37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 439990 |
Time | |
Date | 199906 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : pdz.vor |
State Reference | CA |
Altitude | msl single value : 12000 |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon tower : cgi.tower |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival star : pdz 3 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 439990 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : became reoriented flight crew : overrode automation |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On pdz arrival approaching tejay intersection, inadvertently went approximately 300 ft below while 1 mi short of fix. Was in VNAV with altitude set to 10000 ft per the arrival. ATC injected several speed reductions. First officer, flying, switched to flight level change mode to handle ATC speeds and this negated FMC altitude management protections. I was unaware of mode change and we had called out the 13000 ft call but due to task loading first officer descended through 12000 ft. We smoothly stopped descent and regained altitude with no comment from ATC, and no apparent traffic conflict per TCASII. Event occurred due to rapid pace of ATC speed fluctuations and navigation task loading as we were turning on the arrival and switching frequencys, etc. More verbalization of mode changes might have heightened my awareness. We will be more alert to task saturation and prioritizing in the future.
Original NASA ASRS Text
Title: ACR FLC INATTENTIVENESS LEADS TO DSCNT THROUGH ALT RESTR ON A STAR INTO LAX.
Narrative: ON PDZ ARR APCHING TEJAY INTXN, INADVERTENTLY WENT APPROX 300 FT BELOW WHILE 1 MI SHORT OF FIX. WAS IN VNAV WITH ALT SET TO 10000 FT PER THE ARR. ATC INJECTED SEVERAL SPD REDUCTIONS. FO, FLYING, SWITCHED TO FLT LEVEL CHANGE MODE TO HANDLE ATC SPDS AND THIS NEGATED FMC ALT MGMNT PROTECTIONS. I WAS UNAWARE OF MODE CHANGE AND WE HAD CALLED OUT THE 13000 FT CALL BUT DUE TO TASK LOADING FO DSNDED THROUGH 12000 FT. WE SMOOTHLY STOPPED DSCNT AND REGAINED ALT WITH NO COMMENT FROM ATC, AND NO APPARENT TFC CONFLICT PER TCASII. EVENT OCCURRED DUE TO RAPID PACE OF ATC SPD FLUCTUATIONS AND NAV TASK LOADING AS WE WERE TURNING ON THE ARR AND SWITCHING FREQS, ETC. MORE VERBALIZATION OF MODE CHANGES MIGHT HAVE HEIGHTENED MY AWARENESS. WE WILL BE MORE ALERT TO TASK SATURATION AND PRIORITIZING IN THE FUTURE.
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.