A B737-200 FLC CLBS ABOVE THEIR LAST ASSIGNED ALT WHEN THE CAPT FAILS TO SET THAT NEWLY ASSIGNED ALT IN THEIR ALT ALERTER. ZAN; AK.

Date: 1999-12 · Aircraft: B737-200

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

Synopsis

A B737-200 FLC CLBS ABOVE THEIR LAST ASSIGNED ALT WHEN THE CAPT FAILS TO SET THAT NEWLY ASSIGNED ALT IN THEIR ALT ALERTER. ZAN; AK.

Narrative

CLRED R99-SALDO-AKN-AS FILED TO MAINTAIN FL330. RADAR CONTACT WAS ESTABLISHED WITH CTR CLBING THROUGH 15000 FT. RECLRED GPS DIRECT GASTO-ANC-DIRECT WITH A FL290 RESTR. WE WERE MINIMUM FUEL TO ANC WITH A CORDOVA ALTERNATE; WITH DETERIORATING WX THROUGHOUT ANCHORAGE BOWEL. FO WAS FLYING. I MADE A MENTAL CALCULATION ON OUR FUEL REQUIREMENT BEFORE ACCEPTING THE CLRNC. THEN READ BACK CLRNC; PROGRAMMED GPS. THE ALT ALERTER WAS NOT RESET. FO STATES HE DID NOT HEAR THE FL290 RESTR. CLBING THROUGH FL315; ATC ALERTED US TO ALT BUST. WE DSNDED AND WERE RECLRED TO FL310. THERE WAS NO TFC CONFLICT THIS TIME; BUT COULD HAVE BEEN DIFFERENT IN MORE CONGESTED LOCATION. POOR TECHNIQUE PROGRAMMING GPS PRIOR TO SETTING ALT ALERTER. SET ALT ALERTER FIRST. MADE CALLOUT TO FO; THEN PROGRAMMED GPS. POOR CREW COORD. PF WAS UNABLE TO BACK UP CLRNC. SUPPLEMENTAL INFO FROM ACN 458263: WE WERE FMS AND GPS EQUIPPED TO PERFORM THIS ROUTING. I WAS HAND FLYING AS NORMAL IN OUR ACFT; WHILE THE CAPT (PNF) WAS HANDLING ALL COMS. AFTER LEVELING OFF AT FL330 FOR A FEW MINS; THE CTLR ASKED US WHAT ALT WE WERE AT. THE CAPT RESPONDED THAT WE WERE AT FL330. THE CTLR THEN SAID WE HAD ONLY BEEN CLRED TO FL290. I STARTED AN IMMEDIATE DSCNT. THE CTLR THEN SAID TO LEVEL OFF AT FL310. THE CAPT (PNF) REMEMBERED RECEIVING AND READING BACK THE REVISED ALT CLRNC. THIS WAS AT THE SAME TIME AS WE RECEIVED THE DIRECT TO GASTO INSTRUCTION. I; THE PF; CANNOT REMEMBER HEARING THE ALT RESTR. I WAS BUSY FLYING AND REPROGRAMMING THE FMS; AND DID NOT ASSIMILATE THE NEW ALT CLRNC. THIS ERROR OCCURRED DUE TO A HIGH MENTAL WORKLOAD FOR BOTH PLTS AND THE CTLR; AND UNDER-USING OUR AUTOMATION BY HAND FLYING WHILE LISTENING TO SEVERAL REVISED CLRNCS. THE FLC NEEDS TO USE THE APPROPRIATE LEVEL OF AUTOMATION. IN THIS ASE; THE AUTOPLT ON; IN ORDER TO BOTH CONCENTRATE ON COMS AND NEW ATC CLRNCS DURING A HIGH WORKLOAD PERIOD. OUR B737-200 OP HAS THE LOWEST LEVEL OF AUTOMATION IN OUR FLEET; BUT FMS/GPS HAS BEEN OPERATIONAL IN OUR 200 FLEET FOR ABOUT A YR.

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