37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 298250 |
Time | |
Date | 199503 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : rbv airport : ewr |
State Reference | NJ |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent other |
Route In Use | arrival other arrival star : star enroute airway : zdc |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 9000 flight time type : 2400 |
ASRS Report | 298250 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 210 flight time total : 12000 flight time type : 8000 |
ASRS Report | 298249 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
ATC gave us clearance to cross holey at 11000 ft. I dialed 11000 ft in the altitude alert. The captain was reaching down and accidentally knocked the altitude alert to 10000 ft, and I didn't catch it. The autoplt leveled the aircraft off at 10000 ft, and we immediately caught the deviation climbing back to 11000 ft. Factors: end of A3 day trip, and we flew 5 legs that day. Callback conversation with reporter revealed the following information: the reporter flies the B-737-100 and -200 for a major united states air carrier. The first officer had never flown with this captain before, but this had no bearing on the incident. The first officer inserted 11000 ft in the altitude alert and the captain admits that he accidentally moved it to 10000 ft. The first officer did not see any need to rechk the alert as it had been set properly earlier. The first officer believes that the only way to prevent this would be to watch the other pilot's every move, all of the time, an impossible task.
Original NASA ASRS Text
Title: ALTDEV ON DSCNT.
Narrative: ATC GAVE US CLRNC TO CROSS HOLEY AT 11000 FT. I DIALED 11000 FT IN THE ALT ALERT. THE CAPT WAS REACHING DOWN AND ACCIDENTALLY KNOCKED THE ALT ALERT TO 10000 FT, AND I DIDN'T CATCH IT. THE AUTOPLT LEVELED THE ACFT OFF AT 10000 FT, AND WE IMMEDIATELY CAUGHT THE DEV CLBING BACK TO 11000 FT. FACTORS: END OF A3 DAY TRIP, AND WE FLEW 5 LEGS THAT DAY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR FLIES THE B-737-100 AND -200 FOR A MAJOR UNITED STATES ACR. THE FO HAD NEVER FLOWN WITH THIS CAPT BEFORE, BUT THIS HAD NO BEARING ON THE INCIDENT. THE FO INSERTED 11000 FT IN THE ALT ALERT AND THE CAPT ADMITS THAT HE ACCIDENTALLY MOVED IT TO 10000 FT. THE FO DID NOT SEE ANY NEED TO RECHK THE ALERT AS IT HAD BEEN SET PROPERLY EARLIER. THE FO BELIEVES THAT THE ONLY WAY TO PREVENT THIS WOULD BE TO WATCH THE OTHER PLT'S EVERY MOVE, ALL OF THE TIME, AN IMPOSSIBLE TASK.
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.