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|
Attributes | |
ACN | 305448 |
Time | |
Date | 199505 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : las |
State Reference | NV |
Altitude | msl bound lower : 17000 msl bound upper : 17800 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
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 : atp |
Experience | flight time last 90 days : 150 flight time total : 14000 flight time type : 500 |
ASRS Report | 305448 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : cfi pilot : atp |
Experience | flight time last 90 days : 160 flight time total : 4000 flight time type : 750 |
ASRS Report | 305456 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On climb out of las after an unscheduled emergency landing due to a passenger medical problem on a scheduled flight from den to sna, we were flying a SID in scattered to broken thunderstorms. We were cleared to 17000 ft by departure control. The first officer was flying when I left the radio to her while I contacted the company on the #2 radio. I returned to the ATC radio just as we were being handed off to ZLA. I reported on climbing through 17800 ft for XXX and as I looked at the altitude alert window it read 20800 ft, obviously not the right altitude. I told ZLA ATC we were confused about the cleared altitude and were immediately cleared to FL230. I believe that the altitude alert knob got turned by mistake as the first officer was reaching for the heading select knob while attempting to circumnav the numerous small thunderstorms in the area. The knobs on the airbus A320 are next to each other, and are very similar in size, shape and texture. There was apparently no conflict with any other traffic. Callback conversation with reporter revealed the following information: the reporter stated there were a number of problems that had accumulated on this flight. For one, the ACARS was out so the information had to be communicated to company via the #2 communication that would normally be sent automatically via the ACARS like off time and ETA and fuel on board. We had just made an off schedule medical emergency landing at las. This stop had generated several problems to complicate the day. The only recommendation would be that there would be a different shape of the knob like one triangular, square or h-shaped for heading and the other round. But, make sure the heading knob won't interface with the altitude knob shaft or some mechanic will put the heading knob on the altitude shaft. Normally, when workload is not so high the pilot selects the heading and watches for the response to occur. But in this case the thunderstorm ahead would not permit waiting for the autoplt and its logic to respond so the autoplt was disconnected to hand fly around the thunderstorm. Supplemental information from acn 305456: first officer (me) decided to go around a buildup and selected heading knob to the right. Autoplt roll rate was not sufficient to turn and avoid, so I turned off autoplt to increase roll rate. Captain returned from talking to company and departure handed us off to center. Callback conversation with reporter revealed the following information: the reporter stated the event commenced with a medical emergency deviating into las, a passenger '0' blood pressure. The afternoon temperature was very hot and with a quick turn around the A-320 automatic brake overtemp warning features precluded departure for 30 mins. Then when the brakes did cool and tower cleared us into position and hold the brake overtemp warnings occurred again. The captain and myself were very concerned with the discomfort, delay and inconvenience endured by our passenger. When I was programming the ACARS I inadvertently programmed lax instead of las as the departure point which unknown to us at the time rendered the ACARS unusable. The reporter has been on the A-320 for 2 yrs and never had any problems like this and likes the airplane although believes the heading and altitude selector knobs should be shaped differently. The reporter has had no complaints from the FAA regarding this incident.
Original NASA ASRS Text
Title: FLC CLBS THROUGH ASSIGNED ALT.
Narrative: ON CLBOUT OF LAS AFTER AN UNSCHEDULED EMER LNDG DUE TO A PAX MEDICAL PROB ON A SCHEDULED FLT FROM DEN TO SNA, WE WERE FLYING A SID IN SCATTERED TO BROKEN TSTMS. WE WERE CLRED TO 17000 FT BY DEP CTL. THE FO WAS FLYING WHEN I LEFT THE RADIO TO HER WHILE I CONTACTED THE COMPANY ON THE #2 RADIO. I RETURNED TO THE ATC RADIO JUST AS WE WERE BEING HANDED OFF TO ZLA. I RPTED ON CLBING THROUGH 17800 FT FOR XXX AND AS I LOOKED AT THE ALT ALERT WINDOW IT READ 20800 FT, OBVIOUSLY NOT THE RIGHT ALT. I TOLD ZLA ATC WE WERE CONFUSED ABOUT THE CLRED ALT AND WERE IMMEDIATELY CLRED TO FL230. I BELIEVE THAT THE ALT ALERT KNOB GOT TURNED BY MISTAKE AS THE FO WAS REACHING FOR THE HDG SELECT KNOB WHILE ATTEMPTING TO CIRCUMNAV THE NUMEROUS SMALL TSTMS IN THE AREA. THE KNOBS ON THE AIRBUS A320 ARE NEXT TO EACH OTHER, AND ARE VERY SIMILAR IN SIZE, SHAPE AND TEXTURE. THERE WAS APPARENTLY NO CONFLICT WITH ANY OTHER TFC. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THERE WERE A NUMBER OF PROBS THAT HAD ACCUMULATED ON THIS FLT. FOR ONE, THE ACARS WAS OUT SO THE INFO HAD TO BE COMMUNICATED TO COMPANY VIA THE #2 COM THAT WOULD NORMALLY BE SENT AUTOMATICALLY VIA THE ACARS LIKE OFF TIME AND ETA AND FUEL ON BOARD. WE HAD JUST MADE AN OFF SCHEDULE MEDICAL EMER LNDG AT LAS. THIS STOP HAD GENERATED SEVERAL PROBS TO COMPLICATE THE DAY. THE ONLY RECOMMENDATION WOULD BE THAT THERE WOULD BE A DIFFERENT SHAPE OF THE KNOB LIKE ONE TRIANGULAR, SQUARE OR H-SHAPED FOR HDG AND THE OTHER ROUND. BUT, MAKE SURE THE HDG KNOB WON'T INTERFACE WITH THE ALT KNOB SHAFT OR SOME MECH WILL PUT THE HDG KNOB ON THE ALT SHAFT. NORMALLY, WHEN WORKLOAD IS NOT SO HIGH THE PLT SELECTS THE HDG AND WATCHES FOR THE RESPONSE TO OCCUR. BUT IN THIS CASE THE TSTM AHEAD WOULD NOT PERMIT WAITING FOR THE AUTOPLT AND ITS LOGIC TO RESPOND SO THE AUTOPLT WAS DISCONNECTED TO HAND FLY AROUND THE TSTM. SUPPLEMENTAL INFO FROM ACN 305456: FO (ME) DECIDED TO GAR A BUILDUP AND SELECTED HDG KNOB TO THE R. AUTOPLT ROLL RATE WAS NOT SUFFICIENT TO TURN AND AVOID, SO I TURNED OFF AUTOPLT TO INCREASE ROLL RATE. CAPT RETURNED FROM TALKING TO COMPANY AND DEP HANDED US OFF TO CTR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE EVENT COMMENCED WITH A MEDICAL EMER DEVIATING INTO LAS, A PAX '0' BLOOD PRESSURE. THE AFTERNOON TEMP WAS VERY HOT AND WITH A QUICK TURN AROUND THE A-320 AUTOMATIC BRAKE OVERTEMP WARNING FEATURES PRECLUDED DEP FOR 30 MINS. THEN WHEN THE BRAKES DID COOL AND TWR CLRED US INTO POS AND HOLD THE BRAKE OVERTEMP WARNINGS OCCURRED AGAIN. THE CAPT AND MYSELF WERE VERY CONCERNED WITH THE DISCOMFORT, DELAY AND INCONVENIENCE ENDURED BY OUR PAX. WHEN I WAS PROGRAMMING THE ACARS I INADVERTENTLY PROGRAMMED LAX INSTEAD OF LAS AS THE DEP POINT WHICH UNKNOWN TO US AT THE TIME RENDERED THE ACARS UNUSABLE. THE RPTR HAS BEEN ON THE A-320 FOR 2 YRS AND NEVER HAD ANY PROBS LIKE THIS AND LIKES THE AIRPLANE ALTHOUGH BELIEVES THE HDG AND ALT SELECTOR KNOBS SHOULD BE SHAPED DIFFERENTLY. THE RPTR HAS HAD NO COMPLAINTS FROM THE FAA REGARDING THIS INCIDENT.
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.