37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 331730 |
Time | |
Date | 199603 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : dxo |
State Reference | MI |
Altitude | msl bound lower : 23000 msl bound upper : 24000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zob |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | cruise other descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 210 flight time total : 11350 flight time type : 1850 |
ASRS Report | 331730 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Our flight was given a clearance to cross a fix at FL230. I acknowledged the clearance correctly and so did the captain who was the PF. I also verified that the captain set FL230 in the altitude select window. I then proceeded to obtain the ATIS and program the FMGS. Several mins later I noticed we were crossing the fix level at FL240 with FL240 set in the altitude select window. The captain had no explanation as to how FL240 got set in the altitude select window. The only explanation I could come up with was that when the captain pushed the altitude select knob to begin the descent, he must have also inadvertently turned the knob thereby changing the altitude select to FL240. The altitude select knob on the A320 consists of both an inner and outer knob. Each click of the inner knob will change the altitude select window either 100 or 1000 ft depending on the position of the outer knob. Although it is not company policy, many pilots have made it their policy to always return the outer knob to the 100 ft position after making an altitude selection. That way if they do accidentally turn the inner knob, the amount of altitude error will only be 100 ft instead of 1000 ft. Also, an erroneous altitude selection of FL229 or FL231 would be more obvious.
Original NASA ASRS Text
Title: XING RESTR NOT MET BECAUSE ALT WINDOW IN COCKPIT INADVERTENTLY SET TO WRONG ALT. THE ALT HAD BEEN SET CORRECTLY TO FL230, BUT APPARENTLY WHEN PUSHING THE KNOB TO COMMENCE DSCNT THE ALT CHANGED 1000 FT TO FL240.
Narrative: OUR FLT WAS GIVEN A CLRNC TO CROSS A FIX AT FL230. I ACKNOWLEDGED THE CLRNC CORRECTLY AND SO DID THE CAPT WHO WAS THE PF. I ALSO VERIFIED THAT THE CAPT SET FL230 IN THE ALT SELECT WINDOW. I THEN PROCEEDED TO OBTAIN THE ATIS AND PROGRAM THE FMGS. SEVERAL MINS LATER I NOTICED WE WERE XING THE FIX LEVEL AT FL240 WITH FL240 SET IN THE ALT SELECT WINDOW. THE CAPT HAD NO EXPLANATION AS TO HOW FL240 GOT SET IN THE ALT SELECT WINDOW. THE ONLY EXPLANATION I COULD COME UP WITH WAS THAT WHEN THE CAPT PUSHED THE ALT SELECT KNOB TO BEGIN THE DSCNT, HE MUST HAVE ALSO INADVERTENTLY TURNED THE KNOB THEREBY CHANGING THE ALT SELECT TO FL240. THE ALT SELECT KNOB ON THE A320 CONSISTS OF BOTH AN INNER AND OUTER KNOB. EACH CLICK OF THE INNER KNOB WILL CHANGE THE ALT SELECT WINDOW EITHER 100 OR 1000 FT DEPENDING ON THE POS OF THE OUTER KNOB. ALTHOUGH IT IS NOT COMPANY POLICY, MANY PLTS HAVE MADE IT THEIR POLICY TO ALWAYS RETURN THE OUTER KNOB TO THE 100 FT POS AFTER MAKING AN ALT SELECTION. THAT WAY IF THEY DO ACCIDENTALLY TURN THE INNER KNOB, THE AMOUNT OF ALT ERROR WILL ONLY BE 100 FT INSTEAD OF 1000 FT. ALSO, AN ERRONEOUS ALT SELECTION OF FL229 OR FL231 WOULD BE MORE OBVIOUS.
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.