37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 738303 |
Time | |
Date | 200705 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sna.airport |
State Reference | CA |
Altitude | msl single value : 16000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla.artcc |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : musel |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 90 flight time total : 12000 flight time type : 350 |
ASRS Report | 738303 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 165 flight time total : 8200 flight time type : 2300 |
ASRS Report | 737860 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne critical |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert flight crew : returned to assigned altitude |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 6500 vertical : 200 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Departing sna; the captain was flying and the autoplt had not yet been engaged. Socal had given us clearance to 13000 ft with a speed restr of 250 KTS until reaching that altitude. We were switched to ZLA and given further climb clearance just as the aircraft began to level off. I read back the new altitude and dialed it into the alerter and pointed. The captain responded while pointing at the altitude then asked me to 'pull' on the alerter knob in order to select the 'open climb' mode. We continued the climb and approaching 16000 ft; received a TCAS TA. I reduced range and noted an aircraft at 17000 ft slightly south of us. We acquired it visually and noted that it was diverging to our right. The captain had stopped the climb by 16600 ft with the traffic now about 3.5 mi away. I reported the traffic to ZLA. They responded that our clearance altitude was 16000 ft and told us to 'maintain sixteen thousand.' I reported that we were descending to maintain 16000 ft. We then both looked at the alerter window. It was set to 17000 ft. We reset it to sixteen and leveled off. In discussing what had happened; we agreed that we had followed proper procedure in setting the alerter: each pointing and the PF restating the altitude. It was inconceivable to us that I would have read back sixteen; but dialed seventeen into the window without one of us realizing the mistake. After landing in denver; the captain called the center and was informed that they had listened to the tape and I had indeed read back sixteen thousand. The only other idea we could come up with for how this may have happened is that in pulling on the alerter knob to continue our climb; I might have twisted it and changed the set altitude without either of us noticing. I tried to duplicate this on the ground; but deemed it unlikely due to the amount the knob had to be turned to change the altitude.
Original NASA ASRS Text
Title: A319 FLT CREW OVERSHOOTS ALT IN CLB; CREATING CONFLICT WITH TFC ABOVE.
Narrative: DEPARTING SNA; THE CAPT WAS FLYING AND THE AUTOPLT HAD NOT YET BEEN ENGAGED. SOCAL HAD GIVEN US CLRNC TO 13000 FT WITH A SPD RESTR OF 250 KTS UNTIL REACHING THAT ALT. WE WERE SWITCHED TO ZLA AND GIVEN FURTHER CLB CLRNC JUST AS THE ACFT BEGAN TO LEVEL OFF. I READ BACK THE NEW ALT AND DIALED IT INTO THE ALERTER AND POINTED. THE CAPT RESPONDED WHILE POINTING AT THE ALT THEN ASKED ME TO 'PULL' ON THE ALERTER KNOB IN ORDER TO SELECT THE 'OPEN CLB' MODE. WE CONTINUED THE CLB AND APCHING 16000 FT; RECEIVED A TCAS TA. I REDUCED RANGE AND NOTED AN ACFT AT 17000 FT SLIGHTLY S OF US. WE ACQUIRED IT VISUALLY AND NOTED THAT IT WAS DIVERGING TO OUR R. THE CAPT HAD STOPPED THE CLB BY 16600 FT WITH THE TFC NOW ABOUT 3.5 MI AWAY. I RPTED THE TFC TO ZLA. THEY RESPONDED THAT OUR CLRNC ALT WAS 16000 FT AND TOLD US TO 'MAINTAIN SIXTEEN THOUSAND.' I RPTED THAT WE WERE DSNDING TO MAINTAIN 16000 FT. WE THEN BOTH LOOKED AT THE ALERTER WINDOW. IT WAS SET TO 17000 FT. WE RESET IT TO SIXTEEN AND LEVELED OFF. IN DISCUSSING WHAT HAD HAPPENED; WE AGREED THAT WE HAD FOLLOWED PROPER PROC IN SETTING THE ALERTER: EACH POINTING AND THE PF RESTATING THE ALT. IT WAS INCONCEIVABLE TO US THAT I WOULD HAVE READ BACK SIXTEEN; BUT DIALED SEVENTEEN INTO THE WINDOW WITHOUT ONE OF US REALIZING THE MISTAKE. AFTER LNDG IN DENVER; THE CAPT CALLED THE CTR AND WAS INFORMED THAT THEY HAD LISTENED TO THE TAPE AND I HAD INDEED READ BACK SIXTEEN THOUSAND. THE ONLY OTHER IDEA WE COULD COME UP WITH FOR HOW THIS MAY HAVE HAPPENED IS THAT IN PULLING ON THE ALERTER KNOB TO CONTINUE OUR CLB; I MIGHT HAVE TWISTED IT AND CHANGED THE SET ALT WITHOUT EITHER OF US NOTICING. I TRIED TO DUPLICATE THIS ON THE GND; BUT DEEMED IT UNLIKELY DUE TO THE AMOUNT THE KNOB HAD TO BE TURNED TO CHANGE THE ALT.
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.