37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 324684 |
Time | |
Date | 199512 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : msp |
State Reference | MN |
Altitude | msl bound lower : 3000 msl bound upper : 5000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : msp |
Operator | common carrier : air carrier |
Make Model Name | SA-227 AC Metro III |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : initial climbout : intermediate altitude |
Route In Use | departure other departure sid : sid enroute airway : msp |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : instrument pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 160 flight time total : 5100 flight time type : 3800 |
ASRS Report | 324684 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : atp pilot : cfi |
Experience | flight time last 90 days : 230 flight time total : 3160 flight time type : 1200 |
ASRS Report | 324680 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
First officer and I flew a flight from minneapolis to st cloud, mn. During our acceptance checklist, I covered and reviewed the flight instruments and avionics portion of the checklist. When I got to the altitude alerter, it was set to 1800 ft, which was set by the previous crew that had landed at msp. By this time, prior to starting the acceptance checklist, the first officer has activated the clearance and has normally set the altitude alterter to our initial altitude. Since it was set to 1800 ft, I set it to 5000 ft which is the SID altitude. 99.9 percent of the time 5000 ft is our initial altitude. I said 'going to 5000 ft?' as I set the altitude alerter. The first officer who had written the clearance on a told card which was in her possession, said nothing of the contrary. Per pilot's operating manual (pom), the first officer is to verify my verbal statements during this portion of the acceptance checklist. So after startup I taxi and takeoff on runway heading. We were cleared to msp departure. As the first officer (PNF) contacted departure she apparently said 'msp departure commuter flight xaxb with you passing (some altitude below 3000 ft) for 5000 ft.' departure acknowledged our check-in as we continued our climb through moderate ice to 5000 ft. Tops were at approximately 4500 ft. At approximately 4800 ft MSL, departure asked, 'verify leveling at 5000 ft?' first officer responded, 'leveling at 5000 ft, as assigned.' at that point, I questioned both statements with my first officer. She then referred to the told card which she then said 'our clearance was to 3000 ft not 5000 ft per the SID.' departure said nothing else and handed us off to ZMP and wished us a good day. Perhaps departure was aware as we were climbing through 3000 ft that we would be leveling at 5000 ft. There were no conflicts with any other aircraft. This error will never happen again and I intend to discuss some sort of verbal change on the acceptance check with my chief pilot soon. When the captain says going to or cleared to 5000 ft as he sets or points to the altitude alerter, the first officer should say 'confirmed' -- this should be added to our pom. Supplemental information from acn 324680: the altitude deviation that this is all about occurred on the second day of a 2-DAY trip after a reduced rest overnight. We arrived on time back in our hub city, but we were only scheduled for a 40 min turn- around before our next trip. I wanted to grab a quick breakfast snack and I needed to preflight our new airplane as we were given an aircraft swap. Maintenance had already found that a landing light was burned out on the new airplane and they were in the process of deferring it. I copied down the ATIS and called on the radio to get our clearance. The ramp agents were anxious to board the airplane. The captain had just received our maintenance log back from maintenance and was checking it over when I copied down the clearance. 99 percent of the time when we depart msp we are given an initial altitude of 5000 ft. But, this time, we were given 3000 ft expect 4000 ft in 10 mins. I read this back and then put the squawk code in the transponder. It was at this time, as the people were boarding, that the captain requested the acceptance checklist. I stopped what I was doing and went to the checklist, thus never putting in the 3000 ft in our altitude alerter. We started up normally and taxied out of the gate 10 mins late. After takeoff, tower switched us to departure control and I checked on as 'out of 2200 ft for 5000 ft' to which he responded, 'radar contact.' at 4800 ft, departure came back and asked us to 'verify climbing to 5000 ft,' and I responded with an affirmative '5000 ft.' it was then that I looked down at my clearance written in front of me and saw the 3000 ft expect 4000 ft. I told my captain that I had been wrong and that we were supposed to be at 3000 ft. At this point, my captain asked me 'what should we do now?' we didn't do anything. As far as what can be done to prevent a recurrence, I believe that I should always take my time and not sacrifice thoroughness in an attempt to depart on time. Also, I should complete a task that I have started (ie, putting the clearance information into the proper instruments). I should have reviewed the clearance with the captain, since he was distracted by the maintenance log when I received it. Iwas complacent in accepting 'the usual' when the captain reviewed the flight instruments and avionics, instead of double- checking the actual clearance. I am much more aware of the hazards associated with complacency now.
Original NASA ASRS Text
Title: THE FLT OF AN FA22 OVERSHOT THE ASSIGNED ALT DURING DEP. DURING CHKLIST USE, THE ALT ALERTER WAS SET TO THE SID ALT RATHER THAN THE ASSIGNED ALT. DEP CTLR QUERIED THE FLC.
Narrative: FO AND I FLEW A FLT FROM MINNEAPOLIS TO ST CLOUD, MN. DURING OUR ACCEPTANCE CHKLIST, I COVERED AND REVIEWED THE FLT INSTS AND AVIONICS PORTION OF THE CHKLIST. WHEN I GOT TO THE ALT ALERTER, IT WAS SET TO 1800 FT, WHICH WAS SET BY THE PREVIOUS CREW THAT HAD LANDED AT MSP. BY THIS TIME, PRIOR TO STARTING THE ACCEPTANCE CHKLIST, THE FO HAS ACTIVATED THE CLRNC AND HAS NORMALLY SET THE ALT ALTERTER TO OUR INITIAL ALT. SINCE IT WAS SET TO 1800 FT, I SET IT TO 5000 FT WHICH IS THE SID ALT. 99.9 PERCENT OF THE TIME 5000 FT IS OUR INITIAL ALT. I SAID 'GOING TO 5000 FT?' AS I SET THE ALT ALERTER. THE FO WHO HAD WRITTEN THE CLRNC ON A TOLD CARD WHICH WAS IN HER POSSESSION, SAID NOTHING OF THE CONTRARY. PER PLT'S OPERATING MANUAL (POM), THE FO IS TO VERIFY MY VERBAL STATEMENTS DURING THIS PORTION OF THE ACCEPTANCE CHKLIST. SO AFTER STARTUP I TAXI AND TKOF ON RWY HEADING. WE WERE CLRED TO MSP DEP. AS THE FO (PNF) CONTACTED DEP SHE APPARENTLY SAID 'MSP DEP COMMUTER FLT XAXB WITH YOU PASSING (SOME ALT BELOW 3000 FT) FOR 5000 FT.' DEP ACKNOWLEDGED OUR CHK-IN AS WE CONTINUED OUR CLB THROUGH MODERATE ICE TO 5000 FT. TOPS WERE AT APPROX 4500 FT. AT APPROX 4800 FT MSL, DEP ASKED, 'VERIFY LEVELING AT 5000 FT?' FO RESPONDED, 'LEVELING AT 5000 FT, AS ASSIGNED.' AT THAT POINT, I QUESTIONED BOTH STATEMENTS WITH MY FO. SHE THEN REFERRED TO THE TOLD CARD WHICH SHE THEN SAID 'OUR CLRNC WAS TO 3000 FT NOT 5000 FT PER THE SID.' DEP SAID NOTHING ELSE AND HANDED US OFF TO ZMP AND WISHED US A GOOD DAY. PERHAPS DEP WAS AWARE AS WE WERE CLBING THROUGH 3000 FT THAT WE WOULD BE LEVELING AT 5000 FT. THERE WERE NO CONFLICTS WITH ANY OTHER ACFT. THIS ERROR WILL NEVER HAPPEN AGAIN AND I INTEND TO DISCUSS SOME SORT OF VERBAL CHANGE ON THE ACCEPTANCE CHK WITH MY CHIEF PLT SOON. WHEN THE CAPT SAYS GOING TO OR CLRED TO 5000 FT AS HE SETS OR POINTS TO THE ALT ALERTER, THE FO SHOULD SAY 'CONFIRMED' -- THIS SHOULD BE ADDED TO OUR POM. SUPPLEMENTAL INFO FROM ACN 324680: THE ALTDEV THAT THIS IS ALL ABOUT OCCURRED ON THE SECOND DAY OF A 2-DAY TRIP AFTER A REDUCED REST OVERNIGHT. WE ARRIVED ON TIME BACK IN OUR HUB CITY, BUT WE WERE ONLY SCHEDULED FOR A 40 MIN TURN- AROUND BEFORE OUR NEXT TRIP. I WANTED TO GRAB A QUICK BREAKFAST SNACK AND I NEEDED TO PREFLT OUR NEW AIRPLANE AS WE WERE GIVEN AN ACFT SWAP. MAINT HAD ALREADY FOUND THAT A LNDG LIGHT WAS BURNED OUT ON THE NEW AIRPLANE AND THEY WERE IN THE PROCESS OF DEFERRING IT. I COPIED DOWN THE ATIS AND CALLED ON THE RADIO TO GET OUR CLRNC. THE RAMP AGENTS WERE ANXIOUS TO BOARD THE AIRPLANE. THE CAPT HAD JUST RECEIVED OUR MAINT LOG BACK FROM MAINT AND WAS CHKING IT OVER WHEN I COPIED DOWN THE CLRNC. 99 PERCENT OF THE TIME WHEN WE DEPART MSP WE ARE GIVEN AN INITIAL ALT OF 5000 FT. BUT, THIS TIME, WE WERE GIVEN 3000 FT EXPECT 4000 FT IN 10 MINS. I READ THIS BACK AND THEN PUT THE SQUAWK CODE IN THE XPONDER. IT WAS AT THIS TIME, AS THE PEOPLE WERE BOARDING, THAT THE CAPT REQUESTED THE ACCEPTANCE CHKLIST. I STOPPED WHAT I WAS DOING AND WENT TO THE CHKLIST, THUS NEVER PUTTING IN THE 3000 FT IN OUR ALT ALERTER. WE STARTED UP NORMALLY AND TAXIED OUT OF THE GATE 10 MINS LATE. AFTER TKOF, TWR SWITCHED US TO DEP CTL AND I CHKED ON AS 'OUT OF 2200 FT FOR 5000 FT' TO WHICH HE RESPONDED, 'RADAR CONTACT.' AT 4800 FT, DEP CAME BACK AND ASKED US TO 'VERIFY CLBING TO 5000 FT,' AND I RESPONDED WITH AN AFFIRMATIVE '5000 FT.' IT WAS THEN THAT I LOOKED DOWN AT MY CLRNC WRITTEN IN FRONT OF ME AND SAW THE 3000 FT EXPECT 4000 FT. I TOLD MY CAPT THAT I HAD BEEN WRONG AND THAT WE WERE SUPPOSED TO BE AT 3000 FT. AT THIS POINT, MY CAPT ASKED ME 'WHAT SHOULD WE DO NOW?' WE DIDN'T DO ANYTHING. AS FAR AS WHAT CAN BE DONE TO PREVENT A RECURRENCE, I BELIEVE THAT I SHOULD ALWAYS TAKE MY TIME AND NOT SACRIFICE THOROUGHNESS IN AN ATTEMPT TO DEPART ON TIME. ALSO, I SHOULD COMPLETE A TASK THAT I HAVE STARTED (IE, PUTTING THE CLRNC INFO INTO THE PROPER INSTS). I SHOULD HAVE REVIEWED THE CLRNC WITH THE CAPT, SINCE HE WAS DISTRACTED BY THE MAINT LOG WHEN I RECEIVED IT. IWAS COMPLACENT IN ACCEPTING 'THE USUAL' WHEN THE CAPT REVIEWED THE FLT INSTS AND AVIONICS, INSTEAD OF DOUBLE- CHKING THE ACTUAL CLRNC. I AM MUCH MORE AWARE OF THE HAZARDS ASSOCIATED WITH COMPLACENCY NOW.
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.