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An air carrier twin jet levels off at the previously assigned altitude of FL280 versus the newly cleared to altitude of FL290 when the crew becomes distraction, having failed to reset the FMC to FL290 near dnv, il.
| Attributes | |
| ACN | 476520 |
| Time | |
| Date | 200006 |
| Day | Tue |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| State Reference | IL |
| Altitude | msl bound lower : 28000 msl bound upper : 29000 |
| Environment | |
| Flight Conditions | Mixed |
| Weather Elements | Thunderstorm |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : zau.artcc |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | cruise : level |
| Route In Use | enroute : direct |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 100 flight time total : 14000 flight time type : 3800 |
| ASRS Report | 476520 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : multi engine pilot : instrument pilot : commercial |
| Events | |
| Anomaly | altitude deviation : undershoot non adherence : company policies non adherence : clearance other anomaly other |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued advisory |
| Consequence | Other |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
The traps of automation and crew vigilance. During WX deviations and routing changes, we were assigned to climb to FL290. We were using FMC system. While the first officer was looking up a NAVAID we were cleared to and I was talking to ATC and flying the aircraft. I failed to notice that the FMC had leveled us off at FL280. This was the original flight plan altitude loaded into the system before takeoff and had not been updated yet for the new assigned altitude. It was when center asked us to climb to FL290 again that I realized what happened. Contributing factors: workload management, distrs with route changes and WX deviations, decision making. It comes back to fly the aircraft first, which I failed to do on my part. It's too easy to rely on the automation and become distraction into complacency.
Original NASA ASRS Text
Title: AN ACR TWIN JET LEVELS OFF AT THE PREVIOUSLY ASSIGNED ALT OF FL280 VERSUS THE NEWLY CLRED TO ALT OF FL290 WHEN THE CREW BECOMES DISTR, HAVING FAILED TO RESET THE FMC TO FL290 NEAR DNV, IL.
Narrative: THE TRAPS OF AUTOMATION AND CREW VIGILANCE. DURING WX DEVS AND ROUTING CHANGES, WE WERE ASSIGNED TO CLB TO FL290. WE WERE USING FMC SYS. WHILE THE FO WAS LOOKING UP A NAVAID WE WERE CLRED TO AND I WAS TALKING TO ATC AND FLYING THE ACFT. I FAILED TO NOTICE THAT THE FMC HAD LEVELED US OFF AT FL280. THIS WAS THE ORIGINAL FLT PLAN ALT LOADED INTO THE SYS BEFORE TKOF AND HAD NOT BEEN UPDATED YET FOR THE NEW ASSIGNED ALT. IT WAS WHEN CTR ASKED US TO CLB TO FL290 AGAIN THAT I REALIZED WHAT HAPPENED. CONTRIBUTING FACTORS: WORKLOAD MGMNT, DISTRS WITH RTE CHANGES AND WX DEVS, DECISION MAKING. IT COMES BACK TO FLY THE ACFT FIRST, WHICH I FAILED TO DO ON MY PART. IT'S TOO EASY TO RELY ON THE AUTOMATION AND BECOME DISTR INTO COMPLACENCY.
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.