37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 423095 |
Time | |
Date | 199812 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : dqo airport : phl |
State Reference | DE |
Altitude | msl bound lower : 5000 msl bound upper : 6000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Operator | common carrier : air taxi |
Make Model Name | MU-2 Undifferentiated or Other Model |
Route In Use | departure other enroute : direct |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8 Series Undifferentiated or Other Model |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer oversight : pic |
Qualification | pilot : cfi |
Experience | flight time last 90 days : 137 flight time total : 2576 flight time type : 551 |
ASRS Report | 423095 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : single pilot instruction : trainee |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe other anomaly other |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | Other |
Miss Distance | horizontal : 24000 vertical : 900 |
Supplementary | |
Air Traffic Incident | Pilot Deviation |
Narrative:
This flight was operated as a part 135, unscheduled operation carrying bank checks for the federal reserve. I was PIC, acting as PNF, sitting in the right seat. The pilot in the left seat was PIC qualified and current in type. We had departed runway 17 on the phl 6 departure, and were assigned runway heading to 5000 ft. Departure control vectored us to the southwest, then told us to proceed direct to dupont VOR, which was about 20 NM west of our position. The dash 8 had departed runway 27L and was climbing to 8000 ft direct to dupont. Our operations are usually conducted single pilot, and no CRM has been included in any of our company training. On this flight, the PF had been assigned as a sic to build experience with a qualified captain, before being released on his own. We were using a portable intercom to communicate, which was not working very well, and intracockpit communications were very limited. The PF was doing all the flying and working the radios. I was just observing, yet was the assigned PIC. Adding to the confusion was the use of the altitude alerter. This particular alerter has 4 dials to dial in the altitude, with each dial moving 1 digit. The alerter makes a continuous loud tone from 1000 ft below to 200 ft below the selected altitude. Normally, this is no problem. However, when using the portable intercom, the microphone on the pilot's headset picks up the alerter's tone and it overwhelms the volume on the radios and voice on the intercom. It is also quite uncomfortable. We had gotten around this by selecting an altitude 10000 ft above our assigned altitude on the alerter, so that the chime would not go off, but the alerter would still provide a visual reminder to the pilot in the left seat, as it is not visible from the right seat. So, on the morning of dec/xa/99 we departed runway 17, and were turned towards dqo. We had the dash 8 in sight, and were climbing to 5000 ft. At 4000 ft the alerter went off, and I reached over to select 15000 ft instead of 5000 ft. Unfortunately, I selected 6000 ft, because I turned the wrong knob, and did not realize this. The PF assumed we were cleared to 6000 ft and continued the climb to 6000 ft. ATC advised us of traffic at 12 O'clock, 3 mi, a dash 8 climbing through 6800 ft for 8000 ft, and we replied that we had them in sight. Then ATC told us that they had not yet cleared us to 6000 ft, our en route cruising altitude, but to maintain it now. I feel this deviation occurred because of several reasons: 1) a lack of formal CRM training because of the predominant single pilot operation. 2) nonstandard use of the altitude alerter and portable intercom causing a breakdown in CRM. 3) the effects of chronic fatigue. This was the last leg of the week, during which 4 night, 24 hours and 24 lndgs. This led to both pilots taking a rest right before the final wake- up, taxi and takeoff within 20 mins. While WX was checked and paperwork completed, the airplane was loaded and we left in a somewhat tired, semi-alert condition.
Original NASA ASRS Text
Title: AN MU2 FLC OVERSHOT THEIR ASSIGNED ALT WHEN THE PIC SITTING IN THE R SEAT SETS THE ALT ALERTER TO THE WRONG ALT. POTENTIAL CONFLICT ENSUES.
Narrative: THIS FLT WAS OPERATED AS A PART 135, UNSCHEDULED OP CARRYING BANK CHKS FOR THE FEDERAL RESERVE. I WAS PIC, ACTING AS PNF, SITTING IN THE R SEAT. THE PLT IN THE L SEAT WAS PIC QUALIFIED AND CURRENT IN TYPE. WE HAD DEPARTED RWY 17 ON THE PHL 6 DEP, AND WERE ASSIGNED RWY HDG TO 5000 FT. DEP CTL VECTORED US TO THE SW, THEN TOLD US TO PROCEED DIRECT TO DUPONT VOR, WHICH WAS ABOUT 20 NM W OF OUR POS. THE DASH 8 HAD DEPARTED RWY 27L AND WAS CLBING TO 8000 FT DIRECT TO DUPONT. OUR OPS ARE USUALLY CONDUCTED SINGLE PLT, AND NO CRM HAS BEEN INCLUDED IN ANY OF OUR COMPANY TRAINING. ON THIS FLT, THE PF HAD BEEN ASSIGNED AS A SIC TO BUILD EXPERIENCE WITH A QUALIFIED CAPT, BEFORE BEING RELEASED ON HIS OWN. WE WERE USING A PORTABLE INTERCOM TO COMMUNICATE, WHICH WAS NOT WORKING VERY WELL, AND INTRACOCKPIT COMS WERE VERY LIMITED. THE PF WAS DOING ALL THE FLYING AND WORKING THE RADIOS. I WAS JUST OBSERVING, YET WAS THE ASSIGNED PIC. ADDING TO THE CONFUSION WAS THE USE OF THE ALT ALERTER. THIS PARTICULAR ALERTER HAS 4 DIALS TO DIAL IN THE ALT, WITH EACH DIAL MOVING 1 DIGIT. THE ALERTER MAKES A CONTINUOUS LOUD TONE FROM 1000 FT BELOW TO 200 FT BELOW THE SELECTED ALT. NORMALLY, THIS IS NO PROB. HOWEVER, WHEN USING THE PORTABLE INTERCOM, THE MIKE ON THE PLT'S HEADSET PICKS UP THE ALERTER'S TONE AND IT OVERWHELMS THE VOLUME ON THE RADIOS AND VOICE ON THE INTERCOM. IT IS ALSO QUITE UNCOMFORTABLE. WE HAD GOTTEN AROUND THIS BY SELECTING AN ALT 10000 FT ABOVE OUR ASSIGNED ALT ON THE ALERTER, SO THAT THE CHIME WOULD NOT GO OFF, BUT THE ALERTER WOULD STILL PROVIDE A VISUAL REMINDER TO THE PLT IN THE L SEAT, AS IT IS NOT VISIBLE FROM THE R SEAT. SO, ON THE MORNING OF DEC/XA/99 WE DEPARTED RWY 17, AND WERE TURNED TOWARDS DQO. WE HAD THE DASH 8 IN SIGHT, AND WERE CLBING TO 5000 FT. AT 4000 FT THE ALERTER WENT OFF, AND I REACHED OVER TO SELECT 15000 FT INSTEAD OF 5000 FT. UNFORTUNATELY, I SELECTED 6000 FT, BECAUSE I TURNED THE WRONG KNOB, AND DID NOT REALIZE THIS. THE PF ASSUMED WE WERE CLRED TO 6000 FT AND CONTINUED THE CLB TO 6000 FT. ATC ADVISED US OF TFC AT 12 O'CLOCK, 3 MI, A DASH 8 CLBING THROUGH 6800 FT FOR 8000 FT, AND WE REPLIED THAT WE HAD THEM IN SIGHT. THEN ATC TOLD US THAT THEY HAD NOT YET CLRED US TO 6000 FT, OUR ENRTE CRUISING ALT, BUT TO MAINTAIN IT NOW. I FEEL THIS DEV OCCURRED BECAUSE OF SEVERAL REASONS: 1) A LACK OF FORMAL CRM TRAINING BECAUSE OF THE PREDOMINANT SINGLE PLT OP. 2) NONSTANDARD USE OF THE ALT ALERTER AND PORTABLE INTERCOM CAUSING A BREAKDOWN IN CRM. 3) THE EFFECTS OF CHRONIC FATIGUE. THIS WAS THE LAST LEG OF THE WK, DURING WHICH 4 NIGHT, 24 HRS AND 24 LNDGS. THIS LED TO BOTH PLTS TAKING A REST RIGHT BEFORE THE FINAL WAKE- UP, TAXI AND TKOF WITHIN 20 MINS. WHILE WX WAS CHKED AND PAPERWORK COMPLETED, THE AIRPLANE WAS LOADED AND WE LEFT IN A SOMEWHAT TIRED, SEMI-ALERT CONDITION.
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.