37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 311940 |
Time | |
Date | 199507 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mdw |
State Reference | IL |
Altitude | msl bound lower : 3000 msl bound upper : 3600 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ord |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 236 flight time total : 4363 flight time type : 1211 |
ASRS Report | 311940 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 17000 flight time type : 14000 |
ASRS Report | 311532 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : excursion from assigned altitude altitude deviation : overshoot non adherence : clearance non adherence : far other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : overcame equipment problem |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The captain made the takeoff from chicago midway (elevation 619 ft), with a clearance to 3000 ft. Due to our gross weight, the engine bleeds were switched off (a confign not normally used). This procedure requires reconfign of the engine bleeds shortly after takeoff (after climbing above 1000 ft AGL). At 2000 ft, I called '1 to go,' then my attention was diverted by a master caution and bleed trip off light (a minor aircraft malfunction). As I began correcting the malfunction and reconfiguring the engine bleeds, I saw (as we passed 3000 ft) that the captain was not leveling the aircraft. I quickly pointed out the 3000 ft clearance (it was also dialed into the altitude display), and the captain immediately leveled the aircraft. During the level off, we momentarily reached 3600 ft, then went rapidly back down to 3000 ft. In discussion afterward, the captain indicated that he believed the altitude clearance was 5000 ft, not 3000 ft, and my '1 to go' call didn't register with him. Lesson learned: in some respects, we were victims of an unfortunate combination of events (captain's misunderstanding of the altitude clearance combined with my distraction with the aircraft problem as well as the reconfign of the engine bleeds). However, ultimately the mistake resulted from my incorrect prioritization of tasks. Both the aircraft problem and the reconfign could probably have been delayed until after level off (until a less demanding phase of flight). If so, I could have more carefully monitored our altitude and realized earlier that the captain was not leveling at the assigned altitude.
Original NASA ASRS Text
Title: ALTDEV ALT OVERSHOT -- ACR CLBS ABOVE THE ASSIGNED ALT DUE TO A MISUNDERSTANDING AND A DISTR.
Narrative: THE CAPT MADE THE TKOF FROM CHICAGO MIDWAY (ELEVATION 619 FT), WITH A CLRNC TO 3000 FT. DUE TO OUR GROSS WT, THE ENG BLEEDS WERE SWITCHED OFF (A CONFIGN NOT NORMALLY USED). THIS PROC REQUIRES RECONFIGN OF THE ENG BLEEDS SHORTLY AFTER TKOF (AFTER CLBING ABOVE 1000 FT AGL). AT 2000 FT, I CALLED '1 TO GO,' THEN MY ATTN WAS DIVERTED BY A MASTER CAUTION AND BLEED TRIP OFF LIGHT (A MINOR ACFT MALFUNCTION). AS I BEGAN CORRECTING THE MALFUNCTION AND RECONFIGURING THE ENG BLEEDS, I SAW (AS WE PASSED 3000 FT) THAT THE CAPT WAS NOT LEVELING THE ACFT. I QUICKLY POINTED OUT THE 3000 FT CLRNC (IT WAS ALSO DIALED INTO THE ALT DISPLAY), AND THE CAPT IMMEDIATELY LEVELED THE ACFT. DURING THE LEVEL OFF, WE MOMENTARILY REACHED 3600 FT, THEN WENT RAPIDLY BACK DOWN TO 3000 FT. IN DISCUSSION AFTERWARD, THE CAPT INDICATED THAT HE BELIEVED THE ALT CLRNC WAS 5000 FT, NOT 3000 FT, AND MY '1 TO GO' CALL DIDN'T REGISTER WITH HIM. LESSON LEARNED: IN SOME RESPECTS, WE WERE VICTIMS OF AN UNFORTUNATE COMBINATION OF EVENTS (CAPT'S MISUNDERSTANDING OF THE ALT CLRNC COMBINED WITH MY DISTR WITH THE ACFT PROB AS WELL AS THE RECONFIGN OF THE ENG BLEEDS). HOWEVER, ULTIMATELY THE MISTAKE RESULTED FROM MY INCORRECT PRIORITIZATION OF TASKS. BOTH THE ACFT PROB AND THE RECONFIGN COULD PROBABLY HAVE BEEN DELAYED UNTIL AFTER LEVEL OFF (UNTIL A LESS DEMANDING PHASE OF FLT). IF SO, I COULD HAVE MORE CAREFULLY MONITORED OUR ALT AND REALIZED EARLIER THAT THE CAPT WAS NOT LEVELING AT THE ASSIGNED ALT.
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.