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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Air carrier confuses controller instruction during in cockpit training and fails to level at cleared altitude.
| Attributes | |
| ACN | 453481 |
| Time | |
| Date | 199910 |
| Day | Sun |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : clt.airport |
| State Reference | NC |
| Altitude | msl bound lower : 23000 msl bound upper : 24000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zdc.artcc |
| Operator | common carrier : air carrier |
| Make Model Name | Fokker 100 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | descent : intermediate altitude |
| Route In Use | arrival star : masic 9 |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : multi engine pilot : atp |
| Experience | flight time last 90 days : 250 flight time total : 13000 flight time type : 1000 |
| ASRS Report | 453481 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp pilot : multi engine |
| Experience | flight time last 90 days : 80 flight time total : 3700 flight time type : 120 |
| ASRS Report | 453251 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance |
| Independent Detector | other controllera other flight crewa |
| Resolutory Action | controller : issued new clearance flight crew : became reoriented |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
On descent into clt from northeast, approaching mayos intersection from northeast, we were cleared as follows: aircraft X is cleared to FL240 and plan your descent so as to cross mayos at FL220. The PF dialed FL240 into the altitude window and both the PF and PNF made standard altitude callouts as per company procedure. During the descent, the PF changed the altitude in the altitude window and this was not noticed by the PNF (captain). Required altitude acknowledgements were not made. As a result, the aircraft descended through FL240 and was noted at FL230 by ATC. ATC immediately cleared aircraft to FL220 and stated that no loss of separation occurred. Assessment: 1) aircraft descended through FL240 as assigned because new altitude was set in altitude window and proper and required altitude acknowledgements were not made. 2) PNF was not adequately diligent in maintaining altitude awareness while giving instruction to new hire pilot regarding limitations of aircraft's FMS on descent and tailwind. 3) company procedure of point to and say new altitude in altitude window would have prevented this event had it been adhered to.
Original NASA ASRS Text
Title: ACR CONFUSES CTLR INSTRUCTION DURING IN COCKPIT TRAINING AND FAILS TO LEVEL AT CLRED ALT.
Narrative: ON DSCNT INTO CLT FROM NE, APCHING MAYOS INTXN FROM NE, WE WERE CLRED AS FOLLOWS: ACFT X IS CLRED TO FL240 AND PLAN YOUR DSCNT SO AS TO CROSS MAYOS AT FL220. THE PF DIALED FL240 INTO THE ALT WINDOW AND BOTH THE PF AND PNF MADE STANDARD ALT CALLOUTS AS PER COMPANY PROC. DURING THE DSCNT, THE PF CHANGED THE ALT IN THE ALT WINDOW AND THIS WAS NOT NOTICED BY THE PNF (CAPT). REQUIRED ALT ACKNOWLEDGEMENTS WERE NOT MADE. AS A RESULT, THE ACFT DSNDED THROUGH FL240 AND WAS NOTED AT FL230 BY ATC. ATC IMMEDIATELY CLRED ACFT TO FL220 AND STATED THAT NO LOSS OF SEPARATION OCCURRED. ASSESSMENT: 1) ACFT DSNDED THROUGH FL240 AS ASSIGNED BECAUSE NEW ALT WAS SET IN ALT WINDOW AND PROPER AND REQUIRED ALT ACKNOWLEDGEMENTS WERE NOT MADE. 2) PNF WAS NOT ADEQUATELY DILIGENT IN MAINTAINING ALT AWARENESS WHILE GIVING INSTRUCTION TO NEW HIRE PLT REGARDING LIMITATIONS OF ACFT'S FMS ON DSCNT AND TAILWIND. 3) COMPANY PROC OF POINT TO AND SAY NEW ALT IN ALT WINDOW WOULD HAVE PREVENTED THIS EVENT HAD IT BEEN ADHERED TO.
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.