37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 362964 |
Time | |
Date | 199703 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : vxv |
State Reference | TN |
Altitude | msl bound lower : 19000 msl bound upper : 19000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : ztl |
Operator | other |
Make Model Name | Learjet 24 |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 110 flight time total : 4500 flight time type : 800 |
ASRS Report | 362964 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot non adherence : published procedure non adherence : clearance non adherence : far |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Non standard oxygen servicing by maintenance (exterior access oxygen valve was left off). Low time sic. Failure to designate tasks by PIC. On climb out through FL180, check oxygen masks is part of the checklist. (I had checked oxygen and mask operation prior to flight then had oxygen added.) during the distraction of playing with the oxygen masks, I missed the FL190 leveloff. A light LR24 climbs very well and I missed the altitude substantially. The ATC controller queried me as to the altitude and as happens I lied, shut off the mode C, closed the throttles, opened spoilers and introduced a 60 degree bank to return to my altitude (FL190). There was no further mention of the event by ATC. Human performance considerations: a false reliance on the audio portion of the altitude alerter (it failed to ding). A classic failure to designate responsibility in the face of merely an abnormal situation. In an emergency situation the delegation of responsibility is an automated response as a result of our training. I need to, and will now, treat 'abnormals' more like the emergencys they could lead to. The inexperience of the copilot contributed to him not challenging me. People being as unreliable as they are and computers being so good why isn't there an alert system on the ATC screen when a rate of climb or descent exceeds 2000 FPM or 1500 FPM within 800-1000 ft of an assigned altitude? This would allow the controllers to say 'verify leveling flxxx' as an aid to help minimize these occurrences.
Original NASA ASRS Text
Title: LR24 VERY LIGHT CLBING TO FL190 FOR MAINT CHK. CHKLIST CALLS TO CHK OXYGEN MASK AND IN SO DOING OVERSHOT ALT. CTLR QUERIED AND CAPT TURNED OFF THE XPONDER, CLOSED THROTTLES AND INITIATED A 60 DEG BANK TO EXPEDITE BACK TO ALT.
Narrative: NON STANDARD OXYGEN SVCING BY MAINT (EXTERIOR ACCESS OXYGEN VALVE WAS LEFT OFF). LOW TIME SIC. FAILURE TO DESIGNATE TASKS BY PIC. ON CLBOUT THROUGH FL180, CHK OXYGEN MASKS IS PART OF THE CHKLIST. (I HAD CHKED OXYGEN AND MASK OP PRIOR TO FLT THEN HAD OXYGEN ADDED.) DURING THE DISTR OF PLAYING WITH THE OXYGEN MASKS, I MISSED THE FL190 LEVELOFF. A LIGHT LR24 CLBS VERY WELL AND I MISSED THE ALT SUBSTANTIALLY. THE ATC CTLR QUERIED ME AS TO THE ALT AND AS HAPPENS I LIED, SHUT OFF THE MODE C, CLOSED THE THROTTLES, OPENED SPOILERS AND INTRODUCED A 60 DEG BANK TO RETURN TO MY ALT (FL190). THERE WAS NO FURTHER MENTION OF THE EVENT BY ATC. HUMAN PERFORMANCE CONSIDERATIONS: A FALSE RELIANCE ON THE AUDIO PORTION OF THE ALT ALERTER (IT FAILED TO DING). A CLASSIC FAILURE TO DESIGNATE RESPONSIBILITY IN THE FACE OF MERELY AN ABNORMAL SIT. IN AN EMER SIT THE DELEGATION OF RESPONSIBILITY IS AN AUTOMATED RESPONSE AS A RESULT OF OUR TRAINING. I NEED TO, AND WILL NOW, TREAT 'ABNORMALS' MORE LIKE THE EMERS THEY COULD LEAD TO. THE INEXPERIENCE OF THE COPLT CONTRIBUTED TO HIM NOT CHALLENGING ME. PEOPLE BEING AS UNRELIABLE AS THEY ARE AND COMPUTERS BEING SO GOOD WHY ISN'T THERE AN ALERT SYS ON THE ATC SCREEN WHEN A RATE OF CLB OR DSCNT EXCEEDS 2000 FPM OR 1500 FPM WITHIN 800-1000 FT OF AN ASSIGNED ALT? THIS WOULD ALLOW THE CTLRS TO SAY 'VERIFY LEVELING FLXXX' AS AN AID TO HELP MINIMIZE THESE OCCURRENCES.
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.