37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 539358 |
Time | |
Date | 200202 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : tpa.airport |
State Reference | FL |
Altitude | msl bound lower : 11000 msl bound upper : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : tpa.tracon |
Operator | general aviation : corporate |
Make Model Name | Learjet 25 |
Operating Under FAR Part | Part 135 |
Flight Phase | descent : vacating altitude |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 200 flight time total : 7700 flight time type : 500 |
ASRS Report | 539358 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 250 flight time total : 5000 flight time type : 2500 |
ASRS Report | 539481 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far non adherence : published procedure non adherence : clearance |
Independent Detector | atc equipment other atc equipment : radar other controllera other flight crewa |
Resolutory Action | controller : issued alert controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While descending for landing, we had an altitude incursion. I was the first officer and the PF while the captain was handling the radios and checklists. We had received several step-downs and during these the captain was occupied talking to the medical crew in the cabin, running checklists, finishing final paperwork, and communicating with ATC. During the course of the descent we alternated in setting the altitude alerter because the captain's hands were literally full at times and also because it was on the right side of the cockpit. While descending to 13000 ft we got a clearance to 12000 ft, the captain acknowledged ATC, and no one set the alerter to the new altitude (presumably each assuming the other would set it). I thought I heard 11000 ft and continued down to that altitude when simultaneously the captain and ATC informed me of the 12000 ft clearance. ATC informed us that no corrective action was necessary and we continued the descent to a normal landing. The problem was caused by my failure to understand and verify the correct altitude. I believe standardized altitude alerter procedures should be used in any multi-member crewed aircraft. The PNF should acknowledge the clearance to ATC, set the alerter, point to the alerter and verbalize the new altitude to the PF, and the PF should point to the alerter and repeat aloud the new altitude. This was a failure of basic CRM. I think part 135 operators need to emphasize basic CRM and defined duties for flying and PNF's more. I also think a standardized location of the alerter in the center of the cockpit might eliminate some of the inclination of the closer pilot to 'help' the other guy by setting it. Supplemental information from acn 539481: we were very soon thereafter cleared to 12000 ft. I am not sure who answered this call as I had preoccupied myself with other things. When I looked forward we were leveling at 11000 ft and altitude preselect was set at 13000 ft. About the same time I queried the first officer, tampa queried us about our altitude. I told tampa we were at 11000 ft. Then another aircraft called us in sight. Tampa told us we should be at 12000 ft. I apologized and he answered not to worry, that it didn't cause a problem. I distracted myself from my duties by taking a picture and in the process distracted the rest of the crew also.
Original NASA ASRS Text
Title: AN LJ25 CREW, DSNDING INTO TPA, OVERSHOT THEIR ASSIGNED ALT.
Narrative: WHILE DSNDING FOR LNDG, WE HAD AN ALT INCURSION. I WAS THE FO AND THE PF WHILE THE CAPT WAS HANDLING THE RADIOS AND CHKLISTS. WE HAD RECEIVED SEVERAL STEP-DOWNS AND DURING THESE THE CAPT WAS OCCUPIED TALKING TO THE MEDICAL CREW IN THE CABIN, RUNNING CHKLISTS, FINISHING FINAL PAPERWORK, AND COMMUNICATING WITH ATC. DURING THE COURSE OF THE DSCNT WE ALTERNATED IN SETTING THE ALT ALERTER BECAUSE THE CAPT'S HANDS WERE LITERALLY FULL AT TIMES AND ALSO BECAUSE IT WAS ON THE R SIDE OF THE COCKPIT. WHILE DSNDING TO 13000 FT WE GOT A CLRNC TO 12000 FT, THE CAPT ACKNOWLEDGED ATC, AND NO ONE SET THE ALERTER TO THE NEW ALT (PRESUMABLY EACH ASSUMING THE OTHER WOULD SET IT). I THOUGHT I HEARD 11000 FT AND CONTINUED DOWN TO THAT ALT WHEN SIMULTANEOUSLY THE CAPT AND ATC INFORMED ME OF THE 12000 FT CLRNC. ATC INFORMED US THAT NO CORRECTIVE ACTION WAS NECESSARY AND WE CONTINUED THE DSCNT TO A NORMAL LNDG. THE PROB WAS CAUSED BY MY FAILURE TO UNDERSTAND AND VERIFY THE CORRECT ALT. I BELIEVE STANDARDIZED ALT ALERTER PROCS SHOULD BE USED IN ANY MULTI-MEMBER CREWED ACFT. THE PNF SHOULD ACKNOWLEDGE THE CLRNC TO ATC, SET THE ALERTER, POINT TO THE ALERTER AND VERBALIZE THE NEW ALT TO THE PF, AND THE PF SHOULD POINT TO THE ALERTER AND REPEAT ALOUD THE NEW ALT. THIS WAS A FAILURE OF BASIC CRM. I THINK PART 135 OPERATORS NEED TO EMPHASIZE BASIC CRM AND DEFINED DUTIES FOR FLYING AND PNF'S MORE. I ALSO THINK A STANDARDIZED LOCATION OF THE ALERTER IN THE CTR OF THE COCKPIT MIGHT ELIMINATE SOME OF THE INCLINATION OF THE CLOSER PLT TO 'HELP' THE OTHER GUY BY SETTING IT. SUPPLEMENTAL INFO FROM ACN 539481: WE WERE VERY SOON THEREAFTER CLRED TO 12000 FT. I AM NOT SURE WHO ANSWERED THIS CALL AS I HAD PREOCCUPIED MYSELF WITH OTHER THINGS. WHEN I LOOKED FORWARD WE WERE LEVELING AT 11000 FT AND ALT PRESELECT WAS SET AT 13000 FT. ABOUT THE SAME TIME I QUERIED THE FO, TAMPA QUERIED US ABOUT OUR ALT. I TOLD TAMPA WE WERE AT 11000 FT. THEN ANOTHER ACFT CALLED US IN SIGHT. TAMPA TOLD US WE SHOULD BE AT 12000 FT. I APOLOGIZED AND HE ANSWERED NOT TO WORRY, THAT IT DIDN'T CAUSE A PROB. I DISTRACTED MYSELF FROM MY DUTIES BY TAKING A PICTURE AND IN THE PROCESS DISTRACTED THE REST OF THE CREW ALSO.
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.