37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 482940 |
Time | |
Date | 200008 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : har.vortac |
State Reference | PA |
Altitude | msl bound lower : 17000 msl bound upper : 22000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | common carrier : air carrier |
Operating Under FAR Part | Part 121 |
Navigation In Use | other other vortac |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival star : bunts |
Flight Plan | IFR |
Person 1 | |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 11000 flight time type : 5600 |
ASRS Report | 482940 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Experience | flight time type : 200 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Company ATC Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were given a clearance to cross har at 17000 ft, 250 KTS, the first officer was flying. We failed to comply with the clearance and crossed har at 22000 ft. This required the controller to vector us in a right 360 degrees to avoid climbing traffic. The reason for the failure to comply was that 22000 ft was put in the MCP instead of 17000 ft, and it was not caught by either of us. Factors leading up to the incident were: first officer was relatively new to the aircraft and glass cockpit, having around 200 hours. We were flying the aircraft with new software (pegasus) without adequate training (in my opinion). A handout was all that we were given, which I had to use cookbook fashion. I was trying to instruct first officer in use of software while I was reading/practicing. He was distracted with this as was I. The biggest factor was that we had been given an expect holding information at the same time we were given descent instructions, and I didn't ensure first officer placed proper altitude in MCP, I was programming descent and holding fix. I was trying to contact dispatch (had left center frequency) to discuss holding and necessity of an alternate. I had been off center frequency for 2-3 mins, (never got in touch with dispatch). Came back after given vector. I was preoccupied with determining holding fuel available and alternative actions, we were low on fuel (15 mins maximum holding available). I have no idea why 22000 ft was placed in MCP, we were descending from 25000 ft.
Original NASA ASRS Text
Title: AN S80 FLC FAILS TO MAKE THEIR ASSIGNED ALT XING AT HAR, PA.
Narrative: WE WERE GIVEN A CLRNC TO CROSS HAR AT 17000 FT, 250 KTS, THE FO WAS FLYING. WE FAILED TO COMPLY WITH THE CLRNC AND CROSSED HAR AT 22000 FT. THIS REQUIRED THE CTLR TO VECTOR US IN A R 360 DEGS TO AVOID CLBING TFC. THE REASON FOR THE FAILURE TO COMPLY WAS THAT 22000 FT WAS PUT IN THE MCP INSTEAD OF 17000 FT, AND IT WAS NOT CAUGHT BY EITHER OF US. FACTORS LEADING UP TO THE INCIDENT WERE: FO WAS RELATIVELY NEW TO THE ACFT AND GLASS COCKPIT, HAVING AROUND 200 HRS. WE WERE FLYING THE ACFT WITH NEW SOFTWARE (PEGASUS) WITHOUT ADEQUATE TRAINING (IN MY OPINION). A HANDOUT WAS ALL THAT WE WERE GIVEN, WHICH I HAD TO USE COOKBOOK FASHION. I WAS TRYING TO INSTRUCT FO IN USE OF SOFTWARE WHILE I WAS READING/PRACTICING. HE WAS DISTRACTED WITH THIS AS WAS I. THE BIGGEST FACTOR WAS THAT WE HAD BEEN GIVEN AN EXPECT HOLDING INFO AT THE SAME TIME WE WERE GIVEN DSCNT INSTRUCTIONS, AND I DIDN'T ENSURE FO PLACED PROPER ALT IN MCP, I WAS PROGRAMMING DSCNT AND HOLDING FIX. I WAS TRYING TO CONTACT DISPATCH (HAD LEFT CTR FREQ) TO DISCUSS HOLDING AND NECESSITY OF AN ALTERNATE. I HAD BEEN OFF CTR FREQ FOR 2-3 MINS, (NEVER GOT IN TOUCH WITH DISPATCH). CAME BACK AFTER GIVEN VECTOR. I WAS PREOCCUPIED WITH DETERMINING HOLDING FUEL AVAILABLE AND ALTERNATIVE ACTIONS, WE WERE LOW ON FUEL (15 MINS MAX HOLDING AVAILABLE). I HAVE NO IDEA WHY 22000 FT WAS PLACED IN MCP, WE WERE DSNDING FROM 25000 FT.
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.