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|
Attributes | |
ACN | 614450 |
Time | |
Date | 200404 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : lit.vortac |
State Reference | AR |
Altitude | msl bound lower : 31000 msl bound upper : 31300 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zme.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude cruise : level |
Route In Use | departure sid : lindbergh |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 230 flight time total : 11000 flight time type : 5000 |
ASRS Report | 614450 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 70 flight time total : 17000 flight time type : 10000 |
ASRS Report | 614449 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : overshoot inflight encounter : weather inflight encounter other non adherence : far non adherence : clearance |
Independent Detector | aircraft equipment : altitude alert |
Resolutory Action | controller : issued advisory flight crew : overrode automation flight crew : returned to assigned altitude flight crew : became reoriented |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : repair |
Supplementary | |
Problem Areas | Flight Crew Human Performance FAA Environmental Factor Company Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Climbing to our assigned altitude of FL310. Don't remember if either of us made our '300 for 310' callout. Doesn't seem like we did, but I could be wrong. At FL313, I realized I had flown through our assigned altitude as the captain made a deviation callout. Descending through FL312, center called and said 'company number, verify assigned altitude FL310.' remainder of flight uneventful. The primary cause of the deviation was my inadvertent loss of situational awareness approaching my assigned altitude. I believe there were 4 contributing factors to this. Of course, none of them should be interpreted as an excuse since my primary function as PF is aircraft control. Contributing factors: 1) it was the first leveloff of our first flight our first day of the new procedures. The captain and I had commented to each other on how surprisingly 'behind the aircraft' we both felt in this early transition phase. Due to this, my general situational awareness felt a little compromised. I believe this will be alleviated with time. 2) the aircraft had the automatic function of the pressurization system MEL'ed. I was monitoring the system in standby mode. This might have distraction slightly more from my situational awareness. 3) the old 'one to go' callout was a mental 'trigger' for leveloff (for me anyway). Even if the '300 for 310' callout was made, I don't think it would have had the same effect so early in the transition to the new procedures. I believe that will be alleviated with time. 4) possible failure (again, I'm not sure) of either of us to make to the 'FL300 to 310' callout. I believe this would not have occurred had we been flying the new procedures for a couple of days already. We were supposed to be in a -700 and got a -200. The 300/500/700 autoflt system would also have prevented this. During descent, we got a 'stabilizer out of trim' light which turned out to be an autoplt trim motor problem that required us to hand fly the aircraft for subsequent legs (MEL). The pressurization automatic mode was cleared on arrival in hou. On the last leg in that aircraft, we hand flew around a line of WX, had the pressurization automatic mode fail again and got hit by lightning as we adjusted to the new procedures. It was a fun day. Callback conversation with reporter revealed the following information: reporter advised his carrier had implemented a new procedure for crews to remind each other of an impending leveloff at a cleared altitude. In the past, they had used the phrase 'one to go,' 1000 ft before cleared altitude. The new procedure is to state the passing altitude and the cleared altitude, ie, 'out of FL280 for FL290.' this is intended to provide both the alert about the upcoming leveloff as well as reiterate the altitude itself as a mental check on the appropriateness of the altitude itself.
Original NASA ASRS Text
Title: B737-200 CREW CLB ABOVE CLRED ALT WHILE ACCOMMODATING MANUAL CTL OF MEL'ED AUTO PRESSURE SYS AND ADAPTING TO NEW SOP'S.
Narrative: CLBING TO OUR ASSIGNED ALT OF FL310. DON'T REMEMBER IF EITHER OF US MADE OUR '300 FOR 310' CALLOUT. DOESN'T SEEM LIKE WE DID, BUT I COULD BE WRONG. AT FL313, I REALIZED I HAD FLOWN THROUGH OUR ASSIGNED ALT AS THE CAPT MADE A DEV CALLOUT. DSNDING THROUGH FL312, CTR CALLED AND SAID 'COMPANY NUMBER, VERIFY ASSIGNED ALT FL310.' REMAINDER OF FLT UNEVENTFUL. THE PRIMARY CAUSE OF THE DEV WAS MY INADVERTENT LOSS OF SITUATIONAL AWARENESS APCHING MY ASSIGNED ALT. I BELIEVE THERE WERE 4 CONTRIBUTING FACTORS TO THIS. OF COURSE, NONE OF THEM SHOULD BE INTERPED AS AN EXCUSE SINCE MY PRIMARY FUNCTION AS PF IS ACFT CTL. CONTRIBUTING FACTORS: 1) IT WAS THE FIRST LEVELOFF OF OUR FIRST FLT OUR FIRST DAY OF THE NEW PROCS. THE CAPT AND I HAD COMMENTED TO EACH OTHER ON HOW SURPRISINGLY 'BEHIND THE ACFT' WE BOTH FELT IN THIS EARLY TRANSITION PHASE. DUE TO THIS, MY GENERAL SITUATIONAL AWARENESS FELT A LITTLE COMPROMISED. I BELIEVE THIS WILL BE ALLEVIATED WITH TIME. 2) THE ACFT HAD THE AUTO FUNCTION OF THE PRESSURIZATION SYS MEL'ED. I WAS MONITORING THE SYS IN STANDBY MODE. THIS MIGHT HAVE DISTR SLIGHTLY MORE FROM MY SITUATIONAL AWARENESS. 3) THE OLD 'ONE TO GO' CALLOUT WAS A MENTAL 'TRIGGER' FOR LEVELOFF (FOR ME ANYWAY). EVEN IF THE '300 FOR 310' CALLOUT WAS MADE, I DON'T THINK IT WOULD HAVE HAD THE SAME EFFECT SO EARLY IN THE TRANSITION TO THE NEW PROCS. I BELIEVE THAT WILL BE ALLEVIATED WITH TIME. 4) POSSIBLE FAILURE (AGAIN, I'M NOT SURE) OF EITHER OF US TO MAKE TO THE 'FL300 TO 310' CALLOUT. I BELIEVE THIS WOULD NOT HAVE OCCURRED HAD WE BEEN FLYING THE NEW PROCS FOR A COUPLE OF DAYS ALREADY. WE WERE SUPPOSED TO BE IN A -700 AND GOT A -200. THE 300/500/700 AUTOFLT SYS WOULD ALSO HAVE PREVENTED THIS. DURING DSCNT, WE GOT A 'STABILIZER OUT OF TRIM' LIGHT WHICH TURNED OUT TO BE AN AUTOPLT TRIM MOTOR PROB THAT REQUIRED US TO HAND FLY THE ACFT FOR SUBSEQUENT LEGS (MEL). THE PRESSURIZATION AUTO MODE WAS CLRED ON ARR IN HOU. ON THE LAST LEG IN THAT ACFT, WE HAND FLEW AROUND A LINE OF WX, HAD THE PRESSURIZATION AUTO MODE FAIL AGAIN AND GOT HIT BY LIGHTNING AS WE ADJUSTED TO THE NEW PROCS. IT WAS A FUN DAY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR ADVISED HIS CARRIER HAD IMPLEMENTED A NEW PROC FOR CREWS TO REMIND EACH OTHER OF AN IMPENDING LEVELOFF AT A CLRED ALT. IN THE PAST, THEY HAD USED THE PHRASE 'ONE TO GO,' 1000 FT BEFORE CLRED ALT. THE NEW PROC IS TO STATE THE PASSING ALT AND THE CLRED ALT, IE, 'OUT OF FL280 FOR FL290.' THIS IS INTENDED TO PROVIDE BOTH THE ALERT ABOUT THE UPCOMING LEVELOFF AS WELL AS REITERATE THE ALT ITSELF AS A MENTAL CHK ON THE APPROPRIATENESS OF THE ALT ITSELF.
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.