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|
Attributes | |
ACN | 613322 |
Time | |
Date | 200404 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lax.airport |
State Reference | CA |
Altitude | msl bound lower : 13000 msl bound upper : 13300 |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon tower : lax.tower |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | other other vortac |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : lax enroute : pacific |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 15600 flight time type : 2000 |
ASRS Report | 613322 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Experience | flight time last 90 days : 240 flight time total : 15000 flight time type : 2000 |
ASRS Report | 613320 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : altitude alerter other flight crewa other flight crewb |
Resolutory Action | flight crew : returned to assigned altitude flight crew : became reoriented flight crew : returned to intended or assigned course |
Supplementary | |
Problem Areas | Environmental Factor Flight Crew Human Performance Company ATC Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After initial pushback attempt, departure was delayed due to aircraft and a need for a new release (due to cargo door anomaly). Calling for taxi clearance, we were asked to contact clearance for a rerte. We copied the clearance, then received a taxi clearance to clear the way for inbound aircraft. We held at taxiway to program the new route and contact dispatch regarding new flight plan and cleared fuel. After route was verified and passenger announcement was made, we advised ATC we were ready for takeoff. We failed to review the new departure procedure which resulted in a slightly late turn to the departure procedure's heading. Then, while heads down to check the course we were told we could expect to intercept, the altitude alert sounded due to a 300 ft overshoot. No traffic conflict occurred, and the first officer promptly corrected to the assigned altitude. Possible contributing factors include: several changes from what was routine to us, failure to carefully review the departure procedure, a desire to preserve an eroded schedule, and perhaps a circadian low (XA00 local body time) and short sleep the previous night between trips.
Original NASA ASRS Text
Title: B767-300 FLT CREW EXPERIENCED HDG DEV AND ALT OVERSHOOT ON PUBLISHED DEP FROM LAX.
Narrative: AFTER INITIAL PUSHBACK ATTEMPT, DEP WAS DELAYED DUE TO ACFT AND A NEED FOR A NEW RELEASE (DUE TO CARGO DOOR ANOMALY). CALLING FOR TAXI CLRNC, WE WERE ASKED TO CONTACT CLRNC FOR A RERTE. WE COPIED THE CLRNC, THEN RECEIVED A TAXI CLRNC TO CLR THE WAY FOR INBOUND ACFT. WE HELD AT TXWY TO PROGRAM THE NEW RTE AND CONTACT DISPATCH REGARDING NEW FLT PLAN AND CLRED FUEL. AFTER RTE WAS VERIFIED AND PAX ANNOUNCEMENT WAS MADE, WE ADVISED ATC WE WERE READY FOR TKOF. WE FAILED TO REVIEW THE NEW DEP PROC WHICH RESULTED IN A SLIGHTLY LATE TURN TO THE DEP PROC'S HDG. THEN, WHILE HEADS DOWN TO CHK THE COURSE WE WERE TOLD WE COULD EXPECT TO INTERCEPT, THE ALT ALERT SOUNDED DUE TO A 300 FT OVERSHOOT. NO TFC CONFLICT OCCURRED, AND THE FO PROMPTLY CORRECTED TO THE ASSIGNED ALT. POSSIBLE CONTRIBUTING FACTORS INCLUDE: SEVERAL CHANGES FROM WHAT WAS ROUTINE TO US, FAILURE TO CAREFULLY REVIEW THE DEP PROC, A DESIRE TO PRESERVE AN ERODED SCHEDULE, AND PERHAPS A CIRCADIAN LOW (XA00 LCL BODY TIME) AND SHORT SLEEP THE PREVIOUS NIGHT BTWN TRIPS.
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.