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Captain of a cpr cessna citation 500 overshot by 1300 ft the assigned intermediate departure altitude due to forgetting that the actual assigned altitude was 1000 ft lower than the SID altitude, and then that altitude was overflown by 300 ft.
| Attributes | |
| ACN | 465478 |
| Time | |
| Date | 200002 |
| Day | Wed |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | navaid : sjc.vor |
| State Reference | CA |
| Altitude | msl bound lower : 4000 msl bound upper : 5300 |
| Environment | |
| Flight Conditions | Mixed |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : o90.tracon |
| Operator | general aviation : corporate |
| Make Model Name | Citation I |
| Operating Under FAR Part | Part 91 |
| Navigation In Use | other vortac |
| Flight Phase | climbout : intermediate altitude |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : corporate |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : cfi |
| Experience | flight time total : 5860 |
| ASRS Report | 465478 |
| Person 2 | |
| Affiliation | company : corporate |
| Function | flight crew : first officer |
| Qualification | pilot : multi engine pilot : instrument pilot : commercial |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
| Independent Detector | atc equipment other atc equipment : radar aircraft equipment other aircraft equipment : altimeter other controllera |
| Resolutory Action | controller : issued alert controller : issued new clearance none taken : anomaly accepted none taken : detected after the fact |
| Consequence | faa : reviewed incident with flight crew |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
We were issued an initial altitude of 5000 ft without IFR clearance. As part of the pre-takeoff sequence, we reviewed the SID and clearance. While completing the pre-takeoff checks, the tower controller issued a change to 4000 ft. This as acknowledged by the first officer and we were cleared for takeoff. During the climbing r-hand turn on the SID, we were issued traffic near our altitude. The captain (me) looked out to search for traffic, looked back in and leveled at 5000 ft, looked back out and allowed inadvertently a climb to 5300 ft. I had forgotten about the change to 4000 ft and was trying to hold 5000 ft. Approach asked what our altitude was. First officer replied '5000 ft.' approach asked what we were assigned. First officer replied '4000 ft.' at that point, approach issued a further climb and a phone number to call. Although there are several factors to the incident (aircraft with unfamiliar avionics setup, high task environment, etc) it boils down to the captain not flying the clearance that was issued and acknowledged.
Original NASA ASRS Text
Title: CAPT OF A CPR CESSNA CITATION 500 OVERSHOT BY 1300 FT THE ASSIGNED INTERMEDIATE DEP ALT DUE TO FORGETTING THAT THE ACTUAL ASSIGNED ALT WAS 1000 FT LOWER THAN THE SID ALT, AND THEN THAT ALT WAS OVERFLOWN BY 300 FT.
Narrative: WE WERE ISSUED AN INITIAL ALT OF 5000 FT WITHOUT IFR CLRNC. AS PART OF THE PRE-TKOF SEQUENCE, WE REVIEWED THE SID AND CLRNC. WHILE COMPLETING THE PRE-TKOF CHKS, THE TWR CTLR ISSUED A CHANGE TO 4000 FT. THIS AS ACKNOWLEDGED BY THE FO AND WE WERE CLRED FOR TKOF. DURING THE CLBING R-HAND TURN ON THE SID, WE WERE ISSUED TFC NEAR OUR ALT. THE CAPT (ME) LOOKED OUT TO SEARCH FOR TFC, LOOKED BACK IN AND LEVELED AT 5000 FT, LOOKED BACK OUT AND ALLOWED INADVERTENTLY A CLB TO 5300 FT. I HAD FORGOTTEN ABOUT THE CHANGE TO 4000 FT AND WAS TRYING TO HOLD 5000 FT. APCH ASKED WHAT OUR ALT WAS. FO REPLIED '5000 FT.' APCH ASKED WHAT WE WERE ASSIGNED. FO REPLIED '4000 FT.' AT THAT POINT, APCH ISSUED A FURTHER CLB AND A PHONE NUMBER TO CALL. ALTHOUGH THERE ARE SEVERAL FACTORS TO THE INCIDENT (ACFT WITH UNFAMILIAR AVIONICS SETUP, HIGH TASK ENVIRONMENT, ETC) IT BOILS DOWN TO THE CAPT NOT FLYING THE CLRNC THAT WAS ISSUED AND ACKNOWLEDGED.
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.