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Altitude deviation altitude overshot in descent procedure in a night operation. Lear jet cargo charter.
| Attributes | |
| ACN | 344610 |
| Time | |
| Date | 199608 |
| Day | Thu |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | atc facility : law |
| State Reference | OK |
| Altitude | msl bound lower : 22000 msl bound upper : 24000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : zfw |
| Operator | other |
| Make Model Name | Gates Learjet Corp Undifferentiated or Other Model |
| Operating Under FAR Part | Part 135 |
| Flight Phase | descent other |
| Route In Use | enroute other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | Other |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : instrument pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 150 flight time total : 6200 flight time type : 1600 |
| ASRS Report | 344610 |
| Person 2 | |
| Affiliation | Other |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : commercial |
| ASRS Report | 344609 |
| Events | |
| Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot non adherence : clearance |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued new clearance other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation other |
Narrative:
We departed addison airport at XX15 CDT, en route to lawton, ok. After being cleared to our cruising altitude, FL310, at approximately 29500 ft, we were cleared to descend to FL240. Shortly after this, ZFW asked us to say our altitude. At this time, I realized that not only had our altitude alerter equipment and its illumination failed, but I had descended to FL220. My first officer read back 'FL220, but climbing back to FL240,' which I reached in approximately 30 seconds. ZFW advised us that our assigned altitude was FL240, and then told us to descend to 17000 ft. There was no traffic conflict. We were basically set up for this problem by an unknown failed altitude alerter, missing illumination in night conditions, tired physiological conditions of both crew members, and slightly weak CRM. I plan to stop relying so heavily on mechanical alerting devices, and to practice better crew resource management. The tired physiological conditions will always exist at 24 hour ad hoc charter operations.
Original NASA ASRS Text
Title: ALTDEV ALT OVERSHOT IN DSCNT PROC IN A NIGHT OP. LEAR JET CARGO CHARTER.
Narrative: WE DEPARTED ADDISON ARPT AT XX15 CDT, ENRTE TO LAWTON, OK. AFTER BEING CLRED TO OUR CRUISING ALT, FL310, AT APPROX 29500 FT, WE WERE CLRED TO DSND TO FL240. SHORTLY AFTER THIS, ZFW ASKED US TO SAY OUR ALT. AT THIS TIME, I REALIZED THAT NOT ONLY HAD OUR ALT ALERTER EQUIP AND ITS ILLUMINATION FAILED, BUT I HAD DSNDED TO FL220. MY FO READ BACK 'FL220, BUT CLBING BACK TO FL240,' WHICH I REACHED IN APPROX 30 SECONDS. ZFW ADVISED US THAT OUR ASSIGNED ALT WAS FL240, AND THEN TOLD US TO DSND TO 17000 FT. THERE WAS NO TFC CONFLICT. WE WERE BASICALLY SET UP FOR THIS PROB BY AN UNKNOWN FAILED ALT ALERTER, MISSING ILLUMINATION IN NIGHT CONDITIONS, TIRED PHYSIOLOGICAL CONDITIONS OF BOTH CREW MEMBERS, AND SLIGHTLY WEAK CRM. I PLAN TO STOP RELYING SO HEAVILY ON MECHANICAL ALERTING DEVICES, AND TO PRACTICE BETTER CREW RESOURCE MGMNT. THE TIRED PHYSIOLOGICAL CONDITIONS WILL ALWAYS EXIST AT 24 HR AD HOC CHARTER OPS.
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.