 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Pilot of an air ambulance aeronautical commander AC690 climbed above assigned altitude when the passenger in the right seat accidentally disconnected the autoplt.
| Attributes | |
| ACN | 438882 |
| Time | |
| Date | 199906 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | navaid : lkt.vor |
| State Reference | ID |
| Altitude | msl bound lower : 17000 msl bound upper : 18300 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zlc.artcc |
| Operator | common carrier : air taxi |
| Make Model Name | Turbo Commander 690C |
| Operating Under FAR Part | Part 135 |
| Navigation In Use | other vortac |
| Flight Phase | cruise : level |
| Route In Use | enroute airway : v231.airway |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air taxi |
| Function | flight crew : single pilot |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 60 flight time total : 6300 flight time type : 300 |
| ASRS Report | 438882 |
| Person 2 | |
| Affiliation | other |
| Function | observation : passenger |
| Events | |
| Anomaly | airspace violation : entry altitude deviation : excursion from assigned altitude non adherence : clearance |
| Independent Detector | atc equipment other atc equipment : radar other controllera |
| Resolutory Action | controller : issued alert flight crew : returned to assigned airspace |
| Consequence | Other |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Air ambulance flight. Single pilot. Family member of patient riding in right front seat. Leveled off at 17000 ft. Autoplt was engaged in altitude hold mode. Aircraft stable. Pilot distraction by medical activity in back. Family member must have bumped autoplt disengage switch on right control yoke. Autoplt disengaged (there is no warning bell in this aircraft, just an annunciator light) and aircraft climbed to FL183 before ATC called to ask about altitude. Descended back to 17000 ft. No loss of separation. Altitude alerter had been set to anticipated altitude of FL180, rather than assigned altitude of 17000 ft. So warning bell didn't sound until approaching selected altitude. This is one of the hazards of allowing passenger to ride up front, compounded by pilot's failure to set altitude alerter properly and distrs from the cabin.
Original NASA ASRS Text
Title: PLT OF AN AIR AMBULANCE AERO COMMANDER AC690 CLBED ABOVE ASSIGNED ALT WHEN THE PAX IN THE R SEAT ACCIDENTALLY DISCONNECTED THE AUTOPLT.
Narrative: AIR AMBULANCE FLT. SINGLE PLT. FAMILY MEMBER OF PATIENT RIDING IN R FRONT SEAT. LEVELED OFF AT 17000 FT. AUTOPLT WAS ENGAGED IN ALT HOLD MODE. ACFT STABLE. PLT DISTR BY MEDICAL ACTIVITY IN BACK. FAMILY MEMBER MUST HAVE BUMPED AUTOPLT DISENGAGE SWITCH ON R CTL YOKE. AUTOPLT DISENGAGED (THERE IS NO WARNING BELL IN THIS ACFT, JUST AN ANNUNCIATOR LIGHT) AND ACFT CLBED TO FL183 BEFORE ATC CALLED TO ASK ABOUT ALT. DSNDED BACK TO 17000 FT. NO LOSS OF SEPARATION. ALT ALERTER HAD BEEN SET TO ANTICIPATED ALT OF FL180, RATHER THAN ASSIGNED ALT OF 17000 FT. SO WARNING BELL DIDN'T SOUND UNTIL APCHING SELECTED ALT. THIS IS ONE OF THE HAZARDS OF ALLOWING PAX TO RIDE UP FRONT, COMPOUNDED BY PLT'S FAILURE TO SET ALT ALERTER PROPERLY AND DISTRS FROM THE CABIN.
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.