37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 366830 |
Time | |
Date | 199704 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ewr |
State Reference | NJ |
Altitude | msl bound lower : 4000 msl bound upper : 4500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90 |
Operator | common carrier : air carrier |
Make Model Name | Challenger CL604 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure other departure sid : sid enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 270 flight time total : 12000 flight time type : 2500 |
ASRS Report | 366830 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 2500 flight time type : 150 |
ASRS Report | 366821 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented other |
Consequence | Other |
Miss Distance | horizontal : 2500 vertical : 1000 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Captain was hand-flying newark 6 departure off of runway 22R which calls for a climb to 5000 ft (left to 190 degrees after takeoff and right to 220 degrees after 2.3 DME). The first officer was handling the radios and setting headings and altitudes. Somewhere around 4000 ft MSL ATC ordered right turn to 320 degrees and climb to 4000 ft of which captain heard only right to 320 degrees. First officer set the heading bug to 320 degrees and altitude selector to 6000 ft. As I was busy flying I did not notice the incorrect altitude being set and the first officer only called right to 320 degrees. He did not call 6000 ft set. ATC again called as we were passing through +/-4400 ft to level at 4000 ft and traffic at 10-11 O'clock 5000 ft (altitudes may be incorrect). I immediately reduced power to flight idle in an attempt to descend to 4000 ft. I do not recall what altitude I actually attained prior to my initiation of a descent as I was very busy with the aircraft, trying to rectify a bad situation. Factors contributing to the altitude deviation are as follows: 1) very heavy workload of ATC, 2) 4000 ft leveloff command by ATC came as an after thought, since I was already on a 220 degree heading climbing at 3000 FPM, 3) captain's failure to hear 4000 ft leveloff, 4) first officer failure to set proper altitude, 5) first officer failure to make altitude callout, and 6) first officer second month in aircraft type and second ever trip into and out of newark. Supplemental information from acn 366821: I heard 6000 ft right to 320 degrees. I set 6000 ft in the altitude alerter and verbalized this. The captain was hand-flying and did not respond. We both had visual on the traffic and then received an RA on the TCASII. In retrospect we should have used the automation of the autoplt to relieve the workload and the captain should have confirmed the altitude or challenged it. (Lack of CRM.) I was tired, due to poor sleep the previous night, and should have told this to the captain. With the high workload and busyness of the controller I missed the altitude.
Original NASA ASRS Text
Title: CL65RJ FLC OVERSHOOTS ALT ASSIGNED WHEN THE FO PLACES THE WRONG ALT IN THE ALT ALERTER. CAPT WAS HAND-FLYING THE GLASS COCKPIT ACFT AND HADN'T HEARD THE NEW ALT ASSIGNMENT. FO NEW ON EQUIP.
Narrative: CAPT WAS HAND-FLYING NEWARK 6 DEP OFF OF RWY 22R WHICH CALLS FOR A CLB TO 5000 FT (L TO 190 DEGS AFTER TKOF AND R TO 220 DEGS AFTER 2.3 DME). THE FO WAS HANDLING THE RADIOS AND SETTING HEADINGS AND ALTS. SOMEWHERE AROUND 4000 FT MSL ATC ORDERED R TURN TO 320 DEGS AND CLB TO 4000 FT OF WHICH CAPT HEARD ONLY R TO 320 DEGS. FO SET THE HDG BUG TO 320 DEGS AND ALT SELECTOR TO 6000 FT. AS I WAS BUSY FLYING I DID NOT NOTICE THE INCORRECT ALT BEING SET AND THE FO ONLY CALLED R TO 320 DEGS. HE DID NOT CALL 6000 FT SET. ATC AGAIN CALLED AS WE WERE PASSING THROUGH +/-4400 FT TO LEVEL AT 4000 FT AND TFC AT 10-11 O'CLOCK 5000 FT (ALTS MAY BE INCORRECT). I IMMEDIATELY REDUCED PWR TO FLT IDLE IN AN ATTEMPT TO DSND TO 4000 FT. I DO NOT RECALL WHAT ALT I ACTUALLY ATTAINED PRIOR TO MY INITIATION OF A DSCNT AS I WAS VERY BUSY WITH THE ACFT, TRYING TO RECTIFY A BAD SIT. FACTORS CONTRIBUTING TO THE ALTDEV ARE AS FOLLOWS: 1) VERY HVY WORKLOAD OF ATC, 2) 4000 FT LEVELOFF COMMAND BY ATC CAME AS AN AFTER THOUGHT, SINCE I WAS ALREADY ON A 220 DEG HDG CLBING AT 3000 FPM, 3) CAPT'S FAILURE TO HEAR 4000 FT LEVELOFF, 4) FO FAILURE TO SET PROPER ALT, 5) FO FAILURE TO MAKE ALT CALLOUT, AND 6) FO SECOND MONTH IN ACFT TYPE AND SECOND EVER TRIP INTO AND OUT OF NEWARK. SUPPLEMENTAL INFO FROM ACN 366821: I HEARD 6000 FT R TO 320 DEGS. I SET 6000 FT IN THE ALT ALERTER AND VERBALIZED THIS. THE CAPT WAS HAND-FLYING AND DID NOT RESPOND. WE BOTH HAD VISUAL ON THE TFC AND THEN RECEIVED AN RA ON THE TCASII. IN RETROSPECT WE SHOULD HAVE USED THE AUTOMATION OF THE AUTOPLT TO RELIEVE THE WORKLOAD AND THE CAPT SHOULD HAVE CONFIRMED THE ALT OR CHALLENGED IT. (LACK OF CRM.) I WAS TIRED, DUE TO POOR SLEEP THE PREVIOUS NIGHT, AND SHOULD HAVE TOLD THIS TO THE CAPT. WITH THE HIGH WORKLOAD AND BUSYNESS OF THE CTLR I MISSED THE ALT.
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.