ALTDEV ALT OVERSHOT IN CLB DUE TO INADEQUATE COCKPIT COORD MGMNT.

Date: 1994-09 · Aircraft: Commercial Fixed Wing

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

Synopsis

ALTDEV ALT OVERSHOT IN CLB DUE TO INADEQUATE COCKPIT COORD MGMNT.

Narrative

THIS WAS THE CAPT'S FIRST TRIP IN THE ACFT FOLLOWING INITIAL OPERATING EXPERIENCE IN ASSOCIATION WITH HIS TRANSITION INTO TYPE. ALTHOUGH HE HAS BEEN WITH THE COMPANY MANY YRS; THE AIRPLANE AND ITS PROCS ARE NEW TO HIM. I WAS DESIGNATED PF FROM CVG TO ROA. AS PNF; THE CAPT'S DUTIES INCLUDED AIRBORNE CHKLISTS. I AM NEW TO THE COMPANY AND THE ACFT; AND HAD NEVER BEEN TO THIS DEST. WHILE CONCENTRATING ON MONITORING THE AIRPLANE AND NAVIGATING; I WAS RELYING ON THE CAPT FOR CHKLISTS. WE BOTH MISSED THE CHKLIST WHICH INCLUDES RESETTING THE ALTIMETER TO 29.92. AS WE LEVELED AT FL230 I NOTICED THAT THE ALTIMETER INDICATED A LOWER SETTING. WHEN WE RESET TO 29.92 THE INDICATED ALT ROSE TO NEARLY 200 FT ABOVE THE ASSIGNED ALT. I WENT TO PUSH THE DSND BUTTON ON THE FLT DIRECTOR BUT HIT CLB INSTEAD. I HIT DSND AS SOON AS THE AIRPLANE STARTED PITCHING UP. WE RETURNED TO FL230 WITHOUT FURTHER INCIDENT. THE MAX INDICATED DEV WAS 3000 FT ABOVE ASSIGNED ALT. LESSON: EVEN IN 2-PERSON COCKPITS WITH FLYING AND PNF'S DUTIES CLRLY DEFINED; EACH PLT MUST MENTALLY 'FLY' AS IF SINGLE-PLT IFR. FURTHER; WHEN EITHER CREW MEMBER IS NEW TO THE AIRPLANE; A HEIGHTENED AWARENESS SHOULD BE INSTANTLY TRIGGERED.

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