37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 513640 |
Time | |
Date | 200106 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : zob.artcc |
State Reference | OH |
Altitude | msl bound lower : 20000 msl bound upper : 20500 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | artcc : zob.artcc |
Operator | other |
Make Model Name | Gulfstream I (Large Turboprop) |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude |
Person 1 | |
Affiliation | government other |
Function | flight crew : captain |
Qualification | pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 11500 flight time type : 650 |
ASRS Report | 513640 |
Person 2 | |
Affiliation | government other |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far non adherence : published procedure non adherence : company policies non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During climb I failed to level off at the assigned altitude of FL200. I overshot the leveloff by 500 ft, then immediately returned to assigned altitude. I didn't notice that the altitude preselect/capture button was not engaged on my flight director. As a result, the flight director did not command a leveloff and capture the altitude. Even though the first officer called, 'out of 19 for 20,' I still missed the leveloff. I think a momentary distraction at a critical point in the climb was the cause of the deviation. This is probably a human factors issue, but attempting to evaluate my own performance is difficult. It's hard to be objective. So I will now conduct a personal performance audit, but not by myself. I will ask for the input and guidance from my chief pilot and other instructor pilots in our organization. It's a good idea to do an in-depth evaluation of our performance from time to time, and in light of this recent event, I'm going to do mine now.
Original NASA ASRS Text
Title: G159 CREW HAD ALT OVERSHOT IN ZOB CLASS A.
Narrative: DURING CLB I FAILED TO LEVEL OFF AT THE ASSIGNED ALT OF FL200. I OVERSHOT THE LEVELOFF BY 500 FT, THEN IMMEDIATELY RETURNED TO ASSIGNED ALT. I DIDN'T NOTICE THAT THE ALT PRESELECT/CAPTURE BUTTON WAS NOT ENGAGED ON MY FLT DIRECTOR. AS A RESULT, THE FLT DIRECTOR DID NOT COMMAND A LEVELOFF AND CAPTURE THE ALT. EVEN THOUGH THE FO CALLED, 'OUT OF 19 FOR 20,' I STILL MISSED THE LEVELOFF. I THINK A MOMENTARY DISTR AT A CRITICAL POINT IN THE CLB WAS THE CAUSE OF THE DEV. THIS IS PROBABLY A HUMAN FACTORS ISSUE, BUT ATTEMPTING TO EVALUATE MY OWN PERFORMANCE IS DIFFICULT. IT'S HARD TO BE OBJECTIVE. SO I WILL NOW CONDUCT A PERSONAL PERFORMANCE AUDIT, BUT NOT BY MYSELF. I WILL ASK FOR THE INPUT AND GUIDANCE FROM MY CHIEF PLT AND OTHER INSTRUCTOR PLTS IN OUR ORGANIZATION. IT'S A GOOD IDEA TO DO AN IN-DEPTH EVALUATION OF OUR PERFORMANCE FROM TIME TO TIME, AND IN LIGHT OF THIS RECENT EVENT, I'M GOING TO DO MINE NOW.
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.