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|
Attributes | |
ACN | 574116 |
Time | |
Date | 200302 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
State Reference | MO |
Altitude | msl bound lower : 4000 msl bound upper : 4600 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : mci.tracon |
Operator | other |
Make Model Name | Super King Air 350 |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Function | flight crew : single pilot |
Qualification | pilot : multi engine pilot : instrument pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 5000 flight time type : 3500 |
ASRS Report | 574116 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : far non adherence : clearance other anomaly other |
Independent Detector | atc equipment other atc equipment : mode c other controllera |
Resolutory Action | controller : issued advisory flight crew : became reoriented flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance ATC Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was picking up our king air 350 after some non-scheduled avionics maintenance. Since this was a maintenance hop, I was a single pilot operation. Our mfd had been replaced causing the checklist in the mdd we normally use to be nonfunctional. I was using the aircraft pilot's checklist, which is in book form. After receiving the ATIS and contacting ground control for and receiving my clearance, I was doing the before taxi checklist, when I was given a route change due to center radar coverage being out and everyone being rted over the VOR's. At that time, I started re-programming the FMS with the new route and got out the low altitude chart to insure the heading for V-4 airway. When I went back to the checklist, I apparently missed the altimeter setting. After getting taxi clearance, I taxied up to runway 1, and another aircraft taxied up behind me. I contacted tower to get my takeoff clearance and was going through the before takeoff/final items checklist. I was told to hold short, I was then told to taxi into position and be ready for an immediate takeoff. As I was rounding the corner onto the runway, tower told me to keep the power in, I was cleared for an immediate takeoff without delay. I was assigned runway heading to 3000 ft. Due to the quickness I was cleared for takeoff, I didn't get to the confirm altimeter item on the final items checklist. As I was climbing to my initial assigned altitude of 3000 ft, I was handed off to departure control. After reporting that I was 2800 ft for 3000 ft runway heading, I was cleared to 4000 ft. I don't believe that he ever confirmed my altitude callout, but I was climbing at approximately 1500 FPM. At about 3500 ft, indicated I was given a left turn to 270 degrees, as I was leveling off at 4000 ft and was completing the turn, the controller asked my altitude. I advised 4000 ft. He then gave the current mci altimeter and said he showed me at 4600 ft. Seeing the altimeter setting, I realized what I had done, set the current altimeter and started an immediate descent to 4000 ft. I was then given direct to kansas city VOR and V-4 airway. The controller never indicated there was any conflict or problem other than asking my altitude. The onboard TCASII also didn't indicate any aircraft within 5 NM of me or give any conflict warnings. I believe this to be a human performance problem that started when I had to use the checklist that I don't normally use. After getting used to the one in the mfd, I have allowed myself to become a little unfamiliar with the layout of the book checklist. Also, the fact that I had been distracted during the before taxi checklist, to re-program the FMS and to look up the correct chart and headings for v-r airway didn't help. But, the biggest factor was accepting a takeoff clearance before I was ready to do so. There was no need to hurry since I was only taking the plane back after maintenance.
Original NASA ASRS Text
Title: B350 PLT OVERSHOOTS HIS ASSIGNED DEP ALT WHEN FAILING TO SET HIS ALTIMETER TO LCL QNH, MKC, MO.
Narrative: I WAS PICKING UP OUR KING AIR 350 AFTER SOME NON-SCHEDULED AVIONICS MAINT. SINCE THIS WAS A MAINT HOP, I WAS A SINGLE PLT OP. OUR MFD HAD BEEN REPLACED CAUSING THE CHKLIST IN THE MDD WE NORMALLY USE TO BE NONFUNCTIONAL. I WAS USING THE ACFT PLT'S CHKLIST, WHICH IS IN BOOK FORM. AFTER RECEIVING THE ATIS AND CONTACTING GND CTL FOR AND RECEIVING MY CLRNC, I WAS DOING THE BEFORE TAXI CHKLIST, WHEN I WAS GIVEN A RTE CHANGE DUE TO CTR RADAR COVERAGE BEING OUT AND EVERYONE BEING RTED OVER THE VOR'S. AT THAT TIME, I STARTED RE-PROGRAMMING THE FMS WITH THE NEW RTE AND GOT OUT THE LOW ALT CHART TO INSURE THE HDG FOR V-4 AIRWAY. WHEN I WENT BACK TO THE CHKLIST, I APPARENTLY MISSED THE ALTIMETER SETTING. AFTER GETTING TAXI CLRNC, I TAXIED UP TO RWY 1, AND ANOTHER ACFT TAXIED UP BEHIND ME. I CONTACTED TWR TO GET MY TKOF CLRNC AND WAS GOING THROUGH THE BEFORE TKOF/FINAL ITEMS CHKLIST. I WAS TOLD TO HOLD SHORT, I WAS THEN TOLD TO TAXI INTO POS AND BE READY FOR AN IMMEDIATE TKOF. AS I WAS ROUNDING THE CORNER ONTO THE RWY, TWR TOLD ME TO KEEP THE PWR IN, I WAS CLRED FOR AN IMMEDIATE TKOF WITHOUT DELAY. I WAS ASSIGNED RWY HDG TO 3000 FT. DUE TO THE QUICKNESS I WAS CLRED FOR TKOF, I DIDN'T GET TO THE CONFIRM ALTIMETER ITEM ON THE FINAL ITEMS CHKLIST. AS I WAS CLBING TO MY INITIAL ASSIGNED ALT OF 3000 FT, I WAS HANDED OFF TO DEP CTL. AFTER RPTING THAT I WAS 2800 FT FOR 3000 FT RWY HDG, I WAS CLRED TO 4000 FT. I DON'T BELIEVE THAT HE EVER CONFIRMED MY ALT CALLOUT, BUT I WAS CLBING AT APPROX 1500 FPM. AT ABOUT 3500 FT, INDICATED I WAS GIVEN A L TURN TO 270 DEGS, AS I WAS LEVELING OFF AT 4000 FT AND WAS COMPLETING THE TURN, THE CTLR ASKED MY ALT. I ADVISED 4000 FT. HE THEN GAVE THE CURRENT MCI ALTIMETER AND SAID HE SHOWED ME AT 4600 FT. SEEING THE ALTIMETER SETTING, I REALIZED WHAT I HAD DONE, SET THE CURRENT ALTIMETER AND STARTED AN IMMEDIATE DSCNT TO 4000 FT. I WAS THEN GIVEN DIRECT TO KANSAS CITY VOR AND V-4 AIRWAY. THE CTLR NEVER INDICATED THERE WAS ANY CONFLICT OR PROB OTHER THAN ASKING MY ALT. THE ONBOARD TCASII ALSO DIDN'T INDICATE ANY ACFT WITHIN 5 NM OF ME OR GIVE ANY CONFLICT WARNINGS. I BELIEVE THIS TO BE A HUMAN PERFORMANCE PROB THAT STARTED WHEN I HAD TO USE THE CHKLIST THAT I DON'T NORMALLY USE. AFTER GETTING USED TO THE ONE IN THE MFD, I HAVE ALLOWED MYSELF TO BECOME A LITTLE UNFAMILIAR WITH THE LAYOUT OF THE BOOK CHKLIST. ALSO, THE FACT THAT I HAD BEEN DISTRACTED DURING THE BEFORE TAXI CHKLIST, TO RE-PROGRAM THE FMS AND TO LOOK UP THE CORRECT CHART AND HDGS FOR V-R AIRWAY DIDN'T HELP. BUT, THE BIGGEST FACTOR WAS ACCEPTING A TKOF CLRNC BEFORE I WAS READY TO DO SO. THERE WAS NO NEED TO HURRY SINCE I WAS ONLY TAKING THE PLANE BACK AFTER MAINT.
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.