37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 413560 |
Time | |
Date | 199809 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : hpw |
State Reference | VA |
Altitude | msl bound lower : 34600 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc tower : efd |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : instrument pilot : atp pilot : commercial |
Experience | flight time last 90 days : 250 flight time total : 14000 flight time type : 3500 |
ASRS Report | 413560 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 5500 flight time type : 800 |
ASRS Report | 413649 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : became reoriented other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I, as the captain, was the PNF. Center asked us to turn left to heading 330 degrees. I read back the clearance and verified it with the first officer who was the PF. The very next moment, my attention was distraction by the interphone to the flight attendant in the back. As I was talking to her, center came up on the radio and asked us to maintain FL350. I looked up at the altimeter and low and behold I saw us descending through FL346. I grabbed the yoke and disconnected the autoplt and climbed us back to FL350. I asked the first officer why he began a descent. He told me that he had not heard the center's clearance, and when he looked at me he heard me say '340,' so he thought that meant descend to FL340. I told him we never used '340' as an altitude. He suddenly realized this and said he just had not heard the clearance. I told him that the next time he doesn't hear a clearance, please let me know so we can verify it. I fault myself for not watching him and allowing myself to become distraction. It happened so quickly. Supplemental information from acn 413649: ...and heard him say '340.' I incorrectly understood that to mean FL340 and entered the altitude FL340 into the MCP and on the cruise page of the FMC. We started descending 1000 ft and at approximately FL346 ZDC instructed us to maintain FL350 and turn left to a heading of 340 degrees. The captain looked up from the paperwork and we disconnected the autoplt, climbed back to FL350 and commenced a turn left to a heading of 340 degrees. The remainder of flight was uneventful. In discussion with the captain and reflection on what occurred, I believe the primary cause was temporary breakdown in crew coordination in carrying out standard procedures in setting an altitude/flight level into the MCP. Our company's SOP for setting altitudes/flight levels is for the PF to set the altitude and for pilot monitoring to audibly verify that the correct altitude/flight level was entered. Additionally, complacency on my part contributed because I allowed myself to get immersed in non flying activity, particularly when having just returned to the flight deck and not readjusting headset volume as well as situational awareness, ie, position of the aircraft. Also, FL340 is not a standard cruising flight level, which should have set off a warning flag in my own mind. Finally, I should have, at a minimum, queried the captain on what the clearance was given that I did not hear the radio transmission or response, and I should have repeated the flight level/altitude I set in the MCP until it elicited a response from the captain, which would have broken the chain and prevented the occurrence.
Original NASA ASRS Text
Title: AS MLG HAS AN ALT EXCURSION IN ZDC AIRSPACE BECAUSE OF THE PF MISTAKES A HDG FOR AN ASSIGNED ALT.
Narrative: I, AS THE CAPT, WAS THE PNF. CTR ASKED US TO TURN L TO HDG 330 DEGS. I READ BACK THE CLRNC AND VERIFIED IT WITH THE FO WHO WAS THE PF. THE VERY NEXT MOMENT, MY ATTN WAS DISTR BY THE INTERPHONE TO THE FLT ATTENDANT IN THE BACK. AS I WAS TALKING TO HER, CTR CAME UP ON THE RADIO AND ASKED US TO MAINTAIN FL350. I LOOKED UP AT THE ALTIMETER AND LOW AND BEHOLD I SAW US DSNDING THROUGH FL346. I GRABBED THE YOKE AND DISCONNECTED THE AUTOPLT AND CLBED US BACK TO FL350. I ASKED THE FO WHY HE BEGAN A DSCNT. HE TOLD ME THAT HE HAD NOT HEARD THE CTR'S CLRNC, AND WHEN HE LOOKED AT ME HE HEARD ME SAY '340,' SO HE THOUGHT THAT MEANT DSND TO FL340. I TOLD HIM WE NEVER USED '340' AS AN ALT. HE SUDDENLY REALIZED THIS AND SAID HE JUST HAD NOT HEARD THE CLRNC. I TOLD HIM THAT THE NEXT TIME HE DOESN'T HEAR A CLRNC, PLEASE LET ME KNOW SO WE CAN VERIFY IT. I FAULT MYSELF FOR NOT WATCHING HIM AND ALLOWING MYSELF TO BECOME DISTR. IT HAPPENED SO QUICKLY. SUPPLEMENTAL INFO FROM ACN 413649: ...AND HEARD HIM SAY '340.' I INCORRECTLY UNDERSTOOD THAT TO MEAN FL340 AND ENTERED THE ALT FL340 INTO THE MCP AND ON THE CRUISE PAGE OF THE FMC. WE STARTED DSNDING 1000 FT AND AT APPROX FL346 ZDC INSTRUCTED US TO MAINTAIN FL350 AND TURN L TO A HDG OF 340 DEGS. THE CAPT LOOKED UP FROM THE PAPERWORK AND WE DISCONNECTED THE AUTOPLT, CLBED BACK TO FL350 AND COMMENCED A TURN L TO A HDG OF 340 DEGS. THE REMAINDER OF FLT WAS UNEVENTFUL. IN DISCUSSION WITH THE CAPT AND REFLECTION ON WHAT OCCURRED, I BELIEVE THE PRIMARY CAUSE WAS TEMPORARY BREAKDOWN IN CREW COORD IN CARRYING OUT STANDARD PROCS IN SETTING AN ALT/FLT LEVEL INTO THE MCP. OUR COMPANY'S SOP FOR SETTING ALTS/FLT LEVELS IS FOR THE PF TO SET THE ALT AND FOR PLT MONITORING TO AUDIBLY VERIFY THAT THE CORRECT ALT/FLT LEVEL WAS ENTERED. ADDITIONALLY, COMPLACENCY ON MY PART CONTRIBUTED BECAUSE I ALLOWED MYSELF TO GET IMMERSED IN NON FLYING ACTIVITY, PARTICULARLY WHEN HAVING JUST RETURNED TO THE FLT DECK AND NOT READJUSTING HEADSET VOLUME AS WELL AS SITUATIONAL AWARENESS, IE, POS OF THE ACFT. ALSO, FL340 IS NOT A STANDARD CRUISING FLT LEVEL, WHICH SHOULD HAVE SET OFF A WARNING FLAG IN MY OWN MIND. FINALLY, I SHOULD HAVE, AT A MINIMUM, QUERIED THE CAPT ON WHAT THE CLRNC WAS GIVEN THAT I DID NOT HEAR THE RADIO XMISSION OR RESPONSE, AND I SHOULD HAVE REPEATED THE FLT LEVEL/ALT I SET IN THE MCP UNTIL IT ELICITED A RESPONSE FROM THE CAPT, WHICH WOULD HAVE BROKEN THE CHAIN AND PREVENTED THE OCCURRENCE.
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.