37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 308860 |
Time | |
Date | 199506 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : art |
State Reference | NY |
Altitude | msl bound lower : 3800 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zbw |
Operator | general aviation : corporate |
Make Model Name | Super King Air 200/Huron |
Operating Under FAR Part | Part 91 |
Flight Phase | descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 60 flight time total : 850 flight time type : 300 |
ASRS Report | 308860 |
Person 2 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 94 flight time total : 6480 flight time type : 3950 |
ASRS Report | 308504 |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : weather non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance 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:
On a routine trip, ATC cleared our aircraft from cruising altitude down to 5000 ft MSL. While copying holding instructions, during a diversion around a thunderstorm, I noticed that the pilot at the controls was properly executing a leveloff at 5000 ft. I began, or continued, to contact the reported traffic at watertown, as well as making fuel arrangements. The PIC was communicating with ATC, flying the aircraft, and navigating around WX. 5000 ft was set in the altitude preselect and I observed the altitude capture light illuminate prior to 5000 ft. Once I had completed my duties on the secondary radio, I turned the volume back on the primary (ATC) radio. The controller asked what our altitude was. The aircraft had descended to 3800 ft. The PIC responded, 'climbing back to 5000 ft,' and began initiating immediate climb. The controller re-cleared us to 3000 ft at this time. The aircraft was landed without incident. Some factors contributing to this violation: unusually high crew workload including, WX, turbulence, VFR and IFR traffic operating at art, coordinating customs, arranging for fuel, copying holding instructions, also, failure in crew coordination, failure to cross-monitor other crewmember's performance. Failure to correctly prioritize tasks. Failure to properly distribute workload. Overconfidence, specifically on my part, in the abilities of senior crewmembers. This was not a pilot error, but a crew error. Although simple mistakes will always be present in aviation, more emphasis on crew coordination or cockpit resource management may help eliminate the potentially disastrous results of a simple human error such as this. Callback conversation with reporter revealed the following information: the first officer said that they were flying a beech super king air 200/huron and that he was very busy on 3 different frequencys during the descent. He did watch to make sure that the captain did leveloff and once that occurred he then called the refueling facility. While thus engaged the aircraft started to descend and he did not notice this until he had completed his conversation with the fueler. He has not heard from the FAA to this date.
Original NASA ASRS Text
Title: ALTDEV ALT OVERSHOT -- CPR CREW DSNDS BELOW THEIR ASSIGNED ALT AFTER FIRST CORRECTLY LEVELING OFF AT THE PROPER ALT.
Narrative: ON A ROUTINE TRIP, ATC CLRED OUR ACFT FROM CRUISING ALT DOWN TO 5000 FT MSL. WHILE COPYING HOLDING INSTRUCTIONS, DURING A DIVERSION AROUND A TSTM, I NOTICED THAT THE PLT AT THE CTLS WAS PROPERLY EXECUTING A LEVELOFF AT 5000 FT. I BEGAN, OR CONTINUED, TO CONTACT THE RPTED TFC AT WATERTOWN, AS WELL AS MAKING FUEL ARRANGEMENTS. THE PIC WAS COMMUNICATING WITH ATC, FLYING THE ACFT, AND NAVIGATING AROUND WX. 5000 FT WAS SET IN THE ALT PRESELECT AND I OBSERVED THE ALT CAPTURE LIGHT ILLUMINATE PRIOR TO 5000 FT. ONCE I HAD COMPLETED MY DUTIES ON THE SECONDARY RADIO, I TURNED THE VOLUME BACK ON THE PRIMARY (ATC) RADIO. THE CTLR ASKED WHAT OUR ALT WAS. THE ACFT HAD DSNDED TO 3800 FT. THE PIC RESPONDED, 'CLBING BACK TO 5000 FT,' AND BEGAN INITIATING IMMEDIATE CLB. THE CTLR RE-CLRED US TO 3000 FT AT THIS TIME. THE ACFT WAS LANDED WITHOUT INCIDENT. SOME FACTORS CONTRIBUTING TO THIS VIOLATION: UNUSUALLY HIGH CREW WORKLOAD INCLUDING, WX, TURB, VFR AND IFR TFC OPERATING AT ART, COORDINATING CUSTOMS, ARRANGING FOR FUEL, COPYING HOLDING INSTRUCTIONS, ALSO, FAILURE IN CREW COORD, FAILURE TO CROSS-MONITOR OTHER CREWMEMBER'S PERFORMANCE. FAILURE TO CORRECTLY PRIORITIZE TASKS. FAILURE TO PROPERLY DISTRIBUTE WORKLOAD. OVERCONFIDENCE, SPECIFICALLY ON MY PART, IN THE ABILITIES OF SENIOR CREWMEMBERS. THIS WAS NOT A PLT ERROR, BUT A CREW ERROR. ALTHOUGH SIMPLE MISTAKES WILL ALWAYS BE PRESENT IN AVIATION, MORE EMPHASIS ON CREW COORD OR COCKPIT RESOURCE MGMNT MAY HELP ELIMINATE THE POTENTIALLY DISASTROUS RESULTS OF A SIMPLE HUMAN ERROR SUCH AS THIS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE FO SAID THAT THEY WERE FLYING A BEECH SUPER KING AIR 200/HURON AND THAT HE WAS VERY BUSY ON 3 DIFFERENT FREQS DURING THE DSCNT. HE DID WATCH TO MAKE SURE THAT THE CAPT DID LEVELOFF AND ONCE THAT OCCURRED HE THEN CALLED THE REFUELING FACILITY. WHILE THUS ENGAGED THE ACFT STARTED TO DSND AND HE DID NOT NOTICE THIS UNTIL HE HAD COMPLETED HIS CONVERSATION WITH THE FUELER. HE HAS NOT HEARD FROM THE FAA TO THIS 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.