37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 316410 |
Time | |
Date | 199509 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : mlf |
State Reference | UT |
Altitude | msl bound lower : 31000 msl bound upper : 31600 |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zlc |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute airway : zlc |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp pilot : private |
Experience | flight time last 90 days : 120 flight time total : 15000 flight time type : 2000 |
ASRS Report | 316410 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : instrument pilot : atp pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 120 flight time total : 10000 flight time type : 2000 |
ASRS Report | 316622 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Referenced incident occurred on second leg of flight jfk- slc-las, predep clearance received on ground slc was FFU2-mlf -- then as filed -- maintain 8000 ft. Expect requested altitude 10 mins after takeoff. Filed (requested) flight level was FL350. During climb, at approximately FL250 cleared to FL280, an ACARS message was received from company dispatch requesting reason for delayed departure (6 mins) from gate slc. I transferred ATC communications to first officer and contacted dispatch to resolve question. I was out of the loop!! During this time, further climb clearance was received from ATC by first officer. At the conclusion of my talk with dispatch my attention was caught by the altitude alert light. Altitude at time was noted to be 31400 ft, very unusual!! A quick glance at apfd altitude window showed my altitude at 32100 ft. Big problem!! Simultaneously, I requested our assigned altitude from ATC (reply was FL310) disengaged autoplt, and returned aircraft to FL310. Altimeter indicated 31600 ft at time descent was initiated. We are both (captain and first officer) unclr as to how an altitude of 32100 ft came to be set in apfd altitude window. We feel that the altitude set knob was inadvertently turned, after the first officer had set it as a follow up to ATC clearance, as he turned his attention to other duties. Lesson learned/reinforced: do not allow attention to primary tasks at hand, particularly during any portion of maneuvering flight (climb to cruise certainly being one) to be diverted by requests for or occurrences of significantly less import. The workloads experienced by 2 man crews in transport category aircraft are high at all times. My attention to a relatively insignificant dispatch request took me out of the safety and compliance loop at a time when my attention should certainly have been focused on the primary task at hand -- climb to and level at assigned altitude!!
Original NASA ASRS Text
Title: ALTDEV ALT OVERSHOT -- ACR CLBS ABOVE ITS ASSIGNED ALT WHEN THE ALT ALERTER IS MISSET.
Narrative: REFERENCED INCIDENT OCCURRED ON SECOND LEG OF FLT JFK- SLC-LAS, PREDEP CLRNC RECEIVED ON GND SLC WAS FFU2-MLF -- THEN AS FILED -- MAINTAIN 8000 FT. EXPECT REQUESTED ALT 10 MINS AFTER TKOF. FILED (REQUESTED) FLT LEVEL WAS FL350. DURING CLB, AT APPROX FL250 CLRED TO FL280, AN ACARS MESSAGE WAS RECEIVED FROM COMPANY DISPATCH REQUESTING REASON FOR DELAYED DEP (6 MINS) FROM GATE SLC. I TRANSFERRED ATC COMS TO FO AND CONTACTED DISPATCH TO RESOLVE QUESTION. I WAS OUT OF THE LOOP!! DURING THIS TIME, FURTHER CLB CLRNC WAS RECEIVED FROM ATC BY FO. AT THE CONCLUSION OF MY TALK WITH DISPATCH MY ATTN WAS CAUGHT BY THE ALT ALERT LIGHT. ALT AT TIME WAS NOTED TO BE 31400 FT, VERY UNUSUAL!! A QUICK GLANCE AT APFD ALT WINDOW SHOWED MY ALT AT 32100 FT. BIG PROB!! SIMULTANEOUSLY, I REQUESTED OUR ASSIGNED ALT FROM ATC (REPLY WAS FL310) DISENGAGED AUTOPLT, AND RETURNED ACFT TO FL310. ALTIMETER INDICATED 31600 FT AT TIME DSCNT WAS INITIATED. WE ARE BOTH (CAPT AND FO) UNCLR AS TO HOW AN ALT OF 32100 FT CAME TO BE SET IN APFD ALT WINDOW. WE FEEL THAT THE ALT SET KNOB WAS INADVERTENTLY TURNED, AFTER THE FO HAD SET IT AS A FOLLOW UP TO ATC CLRNC, AS HE TURNED HIS ATTN TO OTHER DUTIES. LESSON LEARNED/REINFORCED: DO NOT ALLOW ATTN TO PRIMARY TASKS AT HAND, PARTICULARLY DURING ANY PORTION OF MANEUVERING FLT (CLB TO CRUISE CERTAINLY BEING ONE) TO BE DIVERTED BY REQUESTS FOR OR OCCURRENCES OF SIGNIFICANTLY LESS IMPORT. THE WORKLOADS EXPERIENCED BY 2 MAN CREWS IN TRANSPORT CATEGORY ACFT ARE HIGH AT ALL TIMES. MY ATTN TO A RELATIVELY INSIGNIFICANT DISPATCH REQUEST TOOK ME OUT OF THE SAFETY AND COMPLIANCE LOOP AT A TIME WHEN MY ATTN SHOULD CERTAINLY HAVE BEEN FOCUSED ON THE PRIMARY TASK AT HAND -- CLB TO AND LEVEL AT 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.