ACR MLG ALT DEVIATION OVERSHOT DURING CLIMB AND SPEED DEVIATION.

1988-10 · NASA ASRS report 95183

Date: 1988-10 · Aircraft: Medium Large Transport; Low Wing; 2 Turbojet Eng · Phase: climb

Anomalies: deviation-altitude-overshoot|deviation-speed-all-types|deviation-discrepancy-procedural-clearance

Synopsis

ACR MLG ALT DEVIATION OVERSHOT DURING CLIMB AND SPEED DEVIATION.

Narrative

DEP CLRED US TO FL190. CAPT RESET ALT ALERTER; HOWEVER BEFORE HE FINISHED THE F/O STARTED CALLING FOR CLEAN UP AND CLB PROCS/CHKLIST. CLBING THROUGH 10000' DEP HAD THE FLT CONTACT CENTER. A VECTOR HDG OF 100 DEGS WAS ASSIGNED PENDING MORE DIRECT ROUTING AND A SPD OF 320 KTS WAS ASSIGNED FOR SPACING. OUT OF 15000' WE WERE CLRED DIRECT TO THE DEST VOR. THE F/O ADVISED HE WAS UNABLE TO RECEIVE THE VOR SIGNAL. HOWEVER; THE CAPT WAS RECEIVING A STRONG SIGNAL. THE PROCESS OF DIALING IN DIFFERENT FREQS AND LISTENING TO STATION IDENTS BEGAN. SUDDENLY THE F/O SAID 'OH NO;' DISCONNECTED THE AUTOPLT AND STARTED A RAPID NOSE OVER AT 19700'. A DSCNT BACK TO 19000' WAS COMPLETED AND THE ALTIMETERS RESET TO 29.92. IT WAS NOTED THAT THE CAPT HAD INITIALLY SET THE ALT ALERTER ABOVE 19000' WHEN HE LEFT THAT TASK TO ACCOMPLISH THE CLEAN UP/CLB PROCS AND CHKLIST. THE ALERTER HAD BEEN SET TO 22000'. CENTER THEN ADVISED THAT THERE WAS TFC AHEAD THAT WE'D BE FOLLOWING TO DEST. ALSO; THERE WAS DEPARTING TFC. WE IDENTIFIED BOTH TARGETS AND STARTED PREPARING FOR OUR DSCNT WHEN WE REALIZED THAT WE HAD EXCEEDED THE 320 KT SPD RESTRICTION. OUR DAY STARTED AT XA50. THE FLT TOOK OFF AT XG20. THE CAPT HAD JUST FINISHED A 2 HR BREAK AND THE F/O FLEW ANOTHER TRIP WITH A DIFFERENT CAPT. WE TOOK A 17 MIN DELAY FOR MAINT. INITIALLY WE WERE CLRED TO A W DEP. HOWEVER ON TAXI OUT WE WERE ADVISED IT WOULD BE AN E DEP AND THE APPLICABLE PARTS OF THE CLRNC WERE REVISED. THE FIRST MAJOR ERROR WAS MADE BY THE CAPT NOT FINISHING THE TASK AT HAND. THE SECOND ERROR WAS HAVING BOTH CREW MEMBERS DEVOTED TO SOLVING THE VOR PROB; LEAVING NO ONE TO MONITOR THE ACFT. THE THIRD ERROR WAS BOTH CREW MEMBERS LOOKING FOR TFC WITH NO ONE CHKING THE AIRSPD. IT'S A CLASSIC EXAMPLE OF THE SNOWBALL EFFECT: STARTING OUT BEHIND AND NEVER REALLY CATCHING UP. LATE OUT OF THE BLOCKS; A LAST MINUTE CLRNC CHANGE; DISTR FROM SETTING THE ALT ALERTER (DON'T EVER SET IT ABOVE ASSIGNED ALT) AND NOT MONITORING THE ACFT WHILE DOING OTHER TASKS. ONE SEEMINGLY SMALL MISTAKE THAT BY ITSELF WOULD HAVE BEEN NOTICED AND CORRECTED; BUT SINCE THERE WERE SEEMINGLY SO MANY OTHER THINGS GOING ON; WAS NOT CAUGHT IN A TIMELY FASHION.

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

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