<< >> NASA ASRS Report 514570, June 2001

An EMB120 flight crew improperly uses the autoplt, so it fails to capture altitude. The aircraft was 700 ft high.

Attributes
ACN	514570
Time
Date	200106
Day	Fri
Local Time Of Day	0601 To 1200
Place
Locale Reference	airport : bfl.airport
State Reference	CA
Altitude	msl bound lower : 21000 msl bound upper : 21700
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	Brasilia EMB-120 All Series
Flight Phase	climbout : intermediate altitude
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : multi engine pilot : atp pilot : cfi
Experience	flight time last 90 days : 240 flight time total : 5400 flight time type : 2400
ASRS Report	514570
Events
Anomaly	altitude deviation : overshoot non adherence : clearance other anomaly other
Resolutory Action	aircraft : automation overrode flight crew controller : issued new clearance
Consequence	faa : reviewed incident with flight crew
Supplementary
Problem Areas	Flight Crew Human Performance Aircraft ATC Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Cleared to final cruise altitude of FL210. Climbing at approximately 500 FPM. At approximately FL202, ZLA issues a pilot's discretion descent to 15000 ft. Aircraft on autoplt and captain resets altitude alerter to 15000 ft and crew decides not to initiate descent at this time. At FL217, captain notices altitude deviation and directs first officer (PF) to return to FL210. Resetting altitude alerter prior to autoplt capturing final cruise altitude allowed aircraft to continue climb above cleared altitude. Loss of crew situational awareness and/or autoplt usage procedures were primary contributing factors. The center-issued descent to a lower altitude while in a climb was a lesser factor. Possible ways to avoid recurrence: change in company procedure on how to use altitude alerter for discretion dscnts (ie, only reset when current altitude assignment is captured by autoplt). ATC should not issue discretion dscnts unless aircraft is in level flight or already in a descent.

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Original NASA ASRS Text

Title: AN EMB120 FLT CREW IMPROPERLY USES THE AUTOPLT, SO IT FAILS TO CAPTURE ALT. THE ACFT WAS 700 FT HIGH.

Narrative: CLRED TO FINAL CRUISE ALT OF FL210. CLBING AT APPROX 500 FPM. AT APPROX FL202, ZLA ISSUES A PLT'S DISCRETION DSCNT TO 15000 FT. ACFT ON AUTOPLT AND CAPT RESETS ALT ALERTER TO 15000 FT AND CREW DECIDES NOT TO INITIATE DSCNT AT THIS TIME. AT FL217, CAPT NOTICES ALTDEV AND DIRECTS FO (PF) TO RETURN TO FL210. RESETTING ALT ALERTER PRIOR TO AUTOPLT CAPTURING FINAL CRUISE ALT ALLOWED ACFT TO CONTINUE CLB ABOVE CLRED ALT. LOSS OF CREW SITUATIONAL AWARENESS AND/OR AUTOPLT USAGE PROCS WERE PRIMARY CONTRIBUTING FACTORS. THE CTR-ISSUED DSCNT TO A LOWER ALT WHILE IN A CLB WAS A LESSER FACTOR. POSSIBLE WAYS TO AVOID RECURRENCE: CHANGE IN COMPANY PROC ON HOW TO USE ALT ALERTER FOR DISCRETION DSCNTS (IE, ONLY RESET WHEN CURRENT ALT ASSIGNMENT IS CAPTURED BY AUTOPLT). ATC SHOULD NOT ISSUE DISCRETION DSCNTS UNLESS ACFT IS IN LEVEL FLT OR ALREADY IN A DSCNT.

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.