37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 423405 |
Time | |
Date | 199812 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : cbm airport : ubs |
State Reference | MS |
Altitude | msl bound lower : 17000 msl bound upper : 17400 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : pdx |
Operator | general aviation : corporate |
Make Model Name | Cessna Citation Undifferentiated or Other Model |
Navigation In Use | Other |
Route In Use | departure other enroute airway : ztl |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi |
Experience | flight time last 90 days : 120 flight time total : 11750 flight time type : 1360 |
ASRS Report | 423405 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 150 flight time total : 17300 flight time type : 10 |
ASRS Report | 422950 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot other anomaly other |
Independent Detector | other flight crewa |
Consequence | Other |
Supplementary | |
Air Traffic Incident | Pilot Deviation |
Narrative:
Twice during this particular climb out did we climb through an assigned altitude -- first 17000 ft while still with cbm departure control, and second, FL230 during the handoff to ZTL. There was no conflict, no targets were showing on the TCASII within 20 mi. Upon recognition of deviation we immediately returned to assigned altitude. There was no indication by ATC that any conflict or problem had occurred. From postflt analysis of what could have caused this to happen to 2 seasoned professionals, we concluded that there were 4 things that cumulatively contributed to us missing assigned altitudes. 1) unfamiliarity of PF with subtle differences between the autoplt/flight director system in this airplane and the one he normally flies. The PF on this leg of a multi-leg trip is a 20 yr airline veteran, an excellent pilot with no blemishes on his record. He was flying with us that day as a contract pilot, filling in while 2 of our staff pilots were at flight safety for recurrent training. On the aircraft type that he flies for his airline, the autoplt system allows you to keep using the thumb trim wheel all the way to leveloff without affecting the 'altitude capture' mode. On our aircraft, however, once 'altitude select' switches to 'altitude capture' mode (usually around 300-400 ft before reaching selected altitude, depending on rate), any use of the thumb trim wheel will disconnect the 'altitude capture' mode (and 'altitude select' for that matter). Out of his habit of wanting to provide the smoothest possible leveloff, he unknowingly disconnected the 'altitude capture' mode. 2) we discovered on the subsequent climb to our final altitude of FL290 that the altitude select aural tone warning, that is supposed to chime at 1000 ft before reaching selected altitude, and at 300 ft deviation from selected altitude, was not working. It had been operating normally on the previous legs of this flight, but had apparently failed on this climb out (murphy's law!). During the remainder of this flight we verified that it was not giving the aural warning it is supposed to, and it was written up as a squawk at the end of the flight. Maintenance subsequently found a chafed wire leading to the bell (horn) in the overhead, and determined that to be the cause for the failure. 3) this was a relatively short leg, with rather high workload for the PNF -- cleaning up after departure, obtaining WX at destination, and preparing for arrival, handling the radio work, and doing some company required paperwork. 4) radio frequencys were very congested, constant 'noise' so to speak, which probably contributed to our attention being somewhat diverted. We both feel that the first 2 items were the main cause for the altdevs, but this clearly demonstrates the need for increased vigilance when crew members are not used to the same equipment, and especially when they are new to each other as a crew. We also feel that our subconscious reliance on automatic features, such as the autoplt automatic leveloff and the altitude alert warning bell, can easily get one in trouble when these features discretely choose to fail. Supplemental information from acn 422950: on aircraft I usually fly a B747-400. Once in altitude capture mode, you must select vertical speed before the vertical speed rate wheel is active, preventing pilot from disengaging automatic altitude capture (a 2 step method). In the citation, the vertical speed rate wheel is always active, and therefore could be bumped or used and disengage automatic altitude capture. The vertical speed wheel is located on rear of center pedestal between pilots where it could be brushed or bumped.
Original NASA ASRS Text
Title: FO OF A CESSNA CITATION OVERSHOT ASSIGNED ALT ON 2 OCCASIONS DURING CLBOUT DUE TO THE ALT ALERT NOT SOUNDING AS DESIGNED AND MISPROGRAMMING THE AUTOPLT CAPTURE MODE.
Narrative: TWICE DURING THIS PARTICULAR CLBOUT DID WE CLB THROUGH AN ASSIGNED ALT -- FIRST 17000 FT WHILE STILL WITH CBM DEP CTL, AND SECOND, FL230 DURING THE HDOF TO ZTL. THERE WAS NO CONFLICT, NO TARGETS WERE SHOWING ON THE TCASII WITHIN 20 MI. UPON RECOGNITION OF DEV WE IMMEDIATELY RETURNED TO ASSIGNED ALT. THERE WAS NO INDICATION BY ATC THAT ANY CONFLICT OR PROB HAD OCCURRED. FROM POSTFLT ANALYSIS OF WHAT COULD HAVE CAUSED THIS TO HAPPEN TO 2 SEASONED PROFESSIONALS, WE CONCLUDED THAT THERE WERE 4 THINGS THAT CUMULATIVELY CONTRIBUTED TO US MISSING ASSIGNED ALTS. 1) UNFAMILIARITY OF PF WITH SUBTLE DIFFERENCES BTWN THE AUTOPLT/FLT DIRECTOR SYS IN THIS AIRPLANE AND THE ONE HE NORMALLY FLIES. THE PF ON THIS LEG OF A MULTI-LEG TRIP IS A 20 YR AIRLINE VETERAN, AN EXCELLENT PLT WITH NO BLEMISHES ON HIS RECORD. HE WAS FLYING WITH US THAT DAY AS A CONTRACT PLT, FILLING IN WHILE 2 OF OUR STAFF PLTS WERE AT FLT SAFETY FOR RECURRENT TRAINING. ON THE ACFT TYPE THAT HE FLIES FOR HIS AIRLINE, THE AUTOPLT SYS ALLOWS YOU TO KEEP USING THE THUMB TRIM WHEEL ALL THE WAY TO LEVELOFF WITHOUT AFFECTING THE 'ALT CAPTURE' MODE. ON OUR ACFT, HOWEVER, ONCE 'ALT SELECT' SWITCHES TO 'ALT CAPTURE' MODE (USUALLY AROUND 300-400 FT BEFORE REACHING SELECTED ALT, DEPENDING ON RATE), ANY USE OF THE THUMB TRIM WHEEL WILL DISCONNECT THE 'ALT CAPTURE' MODE (AND 'ALT SELECT' FOR THAT MATTER). OUT OF HIS HABIT OF WANTING TO PROVIDE THE SMOOTHEST POSSIBLE LEVELOFF, HE UNKNOWINGLY DISCONNECTED THE 'ALT CAPTURE' MODE. 2) WE DISCOVERED ON THE SUBSEQUENT CLB TO OUR FINAL ALT OF FL290 THAT THE ALT SELECT AURAL TONE WARNING, THAT IS SUPPOSED TO CHIME AT 1000 FT BEFORE REACHING SELECTED ALT, AND AT 300 FT DEV FROM SELECTED ALT, WAS NOT WORKING. IT HAD BEEN OPERATING NORMALLY ON THE PREVIOUS LEGS OF THIS FLT, BUT HAD APPARENTLY FAILED ON THIS CLBOUT (MURPHY'S LAW!). DURING THE REMAINDER OF THIS FLT WE VERIFIED THAT IT WAS NOT GIVING THE AURAL WARNING IT IS SUPPOSED TO, AND IT WAS WRITTEN UP AS A SQUAWK AT THE END OF THE FLT. MAINT SUBSEQUENTLY FOUND A CHAFED WIRE LEADING TO THE BELL (HORN) IN THE OVERHEAD, AND DETERMINED THAT TO BE THE CAUSE FOR THE FAILURE. 3) THIS WAS A RELATIVELY SHORT LEG, WITH RATHER HIGH WORKLOAD FOR THE PNF -- CLEANING UP AFTER DEP, OBTAINING WX AT DEST, AND PREPARING FOR ARR, HANDLING THE RADIO WORK, AND DOING SOME COMPANY REQUIRED PAPERWORK. 4) RADIO FREQS WERE VERY CONGESTED, CONSTANT 'NOISE' SO TO SPEAK, WHICH PROBABLY CONTRIBUTED TO OUR ATTN BEING SOMEWHAT DIVERTED. WE BOTH FEEL THAT THE FIRST 2 ITEMS WERE THE MAIN CAUSE FOR THE ALTDEVS, BUT THIS CLRLY DEMONSTRATES THE NEED FOR INCREASED VIGILANCE WHEN CREW MEMBERS ARE NOT USED TO THE SAME EQUIP, AND ESPECIALLY WHEN THEY ARE NEW TO EACH OTHER AS A CREW. WE ALSO FEEL THAT OUR SUBCONSCIOUS RELIANCE ON AUTOMATIC FEATURES, SUCH AS THE AUTOPLT AUTOMATIC LEVELOFF AND THE ALT ALERT WARNING BELL, CAN EASILY GET ONE IN TROUBLE WHEN THESE FEATURES DISCRETELY CHOOSE TO FAIL. SUPPLEMENTAL INFO FROM ACN 422950: ON ACFT I USUALLY FLY A B747-400. ONCE IN ALT CAPTURE MODE, YOU MUST SELECT VERT SPD BEFORE THE VERT SPD RATE WHEEL IS ACTIVE, PREVENTING PLT FROM DISENGAGING AUTO ALT CAPTURE (A 2 STEP METHOD). IN THE CITATION, THE VERT SPD RATE WHEEL IS ALWAYS ACTIVE, AND THEREFORE COULD BE BUMPED OR USED AND DISENGAGE AUTO ALT CAPTURE. THE VERT SPD WHEEL IS LOCATED ON REAR OF CTR PEDESTAL BTWN PLTS WHERE IT COULD BE BRUSHED OR BUMPED.
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.