37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 309134 |
Time | |
Date | 199507 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : sux |
State Reference | IA |
Altitude | msl bound lower : 16000 msl bound upper : 17500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zmp |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 135 |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 5700 flight time type : 700 |
ASRS Report | 309134 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 3900 flight time type : 1500 |
ASRS Report | 309393 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While in cruise at 16000 ft, center gave us discretion to 11000 ft. He then gave us the sux altimeter setting which was 0.15 inches lower than the current setting. Resetting the altimeter put us 150 ft low. I engaged the climb mode on the flight director to bring us back to 16000 ft. That is the altitude I was going to stay at for another 35 mi and then begin my descent. I believed that the altitude had captured at 16000 ft and now dialed in 11000 ft in the altitude alerter. At this time I began my company manifest for the return trip, my first officer was getting sux ATIS. As I looked up from the paperwork, the flight director was still in the climb mode with no altitude to capture due to 11000 ft set in. I disengaged the autoplt at 17500 ft and began a rapid descent towards my assigned altitude of 11000 ft. Center then handed us off to sux approach at 11000 ft. The center made no mention of the altitude discrepancy at that time. This incident should have been avoided by me not doing paperwork while the other crew member had his head down also doing paperwork. I felt rushed and out of my normal routine due to a 30 min late departure out of our originating station. I was trying to save time, I normally do the manifest on the ground. Another contributing factor is the company policy of reserve captain or captain qualified first officer. The company has these crew members fly both left and right seat in a particular aircraft. This was my first trip as a captain in 65 days. I had flown as a first officer that previous amount of time. This policy does lead to confusing roles in the cockpit. It is hard to change job roles on a daily basis. This is not to say that I have not adapted to the roles in the past, but my judgement was not what it should have been on this flight. Supplemental information from acn 309393: captain initiated climb back to 16000 ft on new altimeter setting (approximately 150 ft to climb). After observing this, I began to copy destination ATIS and determine landing data. After a short time I felt the airplane pitching vertically, looked up and found the aircraft at 17500 ft and climbing. After excitedly notifying the captain, we began a rapid descent back to 16000 ft and then continued to 11000 ft. The problem turned out to be this: captain had set the altitude select to 11000 ft first, then used climb mode to initiate our climb back to 16000 ft. Since the autoplt never came to the selected altitude, it just kept climbing. Neither I nor the captain noticed this, as we were both 'heads down' in the cockpit. With such a short climb, we should have both been more attentive to what the autoplt was doing.
Original NASA ASRS Text
Title: ALTDEV ALT EXCURSION ALT OVERSHOT IN A READJUSTED CLB MODE.
Narrative: WHILE IN CRUISE AT 16000 FT, CTR GAVE US DISCRETION TO 11000 FT. HE THEN GAVE US THE SUX ALTIMETER SETTING WHICH WAS 0.15 INCHES LOWER THAN THE CURRENT SETTING. RESETTING THE ALTIMETER PUT US 150 FT LOW. I ENGAGED THE CLB MODE ON THE FLT DIRECTOR TO BRING US BACK TO 16000 FT. THAT IS THE ALT I WAS GOING TO STAY AT FOR ANOTHER 35 MI AND THEN BEGIN MY DSCNT. I BELIEVED THAT THE ALT HAD CAPTURED AT 16000 FT AND NOW DIALED IN 11000 FT IN THE ALT ALERTER. AT THIS TIME I BEGAN MY COMPANY MANIFEST FOR THE RETURN TRIP, MY FO WAS GETTING SUX ATIS. AS I LOOKED UP FROM THE PAPERWORK, THE FLT DIRECTOR WAS STILL IN THE CLB MODE WITH NO ALT TO CAPTURE DUE TO 11000 FT SET IN. I DISENGAGED THE AUTOPLT AT 17500 FT AND BEGAN A RAPID DSCNT TOWARDS MY ASSIGNED ALT OF 11000 FT. CTR THEN HANDED US OFF TO SUX APCH AT 11000 FT. THE CTR MADE NO MENTION OF THE ALT DISCREPANCY AT THAT TIME. THIS INCIDENT SHOULD HAVE BEEN AVOIDED BY ME NOT DOING PAPERWORK WHILE THE OTHER CREW MEMBER HAD HIS HEAD DOWN ALSO DOING PAPERWORK. I FELT RUSHED AND OUT OF MY NORMAL ROUTINE DUE TO A 30 MIN LATE DEP OUT OF OUR ORIGINATING STATION. I WAS TRYING TO SAVE TIME, I NORMALLY DO THE MANIFEST ON THE GND. ANOTHER CONTRIBUTING FACTOR IS THE COMPANY POLICY OF RESERVE CAPT OR CAPT QUALIFIED FO. THE COMPANY HAS THESE CREW MEMBERS FLY BOTH L AND R SEAT IN A PARTICULAR ACFT. THIS WAS MY FIRST TRIP AS A CAPT IN 65 DAYS. I HAD FLOWN AS A FO THAT PREVIOUS AMOUNT OF TIME. THIS POLICY DOES LEAD TO CONFUSING ROLES IN THE COCKPIT. IT IS HARD TO CHANGE JOB ROLES ON A DAILY BASIS. THIS IS NOT TO SAY THAT I HAVE NOT ADAPTED TO THE ROLES IN THE PAST, BUT MY JUDGEMENT WAS NOT WHAT IT SHOULD HAVE BEEN ON THIS FLT. SUPPLEMENTAL INFO FROM ACN 309393: CAPT INITIATED CLB BACK TO 16000 FT ON NEW ALTIMETER SETTING (APPROX 150 FT TO CLB). AFTER OBSERVING THIS, I BEGAN TO COPY DEST ATIS AND DETERMINE LNDG DATA. AFTER A SHORT TIME I FELT THE AIRPLANE PITCHING VERTLY, LOOKED UP AND FOUND THE ACFT AT 17500 FT AND CLBING. AFTER EXCITEDLY NOTIFYING THE CAPT, WE BEGAN A RAPID DSCNT BACK TO 16000 FT AND THEN CONTINUED TO 11000 FT. THE PROB TURNED OUT TO BE THIS: CAPT HAD SET THE ALT SELECT TO 11000 FT FIRST, THEN USED CLB MODE TO INITIATE OUR CLB BACK TO 16000 FT. SINCE THE AUTOPLT NEVER CAME TO THE SELECTED ALT, IT JUST KEPT CLBING. NEITHER I NOR THE CAPT NOTICED THIS, AS WE WERE BOTH 'HEADS DOWN' IN THE COCKPIT. WITH SUCH A SHORT CLB, WE SHOULD HAVE BOTH BEEN MORE ATTENTIVE TO WHAT THE AUTOPLT WAS DOING.
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.