AN ACR FLC CLBS ABOVE 13000 FT ASSIGNED AND IMMEDIATELY RETURNS.

Date: 1996-03 · Aircraft: DC-9 50 · Phase: climb

Anomalies: deviation-altitude-overshoot|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-far

Synopsis

AN ACR FLC CLBS ABOVE 13000 FT ASSIGNED AND IMMEDIATELY RETURNS.

Narrative

FLEW THROUGH 13000 FT (ASSIGNED) TO APPROX 13300 FT AND IMMEDIATELY RETURNED TO 13000 FT. I CONTINUE TO FILE NASA RPTS EACH TIME I HAVE A SMALL ALTDEV; EVEN THOUGH MY ASSOCIATES SAY THEY DO NOT DO SO. IN ANY EVENT; THERE APPEARS TO BE A PROB WITH 'ALMOST' ALTDEVS; AS WELL AS THESE SMALL DEVS; AMONG ACR CREWS IN GENERAL THAT APPEAR TO HAVE A COMMON CAUSE; AS WELL AS AN EASY FIX. CAUSE: FATIGUE. IN EVERY CASE I'VE FILED A NASA RPT ON; AS WELL AS THOSE 'ALMOST DEVS;' FATIGUE; RESULTING MOST OFTEN FROM AN EARLY MORNING 'GET-UP;' AND LESS OFTEN; SIMPLY FROM A BAD NIGHT'S SLEEP; HAS PRECEDED THESE EVENTS. WHEN CLBING THE LAST 1000 FT BEFORE LEVEL OFF AT 500-1000 FPM; YOUR BRAIN HAS APPROX 2 MINS AFTER THE ALT ALERT SOUNDS TO MAINTAIN CONCENTRATION FOR LEVELING OFF. IN A BUSY ENVIRONMENT WITH A FATIGUED BRAIN; NEARLY 2 MINS IS A LONG TIME TO MAINTAIN THAT CONCENTRATION. THE OTHER AND LESS OBVIOUS FATIGUE FACTOR WITH OUR AIRLINE IS THE FACT THAT VACATIONS ARE BEING CANCELED; I SEE A STRONG RELATIONSHIP BTWN THOSE CANCELLATIONS AND MORALE/FATIGUE. AND AGAIN; LESS CONCENTRATION ABILITY. FIX FOR PROB: THE ALT ALERTER SOUNDS AT 1000 FT PRIOR TO ASSIGNED ALT; THEN GOES OFF BEFORE REACHING ASSIGNED ALT. IF THE ALERTER WERE MODIFIED SO THAT IT HAD ANOTHER AURAL WARNING APPROX 200 FT BEFORE LEVEL OFF; EVEN A FATIGUED BRAIN WOULD RE- ENGAGE IN TIME TO ACT.

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