An altitude deviation overshot when a B737-400 flight crew gets involved in an error chain while dep...

Attributes
ACN	538578
Time
Date	200202
Day	Mon
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : psp.airport
State Reference	CA
Altitude	msl bound lower : 13000 msl bound upper : 13800
Environment
Flight Conditions	VMC
Weather Elements	Turbulence
Light	Daylight
Aircraft 1
Controlling Facilities	artcc : zla.artcc tracon : psp.tracon
Operator	common carrier : air carrier
Make Model Name	B737-400
Operating Under FAR Part	Part 121
Navigation In Use	other
Flight Phase	climbout : vacating altitude
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : multi engine pilot : atp
Experience	flight time last 90 days : 180 flight time total : 6500 flight time type : 1100
ASRS Report	538578
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Events
Anomaly	altitude deviation : overshoot non adherence : published procedure non adherence : company policies non adherence : clearance
Independent Detector	other controllera
Resolutory Action	controller : issued advisory flight crew : returned to assigned altitude flight crew : became reoriented
Consequence	faa : reviewed incident with flight crew other
Supplementary
Problem Areas	Airspace Structure Cabin Crew Human Performance ATC Human Performance Environmental Factor Flight Crew Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Our altitude deviation occurred because of many events. I never thought it would happen to me. The chain of events started with the receipt of ATC clearance. A jump seater showed up right in the middle of receiving it, a company check airman. The captain thought the clearance was to 15000 ft, when it was actually to 13000 ft. The captain set 15000 ft in the altitude alerter. I didn't catch the mistake. The jump seater helped me get a job with the airline, and I was distracted talking with him. The next event in the chain was our pre-departure scan. The captain did the scan, I was xchking. As we got to the altitude (during the scan), the 'a' flight attendant asked us if we needed anything. We skipped over the altitude in the scan. The next event in the chain was just after takeoff. There was a cessna entering a straight-in downwind descending out of 4200 ft. We were distracted looking for the aircraft. Checked in with departure and read climbing to 15000 ft. Departure control acknowledged and immediately called traffic at 2-3 O'clock position. We saw the aircraft passing off our right. Next event was receipt of ZLA frequency. We were given 126.35. I read back 136.35, waited for response if incorrect, and switched the radio. We tried to contact ZLA twice on 136.35. We switched back to psp departure and received ZLA on 126.35. And 'by the way, you are only cleared to FL130,' we were passing through 13500 ft. We let the aircraft reach 13800 ft on the leveloff back to 13000 ft. We checked in with ZLA and confirmed leveling off back at 13000 ft. We then were given a climb to FL220. There was no traffic conflict. I pride myself on doing my job well, following every rule and procedure in place. The procedures are there to stop this from happening. The holes in the classic 'swiss cheese' incident/accident model just lined up. All we needed was an MEL'ed TCAS system and another aircraft coming the other way. It could have been ugly. As I said before, I never thought it would happen to me.

Original NASA ASRS Text

Title: AN ALTDEV OVERSHOT WHEN A B737-400 FLC GETS INVOLVED IN AN ERROR CHAIN WHILE DEP PSP, CA.

Narrative: OUR ALTDEV OCCURRED BECAUSE OF MANY EVENTS. I NEVER THOUGHT IT WOULD HAPPEN TO ME. THE CHAIN OF EVENTS STARTED WITH THE RECEIPT OF ATC CLRNC. A JUMP SEATER SHOWED UP RIGHT IN THE MIDDLE OF RECEIVING IT, A COMPANY CHK AIRMAN. THE CAPT THOUGHT THE CLRNC WAS TO 15000 FT, WHEN IT WAS ACTUALLY TO 13000 FT. THE CAPT SET 15000 FT IN THE ALT ALERTER. I DIDN'T CATCH THE MISTAKE. THE JUMP SEATER HELPED ME GET A JOB WITH THE AIRLINE, AND I WAS DISTRACTED TALKING WITH HIM. THE NEXT EVENT IN THE CHAIN WAS OUR PRE-DEP SCAN. THE CAPT DID THE SCAN, I WAS XCHKING. AS WE GOT TO THE ALT (DURING THE SCAN), THE 'A' FLT ATTENDANT ASKED US IF WE NEEDED ANYTHING. WE SKIPPED OVER THE ALT IN THE SCAN. THE NEXT EVENT IN THE CHAIN WAS JUST AFTER TKOF. THERE WAS A CESSNA ENTERING A STRAIGHT-IN DOWNWIND DSNDING OUT OF 4200 FT. WE WERE DISTRACTED LOOKING FOR THE ACFT. CHKED IN WITH DEP AND READ CLBING TO 15000 FT. DEP CTL ACKNOWLEDGED AND IMMEDIATELY CALLED TFC AT 2-3 O'CLOCK POS. WE SAW THE ACFT PASSING OFF OUR R. NEXT EVENT WAS RECEIPT OF ZLA FREQ. WE WERE GIVEN 126.35. I READ BACK 136.35, WAITED FOR RESPONSE IF INCORRECT, AND SWITCHED THE RADIO. WE TRIED TO CONTACT ZLA TWICE ON 136.35. WE SWITCHED BACK TO PSP DEP AND RECEIVED ZLA ON 126.35. AND 'BY THE WAY, YOU ARE ONLY CLRED TO FL130,' WE WERE PASSING THROUGH 13500 FT. WE LET THE ACFT REACH 13800 FT ON THE LEVELOFF BACK TO 13000 FT. WE CHKED IN WITH ZLA AND CONFIRMED LEVELING OFF BACK AT 13000 FT. WE THEN WERE GIVEN A CLB TO FL220. THERE WAS NO TFC CONFLICT. I PRIDE MYSELF ON DOING MY JOB WELL, FOLLOWING EVERY RULE AND PROC IN PLACE. THE PROCS ARE THERE TO STOP THIS FROM HAPPENING. THE HOLES IN THE CLASSIC 'SWISS CHEESE' INCIDENT/ACCIDENT MODEL JUST LINED UP. ALL WE NEEDED WAS AN MEL'ED TCAS SYS AND ANOTHER ACFT COMING THE OTHER WAY. IT COULD HAVE BEEN UGLY. AS I SAID BEFORE, I NEVER THOUGHT IT WOULD HAPPEN TO ME.

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.

An altitude deviation overshot when a B737-400 flight crew gets involved in an error chain while departure psp, ca.