37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 580287 |
Time | |
Date | 200304 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : cvg.airport |
State Reference | OH |
Altitude | msl single value : 13000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zid.artcc |
Operator | common carrier : air carrier |
Make Model Name | MD-88 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 225 flight time total : 3500 flight time type : 1600 |
ASRS Report | 580287 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : far |
Independent Detector | atc equipment other atc equipment : artcc radar other controllera |
Resolutory Action | controller : issued new clearance |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Altitude was incorrectly set in altitude capture window or change knob was bumped to different altitude (when autoplt was engaged). Assigned altitude was 13000 ft and an aircraft went through 13000 ft both pilots pointed to altitude set knob and responded 13000 ft for 14000 ft. Shortly thereafter, captain stated 'when were we cleared to 14000 ft?' (note that 14000 ft was set in.) as we were leveling off at 14000 ft, controller inquired about what altitude we were at and captain stated '14000 ft.' at that time, controller told us we were only cleared to 13000 ft. Seconds later, ATC cleared us to FL230. No conflict occurred. After discussing situation with captain, he stated that he was sure he set in 13000 ft. I am pretty sure that 13000 ft was set in when change was made (8000 ft to 13000 ft, autoplt not engaged). Somewhere in there, altitude in readout window was changed to 14000 ft. Was it set in incorrectly or was it bumped? We're not sure how the change occurred. Once on the ground in dca, we experimented with the set knob to see if we could set an altitude with the set knob (quit) not in the detent. (Ie, 13000 ft showing in the window and the set knob not in the detent.) we were able to do so and when I pointed to set knob and touched it, I was able to change altitude to 14000 ft. Other than setting altitude incorrectly, the only other situation that we thought might have happened was that as going through approximately 11000 ft, I engaged the autoplt and might have bumped altitude set knob while doing so. To avoid this situation in the future, we must be more careful setting altitude (ie, wiggle knob slightly to make sure it is in detent) if a change is made or be careful when adjacent switches/knobs are operated.
Original NASA ASRS Text
Title: FLT CREW OF MD80 INADVERTENTLY CLBED TO 14000 FT WHEN ONLY CLRED TO 13000 FT.
Narrative: ALT WAS INCORRECTLY SET IN ALT CAPTURE WINDOW OR CHANGE KNOB WAS BUMPED TO DIFFERENT ALT (WHEN AUTOPLT WAS ENGAGED). ASSIGNED ALT WAS 13000 FT AND AN ACFT WENT THROUGH 13000 FT BOTH PLTS POINTED TO ALT SET KNOB AND RESPONDED 13000 FT FOR 14000 FT. SHORTLY THEREAFTER, CAPT STATED 'WHEN WERE WE CLRED TO 14000 FT?' (NOTE THAT 14000 FT WAS SET IN.) AS WE WERE LEVELING OFF AT 14000 FT, CTLR INQUIRED ABOUT WHAT ALT WE WERE AT AND CAPT STATED '14000 FT.' AT THAT TIME, CTLR TOLD US WE WERE ONLY CLRED TO 13000 FT. SECONDS LATER, ATC CLRED US TO FL230. NO CONFLICT OCCURRED. AFTER DISCUSSING SIT WITH CAPT, HE STATED THAT HE WAS SURE HE SET IN 13000 FT. I AM PRETTY SURE THAT 13000 FT WAS SET IN WHEN CHANGE WAS MADE (8000 FT TO 13000 FT, AUTOPLT NOT ENGAGED). SOMEWHERE IN THERE, ALT IN READOUT WINDOW WAS CHANGED TO 14000 FT. WAS IT SET IN INCORRECTLY OR WAS IT BUMPED? WE'RE NOT SURE HOW THE CHANGE OCCURRED. ONCE ON THE GND IN DCA, WE EXPERIMENTED WITH THE SET KNOB TO SEE IF WE COULD SET AN ALT WITH THE SET KNOB (QUIT) NOT IN THE DETENT. (IE, 13000 FT SHOWING IN THE WINDOW AND THE SET KNOB NOT IN THE DETENT.) WE WERE ABLE TO DO SO AND WHEN I POINTED TO SET KNOB AND TOUCHED IT, I WAS ABLE TO CHANGE ALT TO 14000 FT. OTHER THAN SETTING ALT INCORRECTLY, THE ONLY OTHER SIT THAT WE THOUGHT MIGHT HAVE HAPPENED WAS THAT AS GOING THROUGH APPROX 11000 FT, I ENGAGED THE AUTOPLT AND MIGHT HAVE BUMPED ALT SET KNOB WHILE DOING SO. TO AVOID THIS SIT IN THE FUTURE, WE MUST BE MORE CAREFUL SETTING ALT (IE, WIGGLE KNOB SLIGHTLY TO MAKE SURE IT IS IN DETENT) IF A CHANGE IS MADE OR BE CAREFUL WHEN ADJACENT SWITCHES/KNOBS ARE OPERATED.
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.