37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 594237 |
Time | |
Date | 200309 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl bound lower : 7000 msl bound upper : 7400 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 200 flight time total : 7500 flight time type : 400 |
ASRS Report | 594237 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : clearance other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : aural warning other flight crewa other flight crewb |
Resolutory Action | flight crew : returned to assigned altitude flight crew : overcame equipment problem |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Environmental Factor Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
Scheduled far .121 flight from ZZZ to ZZZ1. WX was perfectly clear with unlimited visibility, and 2 capts were paired (flying) together. On climb out from ZZZ, we received an 'ADI bell mismatch' warning. Both of us (I was in the left seat) immediately went into our problem-solving mode and determined that it was the #2 ADI that was in error (we compared the #1 ADI, #2 ADI, and standby ADI). Unfortunately, in our haste to solve our problem, we lost our common sense and nobody was flying the airplane. The autoplt disconnect when the original 'ADI bell mismatch' warning annunciated. However, neither of us noticed there is no aural warning of an autoplt disconnect -- only a visual annunciator, which neither of us noticed while trying to solve our problem. The end result was the airplane climbed through our assigned altitude at 7000 ft. We leveled off at 7400 ft and immediately descended back to 7000 ft. I checked the TCASII -- no conflict, and the controller said nothing.
Original NASA ASRS Text
Title: A DEHAVILLAND-8-200 IN CLB AT 7000 FT RECEIVED AN ADI AURAL MISMATCH WARNING. ATTEMPTING TO SOLVE MISMATCH INCURRED ALT EXCURSION.
Narrative: SCHEDULED FAR .121 FLT FROM ZZZ TO ZZZ1. WX WAS PERFECTLY CLR WITH UNLIMITED VISIBILITY, AND 2 CAPTS WERE PAIRED (FLYING) TOGETHER. ON CLBOUT FROM ZZZ, WE RECEIVED AN 'ADI BELL MISMATCH' WARNING. BOTH OF US (I WAS IN THE L SEAT) IMMEDIATELY WENT INTO OUR PROB-SOLVING MODE AND DETERMINED THAT IT WAS THE #2 ADI THAT WAS IN ERROR (WE COMPARED THE #1 ADI, #2 ADI, AND STANDBY ADI). UNFORTUNATELY, IN OUR HASTE TO SOLVE OUR PROB, WE LOST OUR COMMON SENSE AND NOBODY WAS FLYING THE AIRPLANE. THE AUTOPLT DISCONNECT WHEN THE ORIGINAL 'ADI BELL MISMATCH' WARNING ANNUNCIATED. HOWEVER, NEITHER OF US NOTICED THERE IS NO AURAL WARNING OF AN AUTOPLT DISCONNECT -- ONLY A VISUAL ANNUNCIATOR, WHICH NEITHER OF US NOTICED WHILE TRYING TO SOLVE OUR PROB. THE END RESULT WAS THE AIRPLANE CLBED THROUGH OUR ASSIGNED ALT AT 7000 FT. WE LEVELED OFF AT 7400 FT AND IMMEDIATELY DSNDED BACK TO 7000 FT. I CHKED THE TCASII -- NO CONFLICT, AND THE CTLR SAID NOTHING.
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.