37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 306900 |
Time | |
Date | 199506 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : sdz |
State Reference | NC |
Altitude | msl bound lower : 10700 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc |
Operator | general aviation : corporate |
Make Model Name | Citation III, VI, VII |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival other arrival star : star enroute airway : zdc |
Flight Plan | VFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 8300 flight time type : 500 |
ASRS Report | 306900 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 11500 flight time type : 10 |
ASRS Report | 306901 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were flying from clt to rou, first officer's leg to fly. We failed to communication proper procedures for how we were going to use our advanced navigation system for the short flight. During the trip, it was observed that we were not proceeding to the intersection cleared to. At the same time we were issued descent instructions. With both things going on at the same time, we descended below our assigned altitude. Both problems (navigation and altitude) were corrected, post-haste. We both discussed this thoroughly with each other and felt there were 2 major errors and/or breaks in the error chain: not properly briefing each other before leaving the ramp. Both pilots became distracted with a problem (navigation) and momentarily left the aircraft control unattended which caused the altitude problem. We both feel fortunate we were able to recognize and break this chain of errors before anything worse happened. Callback conversation with reporter revealed the following: the reporter said that the first officer was fairly new to the citation III 650 with FMC and the first officer set up the FMC to track the route, but he intended to fly using the VHF navigation only. The captain was aware that the first officer was doing something non- standard, but due to the press of other duties he did not get a briefing. The captain said that he knew that he should have resolved the questions while on the ground, but they were taxiing out at the time and he did not want to miss his departure slot so he pressed on. The first problem that the captain noticed was that they were off route during the buzzy 5 arrival. The captain said that he and the first officer discussed the series of events extensively over the next 2 days and they were both satisfied that the lessons were well learned. There has been no contact from the FAA to date.
Original NASA ASRS Text
Title: DEV FROM CLRNC RTE -- ALTDEV ALT OVERSHOT -- CP JET GETS OFF RTE AND WHILE THE FLC IS DISCUSSING THIS PROB THEY MISS A XING ALT.
Narrative: WE WERE FLYING FROM CLT TO ROU, FO'S LEG TO FLY. WE FAILED TO COM PROPER PROCS FOR HOW WE WERE GOING TO USE OUR ADVANCED NAV SYS FOR THE SHORT FLT. DURING THE TRIP, IT WAS OBSERVED THAT WE WERE NOT PROCEEDING TO THE INTXN CLRED TO. AT THE SAME TIME WE WERE ISSUED DSCNT INSTRUCTIONS. WITH BOTH THINGS GOING ON AT THE SAME TIME, WE DSNDED BELOW OUR ASSIGNED ALT. BOTH PROBS (NAV AND ALT) WERE CORRECTED, POST-HASTE. WE BOTH DISCUSSED THIS THOROUGHLY WITH EACH OTHER AND FELT THERE WERE 2 MAJOR ERRORS AND/OR BREAKS IN THE ERROR CHAIN: NOT PROPERLY BRIEFING EACH OTHER BEFORE LEAVING THE RAMP. BOTH PLTS BECAME DISTRACTED WITH A PROB (NAV) AND MOMENTARILY LEFT THE ACFT CTL UNATTENDED WHICH CAUSED THE ALT PROB. WE BOTH FEEL FORTUNATE WE WERE ABLE TO RECOGNIZE AND BREAK THIS CHAIN OF ERRORS BEFORE ANYTHING WORSE HAPPENED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: THE RPTR SAID THAT THE FO WAS FAIRLY NEW TO THE CITATION III 650 WITH FMC AND THE FO SET UP THE FMC TO TRACK THE RTE, BUT HE INTENDED TO FLY USING THE VHF NAV ONLY. THE CAPT WAS AWARE THAT THE FO WAS DOING SOMETHING NON- STANDARD, BUT DUE TO THE PRESS OF OTHER DUTIES HE DID NOT GET A BRIEFING. THE CAPT SAID THAT HE KNEW THAT HE SHOULD HAVE RESOLVED THE QUESTIONS WHILE ON THE GND, BUT THEY WERE TAXIING OUT AT THE TIME AND HE DID NOT WANT TO MISS HIS DEP SLOT SO HE PRESSED ON. THE FIRST PROB THAT THE CAPT NOTICED WAS THAT THEY WERE OFF RTE DURING THE BUZZY 5 ARR. THE CAPT SAID THAT HE AND THE FO DISCUSSED THE SERIES OF EVENTS EXTENSIVELY OVER THE NEXT 2 DAYS AND THEY WERE BOTH SATISFIED THAT THE LESSONS WERE WELL LEARNED. THERE HAS BEEN NO CONTACT FROM THE FAA TO DATE.
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.