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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Flight crew technique flying. Cockpit coordination attempted, captain didn't hear altitude callout procedure. First officer flight crew duty priority misaligned as checklist use was too soon at too low an altitude. Level off first. Sterile cockpit concept violated. Management problem.
| Attributes | |
| ACN | 354260 |
| Time | |
| Date | 199611 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : pdk |
| State Reference | GA |
| Altitude | msl bound lower : 3100 msl bound upper : 3400 |
| Environment | |
| Flight Conditions | IMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : atl |
| Operator | general aviation : corporate |
| Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
| Operating Under FAR Part | Part 91 |
| Navigation In Use | Other Other |
| Flight Phase | climbout : intermediate altitude |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | Other |
| Function | flight crew : first officer |
| Qualification | pilot : atp pilot : cfi |
| Experience | flight time last 90 days : 175 flight time total : 9925 flight time type : 2150 |
| ASRS Report | 354260 |
| Person 2 | |
| Affiliation | Other |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation other |
Narrative:
Takeoff normal on runway 20L. At approximately 1000 ft AGL tower said 'switch to departure' which I did. At that time, altitude reminder went off, and I stated to captain '2.1 for 3.1' as per company SOP. He stated 'ok.' I continued to complete after takeoff checklist, and as I verified the last of the items, my body and brain told me we were still climbing. As I looked up, I saw us passing through 3000 ft MSL (cleared to 3100 ft). I stated to captain 'maintain 3100 ft.' he stated 'oops, I thought they said 5,' meaning 5000 ft. (The radar vector was 050 degrees.) we overshot by 300 ft while IMC. What I really believe caused the problem was low situational awareness by the captain. This has been brought on recently by internal (department and company) conflict, change, and philosophical differences. The whole gamut -- economic, personal, personnel, WX, heavy flying schedule, variances to sops, lack of honest communications (cockpit and office), etc. The captain is also the chief pilot and is overwhelmed by the situation and his flying/management style shows it. I have worked with him long enough to know and understand this. Therefore, I will continue to monitor and break the error chain so as to prevent an accident or incident. I continue to reinforce positively correct procedures and policies while attempting to alleviate the situation. Our boss is preoccupied.
Original NASA ASRS Text
Title: FLC TECHNIQUE FLYING. COCKPIT COORD ATTEMPTED, CAPT DIDN'T HEAR ALT CALLOUT PROC. FO FLC DUTY PRIORITY MISALIGNED AS CHKLIST USE WAS TOO SOON AT TOO LOW AN ALT. LEVEL OFF FIRST. STERILE COCKPIT CONCEPT VIOLATED. MGMNT PROB.
Narrative: TKOF NORMAL ON RWY 20L. AT APPROX 1000 FT AGL TWR SAID 'SWITCH TO DEP' WHICH I DID. AT THAT TIME, ALT REMINDER WENT OFF, AND I STATED TO CAPT '2.1 FOR 3.1' AS PER COMPANY SOP. HE STATED 'OK.' I CONTINUED TO COMPLETE AFTER TKOF CHKLIST, AND AS I VERIFIED THE LAST OF THE ITEMS, MY BODY AND BRAIN TOLD ME WE WERE STILL CLBING. AS I LOOKED UP, I SAW US PASSING THROUGH 3000 FT MSL (CLRED TO 3100 FT). I STATED TO CAPT 'MAINTAIN 3100 FT.' HE STATED 'OOPS, I THOUGHT THEY SAID 5,' MEANING 5000 FT. (THE RADAR VECTOR WAS 050 DEGS.) WE OVERSHOT BY 300 FT WHILE IMC. WHAT I REALLY BELIEVE CAUSED THE PROB WAS LOW SITUATIONAL AWARENESS BY THE CAPT. THIS HAS BEEN BROUGHT ON RECENTLY BY INTERNAL (DEPT AND COMPANY) CONFLICT, CHANGE, AND PHILOSOPHICAL DIFFERENCES. THE WHOLE GAMUT -- ECONOMIC, PERSONAL, PERSONNEL, WX, HVY FLYING SCHEDULE, VARIANCES TO SOPS, LACK OF HONEST COMS (COCKPIT AND OFFICE), ETC. THE CAPT IS ALSO THE CHIEF PLT AND IS OVERWHELMED BY THE SIT AND HIS FLYING/MGMNT STYLE SHOWS IT. I HAVE WORKED WITH HIM LONG ENOUGH TO KNOW AND UNDERSTAND THIS. THEREFORE, I WILL CONTINUE TO MONITOR AND BREAK THE ERROR CHAIN SO AS TO PREVENT AN ACCIDENT OR INCIDENT. I CONTINUE TO REINFORCE POSITIVELY CORRECT PROCS AND POLICIES WHILE ATTEMPTING TO ALLEVIATE THE SIT. OUR BOSS IS PREOCCUPIED.
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.