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|
Attributes | |
ACN | 95183 |
Time | |
Date | 198810 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : lny |
State Reference | HI |
Altitude | msl bound lower : 19000 msl bound upper : 19700 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zhn |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 6500 flight time type : 2700 |
ASRS Report | 95183 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Departure cleared us to FL190. Captain reset altitude alerter, however before he finished the first officer started calling for clean up and climb procedures/checklist. Climbing through 10000' departure had the flight contact center. A vector heading of 100 degrees was assigned pending more direct routing and a speed of 320 KTS was assigned for spacing. Out of 15000' we were cleared direct to the destination VOR. The first officer advised he was unable to receive the VOR signal. However, the captain was receiving a strong signal. The process of dialing in different frequencys and listening to station idents began. Suddenly the first officer said 'oh no,' disconnected the autoplt and started a rapid nose over at 19700'. A descent back to 19000' was completed and the altimeters reset to 29.92. It was noted that the captain had initially set the altitude alerter above 19000' when he left that task to accomplish the clean up/climb procedures and checklist. The alerter had been set to 22000'. Center then advised that there was traffic ahead that we'd be following to destination. Also, there was departing traffic. We identified both targets and started preparing for our descent when we realized that we had exceeded the 320 KT speed restriction. Our day started at XA50. The flight took off at XG20. The captain had just finished a 2 hour break and the first officer flew another trip with a different captain. We took a 17 min delay for maintenance. Initially we were cleared to a west departure. However on taxi out we were advised it would be an east departure and the applicable parts of the clearance were revised. The first major error was made by the captain not finishing the task at hand. The second error was having both crew members devoted to solving the VOR problem, leaving no one to monitor the aircraft. The third error was both crew members looking for traffic with no one checking the airspeed. It's a classic example of the snowball effect: starting out behind and never really catching up. Late out of the blocks, a last minute clearance change, distraction from setting the altitude alerter (don't ever set it above assigned altitude) and not monitoring the aircraft while doing other tasks. One seemingly small mistake that by itself would have been noticed and corrected, but since there were seemingly so many other things going on, was not caught in a timely fashion.
Original NASA ASRS Text
Title: ACR MLG ALT DEVIATION OVERSHOT DURING CLIMB AND SPEED DEVIATION.
Narrative: DEP CLRED US TO FL190. CAPT RESET ALT ALERTER, HOWEVER BEFORE HE FINISHED THE F/O STARTED CALLING FOR CLEAN UP AND CLB PROCS/CHKLIST. CLBING THROUGH 10000' DEP HAD THE FLT CONTACT CENTER. A VECTOR HDG OF 100 DEGS WAS ASSIGNED PENDING MORE DIRECT ROUTING AND A SPD OF 320 KTS WAS ASSIGNED FOR SPACING. OUT OF 15000' WE WERE CLRED DIRECT TO THE DEST VOR. THE F/O ADVISED HE WAS UNABLE TO RECEIVE THE VOR SIGNAL. HOWEVER, THE CAPT WAS RECEIVING A STRONG SIGNAL. THE PROCESS OF DIALING IN DIFFERENT FREQS AND LISTENING TO STATION IDENTS BEGAN. SUDDENLY THE F/O SAID 'OH NO,' DISCONNECTED THE AUTOPLT AND STARTED A RAPID NOSE OVER AT 19700'. A DSCNT BACK TO 19000' WAS COMPLETED AND THE ALTIMETERS RESET TO 29.92. IT WAS NOTED THAT THE CAPT HAD INITIALLY SET THE ALT ALERTER ABOVE 19000' WHEN HE LEFT THAT TASK TO ACCOMPLISH THE CLEAN UP/CLB PROCS AND CHKLIST. THE ALERTER HAD BEEN SET TO 22000'. CENTER THEN ADVISED THAT THERE WAS TFC AHEAD THAT WE'D BE FOLLOWING TO DEST. ALSO, THERE WAS DEPARTING TFC. WE IDENTIFIED BOTH TARGETS AND STARTED PREPARING FOR OUR DSCNT WHEN WE REALIZED THAT WE HAD EXCEEDED THE 320 KT SPD RESTRICTION. OUR DAY STARTED AT XA50. THE FLT TOOK OFF AT XG20. THE CAPT HAD JUST FINISHED A 2 HR BREAK AND THE F/O FLEW ANOTHER TRIP WITH A DIFFERENT CAPT. WE TOOK A 17 MIN DELAY FOR MAINT. INITIALLY WE WERE CLRED TO A W DEP. HOWEVER ON TAXI OUT WE WERE ADVISED IT WOULD BE AN E DEP AND THE APPLICABLE PARTS OF THE CLRNC WERE REVISED. THE FIRST MAJOR ERROR WAS MADE BY THE CAPT NOT FINISHING THE TASK AT HAND. THE SECOND ERROR WAS HAVING BOTH CREW MEMBERS DEVOTED TO SOLVING THE VOR PROB, LEAVING NO ONE TO MONITOR THE ACFT. THE THIRD ERROR WAS BOTH CREW MEMBERS LOOKING FOR TFC WITH NO ONE CHKING THE AIRSPD. IT'S A CLASSIC EXAMPLE OF THE SNOWBALL EFFECT: STARTING OUT BEHIND AND NEVER REALLY CATCHING UP. LATE OUT OF THE BLOCKS, A LAST MINUTE CLRNC CHANGE, DISTR FROM SETTING THE ALT ALERTER (DON'T EVER SET IT ABOVE ASSIGNED ALT) AND NOT MONITORING THE ACFT WHILE DOING OTHER TASKS. ONE SEEMINGLY SMALL MISTAKE THAT BY ITSELF WOULD HAVE BEEN NOTICED AND CORRECTED, BUT SINCE THERE WERE SEEMINGLY SO MANY OTHER THINGS GOING ON, WAS NOT CAUGHT IN A TIMELY FASHION.
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.