37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 474800 |
Time | |
Date | 200005 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : las.vortac |
State Reference | NV |
Altitude | msl bound lower : 15000 msl bound upper : 16000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla.artcc tower : pdk.tower |
Operator | common carrier : air carrier |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 135 |
Navigation In Use | other vortac |
Flight Phase | cruise : level |
Route In Use | enroute airway : ns.airway |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Experience | flight time last 90 days : 180 flight time total : 2800 flight time type : 350 |
ASRS Report | 474800 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 2200 flight time type : 4000 |
ASRS Report | 474683 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne critical non adherence : clearance non adherence : company policies other anomaly other other spatial deviation |
Independent Detector | atc equipment : conflict alert other controllera |
Resolutory Action | flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | vertical : 0 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
ZLA cleared us up to 15000 ft. We mistakenly set 16000 ft and leveled off at 16000 ft. We were then advised of our mistake and instructed to deviate to avoid traffic. Mistake caused by human error. Supplemental information from acn 474683: when we leveled off at 16000 ft, we were instructed to make a 90 degree turn to avoid head-on traffic. I set 16000 ft in the altitude alerter by mistake. I believe this mistake was caused by fatigue by both crew members. This was the first flight of the day and we just had gotten off a 12 hour rest period. I was on my 6TH duty day. I believe I read back 15000 ft but inadvertently set 16000 ft. The copilot did not catch the error.
Original NASA ASRS Text
Title: A BE1900 FLC LEVELS OFF 100 FT ABOVE THEIR ASSIGNED ALT AND ARE TURNED IMMEDIATELY BY ATC TO AVOID OPPOSITE DIRECTION, SAME ALT TFC, 90 NM NE OF LAS, NV.
Narrative: ZLA CLRED US UP TO 15000 FT. WE MISTAKENLY SET 16000 FT AND LEVELED OFF AT 16000 FT. WE WERE THEN ADVISED OF OUR MISTAKE AND INSTRUCTED TO DEVIATE TO AVOID TFC. MISTAKE CAUSED BY HUMAN ERROR. SUPPLEMENTAL INFO FROM ACN 474683: WHEN WE LEVELED OFF AT 16000 FT, WE WERE INSTRUCTED TO MAKE A 90 DEG TURN TO AVOID HEAD-ON TFC. I SET 16000 FT IN THE ALT ALERTER BY MISTAKE. I BELIEVE THIS MISTAKE WAS CAUSED BY FATIGUE BY BOTH CREW MEMBERS. THIS WAS THE FIRST FLT OF THE DAY AND WE JUST HAD GOTTEN OFF A 12 HR REST PERIOD. I WAS ON MY 6TH DUTY DAY. I BELIEVE I READ BACK 15000 FT BUT INADVERTENTLY SET 16000 FT. THE COPLT DID NOT CATCH THE ERROR.
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.