37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 338780 |
Time | |
Date | 199606 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : roa |
State Reference | VA |
Altitude | msl bound lower : 22000 msl bound upper : 22000 |
Aircraft 1 | |
Controlling Facilities | artcc : zid |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
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 : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 6000 |
ASRS Report | 338780 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude |
Independent Detector | 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:
Operating cvg to roa, approximately 80 mi west of roa. Controller cleared us for pilot's discretion descent from FL220 down to 13000 ft or 15000 ft (can't remember which). I reset altitude window and pushed 'dsc' (descent) button, noted altitude armed illuminated followed by slight pitchover. After a few seconds, with about 1500 FPM rate established, I again pushed dsc to stabilize rate, or so I thought. I picked up the chart I had been looking at before the call from center. About a min later, first officer said 'hey, we're climbing.' I dropped the chart, noting that we had entered a subtle climb, or at least subtly entered a climb. Immediately disconnected autoplt and pushed over as gingerly as I dared with the seat belt light off. I'm not sure how high we got, but it was above initial altitude. As far as I know there was no traffic conflict, and controller said nothing. My observations on this event: I was negligent in holding the chart up obscuring the panel long enough for this to happen, and for not noting incorrect annunciator lights. I think there are several factors that might have contributed. I was completely unfamiliar with roa, having never been anywhere near there before, and it is a 'special airport.' as we were expecting a chance of the WX being low in rw/trw, I was very concerned with familiarizing myself with terrain, obstructions, and alternates. At the time of the event I was looking at the orientation of possible alternates on the en route low chart. Flight control panel mode buttons are tiny, and very close to each other. Almost certainly I must have pushed climb vice descent, but this is very easy to do, and one must be vigilant to look for the correct annunciator light to come on (or go off). At this point I had less than 50 hours in type aircraft since transitioning/upgrading from CL65 with entirely different autoplt controls. We had just done a continuous duty overnight, landing at day at XA02 am, and departing day at XF45 am, with about 4 1/2 hours actual rest time in the hotel. Neither of us was as sharp as we would normally be.
Original NASA ASRS Text
Title: LTT FLC CLRED TO DSND, BUT ACFT BEGINS A SUBTLE CLB DUE TO APPARENT SELECTION OF WRONG BUTTON ON MCP. ALTDEV. IMPROPER MODE CTL PANEL USE.
Narrative: OPERATING CVG TO ROA, APPROX 80 MI W OF ROA. CTLR CLRED US FOR PLT'S DISCRETION DSCNT FROM FL220 DOWN TO 13000 FT OR 15000 FT (CAN'T REMEMBER WHICH). I RESET ALT WINDOW AND PUSHED 'DSC' (DSCNT) BUTTON, NOTED ALT ARMED ILLUMINATED FOLLOWED BY SLIGHT PITCHOVER. AFTER A FEW SECONDS, WITH ABOUT 1500 FPM RATE ESTABLISHED, I AGAIN PUSHED DSC TO STABILIZE RATE, OR SO I THOUGHT. I PICKED UP THE CHART I HAD BEEN LOOKING AT BEFORE THE CALL FROM CTR. ABOUT A MIN LATER, FO SAID 'HEY, WE'RE CLBING.' I DROPPED THE CHART, NOTING THAT WE HAD ENTERED A SUBTLE CLB, OR AT LEAST SUBTLY ENTERED A CLB. IMMEDIATELY DISCONNECTED AUTOPLT AND PUSHED OVER AS GINGERLY AS I DARED WITH THE SEAT BELT LIGHT OFF. I'M NOT SURE HOW HIGH WE GOT, BUT IT WAS ABOVE INITIAL ALT. AS FAR AS I KNOW THERE WAS NO TFC CONFLICT, AND CTLR SAID NOTHING. MY OBSERVATIONS ON THIS EVENT: I WAS NEGLIGENT IN HOLDING THE CHART UP OBSCURING THE PANEL LONG ENOUGH FOR THIS TO HAPPEN, AND FOR NOT NOTING INCORRECT ANNUNCIATOR LIGHTS. I THINK THERE ARE SEVERAL FACTORS THAT MIGHT HAVE CONTRIBUTED. I WAS COMPLETELY UNFAMILIAR WITH ROA, HAVING NEVER BEEN ANYWHERE NEAR THERE BEFORE, AND IT IS A 'SPECIAL ARPT.' AS WE WERE EXPECTING A CHANCE OF THE WX BEING LOW IN RW/TRW, I WAS VERY CONCERNED WITH FAMILIARIZING MYSELF WITH TERRAIN, OBSTRUCTIONS, AND ALTERNATES. AT THE TIME OF THE EVENT I WAS LOOKING AT THE ORIENTATION OF POSSIBLE ALTERNATES ON THE ENRTE LOW CHART. FLT CTL PANEL MODE BUTTONS ARE TINY, AND VERY CLOSE TO EACH OTHER. ALMOST CERTAINLY I MUST HAVE PUSHED CLB VICE DSCNT, BUT THIS IS VERY EASY TO DO, AND ONE MUST BE VIGILANT TO LOOK FOR THE CORRECT ANNUNCIATOR LIGHT TO COME ON (OR GO OFF). AT THIS POINT I HAD LESS THAN 50 HRS IN TYPE ACFT SINCE TRANSITIONING/UPGRADING FROM CL65 WITH ENTIRELY DIFFERENT AUTOPLT CTLS. WE HAD JUST DONE A CONTINUOUS DUTY OVERNIGHT, LNDG AT DAY AT XA02 AM, AND DEPARTING DAY AT XF45 AM, WITH ABOUT 4 1/2 HRS ACTUAL REST TIME IN THE HOTEL. NEITHER OF US WAS AS SHARP AS WE WOULD NORMALLY BE.
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.