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A B737-200 flight crew climbs above their last assigned altitude when the captain fails to set that newly assigned altitude in their altitude alerter. Zan, ak.
| Attributes | |
| ACN | 458139 |
| Time | |
| Date | 199912 |
| Day | Sun |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| State Reference | AK |
| Altitude | msl bound lower : 29000 msl bound upper : 33000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zan.artcc tracon : phl.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B737-200 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other other |
| Flight Phase | climbout : vacating altitude cruise : level |
| Route In Use | enroute : direct |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : flight engineer pilot : atp pilot : cfi |
| Experience | flight time last 90 days : 300 flight time total : 15000 flight time type : 3000 |
| ASRS Report | 458139 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : atp |
| Experience | flight time last 90 days : 205 flight time total : 16000 flight time type : 4000 |
| ASRS Report | 458263 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : company policies other anomaly other |
| Independent Detector | atc equipment other atc equipment : radar, mode c other controllera |
| Resolutory Action | controller : issued advisory controller : issued new clearance |
| Supplementary | |
| Problem Areas | ATC Human Performance Airspace Structure Flight Crew Human Performance ATC Facility |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Cleared R99-saldo-akn-as filed to maintain FL330. Radar contact was established with center climbing through 15000 ft. Reclred GPS direct gasto-anc-direct with a FL290 restr. We were minimum fuel to anc with a cordova alternate, with deteriorating WX throughout anchorage bowel. First officer was flying. I made a mental calculation on our fuel requirement before accepting the clearance. Then read back clearance, programmed GPS. The altitude alerter was not reset. First officer states he did not hear the FL290 restr. Climbing through FL315, ATC alerted us to altitude bust. We descended and were reclred to FL310. There was no traffic conflict this time, but could have been different in more congested location. Poor technique programming GPS prior to setting altitude alerter. Set altitude alerter first. Made callout to first officer, then programmed GPS. Poor crew coordination. PF was unable to back up clearance. Supplemental information from acn 458263: we were FMS and GPS equipped to perform this routing. I was hand flying as normal in our aircraft, while the captain (PNF) was handling all communications. After leveling off at FL330 for a few mins, the controller asked us what altitude we were at. The captain responded that we were at FL330. The controller then said we had only been cleared to FL290. I started an immediate descent. The controller then said to level off at FL310. The captain (PNF) remembered receiving and reading back the revised altitude clearance. This was at the same time as we received the direct to gasto instruction. I, the PF, cannot remember hearing the altitude restr. I was busy flying and reprogramming the FMS, and did not assimilate the new altitude clearance. This error occurred due to a high mental workload for both pilots and the controller, and under-using our automation by hand flying while listening to several revised clrncs. The flight crew needs to use the appropriate level of automation. In this ase, the autoplt on, in order to both concentrate on communications and new ATC clrncs during a high workload period. Our B737-200 operation has the lowest level of automation in our fleet, but FMS/GPS has been operational in our 200 fleet for about a yr.
Original NASA ASRS Text
Title: A B737-200 FLC CLBS ABOVE THEIR LAST ASSIGNED ALT WHEN THE CAPT FAILS TO SET THAT NEWLY ASSIGNED ALT IN THEIR ALT ALERTER. ZAN, AK.
Narrative: CLRED R99-SALDO-AKN-AS FILED TO MAINTAIN FL330. RADAR CONTACT WAS ESTABLISHED WITH CTR CLBING THROUGH 15000 FT. RECLRED GPS DIRECT GASTO-ANC-DIRECT WITH A FL290 RESTR. WE WERE MINIMUM FUEL TO ANC WITH A CORDOVA ALTERNATE, WITH DETERIORATING WX THROUGHOUT ANCHORAGE BOWEL. FO WAS FLYING. I MADE A MENTAL CALCULATION ON OUR FUEL REQUIREMENT BEFORE ACCEPTING THE CLRNC. THEN READ BACK CLRNC, PROGRAMMED GPS. THE ALT ALERTER WAS NOT RESET. FO STATES HE DID NOT HEAR THE FL290 RESTR. CLBING THROUGH FL315, ATC ALERTED US TO ALT BUST. WE DSNDED AND WERE RECLRED TO FL310. THERE WAS NO TFC CONFLICT THIS TIME, BUT COULD HAVE BEEN DIFFERENT IN MORE CONGESTED LOCATION. POOR TECHNIQUE PROGRAMMING GPS PRIOR TO SETTING ALT ALERTER. SET ALT ALERTER FIRST. MADE CALLOUT TO FO, THEN PROGRAMMED GPS. POOR CREW COORD. PF WAS UNABLE TO BACK UP CLRNC. SUPPLEMENTAL INFO FROM ACN 458263: WE WERE FMS AND GPS EQUIPPED TO PERFORM THIS ROUTING. I WAS HAND FLYING AS NORMAL IN OUR ACFT, WHILE THE CAPT (PNF) WAS HANDLING ALL COMS. AFTER LEVELING OFF AT FL330 FOR A FEW MINS, THE CTLR ASKED US WHAT ALT WE WERE AT. THE CAPT RESPONDED THAT WE WERE AT FL330. THE CTLR THEN SAID WE HAD ONLY BEEN CLRED TO FL290. I STARTED AN IMMEDIATE DSCNT. THE CTLR THEN SAID TO LEVEL OFF AT FL310. THE CAPT (PNF) REMEMBERED RECEIVING AND READING BACK THE REVISED ALT CLRNC. THIS WAS AT THE SAME TIME AS WE RECEIVED THE DIRECT TO GASTO INSTRUCTION. I, THE PF, CANNOT REMEMBER HEARING THE ALT RESTR. I WAS BUSY FLYING AND REPROGRAMMING THE FMS, AND DID NOT ASSIMILATE THE NEW ALT CLRNC. THIS ERROR OCCURRED DUE TO A HIGH MENTAL WORKLOAD FOR BOTH PLTS AND THE CTLR, AND UNDER-USING OUR AUTOMATION BY HAND FLYING WHILE LISTENING TO SEVERAL REVISED CLRNCS. THE FLC NEEDS TO USE THE APPROPRIATE LEVEL OF AUTOMATION. IN THIS ASE, THE AUTOPLT ON, IN ORDER TO BOTH CONCENTRATE ON COMS AND NEW ATC CLRNCS DURING A HIGH WORKLOAD PERIOD. OUR B737-200 OP HAS THE LOWEST LEVEL OF AUTOMATION IN OUR FLEET, BUT FMS/GPS HAS BEEN OPERATIONAL IN OUR 200 FLEET FOR ABOUT A YR.
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.