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|
Attributes | |
ACN | 298571 |
Time | |
Date | 199503 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : cle |
State Reference | OH |
Altitude | msl bound lower : 24000 msl bound upper : 25800 |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zob tower : hou |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 9000 flight time type : 2000 |
ASRS Report | 298571 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 80 flight time total : 4500 flight time type : 1800 |
ASRS Report | 298987 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : excursion from assigned altitude inflight encounter : weather non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This was our first night of a 5-DAY trip flying nights cle-ind-cle. I was very tired due to time of event and lack of sleep for 21 hours. Also I was a little slow due to recent 3 week break from flying. This was my first leg as PF. En route, 100 mi southwest of cle, level at 25000 ft, we were cleared pilot's discretion to FL240. We dialed 240 into our altitude reminder/warning. We were distracted with area thunderstorms, light turbulence, icing conditions and fatigue. I was planning on flying 30 more mi or so, prior to descending to FL240. Captain noticed we somehow were now at 25800 ft, not 25000 ft. No word from ATC. I gently descended to FL240. No known traffic in our area. We didn't call ATC other than to report leaving 25000 ft for 24000 ft. How we got to 25800 ft remains a mystery. Supplemental information from acn 298987: aircraft was on autoplt with first officer flying. The captain was reviewing the approach to cle. The first officer was operating the radar for thunderstorm avoidance. The so was preparing the cabin for descent and monitoring the icing system. An immediate descent using flight spoilers was initiated to FL240. We determined after the fact, on a subsequent flight, that the cause of the deviation was that 24000 ft was set into the altitude alerter prior to the autoplt's completion of leveloff. In that case, it continues to climb with no alert warning. Contributing factors: high workload period, icing and thunderstorms, fatigue -- first all night flight of the week. Supplemental information from acn 298566: on evaluation, it was realized that the autoplt failed to hold at FL250 after altitude select (FL240) was engaged. On a subsequent flight, the same failure was noted but altitude deviation was minimal. This confirmed a system failure and was immediately noted in aircraft maintenance log and discussed with maintenance personnel.
Original NASA ASRS Text
Title: ALTDEV ALT UNDERSHOT EXCURSION.
Narrative: THIS WAS OUR FIRST NIGHT OF A 5-DAY TRIP FLYING NIGHTS CLE-IND-CLE. I WAS VERY TIRED DUE TO TIME OF EVENT AND LACK OF SLEEP FOR 21 HRS. ALSO I WAS A LITTLE SLOW DUE TO RECENT 3 WK BREAK FROM FLYING. THIS WAS MY FIRST LEG AS PF. ENRTE, 100 MI SW OF CLE, LEVEL AT 25000 FT, WE WERE CLRED PLT'S DISCRETION TO FL240. WE DIALED 240 INTO OUR ALT REMINDER/WARNING. WE WERE DISTRACTED WITH AREA TSTMS, LIGHT TURB, ICING CONDITIONS AND FATIGUE. I WAS PLANNING ON FLYING 30 MORE MI OR SO, PRIOR TO DSNDING TO FL240. CAPT NOTICED WE SOMEHOW WERE NOW AT 25800 FT, NOT 25000 FT. NO WORD FROM ATC. I GENTLY DSNDED TO FL240. NO KNOWN TFC IN OUR AREA. WE DIDN'T CALL ATC OTHER THAN TO RPT LEAVING 25000 FT FOR 24000 FT. HOW WE GOT TO 25800 FT REMAINS A MYSTERY. SUPPLEMENTAL INFO FROM ACN 298987: ACFT WAS ON AUTOPLT WITH FO FLYING. THE CAPT WAS REVIEWING THE APCH TO CLE. THE FO WAS OPERATING THE RADAR FOR TSTM AVOIDANCE. THE SO WAS PREPARING THE CABIN FOR DSCNT AND MONITORING THE ICING SYS. AN IMMEDIATE DSCNT USING FLT SPOILERS WAS INITIATED TO FL240. WE DETERMINED AFTER THE FACT, ON A SUBSEQUENT FLT, THAT THE CAUSE OF THE DEV WAS THAT 24000 FT WAS SET INTO THE ALT ALERTER PRIOR TO THE AUTOPLT'S COMPLETION OF LEVELOFF. IN THAT CASE, IT CONTINUES TO CLB WITH NO ALERT WARNING. CONTRIBUTING FACTORS: HIGH WORKLOAD PERIOD, ICING AND TSTMS, FATIGUE -- FIRST ALL NIGHT FLT OF THE WK. SUPPLEMENTAL INFO FROM ACN 298566: ON EVALUATION, IT WAS REALIZED THAT THE AUTOPLT FAILED TO HOLD AT FL250 AFTER ALT SELECT (FL240) WAS ENGAGED. ON A SUBSEQUENT FLT, THE SAME FAILURE WAS NOTED BUT ALTDEV WAS MINIMAL. THIS CONFIRMED A SYS FAILURE AND WAS IMMEDIATELY NOTED IN ACFT MAINT LOG AND DISCUSSED WITH MAINT PERSONNEL.
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.