37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 455220 |
Time | |
Date | 199911 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : aml.vor |
State Reference | VA |
Altitude | msl single value : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 10000 flight time type : 2000 |
ASRS Report | 455220 |
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 |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Event: when descending to 12000 ft, the master caution light illuminated as I was leveling off. Attention was diverted to the overhead panel to identify the malfunction. (A previous malfunction had occurred and corrective action performed.) because of weak lighting, proper identify was difficult. As I idented the malfunction, I also observed that I had deviated 400 ft below the assigned altitude. I immediately corrected to the proper altitude. The controller made no call and TCASII showed no aircraft within 20 mi. The malfunction was written up and the system was disabled and an MEL was documented. Chain of events: the malfunction occurred during a critical phase of flight which diverted both pilot's attention. Timely identify prevented PF from returning to flying duties. Once idented, flying duties corrected deviation. Human performance: pilot tendencies are to identify the malfunction and direct corrective action. When caution system cannot readily identify problem, then both pilot's diversion is almost imminent. Lack of self discipline caused me to fail to level the aircraft at the proper altitude. Had the caution system adequately illuminated the malfunction, this would not have occurred.
Original NASA ASRS Text
Title: A DC9 FLC DSNDED BELOW THE ASSIGNED ALT NEAR AML.
Narrative: EVENT: WHEN DSNDING TO 12000 FT, THE MASTER CAUTION LIGHT ILLUMINATED AS I WAS LEVELING OFF. ATTN WAS DIVERTED TO THE OVERHEAD PANEL TO IDENT THE MALFUNCTION. (A PREVIOUS MALFUNCTION HAD OCCURRED AND CORRECTIVE ACTION PERFORMED.) BECAUSE OF WEAK LIGHTING, PROPER IDENT WAS DIFFICULT. AS I IDENTED THE MALFUNCTION, I ALSO OBSERVED THAT I HAD DEVIATED 400 FT BELOW THE ASSIGNED ALT. I IMMEDIATELY CORRECTED TO THE PROPER ALT. THE CTLR MADE NO CALL AND TCASII SHOWED NO ACFT WITHIN 20 MI. THE MALFUNCTION WAS WRITTEN UP AND THE SYS WAS DISABLED AND AN MEL WAS DOCUMENTED. CHAIN OF EVENTS: THE MALFUNCTION OCCURRED DURING A CRITICAL PHASE OF FLT WHICH DIVERTED BOTH PLT'S ATTN. TIMELY IDENT PREVENTED PF FROM RETURNING TO FLYING DUTIES. ONCE IDENTED, FLYING DUTIES CORRECTED DEV. HUMAN PERFORMANCE: PLT TENDENCIES ARE TO IDENT THE MALFUNCTION AND DIRECT CORRECTIVE ACTION. WHEN CAUTION SYS CANNOT READILY IDENT PROB, THEN BOTH PLT'S DIVERSION IS ALMOST IMMINENT. LACK OF SELF DISCIPLINE CAUSED ME TO FAIL TO LEVEL THE ACFT AT THE PROPER ALT. HAD THE CAUTION SYS ADEQUATELY ILLUMINATED THE MALFUNCTION, THIS WOULD NOT HAVE OCCURRED.
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.