37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 515683 |
Time | |
Date | 200106 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : bsv.vor |
Altitude | msl bound lower : 12000 msl bound upper : 12400 |
Environment | |
Flight Conditions | Mixed |
Weather Elements | Turbulence Thunderstorm |
Aircraft 1 | |
Controlling Facilities | artcc : zob.artcc |
Operator | common carrier : air carrier |
Make Model Name | SF 340A |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zob.artcc |
Operator | common carrier : air carrier |
Make Model Name | Fokker 100 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 3500 flight time type : 1000 |
ASRS Report | 515683 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : weather non adherence : company policies non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude flight crew : became reoriented |
Supplementary | |
Problem Areas | Weather Aircraft Airspace Structure Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Event occurred on third day of a 4-DAY trip. First day's overnight was scheduled reduced rest (8 hours) which caused noticeable fatigue and decreased synergy between myself and my first officer. The leg being operated was the 6TH leg of a 6 leg day. The crew had reported at XA30. For the past 3 days, all flts preceding incident were conducted in dense air traffic and thunderstorms -- increasing our workload more than normal. The first officer (PNF) was relatively new with approximately 70 hours in type and 5 months at our company. On climb out from pit, crew was cleared by ZOB to 'climb and maintain 16000 ft.' due to a full load of passenger and cargo, in addition to warm outside air temperatures, aircraft climb performance was limited to 700 FPM. Because our aircraft was not climbing fast enough, center instructed us to 'stop climb at 12000 ft' so he could climb an F100 above us. PNF first officer read back instructions, however, did not verify new altitude was set in altitude preselect by PF PIC, as is our standard company procedure. PF neglected to set 12000 ft into altitude preselect. PNF first officer was then distraction by a call from the flight attendant, a checklist and the need to obtain a climb torque setting from performance charts. PF flew through 12000 ft and did not notice altitude deviation until 12300 ft. He initiated an immediate descent, however, aircraft did not begin descending until 12400 ft (400 ft above assigned altitude). Flight continued to tol with no further incident.
Original NASA ASRS Text
Title: THE PIC OF AN SF340 CLBS 400 FT ABOVE HIS REASSIGNED ALT WHEN THE FO FAILS TO SET THE ALERTER. THE PIC CITED THAT AS THE PIC'S DUTY AS THE PF.
Narrative: EVENT OCCURRED ON THIRD DAY OF A 4-DAY TRIP. FIRST DAY'S OVERNIGHT WAS SCHEDULED REDUCED REST (8 HRS) WHICH CAUSED NOTICEABLE FATIGUE AND DECREASED SYNERGY BTWN MYSELF AND MY FO. THE LEG BEING OPERATED WAS THE 6TH LEG OF A 6 LEG DAY. THE CREW HAD RPTED AT XA30. FOR THE PAST 3 DAYS, ALL FLTS PRECEDING INCIDENT WERE CONDUCTED IN DENSE AIR TFC AND TSTMS -- INCREASING OUR WORKLOAD MORE THAN NORMAL. THE FO (PNF) WAS RELATIVELY NEW WITH APPROX 70 HRS IN TYPE AND 5 MONTHS AT OUR COMPANY. ON CLBOUT FROM PIT, CREW WAS CLRED BY ZOB TO 'CLB AND MAINTAIN 16000 FT.' DUE TO A FULL LOAD OF PAX AND CARGO, IN ADDITION TO WARM OUTSIDE AIR TEMPS, ACFT CLB PERFORMANCE WAS LIMITED TO 700 FPM. BECAUSE OUR ACFT WAS NOT CLBING FAST ENOUGH, CTR INSTRUCTED US TO 'STOP CLB AT 12000 FT' SO HE COULD CLB AN F100 ABOVE US. PNF FO READ BACK INSTRUCTIONS, HOWEVER, DID NOT VERIFY NEW ALT WAS SET IN ALT PRESELECT BY PF PIC, AS IS OUR STANDARD COMPANY PROC. PF NEGLECTED TO SET 12000 FT INTO ALT PRESELECT. PNF FO WAS THEN DISTR BY A CALL FROM THE FLT ATTENDANT, A CHKLIST AND THE NEED TO OBTAIN A CLB TORQUE SETTING FROM PERFORMANCE CHARTS. PF FLEW THROUGH 12000 FT AND DID NOT NOTICE ALTDEV UNTIL 12300 FT. HE INITIATED AN IMMEDIATE DSCNT, HOWEVER, ACFT DID NOT BEGIN DSNDING UNTIL 12400 FT (400 FT ABOVE ASSIGNED ALT). FLT CONTINUED TO TOL WITH NO FURTHER INCIDENT.
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.