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Attributes | |
ACN | 83302 |
Time | |
Date | 198803 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : azo |
State Reference | MI |
Altitude | msl bound lower : 3000 msl bound upper : 4300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : azo |
Operator | common carrier : air carrier |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | cruise other |
Flight Plan | VFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 259 flight time total : 3603 flight time type : 379 |
ASRS Report | 83302 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 200 flight time total : 5000 flight time type : 2400 |
ASRS Report | 83305 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : far |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance |
Consequence | faa : investigated |
Miss Distance | horizontal : 6000 vertical : 0 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Departure clearance issued well before arrival at runway included initial 3000' climb restriction. Start up and taxi normal, and checklist items completed, including navigation radios, communication radios, bearings selected on HSI's and 3000' set in altitude alerter. Takeoff clearance received with a heading of 140 degrees assigned (departed runway 17). Takeoff was normal, climb attitude and power established and handoff to departure frequency. Departure frequency very busy and after takeoff checks were completed. Did not hear or see altitude alerter. First noticed altitude bust as I completed initial call to departure (we were already at 4300' MSL). Captain had reached over to turn off mode C, which brought some chiding remarks from the departure controller ('I notice your mode C has mysteriously disappeared'). We were subsequently cleared to 8000'. I requested and received RAPCON/TRACON's phone number (which I subsequently called to discuss our blunder and was politely informed a deviation had been filed. I specifically requested the distance/sep of a nearby aircraft and was told 1 NM horizontal, the small aircraft was level at 3500' MSL). That both captain and I would not recognize the altitude excursion until too late suggests complacency or misguided procedures/priorities. It is my habit to ritualistically review departure instructions/restrictions prior to gaining the runway (part of takeoff briefing on checklist) and the relatively low initial altitude should have been ample cue to climb conservatively after achieving safe maneuvering altitude. I don't remember hearing or seeing the altitude alerter, and after instructed to change to departure, that frequency was swamped with conversation and I couldn't check in (perhaps the captain was anticipating further climb to the exclusion of our clearance limit?). While the aim recommends climbs and dscnts at maximum rate until the last 1000', when 500 FPM is suggested, I have quit nagging my capts on this technique as the majority appear to enjoy the small transport impressive cold WX climb capability (many capts have not had previous jet and/or military jet experience which is part of my background), and press the margins in both directions. Alas, I became focused on a wandering propeller governor and neither altimeter and it was fait accomplish by the time I keyed the transmitter. (Oddly or ironically, several weeks ago I discussed with this captain his tendency to climb very slowly, the benefits of climbing--to assigned altitudes--rapidly (less exposure to low altitude congestion, more rapid assimilation into en route structure, advantages of altitude in the event of engine failure or some catastrophe requiring or forcing a gradual descent/inability to climb).) although the captain was PF, I acknowledge my failure to supervise the departure adequately. The purpose of a 2-CREW cockpit is to avert such errors, each pilot reinforcing the efforts of the other. We departed an aerodrome at nearly 1000' MSL elevation, and were required to arrest our ascent only 2000' AGL or in less than 60 seconds (based on climb performance and profile). There are few airports that limit initial climb for high performance aircraft, and until this event/incident, I've weathered the requirements west/O difficulty. Once again I'm reminded how critical the first seconds of any flight can be. I don't like to consider my cockpit performance as complacent, and I'll redouble my efforts to insure similar errors never occur.
Original NASA ASRS Text
Title: ACR-SMT OVERSHOT ALT ON DEP CLIMB CAUSING PETENTIAL WITH GA-SMA. CAPT TURNED OFF MODE C.
Narrative: DEP CLRNC ISSUED WELL BEFORE ARR AT RWY INCLUDED INITIAL 3000' CLB RESTRICTION. START UP AND TAXI NORMAL, AND CHKLIST ITEMS COMPLETED, INCLUDING NAV RADIOS, COM RADIOS, BEARINGS SELECTED ON HSI'S AND 3000' SET IN ALT ALERTER. TKOF CLRNC RECEIVED WITH A HDG OF 140 DEGS ASSIGNED (DEPARTED RWY 17). TKOF WAS NORMAL, CLB ATTITUDE AND PWR ESTABLISHED AND HDOF TO DEP FREQ. DEP FREQ VERY BUSY AND AFTER TKOF CHKS WERE COMPLETED. DID NOT HEAR OR SEE ALT ALERTER. FIRST NOTICED ALT BUST AS I COMPLETED INITIAL CALL TO DEP (WE WERE ALREADY AT 4300' MSL). CAPT HAD REACHED OVER TO TURN OFF MODE C, WHICH BROUGHT SOME CHIDING REMARKS FROM THE DEP CTLR ('I NOTICE YOUR MODE C HAS MYSTERIOUSLY DISAPPEARED'). WE WERE SUBSEQUENTLY CLRED TO 8000'. I REQUESTED AND RECEIVED RAPCON/TRACON'S PHONE NUMBER (WHICH I SUBSEQUENTLY CALLED TO DISCUSS OUR BLUNDER AND WAS POLITELY INFORMED A DEVIATION HAD BEEN FILED. I SPECIFICALLY REQUESTED THE DISTANCE/SEP OF A NEARBY ACFT AND WAS TOLD 1 NM HORIZ, THE SMA WAS LEVEL AT 3500' MSL). THAT BOTH CAPT AND I WOULD NOT RECOGNIZE THE ALT EXCURSION UNTIL TOO LATE SUGGESTS COMPLACENCY OR MISGUIDED PROCS/PRIORITIES. IT IS MY HABIT TO RITUALISTICALLY REVIEW DEP INSTRUCTIONS/RESTRICTIONS PRIOR TO GAINING THE RWY (PART OF TKOF BRIEFING ON CHKLIST) AND THE RELATIVELY LOW INITIAL ALT SHOULD HAVE BEEN AMPLE CUE TO CLB CONSERVATIVELY AFTER ACHIEVING SAFE MANEUVERING ALT. I DON'T REMEMBER HEARING OR SEEING THE ALT ALERTER, AND AFTER INSTRUCTED TO CHANGE TO DEP, THAT FREQ WAS SWAMPED WITH CONVERSATION AND I COULDN'T CHK IN (PERHAPS THE CAPT WAS ANTICIPATING FURTHER CLB TO THE EXCLUSION OF OUR CLRNC LIMIT?). WHILE THE AIM RECOMMENDS CLBS AND DSCNTS AT MAX RATE UNTIL THE LAST 1000', WHEN 500 FPM IS SUGGESTED, I HAVE QUIT NAGGING MY CAPTS ON THIS TECHNIQUE AS THE MAJORITY APPEAR TO ENJOY THE SMT IMPRESSIVE COLD WX CLB CAPABILITY (MANY CAPTS HAVE NOT HAD PREVIOUS JET AND/OR MIL JET EXPERIENCE WHICH IS PART OF MY BACKGROUND), AND PRESS THE MARGINS IN BOTH DIRECTIONS. ALAS, I BECAME FOCUSED ON A WANDERING PROP GOVERNOR AND NEITHER ALTIMETER AND IT WAS FAIT ACCOMPLISH BY THE TIME I KEYED THE XMITTER. (ODDLY OR IRONICALLY, SEVERAL WKS AGO I DISCUSSED WITH THIS CAPT HIS TENDENCY TO CLB VERY SLOWLY, THE BENEFITS OF CLBING--TO ASSIGNED ALTS--RAPIDLY (LESS EXPOSURE TO LOW ALT CONGESTION, MORE RAPID ASSIMILATION INTO ENRTE STRUCTURE, ADVANTAGES OF ALT IN THE EVENT OF ENG FAILURE OR SOME CATASTROPHE REQUIRING OR FORCING A GRADUAL DSCNT/INABILITY TO CLB).) ALTHOUGH THE CAPT WAS PF, I ACKNOWLEDGE MY FAILURE TO SUPERVISE THE DEP ADEQUATELY. THE PURPOSE OF A 2-CREW COCKPIT IS TO AVERT SUCH ERRORS, EACH PLT REINFORCING THE EFFORTS OF THE OTHER. WE DEPARTED AN AERODROME AT NEARLY 1000' MSL ELEVATION, AND WERE REQUIRED TO ARREST OUR ASCENT ONLY 2000' AGL OR IN LESS THAN 60 SECS (BASED ON CLB PERFORMANCE AND PROFILE). THERE ARE FEW ARPTS THAT LIMIT INITIAL CLB FOR HIGH PERFORMANCE ACFT, AND UNTIL THIS EVENT/INCIDENT, I'VE WEATHERED THE REQUIREMENTS W/O DIFFICULTY. ONCE AGAIN I'M REMINDED HOW CRITICAL THE FIRST SECS OF ANY FLT CAN BE. I DON'T LIKE TO CONSIDER MY COCKPIT PERFORMANCE AS COMPLACENT, AND I'LL REDOUBLE MY EFFORTS TO INSURE SIMILAR ERRORS NEVER OCCUR.
Data retrieved from NASA's ASRS site as of August 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.