37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 727239 |
Time | |
Date | 200702 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : fll.airport |
State Reference | FL |
Altitude | msl bound lower : 3000 msl bound upper : 4800 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : mia.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 67 flight time total : 7700 flight time type : 4521 |
ASRS Report | 727239 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : regained aircraft control flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Weather ATC Human Performance Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I allowed complacency to enter the cockpit; thus allowing 5 or 6 benign events to combine and escalate into an opportunity for myself to get behind the aircraft and possibly get violated. It was the last leg of a 3 legged night. I didn't feel overly tired (though I had been up about 20 hours) and it was just a 20 min flight from pt a to pt B. My first officer is experienced on the aircraft and the night had gone smooth. The airplane was empty. We were basically a ferry flight. I was complacent in my takeoff brief and forgot to brief the first officer for a possible low altitude capture. Clearance was runway heading with a 3000 ft leveloff. We took off on runway 9 and at about 800 ft went IMC. Though it wasn't anything convective; the clouds were of the kind that cause quite a bit of chop. We were then given a course reversal to turn to a heading of 270 degrees. And then I got that low altitude capture...at about 1400-1500 ft. I was late with the VNAV call because of all the things going on in the cockpit (ATC calls; moderate chop and the turn); coupled with the light aircraft. I didn't think it was a big deal and called for the first officer to bug me clean maneuvering. But I didn't call for 'speed' first and he didn't select it. I kept calling for speed and he kept dialing the speed knob up. He then realized that what I wanted and selected 'speed.' unfortunately for me; because we were light; I was in a big turn; IMC and getting bounced around; I got a little vertigo. Couple all that with the big acceleration from the autothrottles advancing and my inner ear and body made it feel like the plane was descending and fast. And though I could see the vsi climbing; the altimeter climbing and the flight director commanding me to push the nose over; I couldn't shake the sensation of a rapid descent. And so I wasn't being very aggressive in holding the nose of the aircraft down. At this point I could see that we were rapidly climbing through 3000 ft and still climbing. I ask my first officer to select autoplt; which he did; but the autoplt wouldn't connect and to add insult to injury; the autoplt disconnect warning horn and light started going off. Another added stressor. I asked the first officer to call ATC and request a 4000 ft leveloff which he did and they granted. I still had the vertigo and sensation of descending. I finally decided to roll wings level while clicking off the autoplt disconnect warning horn. At about this time; the airplane is reaching 250 KTS; so the autothrottles begin to retard also helping decrease my vertigo sensation. My body begins to believe what my eyes have been telling it all along; that yes we are climbing and everything is going to be ok. We finally get the autoplt on and get the airplane under control. Unfortunately; by this time I'm at 4700-4800 ft. For some reason though; ATC couldn't read our mode C and the transponder was on. I descended back to 4000 ft and leveled off; recycled the transponder and had the first officer report level. ATC said they were now receiving the mode C and nothing else was said. I will now always give a thorough brief. I won't assume my first officer has the same knowledge as I do. Better to brief it and ensure that he/she knows what to expect. None of these events by themselves was a problem. Even a combination of them we handle all the time. But the total combined; along with the timing placed me in a very precarious situation all caused by not briefing low altitude capture.
Original NASA ASRS Text
Title: A B757 CAPT REPORTS HAVING VERTIGO DURING A RAPID POST TKOF TURNING CLB WITH A LOW ALT LEVEL OFF. POOR CRM CITED ON AN EARLY MORNING FATIGUED FLT.
Narrative: I ALLOWED COMPLACENCY TO ENTER THE COCKPIT; THUS ALLOWING 5 OR 6 BENIGN EVENTS TO COMBINE AND ESCALATE INTO AN OPPORTUNITY FOR MYSELF TO GET BEHIND THE ACFT AND POSSIBLY GET VIOLATED. IT WAS THE LAST LEG OF A 3 LEGGED NIGHT. I DIDN'T FEEL OVERLY TIRED (THOUGH I HAD BEEN UP ABOUT 20 HRS) AND IT WAS JUST A 20 MIN FLT FROM PT A TO PT B. MY FO IS EXPERIENCED ON THE ACFT AND THE NIGHT HAD GONE SMOOTH. THE AIRPLANE WAS EMPTY. WE WERE BASICALLY A FERRY FLT. I WAS COMPLACENT IN MY TKOF BRIEF AND FORGOT TO BRIEF THE FO FOR A POSSIBLE LOW ALT CAPTURE. CLRNC WAS RWY HDG WITH A 3000 FT LEVELOFF. WE TOOK OFF ON RWY 9 AND AT ABOUT 800 FT WENT IMC. THOUGH IT WASN'T ANYTHING CONVECTIVE; THE CLOUDS WERE OF THE KIND THAT CAUSE QUITE A BIT OF CHOP. WE WERE THEN GIVEN A COURSE REVERSAL TO TURN TO A HDG OF 270 DEGS. AND THEN I GOT THAT LOW ALT CAPTURE...AT ABOUT 1400-1500 FT. I WAS LATE WITH THE VNAV CALL BECAUSE OF ALL THE THINGS GOING ON IN THE COCKPIT (ATC CALLS; MODERATE CHOP AND THE TURN); COUPLED WITH THE LIGHT ACFT. I DIDN'T THINK IT WAS A BIG DEAL AND CALLED FOR THE FO TO BUG ME CLEAN MANEUVERING. BUT I DIDN'T CALL FOR 'SPD' FIRST AND HE DIDN'T SELECT IT. I KEPT CALLING FOR SPD AND HE KEPT DIALING THE SPD KNOB UP. HE THEN REALIZED THAT WHAT I WANTED AND SELECTED 'SPD.' UNFORTUNATELY FOR ME; BECAUSE WE WERE LIGHT; I WAS IN A BIG TURN; IMC AND GETTING BOUNCED AROUND; I GOT A LITTLE VERTIGO. COUPLE ALL THAT WITH THE BIG ACCELERATION FROM THE AUTOTHROTTLES ADVANCING AND MY INNER EAR AND BODY MADE IT FEEL LIKE THE PLANE WAS DSNDING AND FAST. AND THOUGH I COULD SEE THE VSI CLBING; THE ALTIMETER CLBING AND THE FLT DIRECTOR COMMANDING ME TO PUSH THE NOSE OVER; I COULDN'T SHAKE THE SENSATION OF A RAPID DSCNT. AND SO I WASN'T BEING VERY AGGRESSIVE IN HOLDING THE NOSE OF THE ACFT DOWN. AT THIS POINT I COULD SEE THAT WE WERE RAPIDLY CLBING THROUGH 3000 FT AND STILL CLBING. I ASK MY FO TO SELECT AUTOPLT; WHICH HE DID; BUT THE AUTOPLT WOULDN'T CONNECT AND TO ADD INSULT TO INJURY; THE AUTOPLT DISCONNECT WARNING HORN AND LIGHT STARTED GOING OFF. ANOTHER ADDED STRESSOR. I ASKED THE FO TO CALL ATC AND REQUEST A 4000 FT LEVELOFF WHICH HE DID AND THEY GRANTED. I STILL HAD THE VERTIGO AND SENSATION OF DSNDING. I FINALLY DECIDED TO ROLL WINGS LEVEL WHILE CLICKING OFF THE AUTOPLT DISCONNECT WARNING HORN. AT ABOUT THIS TIME; THE AIRPLANE IS REACHING 250 KTS; SO THE AUTOTHROTTLES BEGIN TO RETARD ALSO HELPING DECREASE MY VERTIGO SENSATION. MY BODY BEGINS TO BELIEVE WHAT MY EYES HAVE BEEN TELLING IT ALL ALONG; THAT YES WE ARE CLBING AND EVERYTHING IS GOING TO BE OK. WE FINALLY GET THE AUTOPLT ON AND GET THE AIRPLANE UNDER CTL. UNFORTUNATELY; BY THIS TIME I'M AT 4700-4800 FT. FOR SOME REASON THOUGH; ATC COULDN'T READ OUR MODE C AND THE XPONDER WAS ON. I DSNDED BACK TO 4000 FT AND LEVELED OFF; RECYCLED THE XPONDER AND HAD THE FO RPT LEVEL. ATC SAID THEY WERE NOW RECEIVING THE MODE C AND NOTHING ELSE WAS SAID. I WILL NOW ALWAYS GIVE A THOROUGH BRIEF. I WON'T ASSUME MY FO HAS THE SAME KNOWLEDGE AS I DO. BETTER TO BRIEF IT AND ENSURE THAT HE/SHE KNOWS WHAT TO EXPECT. NONE OF THESE EVENTS BY THEMSELVES WAS A PROB. EVEN A COMBINATION OF THEM WE HANDLE ALL THE TIME. BUT THE TOTAL COMBINED; ALONG WITH THE TIMING PLACED ME IN A VERY PRECARIOUS SITUATION ALL CAUSED BY NOT BRIEFING LOW ALT CAPTURE.
Data retrieved from NASA's ASRS site as of January 2009 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.