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|
Attributes | |
ACN | 586780 |
Time | |
Date | 200306 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : cyow.airport |
State Reference | ON |
Altitude | msl bound lower : 4700 msl bound upper : 5100 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : on vectors departure sid : ottawa |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 2500 flight time type : 250 |
ASRS Report | 586780 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : detected after the fact other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were departing cyow runway 25 on the ottawa nine departure (251 degree heading and 3000 ft). The normal procedure is to contact departure once airborne, but immediately after gear up, the tower directed us to stay with him. The captain (PNF) responded. I asked for the climb checklist at 1500 ft, and shortly after that the tower told us to turn left direct mss. During the transmission, or during the captain's readback I somehow thought I heard that we were also cleared up to 10000 ft. So I said, on the intercom, 'direct mss and up to ten,' and proceeded to do just that. I believe the altitude alerter (2000 ft for 3000 ft) was going off during the direct mss clearance. The captain never confirmed my call, but said 'I'm off one,' meaning that I now had communication #1 and he would be calling our out and off times into cyow operations. While the captain was calling in our times, tower told us to contact departure, which I did. My transmission went something like this: 'ottawa departure, call sign, climbing through 4.7 for....' I released the push to talk switch because as I looked over at the altitude alerter expecting to see 10000 ft I saw 3000 ft and realized I had either flown through our assigned altitude or the captain had failed to reset it to 10000 ft. It was at that point that the captain had finished calling in our times ('back on one') and I was trying to explain what happened, that ATC informed us we were only cleared to 3000 ft but now we could climb and maintain either 10000 ft or 13000 ft (I don't remember). I accept responsibility for flying through the assigned altitude, but attribute the incident to a couple of things. The first thing is that a CRM breakdown occurred right from the start on this trip because we don't have the ability to adjust the intercom volume without simultaneously adjusting all other radio volumes. I asked the captain during the first taxi-out of the pairing if he would mind if I turned the volume down on communication #1 because I was having difficulty hearing him on the intercom. He made it pretty clear that he didn't want me to adjust the volume for communication #1, and stated that I could adjust my panel or headset volume. The problem with turning down my panel or headset volume (because communication #1 was too loud) is that it would make the intercom even harder to hear. The second thing that I think contributed to this incident and I have also found to be a problem in other phases of flight is the volume of the altitude alerter. If the altitude alerter goes off as ATC transmits to you, it is very difficult to hear ATC. I think I have trained myself (unintentionally) to ignore the altitude alerter when ATC is transmitting so that I can understand the transmission. I'm not 100% sure, but I think the altitude alerter (2000 ft for 3000 ft) was going off as cyow tower cleared us direct to mss and what I thought was 10000 ft. In summary, the biggest problem was ineffective crew communication.
Original NASA ASRS Text
Title: INEFFECTIVE CREW COM RESULTS IN AN ALT OVERSHOOT DEPARTING CYOW.
Narrative: WE WERE DEPARTING CYOW RWY 25 ON THE OTTAWA NINE DEP (251 DEG HDG AND 3000 FT). THE NORMAL PROC IS TO CONTACT DEP ONCE AIRBORNE, BUT IMMEDIATELY AFTER GEAR UP, THE TWR DIRECTED US TO STAY WITH HIM. THE CAPT (PNF) RESPONDED. I ASKED FOR THE CLB CHKLIST AT 1500 FT, AND SHORTLY AFTER THAT THE TWR TOLD US TO TURN L DIRECT MSS. DURING THE XMISSION, OR DURING THE CAPT'S READBACK I SOMEHOW THOUGHT I HEARD THAT WE WERE ALSO CLRED UP TO 10000 FT. SO I SAID, ON THE INTERCOM, 'DIRECT MSS AND UP TO TEN,' AND PROCEEDED TO DO JUST THAT. I BELIEVE THE ALT ALERTER (2000 FT FOR 3000 FT) WAS GOING OFF DURING THE DIRECT MSS CLRNC. THE CAPT NEVER CONFIRMED MY CALL, BUT SAID 'I'M OFF ONE,' MEANING THAT I NOW HAD COM #1 AND HE WOULD BE CALLING OUR OUT AND OFF TIMES INTO CYOW OPS. WHILE THE CAPT WAS CALLING IN OUR TIMES, TWR TOLD US TO CONTACT DEP, WHICH I DID. MY XMISSION WENT SOMETHING LIKE THIS: 'OTTAWA DEP, CALL SIGN, CLBING THROUGH 4.7 FOR....' I RELEASED THE PUSH TO TALK SWITCH BECAUSE AS I LOOKED OVER AT THE ALT ALERTER EXPECTING TO SEE 10000 FT I SAW 3000 FT AND REALIZED I HAD EITHER FLOWN THROUGH OUR ASSIGNED ALT OR THE CAPT HAD FAILED TO RESET IT TO 10000 FT. IT WAS AT THAT POINT THAT THE CAPT HAD FINISHED CALLING IN OUR TIMES ('BACK ON ONE') AND I WAS TRYING TO EXPLAIN WHAT HAPPENED, THAT ATC INFORMED US WE WERE ONLY CLRED TO 3000 FT BUT NOW WE COULD CLB AND MAINTAIN EITHER 10000 FT OR 13000 FT (I DON'T REMEMBER). I ACCEPT RESPONSIBILITY FOR FLYING THROUGH THE ASSIGNED ALT, BUT ATTRIBUTE THE INCIDENT TO A COUPLE OF THINGS. THE FIRST THING IS THAT A CRM BREAKDOWN OCCURRED RIGHT FROM THE START ON THIS TRIP BECAUSE WE DON'T HAVE THE ABILITY TO ADJUST THE INTERCOM VOLUME WITHOUT SIMULTANEOUSLY ADJUSTING ALL OTHER RADIO VOLUMES. I ASKED THE CAPT DURING THE FIRST TAXI-OUT OF THE PAIRING IF HE WOULD MIND IF I TURNED THE VOLUME DOWN ON COM #1 BECAUSE I WAS HAVING DIFFICULTY HEARING HIM ON THE INTERCOM. HE MADE IT PRETTY CLR THAT HE DIDN'T WANT ME TO ADJUST THE VOLUME FOR COM #1, AND STATED THAT I COULD ADJUST MY PANEL OR HEADSET VOLUME. THE PROB WITH TURNING DOWN MY PANEL OR HEADSET VOLUME (BECAUSE COM #1 WAS TOO LOUD) IS THAT IT WOULD MAKE THE INTERCOM EVEN HARDER TO HEAR. THE SECOND THING THAT I THINK CONTRIBUTED TO THIS INCIDENT AND I HAVE ALSO FOUND TO BE A PROB IN OTHER PHASES OF FLT IS THE VOLUME OF THE ALT ALERTER. IF THE ALT ALERTER GOES OFF AS ATC XMITS TO YOU, IT IS VERY DIFFICULT TO HEAR ATC. I THINK I HAVE TRAINED MYSELF (UNINTENTIONALLY) TO IGNORE THE ALT ALERTER WHEN ATC IS XMITTING SO THAT I CAN UNDERSTAND THE XMISSION. I'M NOT 100% SURE, BUT I THINK THE ALT ALERTER (2000 FT FOR 3000 FT) WAS GOING OFF AS CYOW TWR CLRED US DIRECT TO MSS AND WHAT I THOUGHT WAS 10000 FT. IN SUMMARY, THE BIGGEST PROB WAS INEFFECTIVE CREW COM.
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.