Altitude deviation altitude overshot after amended clearance altitude change not acted upon. Potenti...

Attributes
ACN	312860
Time
Date	199508
Day	Fri
Local Time Of Day	0601 To 1200
Place
Locale Reference	atc facility : pmd
State Reference	CA
Altitude	msl bound lower : 19000 msl bound upper : 20300
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	artcc : zla
Operator	common carrier : air carrier
Make Model Name	Commercial Fixed Wing
Operating Under FAR Part	Part 135
Flight Phase	climbout : intermediate altitude
Route In Use	enroute other
Flight Plan	IFR
Aircraft 2
Make Model Name	Commercial Fixed Wing
Operating Under FAR Part	other : unknown
Flight Phase	cruise other
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 220 flight time total : 8300 flight time type : 900
ASRS Report	312860
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : cfi pilot : commercial pilot : instrument
Experience	flight time last 90 days : 280 flight time total : 2900 flight time type : 500
ASRS Report	312859
Events
Anomaly	altitude deviation : overshoot altitude deviation : excursion from assigned altitude non adherence : clearance non adherence other other anomaly other
Independent Detector	other controllera
Resolutory Action	controller : issued new clearance flight crew : exited adverse environment other
Consequence	Other
Miss Distance	horizontal : 27000 vertical : 500
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

During climb to assigned altitude of FL230, ATC amended altitude to FL190. I did not hear amendment or first officer's readback due to preoccupation with other in-flight duties. As a consequence I did not set FL190 into autoplt altitude window. At approximately FL203 controller asked our altitude and we replied FL203 for FL230. ATC asked us if we received amended clearance to FL190. At that point I still believed we were cleared to FL230 so I told him to reply negative. We then noticed traffic on TCASII at 6 O'clock and approximately 4-5 mi. Suspecting a possible conflict, we asked ATC what altitude he wanted and he replied, continue to FL230. First officer assumed I had heard clearance to FL190. Lesson #1 always verify clearance and if your company has an altitude awareness procedure, utilize it. #2 always fly the plane first. All other duties are secondary to flying the aircraft. Supplemental information from acn 312859: I readback amended clearance. I assumed captain also heard amended clearance. Soon I was distracted by other duties and did not realize amended altitude was not placed in altitude alerter. Upon further discussion of incident, captain and I should have been more aware of each others duties and followed procedure of verbally identing new altitude and insuring awareness by placing it in the alerter immediately.

Original NASA ASRS Text

Title: ALTDEV ALT OVERSHOT AFTER AMENDED CLRNC ALT CHANGE NOT ACTED UPON. POTENTIAL CONFLICT ENSUED.

Narrative: DURING CLB TO ASSIGNED ALT OF FL230, ATC AMENDED ALT TO FL190. I DID NOT HEAR AMENDMENT OR FO'S READBACK DUE TO PREOCCUPATION WITH OTHER INFLT DUTIES. AS A CONSEQUENCE I DID NOT SET FL190 INTO AUTOPLT ALT WINDOW. AT APPROX FL203 CTLR ASKED OUR ALT AND WE REPLIED FL203 FOR FL230. ATC ASKED US IF WE RECEIVED AMENDED CLRNC TO FL190. AT THAT POINT I STILL BELIEVED WE WERE CLRED TO FL230 SO I TOLD HIM TO REPLY NEGATIVE. WE THEN NOTICED TFC ON TCASII AT 6 O'CLOCK AND APPROX 4-5 MI. SUSPECTING A POSSIBLE CONFLICT, WE ASKED ATC WHAT ALT HE WANTED AND HE REPLIED, CONTINUE TO FL230. FO ASSUMED I HAD HEARD CLRNC TO FL190. LESSON #1 ALWAYS VERIFY CLRNC AND IF YOUR COMPANY HAS AN ALT AWARENESS PROC, UTILIZE IT. #2 ALWAYS FLY THE PLANE FIRST. ALL OTHER DUTIES ARE SECONDARY TO FLYING THE ACFT. SUPPLEMENTAL INFO FROM ACN 312859: I READBACK AMENDED CLRNC. I ASSUMED CAPT ALSO HEARD AMENDED CLRNC. SOON I WAS DISTRACTED BY OTHER DUTIES AND DID NOT REALIZE AMENDED ALT WAS NOT PLACED IN ALT ALERTER. UPON FURTHER DISCUSSION OF INCIDENT, CAPT AND I SHOULD HAVE BEEN MORE AWARE OF EACH OTHERS DUTIES AND FOLLOWED PROC OF VERBALLY IDENTING NEW ALT AND INSURING AWARENESS BY PLACING IT IN THE ALERTER IMMEDIATELY.

Data retrieved from NASA's ASRS site as of July 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.

Altitude deviation altitude overshot after amended clearance altitude change not acted upon. Potential conflict ensued.