37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 298657 |
Time | |
Date | 199503 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : den |
State Reference | CO |
Altitude | msl bound lower : 10000 msl bound upper : 10600 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : den tracon : den |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 14000 flight time type : 10000 |
ASRS Report | 298657 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 230 flight time total : 3500 flight time type : 800 |
ASRS Report | 298196 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other controllera 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:
First officer failed to pick up copy of ATC clearance from printer. We did not have onboard printer for pre departure clearance's. I assumed first officer had picked up clearance as we briefed the departure and I assumed first officer was briefing from clearance. We took off and during climb den departure noted that they were showing a code of '0000.' I said stand-by and thought first officer had forgotten to put code in transponder. At this point it became clear that first officer did not have clearance in cockpit. I asked departure what code they showed and they replied with the number and a handoff to center. I switched to center, checked in and requested confirmation that they had our clearance and read them the routing we had filed, etc. They responded that theirs was the same. We had been flying out of new den twice a day for the past week and were familiar with the departure. I had briefed what I thought was the clearance and the first officer was really briefing the filed routing. I now ask to see the clearance -- written or printed before every briefing. Major contributing factors boil down to fatigue. The previous day we flew 14 1/2 hours of duty time with WX followed by minimum sleep (6 plus hours) and another scheduled 5 legs for 13 hours and 26 mins plus check in time for a duty day. During climb den departure inquired about our transponder code just as we were to level at 10000 ft. My first officer had been distracted and believed we were going to 11000 ft. I immediately told her to stop at 10000. By the time she had arrested the climb and started back to 10000 ft. We had overshot by about 500-600 ft on the altimeter. Procedural and workloads in cockpit at that moment were a distraction. Also a major contributor was fatigue from a 14 1/2 hour day (5 legs) and minimum layover time followed by a scheduled 13 1/2 hour (5 leg) day.
Original NASA ASRS Text
Title: ALTDEV ALT EXCURSION -- THIS ACR CREW FORGOT TO GET THEIR IFR CLRNC AND WHILE ATTEMPTING TO DO SO ENRTE, THEY CLBED A BIT HIGHER THAN CLRED.
Narrative: FO FAILED TO PICK UP COPY OF ATC CLRNC FROM PRINTER. WE DID NOT HAVE ONBOARD PRINTER FOR PDC'S. I ASSUMED FO HAD PICKED UP CLRNC AS WE BRIEFED THE DEP AND I ASSUMED FO WAS BRIEFING FROM CLRNC. WE TOOK OFF AND DURING CLB DEN DEP NOTED THAT THEY WERE SHOWING A CODE OF '0000.' I SAID STAND-BY AND THOUGHT FO HAD FORGOTTEN TO PUT CODE IN XPONDER. AT THIS POINT IT BECAME CLR THAT FO DID NOT HAVE CLRNC IN COCKPIT. I ASKED DEP WHAT CODE THEY SHOWED AND THEY REPLIED WITH THE NUMBER AND A HDOF TO CTR. I SWITCHED TO CTR, CHKED IN AND REQUESTED CONFIRMATION THAT THEY HAD OUR CLRNC AND READ THEM THE ROUTING WE HAD FILED, ETC. THEY RESPONDED THAT THEIRS WAS THE SAME. WE HAD BEEN FLYING OUT OF NEW DEN TWICE A DAY FOR THE PAST WK AND WERE FAMILIAR WITH THE DEP. I HAD BRIEFED WHAT I THOUGHT WAS THE CLRNC AND THE FO WAS REALLY BRIEFING THE FILED ROUTING. I NOW ASK TO SEE THE CLRNC -- WRITTEN OR PRINTED BEFORE EVERY BRIEFING. MAJOR CONTRIBUTING FACTORS BOIL DOWN TO FATIGUE. THE PREVIOUS DAY WE FLEW 14 1/2 HRS OF DUTY TIME WITH WX FOLLOWED BY MINIMUM SLEEP (6 PLUS HRS) AND ANOTHER SCHEDULED 5 LEGS FOR 13 HRS AND 26 MINS PLUS CHK IN TIME FOR A DUTY DAY. DURING CLB DEN DEP INQUIRED ABOUT OUR XPONDER CODE JUST AS WE WERE TO LEVEL AT 10000 FT. MY FO HAD BEEN DISTRACTED AND BELIEVED WE WERE GOING TO 11000 FT. I IMMEDIATELY TOLD HER TO STOP AT 10000. BY THE TIME SHE HAD ARRESTED THE CLB AND STARTED BACK TO 10000 FT. WE HAD OVERSHOT BY ABOUT 500-600 FT ON THE ALTIMETER. PROCEDURAL AND WORKLOADS IN COCKPIT AT THAT MOMENT WERE A DISTR. ALSO A MAJOR CONTRIBUTOR WAS FATIGUE FROM A 14 1/2 HR DAY (5 LEGS) AND MINIMUM LAYOVER TIME FOLLOWED BY A SCHEDULED 13 1/2 HR (5 LEG) DAY.
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.