37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 368430 |
Time | |
Date | 199705 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : man |
State Reference | FO |
Altitude | msl bound lower : 6000 msl bound upper : 6000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : man |
Operator | common carrier : air carrier |
Make Model Name | DC-10 30 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute airway : man |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 140 flight time total : 3400 flight time type : 550 |
ASRS Report | 368430 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to assigned altitude flight crew : took evasive action other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We departed manchester, england, airport in a DC10-30 for an empty (crew only) ferry to london gatwick airport. The captain was still a high minimums captain and was allowed the takeoff and departure. We were at 1500 ft and per ICAO noise abatement procedures, I called for climb thrust. Climb thrust was selected by PNF, however, N1 was not selected in order to initiate climb thrust. The transition altitude was 6000 ft MSL and I failed to set 1013 millibars in the altimeter base window. On profile at bugged speed, I called for slats retract and climb checklist. The autoplt was on at 12000 ft MSL as indicated on the incorrectly set altimeter. We were cleared to FL150 ft then further to FL190. The altitude FL190 was set and armed in the altitude window I was distraction by navigation while the PNF was on the radio. At FL188 the flight engineer questioned what altitude we were cleared to. I looked at the altimeter and FMA to realize the autoplt was climbing through FL190. I immediately pushed the yoke over and trimmed to disconnect the autoplt. The climb was stopped at FL194 and I descended to FL190. As we leveled at FL190, we received an RA for a climb in conjunction with a controller heading change to 270 degrees from previous heading of 190 degrees. I initiated immediate turn to 270 degrees as the RA subsided. The chain of errors was quite obvious as I sat and wrote them down: climb power not being selected, which I should have caught in the FMA. The 1013 millibars not selected at 6000 ft MSL by myself, and which my mistake should have been caught by the engineer in running the climb checklist. The autoplt not reading altitude capture, which should have been caught by me sooner. Not allowing myself to be distraction during such a phase of flight. I should have overridden the autoplt sooner. And, my fault of relying on the autoplt and not positively monitoring it. I should have selected speed mode on the FMS and slowed the climb to 1000 FPM at 2000 ft below assigned altitude, all in hindsight. Definite contributing factors: 1) climb power not selected. 2) 1013 millibars not being set 6000 ft MSL. 3) 1013 millibars not caught in climb checklist. 4) my distraction from my flying duties. 5) excessive rate of climb could have caused autoplt's faulty capture of altitude.
Original NASA ASRS Text
Title: DC10-30 ACFT DURING CLB FROM FOREIGN ARPT, PF, FO, FORGOT TO CHANGE ALTIMETER AT TRANSITION ALT AND THUS CLBED ABOVE ASSIGNED ALT.
Narrative: WE DEPARTED MANCHESTER, ENGLAND, ARPT IN A DC10-30 FOR AN EMPTY (CREW ONLY) FERRY TO LONDON GATWICK ARPT. THE CAPT WAS STILL A HIGH MINIMUMS CAPT AND WAS ALLOWED THE TKOF AND DEP. WE WERE AT 1500 FT AND PER ICAO NOISE ABATEMENT PROCS, I CALLED FOR CLB THRUST. CLB THRUST WAS SELECTED BY PNF, HOWEVER, N1 WAS NOT SELECTED IN ORDER TO INITIATE CLB THRUST. THE TRANSITION ALT WAS 6000 FT MSL AND I FAILED TO SET 1013 MILLIBARS IN THE ALTIMETER BASE WINDOW. ON PROFILE AT BUGGED SPD, I CALLED FOR SLATS RETRACT AND CLB CHKLIST. THE AUTOPLT WAS ON AT 12000 FT MSL AS INDICATED ON THE INCORRECTLY SET ALTIMETER. WE WERE CLRED TO FL150 FT THEN FURTHER TO FL190. THE ALT FL190 WAS SET AND ARMED IN THE ALT WINDOW I WAS DISTR BY NAV WHILE THE PNF WAS ON THE RADIO. AT FL188 THE FE QUESTIONED WHAT ALT WE WERE CLRED TO. I LOOKED AT THE ALTIMETER AND FMA TO REALIZE THE AUTOPLT WAS CLBING THROUGH FL190. I IMMEDIATELY PUSHED THE YOKE OVER AND TRIMMED TO DISCONNECT THE AUTOPLT. THE CLB WAS STOPPED AT FL194 AND I DSNDED TO FL190. AS WE LEVELED AT FL190, WE RECEIVED AN RA FOR A CLB IN CONJUNCTION WITH A CTLR HDG CHANGE TO 270 DEGS FROM PREVIOUS HDG OF 190 DEGS. I INITIATED IMMEDIATE TURN TO 270 DEGS AS THE RA SUBSIDED. THE CHAIN OF ERRORS WAS QUITE OBVIOUS AS I SAT AND WROTE THEM DOWN: CLB PWR NOT BEING SELECTED, WHICH I SHOULD HAVE CAUGHT IN THE FMA. THE 1013 MILLIBARS NOT SELECTED AT 6000 FT MSL BY MYSELF, AND WHICH MY MISTAKE SHOULD HAVE BEEN CAUGHT BY THE ENGINEER IN RUNNING THE CLB CHKLIST. THE AUTOPLT NOT READING ALT CAPTURE, WHICH SHOULD HAVE BEEN CAUGHT BY ME SOONER. NOT ALLOWING MYSELF TO BE DISTR DURING SUCH A PHASE OF FLT. I SHOULD HAVE OVERRIDDEN THE AUTOPLT SOONER. AND, MY FAULT OF RELYING ON THE AUTOPLT AND NOT POSITIVELY MONITORING IT. I SHOULD HAVE SELECTED SPD MODE ON THE FMS AND SLOWED THE CLB TO 1000 FPM AT 2000 FT BELOW ASSIGNED ALT, ALL IN HINDSIGHT. DEFINITE CONTRIBUTING FACTORS: 1) CLB PWR NOT SELECTED. 2) 1013 MILLIBARS NOT BEING SET 6000 FT MSL. 3) 1013 MILLIBARS NOT CAUGHT IN CLB CHKLIST. 4) MY DISTR FROM MY FLYING DUTIES. 5) EXCESSIVE RATE OF CLB COULD HAVE CAUSED AUTOPLT'S FAULTY CAPTURE OF 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.