37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 335690 |
Time | |
Date | 199605 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | msl bound lower : 11000 msl bound upper : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival other arrival star : star |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 12000 flight time type : 500 |
ASRS Report | 335690 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : crossing restriction not met non adherence : published procedure non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | none taken : insufficient time |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I misread the FMC. I assumed we had passed bremer intersection that had an altitude restr of 12000 ft. I read the next intersection's altitude which stated 11000B-10000A. I set the altitude selector to 10000 ft failing to secure acknowledgement from the first officer. The first officer called my attention to the fact that I was descending at 11000 ft which was 1000 ft below the altitude restr. I quickly climbed back to approximately 11500 ft but was below the intersection's altitude. No mention was made by ATC nor us. I believe the problem occurred for 2 reasons: 1) we had and were flying day 2 of a circadian rhythm violating trip (left lax the evening before) at XA15 hours. Flew all night to phl then attempted to sleep from XX00 local philadelphia time (daylight) until approximately XY00. Sleep was interrupted by hotel cleaners several times. My whole crew was tired. 2) I failed to follow prescribed procedure regarding altitude clrncs and altitude selector knob, I set the next altitude in my descent (on ap) and took my hand away from the knob without waiting for my first officer's acknowledgement of the new altitude's introduction. The obvious solution to prevent this in the future is to not have crews fly these type of trips, but of even more importance, is to follow altitude reporting and changing procedures correctly.
Original NASA ASRS Text
Title: CAPT OF A WDB OVERSHOT DSCNT ALT DURING DSCNT ON A STAR ARR DUE TO MISPROGRAMMING THE ACFT'S FMC.
Narrative: I MISREAD THE FMC. I ASSUMED WE HAD PASSED BREMER INTXN THAT HAD AN ALT RESTR OF 12000 FT. I READ THE NEXT INTXN'S ALT WHICH STATED 11000B-10000A. I SET THE ALT SELECTOR TO 10000 FT FAILING TO SECURE ACKNOWLEDGEMENT FROM THE FO. THE FO CALLED MY ATTN TO THE FACT THAT I WAS DSNDING AT 11000 FT WHICH WAS 1000 FT BELOW THE ALT RESTR. I QUICKLY CLBED BACK TO APPROX 11500 FT BUT WAS BELOW THE INTXN'S ALT. NO MENTION WAS MADE BY ATC NOR US. I BELIEVE THE PROB OCCURRED FOR 2 REASONS: 1) WE HAD AND WERE FLYING DAY 2 OF A CIRCADIAN RHYTHM VIOLATING TRIP (LEFT LAX THE EVENING BEFORE) AT XA15 HRS. FLEW ALL NIGHT TO PHL THEN ATTEMPTED TO SLEEP FROM XX00 LCL PHILADELPHIA TIME (DAYLIGHT) UNTIL APPROX XY00. SLEEP WAS INTERRUPTED BY HOTEL CLEANERS SEVERAL TIMES. MY WHOLE CREW WAS TIRED. 2) I FAILED TO FOLLOW PRESCRIBED PROC REGARDING ALT CLRNCS AND ALT SELECTOR KNOB, I SET THE NEXT ALT IN MY DSCNT (ON AP) AND TOOK MY HAND AWAY FROM THE KNOB WITHOUT WAITING FOR MY FO'S ACKNOWLEDGEMENT OF THE NEW ALT'S INTRODUCTION. THE OBVIOUS SOLUTION TO PREVENT THIS IN THE FUTURE IS TO NOT HAVE CREWS FLY THESE TYPE OF TRIPS, BUT OF EVEN MORE IMPORTANCE, IS TO FOLLOW ALT RPTING AND CHANGING PROCS CORRECTLY.
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.