37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 329810 |
Time | |
Date | 199603 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : svm airport : dtw |
State Reference | MI |
Altitude | msl bound lower : 13000 msl bound upper : 13300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : dtw |
Operator | common carrier : air carrier |
Make Model Name | DC-9 50 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 215 flight time total : 20000 flight time type : 15000 |
ASRS Report | 329810 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : unspecified 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:
Flew through 13000 ft (assigned) to approximately 13300 ft and immediately returned to 13000 ft. I continue to file NASA reports each time I have a small altitude deviation, even though my associates say they do not do so. In any event, there appears to be a problem with 'almost' altdevs, as well as these small deviations, among air carrier crews in general that appear to have a common cause, as well as an easy fix. Cause: fatigue. In every case I've filed a NASA report on, as well as those 'almost deviations,' fatigue, resulting most often from an early morning 'get-up,' and less often, simply from a bad night's sleep, has preceded these events. When climbing the last 1000 ft before level off at 500-1000 FPM, your brain has approximately 2 mins after the altitude alert sounds to maintain concentration for leveling off. In a busy environment with a fatigued brain, nearly 2 mins is a long time to maintain that concentration. The other and less obvious fatigue factor with our airline is the fact that vacations are being canceled, I see a strong relationship between those cancellations and morale/fatigue. And again, less concentration ability. Fix for problem: the altitude alerter sounds at 1000 ft prior to assigned altitude, then goes off before reaching assigned altitude. If the alerter were modified so that it had another aural warning approximately 200 ft before level off, even a fatigued brain would re- engage in time to act.
Original NASA ASRS Text
Title: AN ACR FLC CLBS ABOVE 13000 FT ASSIGNED AND IMMEDIATELY RETURNS.
Narrative: FLEW THROUGH 13000 FT (ASSIGNED) TO APPROX 13300 FT AND IMMEDIATELY RETURNED TO 13000 FT. I CONTINUE TO FILE NASA RPTS EACH TIME I HAVE A SMALL ALTDEV, EVEN THOUGH MY ASSOCIATES SAY THEY DO NOT DO SO. IN ANY EVENT, THERE APPEARS TO BE A PROB WITH 'ALMOST' ALTDEVS, AS WELL AS THESE SMALL DEVS, AMONG ACR CREWS IN GENERAL THAT APPEAR TO HAVE A COMMON CAUSE, AS WELL AS AN EASY FIX. CAUSE: FATIGUE. IN EVERY CASE I'VE FILED A NASA RPT ON, AS WELL AS THOSE 'ALMOST DEVS,' FATIGUE, RESULTING MOST OFTEN FROM AN EARLY MORNING 'GET-UP,' AND LESS OFTEN, SIMPLY FROM A BAD NIGHT'S SLEEP, HAS PRECEDED THESE EVENTS. WHEN CLBING THE LAST 1000 FT BEFORE LEVEL OFF AT 500-1000 FPM, YOUR BRAIN HAS APPROX 2 MINS AFTER THE ALT ALERT SOUNDS TO MAINTAIN CONCENTRATION FOR LEVELING OFF. IN A BUSY ENVIRONMENT WITH A FATIGUED BRAIN, NEARLY 2 MINS IS A LONG TIME TO MAINTAIN THAT CONCENTRATION. THE OTHER AND LESS OBVIOUS FATIGUE FACTOR WITH OUR AIRLINE IS THE FACT THAT VACATIONS ARE BEING CANCELED, I SEE A STRONG RELATIONSHIP BTWN THOSE CANCELLATIONS AND MORALE/FATIGUE. AND AGAIN, LESS CONCENTRATION ABILITY. FIX FOR PROB: THE ALT ALERTER SOUNDS AT 1000 FT PRIOR TO ASSIGNED ALT, THEN GOES OFF BEFORE REACHING ASSIGNED ALT. IF THE ALERTER WERE MODIFIED SO THAT IT HAD ANOTHER AURAL WARNING APPROX 200 FT BEFORE LEVEL OFF, EVEN A FATIGUED BRAIN WOULD RE- ENGAGE IN TIME TO ACT.
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.