ACR PIC CITES FLC BEHAVIOR FATIGUE AS REASON FOR ALT DEV ALT OVERSHOT IN CLBING TFC.

Date: 1993-08 · Aircraft: Medium Large Transport; Low Wing; 2 Turbojet Eng · Phase: climb

Anomalies: deviation-altitude-overshoot|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy|other-unspecified

Synopsis

ACR PIC CITES FLC BEHAVIOR FATIGUE AS REASON FOR ALT DEV ALT OVERSHOT IN CLBING TFC.

Narrative

CLBING THROUGH FL243; THE FO POINTED TO THE ALT REMINDER AND SAID '24000 FT.' THE MAIN CAUSE OF THIS MISTAKE WAS ACUTE FATIGUE. I HAD TROUBLE SLEEPING THE PREVIOUS 2 NIGHTS. THE FIRST ONE WAS DUE TO A LATE ARR AT THE LAYOVER POINT; COUPLED WITH A DISTURBANCE IN THE PARKING LOT OUTSIDE MY ROOM AT XA50 AM. THE SECOND NIGHT I JUST COULDN'T GET TO SLEEP UNTIL XA00 AM AND THEN HAD TO GET UP AT XF30. PRIOR TO GOING TO WORK ON THE SECOND DAY; I RENTED A BICYCLE AND RODE FOR APPROX 20 MI; FAR BEYOND WHAT I SHOULD HAVE DONE IN MY STATE OF PHYSICAL FITNESS. THE END RESULT WAS I WAS VERY TIRED AND MADE THE MISTAKE OF NOT LEVELING OFF AT THE ASSIGNED ALT. IN FACT; I MISINTERPRETED THE ALT WARNING WHEN I PASSED FL240. I THOUGHT IT WAS THE 'ALMOST 1000 FT TO GO' WARNING WHEN IN FACT IT WAS THE 'YOU JUST PASSED YOUR ALT' WARNING. THERE'S NO QUESTION; I WOULD HAVE LEVELED OFF AT FL250. I DON'T KNOW WHAT HAPPENED TO THE '23000 FT FOR 24000 FT' CALLOUT THAT SHOULD HAVE TAKEN PLACE 1000 FT BEFORE THE ASSIGNED ALT. I AM VERY RELIGIOUS IN FOLLOWING THAT SOP AND INSIST MY COPLTS DO SO TOO. IF IT WAS GIVEN; IT DIDN'T REGISTER IN MY CONSCIOUS MIND. IF IT WASN'T GIVEN; I DIDN'T DETECT THAT EITHER. WE ALL HAVE HEARD THAT PLTS ARE NOT TO FLY WHEN TOO TIRED. IN MY 26 YRS WITH THE AIRLINES I HAVE ONLY HEARD OF 1 PLT THAT ACTUALLY TOOK HIMSELF OFF A TRIP DUE TO EXCESS FATIGUE. HE WAS PUT ON A WITHOUT PAY STATUS FOR THE REMAINDER OF THE TRIP. I HAVE KNOWN MANY; MANY OTHERS WHO HAVE ADMITTED TO BEING TOO TIRED TO FLY AND DID SO ANYWAY; BECAUSE OF NOT WANTING TO LOSE THE PAY OR NOT WANTING TO APPEAR TO NOT HAVE THE 'RIGHT STUFF.' IT WOULD BE NICE IF THAT COULD CHANGE. IF I EVER GET THIS TIRED AGAIN; I WILL JOIN THE 1 COURAGEOUS GUY I MENTIONED AND JUST SAY NO.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.