37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 494510 |
Time | |
Date | 200012 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : sns.vortac |
State Reference | CA |
Altitude | msl bound lower : 15700 msl bound upper : 16200 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa.artcc tracon : m87.tracon |
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 |
Route In Use | arrival star : big sur two |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : flight engineer pilot : atp pilot : cfi pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 180 flight time total : 12000 flight time type : 2000 |
ASRS Report | 494510 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : undershoot non adherence : clearance non adherence : company policies non adherence : far non adherence : published procedure non adherence other |
Independent Detector | atc equipment other atc equipment : radar aircraft equipment other aircraft equipment : altimetr other controllera other flight crewa |
Resolutory Action | aircraft : automation overrode flight crew controller : issued alert flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Inbound to san francisco, we were assigned to hold at anjee intersection on the big sur arrival. The first officer was flying, using FMC and (I think) autoplt. The hold was unexpected, and we only had limited hold fuel available. We were given several progressively lower altitude, including FL180, followed by 16000 ft, prior to attaining FL180. The first officer was concerned about our fuel state, and asked several questions as I tried to work out hold time available, inform our dispatcher, and determine a suitable alternate. These distrs caused me to miss the failure to reset our altimeters to 30.07 during the descent, and to miss the first officer's descent below 16000 ft. My first indication of the altitude deviation was the controller asking us to verify if our altimeters were reset. My altimeter indicated approximately 15700 ft, and about 15850 ft when set to 30.07. The first officer may have disconnected the autoplt and pulled back on the yoke, starting a rapid climb. I observed him still climbing through 16000 ft and put my hands on the yoke. I informed him that we should hold at 16000 ft. He indicated surprise that, though the ADI indicated 'altitude hold' it wasn't capturing. By 16200 ft, I was pushing forward on the yoke and indicating that I didn't care what the computer or autoplt said or did, we must maintain 16000 ft. We rose to about 16350 ft, then started down to 16000 ft. At this point the first officer re-engaged the autoplt and we leveled off at 16000 ft. The only other airplane I observed on TCASII in the holding stack was at 12000 ft.
Original NASA ASRS Text
Title: FO OF AN ACR MLG OVERSHOT INTERMEDIATE DSCNT ALT ON A STAR ARR AND THEN OVERSHOT RETURNING TO ASSIGNED DUE TO RELYING ON THE FMC AND AUTOPLT. IN ADDITION, THE ALTIMETERS WERE NOT RESET AFTER LEAVING FL180.
Narrative: INBOUND TO SAN FRANCISCO, WE WERE ASSIGNED TO HOLD AT ANJEE INTXN ON THE BIG SUR ARR. THE FO WAS FLYING, USING FMC AND (I THINK) AUTOPLT. THE HOLD WAS UNEXPECTED, AND WE ONLY HAD LIMITED HOLD FUEL AVAILABLE. WE WERE GIVEN SEVERAL PROGRESSIVELY LOWER ALT, INCLUDING FL180, FOLLOWED BY 16000 FT, PRIOR TO ATTAINING FL180. THE FO WAS CONCERNED ABOUT OUR FUEL STATE, AND ASKED SEVERAL QUESTIONS AS I TRIED TO WORK OUT HOLD TIME AVAILABLE, INFORM OUR DISPATCHER, AND DETERMINE A SUITABLE ALTERNATE. THESE DISTRS CAUSED ME TO MISS THE FAILURE TO RESET OUR ALTIMETERS TO 30.07 DURING THE DSCNT, AND TO MISS THE FO'S DSCNT BELOW 16000 FT. MY FIRST INDICATION OF THE ALTDEV WAS THE CTLR ASKING US TO VERIFY IF OUR ALTIMETERS WERE RESET. MY ALTIMETER INDICATED APPROX 15700 FT, AND ABOUT 15850 FT WHEN SET TO 30.07. THE FO MAY HAVE DISCONNECTED THE AUTOPLT AND PULLED BACK ON THE YOKE, STARTING A RAPID CLB. I OBSERVED HIM STILL CLBING THROUGH 16000 FT AND PUT MY HANDS ON THE YOKE. I INFORMED HIM THAT WE SHOULD HOLD AT 16000 FT. HE INDICATED SURPRISE THAT, THOUGH THE ADI INDICATED 'ALT HOLD' IT WASN'T CAPTURING. BY 16200 FT, I WAS PUSHING FORWARD ON THE YOKE AND INDICATING THAT I DIDN'T CARE WHAT THE COMPUTER OR AUTOPLT SAID OR DID, WE MUST MAINTAIN 16000 FT. WE ROSE TO ABOUT 16350 FT, THEN STARTED DOWN TO 16000 FT. AT THIS POINT THE FO RE-ENGAGED THE AUTOPLT AND WE LEVELED OFF AT 16000 FT. THE ONLY OTHER AIRPLANE I OBSERVED ON TCASII IN THE HOLDING STACK WAS AT 12000 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.