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|
Attributes | |
ACN | 620130 |
Time | |
Date | 200406 |
Day | Tue |
Place | |
Locale Reference | airport : msp.airport |
State Reference | MN |
Altitude | msl bound lower : 4000 msl bound upper : 5000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : m98.tracon |
Operator | common carrier : air carrier |
Make Model Name | SF 340A |
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 : instrument pilot : cfi pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 180 flight time total : 7400 flight time type : 4800 |
ASRS Report | 620130 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 200 flight time total : 5500 flight time type : 4400 |
ASRS Report | 620340 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : company policies non adherence : clearance non adherence : far |
Independent Detector | atc equipment other atc equipment : radar mode c other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Cabin Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While leveling off at 5000 ft, msp departure control asked us to say our altitude. We told them we were leveling at 5000 ft. They asked if msp tower gave us that because they showed we were cleared to 4000 ft in our clearance from clearance delivery. The first officer looked at the clearance she had written down and noted that 4000 ft was indeed our initial assigned altitude. We told departure that it was our mistake and we should be at 4000 ft. The problem arose when the first officer was getting the clearance from clearance delivery. As she was getting the clearance, the flight attendant entered the flight deck and started to ask me a question. During this time, I missed hearing the clearance and the readback. The first officer set the radios for departure and dialed 5000 ft in the altitude alerter. This did not raise a red flag in my mind since 5000 ft is the normal initial altitude given to turboprops departing msp. When I looked at the clearance the first officer had written down, I noticed the 5000 ft written. However, after being queried by departure and after further examination, I noticed she had 40/50 written down. This meant 4000 ft, expect 5000 ft. Factors affecting this altitude deviation was the distraction from the flight attendant during the clearance acquisition, the first officer putting the wrong altitude in the altitude alerter and most importantly, me, the captain, not listening to the clearance and not questioning the first officer about the altitude. To prevent this from happening again, I now make sure I listen to the clearance and verbally go over it with the first officer. Supplemental information from acn 620340: the clearance altitudes were 'maintain 4000 ft, expect 5000 ft in ten.' I wrote them correctly on the card, but failed to put 4000 ft in the altitude preselector. 5000 ft from our previous flight was dialed in. The controller queried us. I remembered being interrupted in the flight deck by the flight attendant while the clearance was being read to me. I had to turn up the volume to sufficiently hear our clearance. She was very new and I know she isn't yet aware of when it is appropriate to chat with the flight deck. 5000 ft is a common initial altitude departing msp and I may have looked at it and figured it was correct, and continued with other preparations. We could have prevented this from occurring if we had been more vigilant and not assumed 5000 ft was correct because it is common. My personal reaction to our flight attendant's behavior is probably a factor. I was irritated, and remember thinking to myself about this as I set in the transponder code. I usually set in the altitude next. How easily something can get missed and errors result! Vigilance with clrncs and recognizing my weaknesses could have prevented this.
Original NASA ASRS Text
Title: ALT OVERSHOOT WHEN AN SF340 FLT CREW CLBS ABOVE THEIR ASSIGNED ALT WHEN THE ALT ALERT IS IMPROPERLY SET BY THE FO PRIOR TO DEPARTING MSP, MN.
Narrative: WHILE LEVELING OFF AT 5000 FT, MSP DEP CTL ASKED US TO SAY OUR ALT. WE TOLD THEM WE WERE LEVELING AT 5000 FT. THEY ASKED IF MSP TWR GAVE US THAT BECAUSE THEY SHOWED WE WERE CLRED TO 4000 FT IN OUR CLRNC FROM CLRNC DELIVERY. THE FO LOOKED AT THE CLRNC SHE HAD WRITTEN DOWN AND NOTED THAT 4000 FT WAS INDEED OUR INITIAL ASSIGNED ALT. WE TOLD DEP THAT IT WAS OUR MISTAKE AND WE SHOULD BE AT 4000 FT. THE PROB AROSE WHEN THE FO WAS GETTING THE CLRNC FROM CLRNC DELIVERY. AS SHE WAS GETTING THE CLRNC, THE FLT ATTENDANT ENTERED THE FLT DECK AND STARTED TO ASK ME A QUESTION. DURING THIS TIME, I MISSED HEARING THE CLRNC AND THE READBACK. THE FO SET THE RADIOS FOR DEP AND DIALED 5000 FT IN THE ALT ALERTER. THIS DID NOT RAISE A RED FLAG IN MY MIND SINCE 5000 FT IS THE NORMAL INITIAL ALT GIVEN TO TURBOPROPS DEPARTING MSP. WHEN I LOOKED AT THE CLRNC THE FO HAD WRITTEN DOWN, I NOTICED THE 5000 FT WRITTEN. HOWEVER, AFTER BEING QUERIED BY DEP AND AFTER FURTHER EXAMINATION, I NOTICED SHE HAD 40/50 WRITTEN DOWN. THIS MEANT 4000 FT, EXPECT 5000 FT. FACTORS AFFECTING THIS ALTDEV WAS THE DISTR FROM THE FLT ATTENDANT DURING THE CLRNC ACQUISITION, THE FO PUTTING THE WRONG ALT IN THE ALT ALERTER AND MOST IMPORTANTLY, ME, THE CAPT, NOT LISTENING TO THE CLRNC AND NOT QUESTIONING THE FO ABOUT THE ALT. TO PREVENT THIS FROM HAPPENING AGAIN, I NOW MAKE SURE I LISTEN TO THE CLRNC AND VERBALLY GO OVER IT WITH THE FO. SUPPLEMENTAL INFO FROM ACN 620340: THE CLRNC ALTS WERE 'MAINTAIN 4000 FT, EXPECT 5000 FT IN TEN.' I WROTE THEM CORRECTLY ON THE CARD, BUT FAILED TO PUT 4000 FT IN THE ALT PRESELECTOR. 5000 FT FROM OUR PREVIOUS FLT WAS DIALED IN. THE CTLR QUERIED US. I REMEMBERED BEING INTERRUPTED IN THE FLT DECK BY THE FLT ATTENDANT WHILE THE CLRNC WAS BEING READ TO ME. I HAD TO TURN UP THE VOLUME TO SUFFICIENTLY HEAR OUR CLRNC. SHE WAS VERY NEW AND I KNOW SHE ISN'T YET AWARE OF WHEN IT IS APPROPRIATE TO CHAT WITH THE FLT DECK. 5000 FT IS A COMMON INITIAL ALT DEPARTING MSP AND I MAY HAVE LOOKED AT IT AND FIGURED IT WAS CORRECT, AND CONTINUED WITH OTHER PREPARATIONS. WE COULD HAVE PREVENTED THIS FROM OCCURRING IF WE HAD BEEN MORE VIGILANT AND NOT ASSUMED 5000 FT WAS CORRECT BECAUSE IT IS COMMON. MY PERSONAL REACTION TO OUR FLT ATTENDANT'S BEHAVIOR IS PROBABLY A FACTOR. I WAS IRRITATED, AND REMEMBER THINKING TO MYSELF ABOUT THIS AS I SET IN THE XPONDER CODE. I USUALLY SET IN THE ALT NEXT. HOW EASILY SOMETHING CAN GET MISSED AND ERRORS RESULT! VIGILANCE WITH CLRNCS AND RECOGNIZING MY WEAKNESSES COULD HAVE PREVENTED THIS.
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.