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Atlas / ASRS / ACN 1675005

NASA · Aviation Safety Reporting System

First Officer reported altitude deviation following loss of cabin pressure.

ACN 1675005 2019-08 Citation II S2/Bravo (C550) Commuter and Corporate Flight Crew Fatigue Reports
Initial ApproachPart 91

What is ASRS?

The Aviation Safety Reporting System is NASA's voluntary, confidential, non- punitive incident-reporting system, established 1976. Pilots, controllers, dispatchers, and maintenance technicians file reports describing safety- relevant events. NASA de-identifies every report before adding it to the public database. Reports are not investigated by NASA, the FAA, or the NTSB — they represent the reporter's perspective.

Pilot narrative

Verbatim from the de-identified NASA record. First-person account by the reporter. NASA strips identifying details (names, company, specific time); anonymization placeholders are ZZZ, X, Y.

Approximately 25 minutes before the altitude deviation occurred, the aircraft suffered loss of cabin altitude from FL330. After completing all checklist and memory items the trip continues normally. Upon reaching TEB airspace the crew was still a bit overwhelmed from the events that had previously occurred. Approach gave us a heading and a descent down to 2,000 ft. The aircraft was turned to the proper heading yet the altitude did not properly capture allowing the aircraft to continue decent down to 1500 ft. before it was fought by the crew. Whilst this decent was occurring the cure was making final adjustments for the aircraft to be set up to cross DANDY intersection at 1,500 ft. and it was made apparent that the Co-Pilot's side HSI had become inoperative. When the altitude deviation was caught by the crew, immediate corrective actions were taken yet approach issued an altitude warning. Contributing factors included crew fatigue from just completing a rapid decent due to loss of cabin pressure. During the course of this action judgment was affected because the crew was still excited from the previous events that transpired.

NASA classification — Anomalies

  • Aircraft Equipment Problem
  • Deviation - Altitude
  • Deviation / Discrepancy - Procedural

NASA classification — Assessments

Contributing Factors / Situations
Human Factors · Aircraft · Procedure
Primary Problem
Human Factors

ASRS reports are voluntarily submitted, de-identified by NASA, and represent the reporter's perspective. The presence of reports on a topic cannot be used to infer prevalence in the National Airspace System. The authoritative source is the NASA ASRS Database Online at asrs.arc.nasa.gov ↗.