 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
DC8 cargo flight in a night operation suffers altitude excursions above and below assigned altitude. PIC forgot to set cruise power. First officer out of seat, in the lavatory.
| Attributes | |
| ACN | 355667 |
| Time | |
| Date | 199612 |
| Day | Sat |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | atc facility : hvq |
| State Reference | WV |
| Altitude | msl bound lower : 32500 msl bound upper : 33350 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : zid |
| Operator | common carrier : air carrier |
| Make Model Name | DC-8 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | climbout : intermediate altitude cruise other |
| Route In Use | enroute other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : flight engineer pilot : atp pilot : cfi |
| Experience | flight time last 90 days : 180 flight time total : 12500 flight time type : 180 |
| ASRS Report | 355667 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 120 flight time total : 7200 flight time type : 1170 |
| ASRS Report | 355420 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other anomaly |
| Independent Detector | other controllera other flight crewa |
| Resolutory Action | flight crew : returned to intended course or assigned course flight crew : regained aircraft control other |
| Consequence | faa : reviewed incident with flight crew faa : investigated |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
While climbing out of FL320, first officer asked me if he could go to the head, I said all right. As he left the flight deck and as I was donning my oxygen mask the autoplt was sluggish with the pitch wheel, so I disengaged it, reverting to manual control. Next, as I was leveling at FL330, center reported traffic ahead and above us (being night-VMC). I began scanning for this traffic (and failed to call for 'cruise power'). Aircraft then ballooned 200-290 ft high (no altitude alert device, warning chime, or light). Simultaneously, the flight engineer said, 'out of FL332 for FL330' and center asked, 'air carrier X, what is your altitude?' while I was applying forward pressure to stop and reverse excursion I tried to be smooth not to injure my first officer (who was in the head). While noticing the unusual forward pressure on yoke to pitch down with the altitude excursion, I was thinking 'mountain wave' and said this over radio as knee jerk reaction (no time for small words like, 'this 'feels' like mountain wave.') next I overshot my altitude (because I forgot I still had climb power) going below my assigned altitude to 300 ft below. (This time I got the altitude alert device warning light and chime.) then, returning immediately (but smoothly) to my assigned altitude and had 'cruise power set.' first officer returned to flight deck (he obviously thought I was 'playing around' when that was not the case at all). Next ZID asked me to contact ind quality assurance. I called them as soon as possible and got answering machine saturday and sunday. But monday morning, talked with them. I sincerely believe this all comes down to me (the captain) being fatigued. (Crew duty started DB45 am EST in iad, so at time of occurrence I was at 14 hours 45 mins into my day on top of many delays, changes and distrs and increased workload.) supplemental information from acn 355420: 14 hours 45 mins into the crew duty period. Prior to departure, the crew remained in the aircraft in excess of 3 hours awaiting aircraft upload. After departure and prior to leveloff, I had to leave my seat to satisfy physiological needs. This need arose because of the long period prior to departure where proper facilities and privacy conditions were not available.
Original NASA ASRS Text
Title: DC8 CARGO FLT IN A NIGHT OP SUFFERS ALT EXCURSIONS ABOVE AND BELOW ASSIGNED ALT. PIC FORGOT TO SET CRUISE PWR. FO OUT OF SEAT, IN THE LAVATORY.
Narrative: WHILE CLBING OUT OF FL320, FO ASKED ME IF HE COULD GO TO THE HEAD, I SAID ALL RIGHT. AS HE LEFT THE FLT DECK AND AS I WAS DONNING MY OXYGEN MASK THE AUTOPLT WAS SLUGGISH WITH THE PITCH WHEEL, SO I DISENGAGED IT, REVERTING TO MANUAL CTL. NEXT, AS I WAS LEVELING AT FL330, CTR RPTED TFC AHEAD AND ABOVE US (BEING NIGHT-VMC). I BEGAN SCANNING FOR THIS TFC (AND FAILED TO CALL FOR 'CRUISE PWR'). ACFT THEN BALLOONED 200-290 FT HIGH (NO ALT ALERT DEVICE, WARNING CHIME, OR LIGHT). SIMULTANEOUSLY, THE FE SAID, 'OUT OF FL332 FOR FL330' AND CTR ASKED, 'ACR X, WHAT IS YOUR ALT?' WHILE I WAS APPLYING FORWARD PRESSURE TO STOP AND REVERSE EXCURSION I TRIED TO BE SMOOTH NOT TO INJURE MY FO (WHO WAS IN THE HEAD). WHILE NOTICING THE UNUSUAL FORWARD PRESSURE ON YOKE TO PITCH DOWN WITH THE ALT EXCURSION, I WAS THINKING 'MOUNTAIN WAVE' AND SAID THIS OVER RADIO AS KNEE JERK REACTION (NO TIME FOR SMALL WORDS LIKE, 'THIS 'FEELS' LIKE MOUNTAIN WAVE.') NEXT I OVERSHOT MY ALT (BECAUSE I FORGOT I STILL HAD CLB PWR) GOING BELOW MY ASSIGNED ALT TO 300 FT BELOW. (THIS TIME I GOT THE ALT ALERT DEVICE WARNING LIGHT AND CHIME.) THEN, RETURNING IMMEDIATELY (BUT SMOOTHLY) TO MY ASSIGNED ALT AND HAD 'CRUISE PWR SET.' FO RETURNED TO FLT DECK (HE OBVIOUSLY THOUGHT I WAS 'PLAYING AROUND' WHEN THAT WAS NOT THE CASE AT ALL). NEXT ZID ASKED ME TO CONTACT IND QUALITY ASSURANCE. I CALLED THEM ASAP AND GOT ANSWERING MACHINE SATURDAY AND SUNDAY. BUT MONDAY MORNING, TALKED WITH THEM. I SINCERELY BELIEVE THIS ALL COMES DOWN TO ME (THE CAPT) BEING FATIGUED. (CREW DUTY STARTED DB45 AM EST IN IAD, SO AT TIME OF OCCURRENCE I WAS AT 14 HRS 45 MINS INTO MY DAY ON TOP OF MANY DELAYS, CHANGES AND DISTRS AND INCREASED WORKLOAD.) SUPPLEMENTAL INFO FROM ACN 355420: 14 HRS 45 MINS INTO THE CREW DUTY PERIOD. PRIOR TO DEP, THE CREW REMAINED IN THE ACFT IN EXCESS OF 3 HRS AWAITING ACFT UPLOAD. AFTER DEP AND PRIOR TO LEVELOFF, I HAD TO LEAVE MY SEAT TO SATISFY PHYSIOLOGICAL NEEDS. THIS NEED AROSE BECAUSE OF THE LONG PERIOD PRIOR TO DEP WHERE PROPER FACILITIES AND PRIVACY CONDITIONS WERE NOT AVAILABLE.
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.