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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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An air carrier first officer reports that distraction during the time that the level- off should have been initiated caused the flight crew to fail to follow the airline's standard operating procedures, which in turn, led to an altitude deviation during the departure climb.
| Attributes | |
| ACN | 330090 |
| Time | |
| Date | 199603 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : air |
| State Reference | OH |
| Altitude | msl bound lower : 11000 msl bound upper : 11600 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zny |
| Operator | common carrier : air carrier |
| Make Model Name | Commercial Fixed Wing |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | enroute : direct enroute airway : zny |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp pilot : flight engineer |
| ASRS Report | 330090 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance |
| 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:
I was PF. Center gave us direct air and climb and maintain 11000 ft. The company SOP requires PNF to point to a new altitude until PF points to it also and says, '11000 ft.' I was pushing up throttles and when I looked up PNF was pointing at vertical speed switch instead of altitude window. I had to stop and think and mentally reject vertical speed and called for VNAV. Hence I never focused on or repeated '11000 ft.' SOP also requires us to both call out '10000 ft for 11000 ft' with PNF initiating the callout exchange. Neither of us made the callout. We reached 11400 ft before PNF caught my error, highest altitude of 11600 ft. Fatigue was additional factor: as west coast based pilots an XE00 departure from philly required a XA00 hours body clock wake-up. At time of occurrence center was very busy and gave us about 7 altitude and navigation clrncs within 4 mins.
Original NASA ASRS Text
Title: AN ACR FO RPTS THAT DISTR DURING THE TIME THAT THE LEVEL- OFF SHOULD HAVE BEEN INITIATED CAUSED THE FLC TO FAIL TO FOLLOW THE AIRLINE'S STANDARD OPERATING PROCS, WHICH IN TURN, LED TO AN ALTDEV DURING THE DEP CLB.
Narrative: I WAS PF. CTR GAVE US DIRECT AIR AND CLB AND MAINTAIN 11000 FT. THE COMPANY SOP REQUIRES PNF TO POINT TO A NEW ALT UNTIL PF POINTS TO IT ALSO AND SAYS, '11000 FT.' I WAS PUSHING UP THROTTLES AND WHEN I LOOKED UP PNF WAS POINTING AT VERT SPD SWITCH INSTEAD OF ALT WINDOW. I HAD TO STOP AND THINK AND MENTALLY REJECT VERT SPD AND CALLED FOR VNAV. HENCE I NEVER FOCUSED ON OR REPEATED '11000 FT.' SOP ALSO REQUIRES US TO BOTH CALL OUT '10000 FT FOR 11000 FT' WITH PNF INITIATING THE CALLOUT EXCHANGE. NEITHER OF US MADE THE CALLOUT. WE REACHED 11400 FT BEFORE PNF CAUGHT MY ERROR, HIGHEST ALT OF 11600 FT. FATIGUE WAS ADDITIONAL FACTOR: AS WEST COAST BASED PLTS AN XE00 DEP FROM PHILLY REQUIRED A XA00 HRS BODY CLOCK WAKE-UP. AT TIME OF OCCURRENCE CTR WAS VERY BUSY AND GAVE US ABOUT 7 ALT AND NAV CLRNCS WITHIN 4 MINS.
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.