37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 795158 |
Time | |
Date | 200807 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bos.airport |
State Reference | MA |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | artcc : zbw.artcc |
Make Model Name | Commercial Fixed Wing |
Navigation In Use | other |
Flight Phase | descent : approach |
Route In Use | arrival star : inndy |
Person 1 | |
Function | flight crew : first officer |
Qualification | pilot : atp |
ASRS Report | 795158 |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : published procedure non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Descending on inndy two RNAV arrival to bos. I was PF; and left the frequency and airplane control for the captain while I made the arrival; WX; gate announcement to the passenger. I returned to frequency and resumed flying duties. We were approaching pvd and nearing our leveloff to meet crossing restr at pvd. ATC told us to slow to 250 KTS about 15 mi early. While slowing; we leveled at 12000 ft and approached pvd. I noticed our airplane descent path indication was showing us high on descent profile; and I wondered why for a few seconds while we crossed pvd. Then realized that our FMS showed 11000 ft at pvd; and we quickly queried ATC on the assigned restr. He said; 'yeah; it should be 11000 ft; but that's ok; contact boston approach on...' we had inadvertently dialed in the fcp 12000 ft in the altitude window. I quickly initiated descent to 11000 ft. There was no traffic conflict; and no further query from ATC. I became distraction during my passenger announcement and didn't adequately xchk the FMS; the fcp altitude window; and the arrival chart to ensure compliance. I became used to being given different altitude assignments than published on arrival dscnts into my base airport which may have caused me to inadvertently ignore published expected descent restrs. Finally; this was the last day of a difficult 4 day for us that began with delays; reduced rest; and early morning shows. The previous week I had workdays that went late in the day and into the early morning; and my body was feeling fatigued and maladjusted. My reaction to seeing the error was slower than normal due to tiredness.
Original NASA ASRS Text
Title: FLT CREW INADVERTENTLY ENTERS 12000 FEET IN THE FCP ALTITUDE WINDOW DURING THE INNDY 2 TO BOS AND FAILS TO CATCH IT PRIOR TO PVD.
Narrative: DSNDING ON INNDY TWO RNAV ARR TO BOS. I WAS PF; AND LEFT THE FREQ AND AIRPLANE CTL FOR THE CAPT WHILE I MADE THE ARR; WX; GATE ANNOUNCEMENT TO THE PAX. I RETURNED TO FREQ AND RESUMED FLYING DUTIES. WE WERE APCHING PVD AND NEARING OUR LEVELOFF TO MEET XING RESTR AT PVD. ATC TOLD US TO SLOW TO 250 KTS ABOUT 15 MI EARLY. WHILE SLOWING; WE LEVELED AT 12000 FT AND APCHED PVD. I NOTICED OUR AIRPLANE DSCNT PATH INDICATION WAS SHOWING US HIGH ON DSCNT PROFILE; AND I WONDERED WHY FOR A FEW SECONDS WHILE WE CROSSED PVD. THEN REALIZED THAT OUR FMS SHOWED 11000 FT AT PVD; AND WE QUICKLY QUERIED ATC ON THE ASSIGNED RESTR. HE SAID; 'YEAH; IT SHOULD BE 11000 FT; BUT THAT'S OK; CONTACT BOSTON APCH ON...' WE HAD INADVERTENTLY DIALED IN THE FCP 12000 FT IN THE ALT WINDOW. I QUICKLY INITIATED DSCNT TO 11000 FT. THERE WAS NO TFC CONFLICT; AND NO FURTHER QUERY FROM ATC. I BECAME DISTR DURING MY PAX ANNOUNCEMENT AND DIDN'T ADEQUATELY XCHK THE FMS; THE FCP ALT WINDOW; AND THE ARR CHART TO ENSURE COMPLIANCE. I BECAME USED TO BEING GIVEN DIFFERENT ALT ASSIGNMENTS THAN PUBLISHED ON ARR DSCNTS INTO MY BASE ARPT WHICH MAY HAVE CAUSED ME TO INADVERTENTLY IGNORE PUBLISHED EXPECTED DSCNT RESTRS. FINALLY; THIS WAS THE LAST DAY OF A DIFFICULT 4 DAY FOR US THAT BEGAN WITH DELAYS; REDUCED REST; AND EARLY MORNING SHOWS. THE PREVIOUS WK I HAD WORKDAYS THAT WENT LATE IN THE DAY AND INTO THE EARLY MORNING; AND MY BODY WAS FEELING FATIGUED AND MALADJUSTED. my REACTION TO SEEING THE ERROR WAS SLOWER THAN NORMAL DUE TO TIREDNESS.
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.