37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 363980 |
Time | |
Date | 199703 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mkk |
State Reference | HI |
Altitude | msl bound lower : 4700 msl bound upper : 5000 |
Environment | |
Flight Conditions | IMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | artcc : zhn |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 300 flight time total : 4500 flight time type : 1900 |
ASRS Report | 363980 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
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 |
Narrative:
We were on a very short leg (normally approximately 15 mins flight time) all IMC and I was trying to obtain up to date WX information for a field very near minimums and discuss with dispatch plans in the event of a missed approach. This took discussion with company, ATIS, and the local tower. I was trying to complete this prior to beginning the approach and so was off frequency when the first officer copied and began holding. He was issued a descent from 6000-5000 ft, began the descent but didn't enter 5000 ft into the autoplt altitude window. As I came back on frequency he gave me the aircraft and began the brief but didn't mention the descent. It was a gradual descent and when I noted that we were descending, we were 300 ft below 5000 ft. I switched off the autoplt and immediately climbed back to 5000 ft. This error was induced by high workload on a very short flight and our failure as a crew to follow normal CRM regarding altitude in general and specifically when changing control of who is flying. I could have avoided the problem by setting aside some of my radio work, more closely supervising the entry to the hold, and then returning to the radio when we were established.
Original NASA ASRS Text
Title: FLC OF AN MDT TURBOPROP OVERSHOT DSCNT HOLDING ALT DUE TO MISCOORD OF THE ACFT CTL BTWN THEMSELVES AND NOT SETTING THE AUTOPLT PRESELECT ALT HOLD FEATURE. THE CAPT IMMEDIATELY RETURNED TO ASSIGNED ALT AFTER A 300 FT LOSS.
Narrative: WE WERE ON A VERY SHORT LEG (NORMALLY APPROX 15 MINS FLT TIME) ALL IMC AND I WAS TRYING TO OBTAIN UP TO DATE WX INFO FOR A FIELD VERY NEAR MINIMUMS AND DISCUSS WITH DISPATCH PLANS IN THE EVENT OF A MISSED APCH. THIS TOOK DISCUSSION WITH COMPANY, ATIS, AND THE LCL TWR. I WAS TRYING TO COMPLETE THIS PRIOR TO BEGINNING THE APCH AND SO WAS OFF FREQ WHEN THE FO COPIED AND BEGAN HOLDING. HE WAS ISSUED A DSCNT FROM 6000-5000 FT, BEGAN THE DSCNT BUT DIDN'T ENTER 5000 FT INTO THE AUTOPLT ALT WINDOW. AS I CAME BACK ON FREQ HE GAVE ME THE ACFT AND BEGAN THE BRIEF BUT DIDN'T MENTION THE DSCNT. IT WAS A GRADUAL DSCNT AND WHEN I NOTED THAT WE WERE DSNDING, WE WERE 300 FT BELOW 5000 FT. I SWITCHED OFF THE AUTOPLT AND IMMEDIATELY CLBED BACK TO 5000 FT. THIS ERROR WAS INDUCED BY HIGH WORKLOAD ON A VERY SHORT FLT AND OUR FAILURE AS A CREW TO FOLLOW NORMAL CRM REGARDING ALT IN GENERAL AND SPECIFICALLY WHEN CHANGING CTL OF WHO IS FLYING. I COULD HAVE AVOIDED THE PROB BY SETTING ASIDE SOME OF MY RADIO WORK, MORE CLOSELY SUPERVISING THE ENTRY TO THE HOLD, AND THEN RETURNING TO THE RADIO WHEN WE WERE ESTABLISHED.
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.