCNT. I THOUGHT WE WERE CLRED TO DSND TO CROSS WEVER AT 14000 FT AND 250 KTS IN ACCORDANCE WITH THE ARR. HOWEVER, WE WERE CLRED ONLY TO 17000 FT. AS WE DSNDED THROUGH 17000 FT, WE RECEIVED THE AURAL SIGNAL FROM THE ALT ALERTER. AT THIS TIME I ASKED THE CAPT AND FE IF WE HAD INDEED BEEN CLRED TO 14000 FT. IN THE ABSENCE OF A CONCLUSIVE RESPONSE, I ARRESTED THE DSCNT AT APPROX 16500 FT. ALMOST SIMULTANEOUSLY ATC CLRED US TO CROSS WEVER AT 14000 FT AND 250 KTS. THE FLT CONTINUED NORMALLY FROM THIS POINT ON. I AM CONVINCED THIS ALTDEV WOULD NOT HAVE OCCURRED IF THE CREW HAD NOT BEEN SO FATIGUED. ALL 3 OF THE CREW MEMBERS HAD BEEN AWAKE FOR OVER 24 HRS. WE HAD SHOWN FOR DUTY APPROX 18 HRS PRIOR TO THE ALTDEV. THIS WAS AN INTL FLT AND THEREFORE WE WERE NOT SUBJECT TO A DUTY TIME LIMITATION. WHEN THE CREW ARRIVED AT THE ARPT FOR THE TRIP, OPS INFORMED US THAT THERE WOULD BE A SLIGHT DELAY DUE TO ACFT MAINT. AFTER APPROX 4 1/2 HRS, WE REQUESTED A REPLACEMENT CREW FOR THE TRIP. THIS REQUEST WAS DENIED AND AFTER NEARLY 6 HRS THE ACFT WAS READY. THE TRIP CONSISTED OF 4 LEGS. THERE WERE NO FACILITIES FOR CREW REST IN BTWN LEGS. ON THE FINAL LEG, ALL OF CREW REMARKED HOW TIRED WE WERE AND WE HOPED WE DID NOT HAVE TO FLY ANYWHERE ELSE UPON OUR ARR INTO MIA. WE HAD ACCUMULATED ONLY ABOUT 7 1/2 HRS OF FLT TIME AND WOULD HAVE BEEN PERFECTLY LEGAL TO FLY ANOTHER 4 1/2 HRS. WE ALL REALIZED THAT OUR PERFORMANCE WAS NOT AS SHARP AS USUAL DUE TO OUR FATIGUE WITH THE END RESULT BEING AN ALTDEV. OF COURSE, BETTER COCKPIT RESOURCE MGMNT COULD HAVE PREVENTED THIS ALTDEV. BOTH PLTS SHOULD RESPOND TO A CLRNC ALT, 1 PLT OVER THE RADIO AND THE OTHER OUT LOUD TO CONFIRM THE CLRNC AND ACKNOWLEDGE ITS RECEIPT. THE BIGGER ISSUE IS THE FATIGUE ISSUE. I BELIEVE THERE IS A REAL NEED TO ESTABLISH DUTY TIME LIMITATIONS FOR INTL FLTS.
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.