37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 771585 |
Time | |
Date | 200801 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl bound lower : 7000 msl bound upper : 7500 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : las |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 4500 flight time type : 120 |
ASRS Report | 771585 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : clearance |
Independent Detector | aircraft equipment : tcas other controllera |
Resolutory Action | controller : issued alert flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
After climbing out on runway 1R in las we were handed off to las departure. He gave us standard TA's that are heard every day. We had a TA indicating that someone was 4 mi away; 2000 ft above us; which is not unusual. ATC then advised us to maintain 7000 ft; which was our original departure clearance altitude. We were at 7400 ft and tried to correct back down; but had 9000 ft in the altitude selector and were confused. We were notified that we should contact departure control when we could talk about the possible deviation. There were some issues that led up to this event. Our original departure clearance was 7000 ft which we got with our clearance from clearance delivery in las. As a crew we do not know why but at the time of the issue we had 9000 ft in our altitude selector. After we took off with the proper takeoff clearance; tower issued us another takeoff clearance; which was meant for the proceeding aircraft. Tower realized the mistake and handed us off to departure with the instructions 'turn 090 degrees direct trailer; and resume to departure; contact departure.' he possibly could have given us 9000 ft on the altitude as well; but we highly doubt it due to the following events; and believe that it would be unusual for tower to do that. There was a little confusion on our behalf with the multiple takeoff clrncs; but then contacted departure. For some reason; when checking in with departure; I indicated the altitude leaving; 3500 ft and climbing to 9000 ft; but don't know why that altitude was stated other than that it was the altitude in the altitude selector and that was 9000 ft. This was not challenged by ATC. It could have been bumped by accident; selected by mistake when the heading of 090 degrees was given or something else. On the ground our altitude selector stated 7000 ft and we check it multiple times throughout the taxi and pre-taxi procedures. Prior to reaching 7000 ft we were given TA and our heads were outside looking for traffic when we vacated 7000 ft; but felt for some reason that with 9000 ft being read back that for some reason it was ok. When ATC informed us to return to 7000 ft it was obvious that it was not ok. Possible reasons for the situation were; first and foremost; pilot fatigue. Both pilots were working late or had worked late the previous night. Myself; the previous night; had worked over 1530 mins of duty and 820 mins of flight time with poor sleep. I was on reserve at XA00 that morning when the issue took place. I had 10 hours of scheduled rest; and expressed to our schedules that it was going to be another long night putting us at 15 hours of duty. They then stated that there was no one else to do the trip. The captain stated that his original trip was supposed to depart early but was pushed back throughout the morning and his start time was changed throughout the morning. It is my true belief that this practice of contacting crew members prior to their start time to change it to a later time is cause for pilot fatigue and will lead to an accident. Also; it is my belief that 16 hours of duty is unsafe. I believe it should be less by the company or by the FAA. He was ready to be at work early and he was looking at over 13 hours of duty at this point and was looking to finish his shift very late; which makes for a really long day. Another possible reason is that our altitude selector knobs have different functions in different airplanes. Some you roll in the altitude then pull the knob to select the altitude. Others; the type we had; can have an altitude knob rolled without being pulled to select the altitude. This could have led to the altitude being bumped or changed during the new assigned heading or when the autoplt was engaged. Standardizing this knob and other switches which functions are drastically different from aircraft to aircraft can improve CRM and standardization. Another; is that if we incorrectly stated an altitude; and that altitude was not challenged on our initial check-in with departure. Again; I do not know why 9000 ft was stated but it was and was not challenged. 9000 ft could have been given to us by the tower but I cannot say for sure. I believe that the TA's also diverted our attention; the incorrect takeoff clearance caused an undue distrand alarm. The advisories are necessary but the timing of those was not good.
Original NASA ASRS Text
Title: MD80 FLT CREW EXCEEDS 7000 FEET ON LAS 3 DEPARTURE AS THEY HAVE INSERTED 9000 FEET IN THE ALTITUDE ALERTER. FATIGUE AND FLEET DIFFERENCES IN THE ALERTER ARE CITED AS POSSIBLE FACTORS.
Narrative: AFTER CLBING OUT ON RWY 1R IN LAS WE WERE HANDED OFF TO LAS DEP. HE GAVE US STANDARD TA'S THAT ARE HEARD EVERY DAY. WE HAD A TA INDICATING THAT SOMEONE WAS 4 MI AWAY; 2000 FT ABOVE US; WHICH IS NOT UNUSUAL. ATC THEN ADVISED US TO MAINTAIN 7000 FT; WHICH WAS OUR ORIGINAL DEP CLRNC ALT. WE WERE AT 7400 FT AND TRIED TO CORRECT BACK DOWN; BUT HAD 9000 FT IN THE ALT SELECTOR AND WERE CONFUSED. WE WERE NOTIFIED THAT WE SHOULD CONTACT DEP CTL WHEN WE COULD TALK ABOUT THE POSSIBLE DEV. THERE WERE SOME ISSUES THAT LED UP TO THIS EVENT. OUR ORIGINAL DEP CLRNC WAS 7000 FT WHICH WE GOT WITH OUR CLRNC FROM CLRNC DELIVERY IN LAS. AS A CREW WE DO NOT KNOW WHY BUT AT THE TIME OF THE ISSUE WE HAD 9000 FT IN OUR ALT SELECTOR. AFTER WE TOOK OFF WITH THE PROPER TKOF CLRNC; TWR ISSUED US ANOTHER TKOF CLRNC; WHICH WAS MEANT FOR THE PROCEEDING ACFT. TWR REALIZED THE MISTAKE AND HANDED US OFF TO DEP WITH THE INSTRUCTIONS 'TURN 090 DEGS DIRECT TRAILER; AND RESUME TO DEP; CONTACT DEP.' HE POSSIBLY COULD HAVE GIVEN US 9000 FT ON THE ALT AS WELL; BUT WE HIGHLY DOUBT IT DUE TO THE FOLLOWING EVENTS; AND BELIEVE THAT IT WOULD BE UNUSUAL FOR TWR TO DO THAT. THERE WAS A LITTLE CONFUSION ON OUR BEHALF WITH THE MULTIPLE TKOF CLRNCS; BUT THEN CONTACTED DEP. FOR SOME REASON; WHEN CHKING IN WITH DEP; I INDICATED THE ALT LEAVING; 3500 FT AND CLBING TO 9000 FT; BUT DON'T KNOW WHY THAT ALT WAS STATED OTHER THAN THAT IT WAS THE ALT IN THE ALT SELECTOR AND THAT WAS 9000 FT. THIS WAS NOT CHALLENGED BY ATC. IT COULD HAVE BEEN BUMPED BY ACCIDENT; SELECTED BY MISTAKE WHEN THE HDG OF 090 DEGS WAS GIVEN OR SOMETHING ELSE. ON THE GND OUR ALT SELECTOR STATED 7000 FT AND WE CHK IT MULTIPLE TIMES THROUGHOUT THE TAXI AND PRE-TAXI PROCS. PRIOR TO REACHING 7000 FT WE WERE GIVEN TA AND OUR HEADS WERE OUTSIDE LOOKING FOR TFC WHEN WE VACATED 7000 FT; BUT FELT FOR SOME REASON THAT WITH 9000 FT BEING READ BACK THAT FOR SOME REASON IT WAS OK. WHEN ATC INFORMED US TO RETURN TO 7000 FT IT WAS OBVIOUS THAT IT WAS NOT OK. POSSIBLE REASONS FOR THE SITUATION WERE; FIRST AND FOREMOST; PLT FATIGUE. BOTH PLTS WERE WORKING LATE OR HAD WORKED LATE THE PREVIOUS NIGHT. MYSELF; THE PREVIOUS NIGHT; HAD WORKED OVER 1530 MINS OF DUTY AND 820 MINS OF FLT TIME WITH POOR SLEEP. I WAS ON RESERVE AT XA00 THAT MORNING WHEN THE ISSUE TOOK PLACE. I HAD 10 HRS OF SCHEDULED REST; AND EXPRESSED TO OUR SCHEDULES THAT IT WAS GOING TO BE ANOTHER LONG NIGHT PUTTING US AT 15 HRS OF DUTY. THEY THEN STATED THAT THERE WAS NO ONE ELSE TO DO THE TRIP. THE CAPT STATED THAT HIS ORIGINAL TRIP WAS SUPPOSED TO DEPART EARLY BUT WAS PUSHED BACK THROUGHOUT THE MORNING AND HIS START TIME WAS CHANGED THROUGHOUT THE MORNING. IT IS MY TRUE BELIEF THAT THIS PRACTICE OF CONTACTING CREW MEMBERS PRIOR TO THEIR START TIME TO CHANGE IT TO A LATER TIME IS CAUSE FOR PLT FATIGUE AND WILL LEAD TO AN ACCIDENT. ALSO; IT IS MY BELIEF THAT 16 HRS OF DUTY IS UNSAFE. I BELIEVE IT SHOULD BE LESS BY THE COMPANY OR BY THE FAA. HE WAS READY TO BE AT WORK EARLY AND HE WAS LOOKING AT OVER 13 HRS OF DUTY AT THIS POINT AND WAS LOOKING TO FINISH HIS SHIFT VERY LATE; WHICH MAKES FOR A REALLY LONG DAY. ANOTHER POSSIBLE REASON IS THAT OUR ALT SELECTOR KNOBS HAVE DIFFERENT FUNCTIONS IN DIFFERENT AIRPLANES. SOME YOU ROLL IN THE ALT THEN PULL THE KNOB TO SELECT THE ALT. OTHERS; THE TYPE WE HAD; CAN HAVE AN ALT KNOB ROLLED WITHOUT BEING PULLED TO SELECT THE ALT. THIS COULD HAVE LED TO THE ALT BEING BUMPED OR CHANGED DURING THE NEW ASSIGNED HDG OR WHEN THE AUTOPLT WAS ENGAGED. STANDARDIZING THIS KNOB AND OTHER SWITCHES WHICH FUNCTIONS ARE DRASTICALLY DIFFERENT FROM ACFT TO ACFT CAN IMPROVE CRM AND STANDARDIZATION. ANOTHER; IS THAT IF WE INCORRECTLY STATED AN ALT; AND THAT ALT WAS NOT CHALLENGED ON OUR INITIAL CHK-IN WITH DEP. AGAIN; I DO NOT KNOW WHY 9000 FT WAS STATED BUT IT WAS AND WAS NOT CHALLENGED. 9000 FT COULD HAVE BEEN GIVEN TO US BY THE TWR BUT I CANNOT SAY FOR SURE. I BELIEVE THAT THE TA'S ALSO DIVERTED OUR ATTN; THE INCORRECT TKOF CLRNC CAUSED AN UNDUE DISTRAND ALARM. THE ADVISORIES ARE NECESSARY BUT THE TIMING OF THOSE WAS NOT GOOD.
Data retrieved from NASA's ASRS site as of May 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.