ALT BUST

Date: 1994-01 · Aircraft: Any Unknown or Unlisted Aircraft Manufacturer · Phase: climb

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

Synopsis

ALT BUST

Narrative

HALFWAY THROUGH A 10 LEG; 10 HR DUTY DAY WHILE STEP CLBING TOWARDS OUR CRUISE ALT; CTR TOLD US TO 'CLB AND MAINTAIN 12000; EXPECT 13000.' THE PNF ACKNOWLEDGED THIS AND PUT 12000 IN THE ALT BOX. AS WE WERE CLBING THROUGH 12300 AT 1000 FPM CTR ADVISED US TO CLB AND MAINTAIN 13000. FORTUNATELY ATC NOTIFIED US TO CLB BEFORE ANY FURTHER ALTDEV OCCURRED AND ANY TFC SEPARATION WAS JEOPARDIZED. THE FACTORS LEADING UP TO THIS EVENT WERE A LONG TIME IN THE MAKING. LONG DUTY DAYS WITH QUICK GND TURNS ARE COMMON AND THE OPPORTUNITY TO 'CATCH OUR BREATH' IS VERY LIMITED. IN THIS PARTICULAR EVENT THE PF AND PNF WERE NOT AS ATTENTIVE AS WE SHOULD HAVE OR COULD HAVE BEEN TO THE SIT AT HAND. I; PF; HAD IN MY MIND THE ALT OF 13000 WHICH WAS THE LAST ALT I HAD HEARD SPOKEN INSTEAD OF 12000 WHICH WE WERE TOLD TO MAINTAIN. LESSON LEARNED IN THIS EVENT WAS TO PAY CLOSER ATTN TO THE CRITICAL PHASES OF FLT NO MATTER HOW MENTALLY AND PHYSICALLY TAXING OUR FLYING SCHEDULE IS. SUPPLEMENTAL INFO FROM ACN 262032: I WAS HUNGRY AND THIS WAS THE ONLY LEG LONG ENOUGH TO EAT ON. NEEDLESS TO SAY I WAS THINKING MORE ABOUT FOOD THAN FLYING. MY FO MISUNDERSTOOD THE CLRNC AND CONTINUED TO CLB TO 13000. I NOTICED HIS ERROR AS HE CLBED THROUGH 124000. JUST AS I STARTED TO SAY SOMETHING; CTR CAME ON AND CLRED US TO 13000. RELATED FACTORS IN THIS INCLUDE A 10 LEG WORKDAY WITH NO MEAL BREAKS; MY OWN COMPLACENCY; AND IMPROPER CREW COORD.

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