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|
Attributes | |
ACN | 446640 |
Time | |
Date | 199908 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : dbq.vortac |
State Reference | IL |
Altitude | msl bound lower : 25000 msl bound upper : 25150 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Thunderstorm |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zau.artcc |
Operator | general aviation : corporate |
Make Model Name | HS 125 Series 700 |
Operating Under FAR Part | Part 91 |
Navigation In Use | other vortac |
Flight Phase | cruise : level |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zau.artcc |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 91 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Experience | flight time last 90 days : 120 flight time total : 1300 flight time type : 220 |
ASRS Report | 446648 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : clearance |
Independent Detector | aircraft equipment : tcas other controllera other flight crewa |
Resolutory Action | controller : issued new clearance controller : separated traffic flight crew : returned to assigned altitude |
Miss Distance | horizontal : 12000 vertical : 1000 |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
In the vicinity of dbq VOR, we were cleared to climb to FL250 by ZAU. The autoplt was engaged in heading and IAS modes. 2000 ft, 1000 ft and 300 ft altitude alert calls were made by copilot (PNF) to the captain (PF). These calls were acknowledged and the PF called leveling at FL250. Altitude hold on the autoplt was engaged at FL250 by the PF. Center called traffic at 12 O'clock and 8 mi at FL260 and advised us to maintain FL250. I scanned and located the traffic, a twin turboprop, at approximately 1 O'clock, 1000 ft above and 5 mi. I then glanced in at the altimeter to verify that we were still level at FL250 and saw that we had drifted up approximately 150 ft and that the PF was correcting the situation by commanding the autoplt to pitch down (which automatically kicked the altitude hold 'offline'). I additionally noted the ivsi trending down. I then called center with the traffic in sight, no factor, and that we were heading back down to FL250. The turboprop called to advise that they were climbing reference their TCASII. Center then called to question what altitude we were cleared to. I advised them FL250. Center then asked why did I reply heading back to FL250 and advised us of a possible pilot deviation. The captain (PF) then told center that the autoplt had drifted up to FL251.5 and we had then immediately descended back down. The controller replied that it was all on tape, advised us to climb to a specified altitude and contact the next controller. During this conversation the turboprop advised that he was returning to FL260. The incident described lasted approximately 5 mins. Chain of events. The problem arose due to: 1) a malfunction in the autoplt's altitude hold function. 2) failure of the flight crew to quickly notice that the autoplt was drifting above FL250 and take timely corrective action. Contributing factors: 1) 'soft' failure of the altitude hold function of the autoplt (ie, no warning flags). 2) confusing radio call that we were heading back down to FL250. How it was discovered: 1) my radio call that we were returning to FL250 after drifting up to FL251.5. 2) other aircraft's TCASII. Corrective actions: 1) management, chief pilot and all line pilots have been advised of problem with the autoplt. 2) a review of proper radio procedures and replies to ATC clrncs was made by PNF. Human performance considerations: lack of attention in monitoring the autoplt.
Original NASA ASRS Text
Title: PLT RPTS AUTOPLT DID NOT HOLD ALT AS PROGRAMMED CAUSING DEV FROM ASSIGNED.
Narrative: IN THE VICINITY OF DBQ VOR, WE WERE CLRED TO CLB TO FL250 BY ZAU. THE AUTOPLT WAS ENGAGED IN HDG AND IAS MODES. 2000 FT, 1000 FT AND 300 FT ALT ALERT CALLS WERE MADE BY COPLT (PNF) TO THE CAPT (PF). THESE CALLS WERE ACKNOWLEDGED AND THE PF CALLED LEVELING AT FL250. ALT HOLD ON THE AUTOPLT WAS ENGAGED AT FL250 BY THE PF. CTR CALLED TFC AT 12 O'CLOCK AND 8 MI AT FL260 AND ADVISED US TO MAINTAIN FL250. I SCANNED AND LOCATED THE TFC, A TWIN TURBOPROP, AT APPROX 1 O'CLOCK, 1000 FT ABOVE AND 5 MI. I THEN GLANCED IN AT THE ALTIMETER TO VERIFY THAT WE WERE STILL LEVEL AT FL250 AND SAW THAT WE HAD DRIFTED UP APPROX 150 FT AND THAT THE PF WAS CORRECTING THE SIT BY COMMANDING THE AUTOPLT TO PITCH DOWN (WHICH AUTOMATICALLY KICKED THE ALT HOLD 'OFFLINE'). I ADDITIONALLY NOTED THE IVSI TRENDING DOWN. I THEN CALLED CTR WITH THE TFC IN SIGHT, NO FACTOR, AND THAT WE WERE HEADING BACK DOWN TO FL250. THE TURBOPROP CALLED TO ADVISE THAT THEY WERE CLBING REF THEIR TCASII. CTR THEN CALLED TO QUESTION WHAT ALT WE WERE CLRED TO. I ADVISED THEM FL250. CTR THEN ASKED WHY DID I REPLY HDG BACK TO FL250 AND ADVISED US OF A POSSIBLE PLTDEV. THE CAPT (PF) THEN TOLD CTR THAT THE AUTOPLT HAD DRIFTED UP TO FL251.5 AND WE HAD THEN IMMEDIATELY DSNDED BACK DOWN. THE CTLR REPLIED THAT IT WAS ALL ON TAPE, ADVISED US TO CLB TO A SPECIFIED ALT AND CONTACT THE NEXT CTLR. DURING THIS CONVERSATION THE TURBOPROP ADVISED THAT HE WAS RETURNING TO FL260. THE INCIDENT DESCRIBED LASTED APPROX 5 MINS. CHAIN OF EVENTS. THE PROB AROSE DUE TO: 1) A MALFUNCTION IN THE AUTOPLT'S ALT HOLD FUNCTION. 2) FAILURE OF THE FLC TO QUICKLY NOTICE THAT THE AUTOPLT WAS DRIFTING ABOVE FL250 AND TAKE TIMELY CORRECTIVE ACTION. CONTRIBUTING FACTORS: 1) 'SOFT' FAILURE OF THE ALT HOLD FUNCTION OF THE AUTOPLT (IE, NO WARNING FLAGS). 2) CONFUSING RADIO CALL THAT WE WERE HEADING BACK DOWN TO FL250. HOW IT WAS DISCOVERED: 1) MY RADIO CALL THAT WE WERE RETURNING TO FL250 AFTER DRIFTING UP TO FL251.5. 2) OTHER ACFT'S TCASII. CORRECTIVE ACTIONS: 1) MGMNT, CHIEF PLT AND ALL LINE PLTS HAVE BEEN ADVISED OF PROB WITH THE AUTOPLT. 2) A REVIEW OF PROPER RADIO PROCS AND REPLIES TO ATC CLRNCS WAS MADE BY PNF. HUMAN PERFORMANCE CONSIDERATIONS: LACK OF ATTN IN MONITORING THE AUTOPLT.
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.