Narrative:

Our flight was climbing out of london. The first officer was flying and I was performing PNF duties. It was a typical london departure with multiple altitude clrncs. We were cleared to 6000 ft via the wobun 2F procedure. Approaching 5000 ft, I asked for higher altitude. We were then cleared to 7000 ft. As we neared 6000 ft (the transition altitude), I announced 'two nine nine two?' then reset both my altimeters and looked over at the first officer and watched him set his altimeter. While I was resetting my altimeters, I felt the nose pitch up. When I sat back upright (I don't recall the exact altitude, but I think it was somewhere around 6300-6500 ft), I noticed that the rate of climb was quite high -- exceeding 3100 FPM. I said loudly, 'seven thousand ft!?' I didn't see the first officer immediately respond, so I grabbed the throttles and immediately retarded them and simultaneously pushed the nose over. We went through 7000 ft and peaked at 7300 ft before descending again. As we reached our peak, the controller admonished us and told us to descend to 7000 ft and turn left about 15 degrees. In the controller's comments, it seemed that he thought we had not set our altimeters, but that was not the cause of the altitude bust. There were no TCASII advisories of any kind. But the relief pilot told me later that he saw another aircraft ahead at 8000 ft on the navigation display, but he couldn't recall the distance because he couldn't recall what scale the navigation display was set at. Later in our discussion, the first officer told me he got fixated on trying to top a cloud that was dead ahead of us and lost situational awareness about the altitude. That was the reason he pulled the nose up passing through 6000 ft. After landing, I had a discussion with the crew and told both of them that I'd made many mistakes in my career, but in almost all of them someone else on the crew caught it before it became a problem. That's why we have a crew. I also added, 'we're all entitled to make mistakes, but we're also all entitled to be backed up by the rest of the crew, and in that respect, I think I and the relief pilot both failed you.' 'while you made a technical error,' I added, 'I made an SOP error and we both made a CRM error by not being where we should have been to be able to back you up and for that I apologize.' an additional lesson I learned for myself is that in a situation like this, where it's apparent the PF has lost his situational awareness and where time is critical, I should have immediately taken the airplane. The short delay in waiting for a response from first officer after my callout is what made the difference in this case, I believe. Supplemental information from acn 614896: just after departure, we were level at 5000 ft with no speed restrs. High speed with resulting high energy state. Early morning body clock departure, XA00 morning wake-up. Recommendations: lower energy state. A slower speed would have been fine until clear of complex traffic and departure maneuvering. Callback conversation with reporter acn 615162 revealed the following information: the captain advised that he didn't remember exactly what the status of the autoflt system was. As a result, it was difficult to analyze the resulting performance of the aircraft and crew. He suggested that perhaps the PF had become fixated on climbing over the cloud about which he was concerned and had the nose at such a high attitude, that even with a leveloff command on the flight command bars, the throttles would have maintained a high thrust in order to maintain the speed commanded, even though an altitude capture had occurred. If the PF were 'outside' looking at the cloud, he would not have seen the command bars indicating a lowering of the nose for the leveloff and the throttles would not have come back due to the speed command. The captain remains convinced the issue was CRM related and not a matter of workload constraints.

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Original NASA ASRS Text

Title: FLT CREW OF B747-400 OVERSHOOT CLRED ALT ON WOBUN DEP FROM EGLL WITH POTENTIAL CONFLICT WITH OTHER TFC.

Narrative: OUR FLT WAS CLBING OUT OF LONDON. THE FO WAS FLYING AND I WAS PERFORMING PNF DUTIES. IT WAS A TYPICAL LONDON DEP WITH MULTIPLE ALT CLRNCS. WE WERE CLRED TO 6000 FT VIA THE WOBUN 2F PROC. APCHING 5000 FT, I ASKED FOR HIGHER ALT. WE WERE THEN CLRED TO 7000 FT. AS WE NEARED 6000 FT (THE TRANSITION ALT), I ANNOUNCED 'TWO NINE NINE TWO?' THEN RESET BOTH MY ALTIMETERS AND LOOKED OVER AT THE FO AND WATCHED HIM SET HIS ALTIMETER. WHILE I WAS RESETTING MY ALTIMETERS, I FELT THE NOSE PITCH UP. WHEN I SAT BACK UPRIGHT (I DON'T RECALL THE EXACT ALT, BUT I THINK IT WAS SOMEWHERE AROUND 6300-6500 FT), I NOTICED THAT THE RATE OF CLB WAS QUITE HIGH -- EXCEEDING 3100 FPM. I SAID LOUDLY, 'SEVEN THOUSAND FT!?' I DIDN'T SEE THE FO IMMEDIATELY RESPOND, SO I GRABBED THE THROTTLES AND IMMEDIATELY RETARDED THEM AND SIMULTANEOUSLY PUSHED THE NOSE OVER. WE WENT THROUGH 7000 FT AND PEAKED AT 7300 FT BEFORE DSNDING AGAIN. AS WE REACHED OUR PEAK, THE CTLR ADMONISHED US AND TOLD US TO DSND TO 7000 FT AND TURN L ABOUT 15 DEGS. IN THE CTLR'S COMMENTS, IT SEEMED THAT HE THOUGHT WE HAD NOT SET OUR ALTIMETERS, BUT THAT WAS NOT THE CAUSE OF THE ALT BUST. THERE WERE NO TCASII ADVISORIES OF ANY KIND. BUT THE RELIEF PLT TOLD ME LATER THAT HE SAW ANOTHER ACFT AHEAD AT 8000 FT ON THE NAV DISPLAY, BUT HE COULDN'T RECALL THE DISTANCE BECAUSE HE COULDN'T RECALL WHAT SCALE THE NAV DISPLAY WAS SET AT. LATER IN OUR DISCUSSION, THE FO TOLD ME HE GOT FIXATED ON TRYING TO TOP A CLOUD THAT WAS DEAD AHEAD OF US AND LOST SITUATIONAL AWARENESS ABOUT THE ALT. THAT WAS THE REASON HE PULLED THE NOSE UP PASSING THROUGH 6000 FT. AFTER LNDG, I HAD A DISCUSSION WITH THE CREW AND TOLD BOTH OF THEM THAT I'D MADE MANY MISTAKES IN MY CAREER, BUT IN ALMOST ALL OF THEM SOMEONE ELSE ON THE CREW CAUGHT IT BEFORE IT BECAME A PROB. THAT'S WHY WE HAVE A CREW. I ALSO ADDED, 'WE'RE ALL ENTITLED TO MAKE MISTAKES, BUT WE'RE ALSO ALL ENTITLED TO BE BACKED UP BY THE REST OF THE CREW, AND IN THAT RESPECT, I THINK I AND THE RELIEF PLT BOTH FAILED YOU.' 'WHILE YOU MADE A TECHNICAL ERROR,' I ADDED, 'I MADE AN SOP ERROR AND WE BOTH MADE A CRM ERROR BY NOT BEING WHERE WE SHOULD HAVE BEEN TO BE ABLE TO BACK YOU UP AND FOR THAT I APOLOGIZE.' AN ADDITIONAL LESSON I LEARNED FOR MYSELF IS THAT IN A SIT LIKE THIS, WHERE IT'S APPARENT THE PF HAS LOST HIS SITUATIONAL AWARENESS AND WHERE TIME IS CRITICAL, I SHOULD HAVE IMMEDIATELY TAKEN THE AIRPLANE. THE SHORT DELAY IN WAITING FOR A RESPONSE FROM FO AFTER MY CALLOUT IS WHAT MADE THE DIFFERENCE IN THIS CASE, I BELIEVE. SUPPLEMENTAL INFO FROM ACN 614896: JUST AFTER DEP, WE WERE LEVEL AT 5000 FT WITH NO SPD RESTRS. HIGH SPD WITH RESULTING HIGH ENERGY STATE. EARLY MORNING BODY CLOCK DEP, XA00 MORNING WAKE-UP. RECOMMENDATIONS: LOWER ENERGY STATE. A SLOWER SPD WOULD HAVE BEEN FINE UNTIL CLR OF COMPLEX TFC AND DEP MANEUVERING. CALLBACK CONVERSATION WITH RPTR ACN 615162 REVEALED THE FOLLOWING INFO: THE CAPT ADVISED THAT HE DIDN'T REMEMBER EXACTLY WHAT THE STATUS OF THE AUTOFLT SYS WAS. AS A RESULT, IT WAS DIFFICULT TO ANALYZE THE RESULTING PERFORMANCE OF THE ACFT AND CREW. HE SUGGESTED THAT PERHAPS THE PF HAD BECOME FIXATED ON CLBING OVER THE CLOUD ABOUT WHICH HE WAS CONCERNED AND HAD THE NOSE AT SUCH A HIGH ATTITUDE, THAT EVEN WITH A LEVELOFF COMMAND ON THE FLT COMMAND BARS, THE THROTTLES WOULD HAVE MAINTAINED A HIGH THRUST IN ORDER TO MAINTAIN THE SPD COMMANDED, EVEN THOUGH AN ALT CAPTURE HAD OCCURRED. IF THE PF WERE 'OUTSIDE' LOOKING AT THE CLOUD, HE WOULD NOT HAVE SEEN THE COMMAND BARS INDICATING A LOWERING OF THE NOSE FOR THE LEVELOFF AND THE THROTTLES WOULD NOT HAVE COME BACK DUE TO THE SPD COMMAND. THE CAPT REMAINS CONVINCED THE ISSUE WAS CRM RELATED AND NOT A MATTER OF WORKLOAD CONSTRAINTS.

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.