<< >> NASA ASRS Report 361240, February 1997

Pilot of a twin turboprop air ambulance overshot assigned climb altitude on climb out for a repositioning flight. He read the altimeter wrong when setting the autoplt altitude hold.

Attributes
ACN	361240
Time
Date	199702
Day	Sat
Local Time Of Day	1201 To 1800
Place
Locale Reference	atc facility : mhr airport : sac
State Reference	CA
Altitude	msl bound lower : 8000 msl bound upper : 9000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : sac
Operator	common carrier : air taxi
Make Model Name	Any Unknown or Unlisted Aircraft Manufacturer
Operating Under FAR Part	Part 135
Navigation In Use	Other
Flight Phase	climbout : intermediate altitude
Route In Use	enroute airway : sac
Flight Plan	IFR
Person 1
Affiliation	company : air taxi
Function	flight crew : single pilot
Qualification	pilot : atp
Experience	flight time last 90 days : 80 flight time total : 6500 flight time type : 20
ASRS Report	361240
Person 2
Affiliation	government : faa
Function	controller : departure
Qualification	controller : radar
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 had just departed xx on an IFR flight plan en route to yy, in VMC. I was using a 'lifeguard' call sign on a prepositioning flight under 14cfr91. I was given one clearance on the ground prior to engine start, and just prior to takeoff I was told by ground control to exact a more direct clearance from departure. Initially I was cleared to 2000 ft MSL. Departure cleared me to 8000 ft MSL which I set in my altitude alerter. I thought I 'armed' it to level off at 8000 ft MSL, but I apparently did not. I got momentarily distracted programming the IFR GPS moving map for this new clearance. I scanned the flight instruments and it looked like I was at 8000 ft MSL, so I hit the altitude hold on the flight director control panel. I then immediately noticed I actually leveled off at 9000 ft MSL. I immediately descended to 8000 ft MSL, at which time xx departure advised me to contact zz ARTCC. Zz then cleared me to 11000 ft MSL. This was caused by being distracted, not correctly programming autoplt flight director, and not monitoring flight instruments adequately.

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Original NASA ASRS Text

Title: PLT OF A TWIN TURBOPROP AIR AMBULANCE OVERSHOT ASSIGNED CLB ALT ON CLBOUT FOR A REPOSITIONING FLT. HE READ THE ALTIMETER WRONG WHEN SETTING THE AUTOPLT ALT HOLD.

Narrative: I HAD JUST DEPARTED XX ON AN IFR FLT PLAN ENRTE TO YY, IN VMC. I WAS USING A 'LIFEGUARD' CALL SIGN ON A PREPOSITIONING FLT UNDER 14CFR91. I WAS GIVEN ONE CLRNC ON THE GND PRIOR TO ENG START, AND JUST PRIOR TO TKOF I WAS TOLD BY GND CTL TO EXACT A MORE DIRECT CLRNC FROM DEP. INITIALLY I WAS CLRED TO 2000 FT MSL. DEP CLRED ME TO 8000 FT MSL WHICH I SET IN MY ALT ALERTER. I THOUGHT I 'ARMED' IT TO LEVEL OFF AT 8000 FT MSL, BUT I APPARENTLY DID NOT. I GOT MOMENTARILY DISTRACTED PROGRAMMING THE IFR GPS MOVING MAP FOR THIS NEW CLRNC. I SCANNED THE FLT INSTS AND IT LOOKED LIKE I WAS AT 8000 FT MSL, SO I HIT THE ALT HOLD ON THE FLT DIRECTOR CTL PANEL. I THEN IMMEDIATELY NOTICED I ACTUALLY LEVELED OFF AT 9000 FT MSL. I IMMEDIATELY DSNDED TO 8000 FT MSL, AT WHICH TIME XX DEP ADVISED ME TO CONTACT ZZ ARTCC. ZZ THEN CLRED ME TO 11000 FT MSL. THIS WAS CAUSED BY BEING DISTRACTED, NOT CORRECTLY PROGRAMMING AUTOPLT FLT DIRECTOR, AND NOT MONITORING FLT INSTS ADEQUATELY.

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.