37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 616779 |
Time | |
Date | 200405 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : egss.airport |
State Reference | FO |
Altitude | msl bound lower : 6000 msl bound upper : 8300 |
Environment | |
Flight Conditions | Mixed |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : egtt.tracon tower : egss.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude ground : maintenance |
Route In Use | departure : on vectors departure sid : buzad |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer observation : company check pilot oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 95 flight time total : 5500 flight time type : 1700 |
ASRS Report | 616779 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 150 flight time total : 11000 flight time type : 42 |
ASRS Report | 616568 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : company policies non adherence : published procedure non adherence : far other anomaly |
Independent Detector | aircraft equipment : tcas other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude none taken : detected after the fact other |
Consequence | faa : reviewed incident with flight crew other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Airspace Structure Aircraft Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This was an altitude deviation while climbing to 8000 ft after being vectored off of the buzad runway 6R departure from egss. It involved student training for a captain on his second flight, IOE. Crew was a student captain, line check airman and 2 first officer relief flight officers, (rfo's). The student captain had been a captain previously on the DC10. One rfo was new to the aircraft (less than 4 months), the other rfo had 2 yrs experience. The line check airman had 5 yrs in the MD11. Unknown to the lca, the other 3 crew members had been trained to maintain 250 KIAS below 10000 ft MSL on departure from egss until they flew above 10000 ft MSL or received ATC approval. This procedure is in error as the ICAO regulation permit exceeding 250 KIAS below 10000 ft MSL with an advisory call to ATC. The captain flew a navigation departure on autoplt using a minimum turn radius technique with the speed held at flap retract (fr). Upon intercepting the outbound course, the captain selected FMS and the aircraft began accelerating to 278 KIAS. The lca noted this as normal. ATC then gave a clearance to FL80 (above the transition altitude) as well as a heading off the SID to 310 degrees. The captain called for flaps up at the same time one rfo brought to his attention the FMS speed ball had moved to 278 KIAS. He advised the student to set a speed edit to hold 290 KIAS. Passing the transition altitude at 6000 ft the lca set his altimeter to 10.13 MB, but failed to ensure the student captain had changed his. The cockpit was very busy with checklists, ATC clrncs, radio calls and the 290 KIAS speed discussion. The lca noted the edited speed and asked the captain what he was doing. The student asked if he should maintain 250 KIAS, the lca reported no. The other rfo's began questioning it, referencing to a note on the departure plates. The lca told the captain to accelerate and he would explain why later. The captain complied, but failed to set his altimeter while passing the transition altitude. The aircraft was climbing at 1000 FPM. At 200 ft prior to 8000 ft the lca noted the 1000 FPM was normal, at 100 ft prior the lca said 'watch your altitude.' at 8000 ft the lca said 'level at 8000 ft.' the student captain still had 500 ft to go to 8000 ft on his altimeter so he saw nothing unusual. At 8050 ft the lca commanded 'level at 8000 ft' and bumped the yoke forward causing the autoplt to disconnect and the aircraft to begin to level. The student captain slowed the climb to 300 FPM. At 8100 ft the lca took control of the aircraft and aggressively leveled the aircraft. The lca noted the aircraft had passed 8300 ft and was at 8100 ft when ATC asked if they were leveling at 8000 ft. The lca admitted the overshoot, asked if it created an unsafe situation and if he should report this event. ATC said everything was ok. Supplemental information from acn 616568: as captain, I was flying and missed changing altimeter at passing level 6000 ft due to confusion in the cockpit. There was a question that arose as to whether we were ok to accelerate to more than 250 KTS as depicted on the SID. When we noticed we were going past level 8000 ft the pilot in the right seat leveled the aircraft and returned the aircraft to level 8000 ft. We deviated by about 300 ft. London control said there was no problem associated with the deviation. We did get an amber TA momentarily but there were no evasive actions required.
Original NASA ASRS Text
Title: AN MD11 CREW, DEPARTING EGSS, MADE AN ALT OVERSHOOT DUE TO IMPROPER SETTING OF THE KOHLSMAN WINDOW IN THE ALT.
Narrative: THIS WAS AN ALTDEV WHILE CLBING TO 8000 FT AFTER BEING VECTORED OFF OF THE BUZAD RWY 6R DEP FROM EGSS. IT INVOLVED STUDENT TRAINING FOR A CAPT ON HIS SECOND FLT, IOE. CREW WAS A STUDENT CAPT, LINE CHK AIRMAN AND 2 FO RELIEF FLT OFFICERS, (RFO'S). THE STUDENT CAPT HAD BEEN A CAPT PREVIOUSLY ON THE DC10. ONE RFO WAS NEW TO THE ACFT (LESS THAN 4 MONTHS), THE OTHER RFO HAD 2 YRS EXPERIENCE. THE LINE CHK AIRMAN HAD 5 YRS IN THE MD11. UNKNOWN TO THE LCA, THE OTHER 3 CREW MEMBERS HAD BEEN TRAINED TO MAINTAIN 250 KIAS BELOW 10000 FT MSL ON DEP FROM EGSS UNTIL THEY FLEW ABOVE 10000 FT MSL OR RECEIVED ATC APPROVAL. THIS PROC IS IN ERROR AS THE ICAO REG PERMIT EXCEEDING 250 KIAS BELOW 10000 FT MSL WITH AN ADVISORY CALL TO ATC. THE CAPT FLEW A NAV DEP ON AUTOPLT USING A MINIMUM TURN RADIUS TECHNIQUE WITH THE SPD HELD AT FLAP RETRACT (FR). UPON INTERCEPTING THE OUTBOUND COURSE, THE CAPT SELECTED FMS AND THE ACFT BEGAN ACCELERATING TO 278 KIAS. THE LCA NOTED THIS AS NORMAL. ATC THEN GAVE A CLRNC TO FL80 (ABOVE THE TRANSITION ALT) AS WELL AS A HDG OFF THE SID TO 310 DEGS. THE CAPT CALLED FOR FLAPS UP AT THE SAME TIME ONE RFO BROUGHT TO HIS ATTN THE FMS SPD BALL HAD MOVED TO 278 KIAS. HE ADVISED THE STUDENT TO SET A SPD EDIT TO HOLD 290 KIAS. PASSING THE TRANSITION ALT AT 6000 FT THE LCA SET HIS ALTIMETER TO 10.13 MB, BUT FAILED TO ENSURE THE STUDENT CAPT HAD CHANGED HIS. THE COCKPIT WAS VERY BUSY WITH CHKLISTS, ATC CLRNCS, RADIO CALLS AND THE 290 KIAS SPD DISCUSSION. THE LCA NOTED THE EDITED SPD AND ASKED THE CAPT WHAT HE WAS DOING. THE STUDENT ASKED IF HE SHOULD MAINTAIN 250 KIAS, THE LCA RPTED NO. THE OTHER RFO'S BEGAN QUESTIONING IT, REFING TO A NOTE ON THE DEP PLATES. THE LCA TOLD THE CAPT TO ACCELERATE AND HE WOULD EXPLAIN WHY LATER. THE CAPT COMPLIED, BUT FAILED TO SET HIS ALTIMETER WHILE PASSING THE TRANSITION ALT. THE ACFT WAS CLBING AT 1000 FPM. AT 200 FT PRIOR TO 8000 FT THE LCA NOTED THE 1000 FPM WAS NORMAL, AT 100 FT PRIOR THE LCA SAID 'WATCH YOUR ALT.' AT 8000 FT THE LCA SAID 'LEVEL AT 8000 FT.' THE STUDENT CAPT STILL HAD 500 FT TO GO TO 8000 FT ON HIS ALTIMETER SO HE SAW NOTHING UNUSUAL. AT 8050 FT THE LCA COMMANDED 'LEVEL AT 8000 FT' AND BUMPED THE YOKE FORWARD CAUSING THE AUTOPLT TO DISCONNECT AND THE ACFT TO BEGIN TO LEVEL. THE STUDENT CAPT SLOWED THE CLB TO 300 FPM. AT 8100 FT THE LCA TOOK CTL OF THE ACFT AND AGGRESSIVELY LEVELED THE ACFT. THE LCA NOTED THE ACFT HAD PASSED 8300 FT AND WAS AT 8100 FT WHEN ATC ASKED IF THEY WERE LEVELING AT 8000 FT. THE LCA ADMITTED THE OVERSHOOT, ASKED IF IT CREATED AN UNSAFE SIT AND IF HE SHOULD RPT THIS EVENT. ATC SAID EVERYTHING WAS OK. SUPPLEMENTAL INFO FROM ACN 616568: AS CAPT, I WAS FLYING AND MISSED CHANGING ALTIMETER AT PASSING LEVEL 6000 FT DUE TO CONFUSION IN THE COCKPIT. THERE WAS A QUESTION THAT AROSE AS TO WHETHER WE WERE OK TO ACCELERATE TO MORE THAN 250 KTS AS DEPICTED ON THE SID. WHEN WE NOTICED WE WERE GOING PAST LEVEL 8000 FT THE PLT IN THE R SEAT LEVELED THE ACFT AND RETURNED THE ACFT TO LEVEL 8000 FT. WE DEVIATED BY ABOUT 300 FT. LONDON CTL SAID THERE WAS NO PROB ASSOCIATED WITH THE DEV. WE DID GET AN AMBER TA MOMENTARILY BUT THERE WERE NO EVASIVE ACTIONS REQUIRED.
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.