37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 485530 |
Time | |
Date | 200009 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | navaid : pvd.vortac |
State Reference | RI |
Altitude | msl bound lower : 16300 msl bound upper : 17000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zbw.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 other vortac |
Flight Phase | descent : vacating altitude |
Route In Use | arrival star : norwich |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 210 flight time total : 19000 flight time type : 1033 |
ASRS Report | 485530 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude inflight encounter other non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory flight crew : returned to assigned altitude |
Consequence | faa : reviewed incident with flight crew Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Environmental Factor Airspace Structure ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was the PF on the leg to bos. While proceeding inbound on the norwich 2 arrival descending to 11000 ft, the captain completed the descent checklist and left frequency to make a cabin PA announcement. During that time, ZBW issued holding instructions at pvd. We were relatively close to pvd and the FMS needed to be programmed for the hold. ZBW issued holding at, what I read back as, 11000 ft. As we passed through 17000 ft, the captain returned to the frequency. As we approached 16300 ft, ZBW asked our altitude. I read back 'through 16300 ft.' ZBW then replied with the assigned altitude of 17000 ft. I stated I read back 11000 ft and proceeded to climb back to 17000 ft. The captain asked me what was happening. I told him that the last known assigned altitude was 11000 ft, and that I also recalled acknowledging 11000 ft during the readback with no questions from the center. To this writing, however, I'm not sure if I may have missed a 17000 ft assignment since I was preoccupied with setting up the hold on the FMS. I believe that had the captain been in the loop, versus making a PA announcement, that this incident would not have happened. I also firmly believe that all non essential PA announcements should be reserved for above FL180. The northeast corridor is too busy of an area to have sterile cockpit procedures no less than below FL180. As this testimonial shows, 1 person out of the loop in a high density environment can prove to be a potential disaster waiting to happen. I can assure you that I will re-evaluate my procedures and that I will practice 'sterile cockpit' any time below FL180 in high density traffic areas.
Original NASA ASRS Text
Title: THE FO OF AN ACR TWIN JET FAILS TO LEVEL OFF AT AN AMENDED ALT DURING AN UNEXPECTED HOLD 11 MI E OF PVD, RI.
Narrative: I WAS THE PF ON THE LEG TO BOS. WHILE PROCEEDING INBOUND ON THE NORWICH 2 ARR DSNDING TO 11000 FT, THE CAPT COMPLETED THE DSCNT CHKLIST AND LEFT FREQ TO MAKE A CABIN PA ANNOUNCEMENT. DURING THAT TIME, ZBW ISSUED HOLDING INSTRUCTIONS AT PVD. WE WERE RELATIVELY CLOSE TO PVD AND THE FMS NEEDED TO BE PROGRAMMED FOR THE HOLD. ZBW ISSUED HOLDING AT, WHAT I READ BACK AS, 11000 FT. AS WE PASSED THROUGH 17000 FT, THE CAPT RETURNED TO THE FREQ. AS WE APCHED 16300 FT, ZBW ASKED OUR ALT. I READ BACK 'THROUGH 16300 FT.' ZBW THEN REPLIED WITH THE ASSIGNED ALT OF 17000 FT. I STATED I READ BACK 11000 FT AND PROCEEDED TO CLB BACK TO 17000 FT. THE CAPT ASKED ME WHAT WAS HAPPENING. I TOLD HIM THAT THE LAST KNOWN ASSIGNED ALT WAS 11000 FT, AND THAT I ALSO RECALLED ACKNOWLEDGING 11000 FT DURING THE READBACK WITH NO QUESTIONS FROM THE CTR. TO THIS WRITING, HOWEVER, I'M NOT SURE IF I MAY HAVE MISSED A 17000 FT ASSIGNMENT SINCE I WAS PREOCCUPIED WITH SETTING UP THE HOLD ON THE FMS. I BELIEVE THAT HAD THE CAPT BEEN IN THE LOOP, VERSUS MAKING A PA ANNOUNCEMENT, THAT THIS INCIDENT WOULD NOT HAVE HAPPENED. I ALSO FIRMLY BELIEVE THAT ALL NON ESSENTIAL PA ANNOUNCEMENTS SHOULD BE RESERVED FOR ABOVE FL180. THE NE CORRIDOR IS TOO BUSY OF AN AREA TO HAVE STERILE COCKPIT PROCS NO LESS THAN BELOW FL180. AS THIS TESTIMONIAL SHOWS, 1 PERSON OUT OF THE LOOP IN A HIGH DENSITY ENVIRONMENT CAN PROVE TO BE A POTENTIAL DISASTER WAITING TO HAPPEN. I CAN ASSURE YOU THAT I WILL RE-EVALUATE MY PROCS AND THAT I WILL PRACTICE 'STERILE COCKPIT' ANY TIME BELOW FL180 IN HIGH DENSITY TFC AREAS.
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.