B737-200 crew had altitude overshoot in ZKC class a.

Attributes
ACN	534964
Time
Date	200201
Day	Sun
Local Time Of Day	0601 To 1200
Place
Locale Reference	navaid : sgf.vortac
State Reference	MO
Altitude	msl bound lower : 35000 msl bound upper : 35400
Environment
Light	Daylight
Aircraft 1
Controlling Facilities	artcc : zkc.artcc
Operator	common carrier : air carrier
Make Model Name	B737-200
Operating Under FAR Part	Part 121
Flight Phase	cruise : level
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 250 flight time total : 23224 flight time type : 20700
ASRS Report	534964
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Events
Anomaly	aircraft equipment problem : less severe altitude deviation : overshoot non adherence : far non adherence : published procedure non adherence : company policies other anomaly other
Independent Detector	aircraft equipment : altitude alert other controllera other flight crewa other flight crewb
Resolutory Action	controller : issued alert controller : issued new clearance flight crew : returned to assigned altitude none taken : detected after the fact
Consequence	other other
Supplementary
Problem Areas	FAA Company Flight Crew Human Performance Aircraft
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Altitude deviation. All operations normal until leveloff at FL350. I observed the first officer level the aircraft and place the altitude hold on. About 30 seconds later I heard the altitude alert aural warning go off. I looked up and discovered that the aircraft was now at FL354. I took control of the aircraft and brought it back to level flight. The center controller asked us our altitude and I informed him that we were correcting back to FL350. He then asked us to change frequencys. Later on, during the same flight, I realized what had happened. When the first officer rotated the altitude hold switch, being unfamiliar with the -200, he rotated it too hard and actually took the switch past the 'altitude hold' position and to a 'detent' that officially does not exist. The switch stayed in that position but it did not control the altitude. Also, the trub function of that switch did not work. Actually, it was impossible to rotate the switch counterclockwise into the turbulence position. The problem was definitely in that switch. I don't think any other elements factor into this altitude deviation. The switch did not work properly. The first officer was not experienced enough in the -200 to realize the amount of rotation needed to actuate 'altitude hold,' and that he had rotated it past 'altitude hold.' I would be less than candid if I did not disclose that I am a permanent 'pm' flyer and that I was now flying an 'am' trip. I was coming off a 3-DAY block of time off, and had received ample rest time, though it is true I woke up 3 hours earlier than I normally would have. I felt rested and alert. How could this have been prevented? 1) eliminate the multiple types of aircraft that we fly. That would mean less types of autoplt/AFDS panels to become familiar with. More continuity with the equipment means less chance of missing the switches. 2) give first officer more training in the -200 autoplt stressing the altitude hold function.

Original NASA ASRS Text

Title: B737-200 CREW HAD ALT OVERSHOOT IN ZKC CLASS A.

Narrative: ALTDEV. ALL OPS NORMAL UNTIL LEVELOFF AT FL350. I OBSERVED THE FO LEVEL THE ACFT AND PLACE THE ALT HOLD ON. ABOUT 30 SECONDS LATER I HEARD THE ALT ALERT AURAL WARNING GO OFF. I LOOKED UP AND DISCOVERED THAT THE ACFT WAS NOW AT FL354. I TOOK CTL OF THE ACFT AND BROUGHT IT BACK TO LEVEL FLT. THE CTR CTLR ASKED US OUR ALT AND I INFORMED HIM THAT WE WERE CORRECTING BACK TO FL350. HE THEN ASKED US TO CHANGE FREQS. LATER ON, DURING THE SAME FLT, I REALIZED WHAT HAD HAPPENED. WHEN THE FO ROTATED THE ALT HOLD SWITCH, BEING UNFAMILIAR WITH THE -200, HE ROTATED IT TOO HARD AND ACTUALLY TOOK THE SWITCH PAST THE 'ALT HOLD' POS AND TO A 'DETENT' THAT OFFICIALLY DOES NOT EXIST. THE SWITCH STAYED IN THAT POS BUT IT DID NOT CTL THE ALT. ALSO, THE TRUB FUNCTION OF THAT SWITCH DID NOT WORK. ACTUALLY, IT WAS IMPOSSIBLE TO ROTATE THE SWITCH COUNTERCLOCKWISE INTO THE TURB POS. THE PROB WAS DEFINITELY IN THAT SWITCH. I DON'T THINK ANY OTHER ELEMENTS FACTOR INTO THIS ALTDEV. THE SWITCH DID NOT WORK PROPERLY. THE FO WAS NOT EXPERIENCED ENOUGH IN THE -200 TO REALIZE THE AMOUNT OF ROTATION NEEDED TO ACTUATE 'ALT HOLD,' AND THAT HE HAD ROTATED IT PAST 'ALT HOLD.' I WOULD BE LESS THAN CANDID IF I DID NOT DISCLOSE THAT I AM A PERMANENT 'PM' FLYER AND THAT I WAS NOW FLYING AN 'AM' TRIP. I WAS COMING OFF A 3-DAY BLOCK OF TIME OFF, AND HAD RECEIVED AMPLE REST TIME, THOUGH IT IS TRUE I WOKE UP 3 HRS EARLIER THAN I NORMALLY WOULD HAVE. I FELT RESTED AND ALERT. HOW COULD THIS HAVE BEEN PREVENTED? 1) ELIMINATE THE MULTIPLE TYPES OF ACFT THAT WE FLY. THAT WOULD MEAN LESS TYPES OF AUTOPLT/AFDS PANELS TO BECOME FAMILIAR WITH. MORE CONTINUITY WITH THE EQUIP MEANS LESS CHANCE OF MISSING THE SWITCHES. 2) GIVE FO MORE TRAINING IN THE -200 AUTOPLT STRESSING THE ALT HOLD FUNCTION.

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.