King Air C90 E90
Flight Crew Multiengine; Flight Crew Instrument; Flight Crew Flight Instructor; Flight Crew Air Transport Pilot (ATP)
Flight Crew Last 90 Days 25; Flight Crew Total 9000; Flight Crew Type 3500
Situational Awareness; Workload; Communication Breakdown; Distraction; Fatigue
Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance
Air Traffic Control Issued New Clearance
Company Policy; Human Factors
Upon reaching 16;000 FT level off was initiated. The altitude alerter had been wrongly set to 17;000 FT. At that point rather than check with ATC; the plane was allowed to continue up to 17;000 FT; 1;000 FT high. There was no traffic in the area. ATC asked if 17;000 FT worked. After we replied 'yes;' the flight was continued at 17;000 FT. This was a last minute unscheduled medical flight at the end of several shifts in a row. The week preceding involved commercial flights out of state to transfer an aircraft from Boise to Moline. It also involved early and late flights with last minute schedule changes. There were repeated changes from day to night [operations] and no certainty of when time off would occur. While [legal] duty rest was always met; due to circadian rhythm upset; sleep was not always possible or productive. Air medical may need tighter definitions of when duty starts. Also there could be limits set on how often day to night shift changes can occur during a given time span along with what constitutes Part 91 after a 14 hour day then a trip back to base? Some pilots are subject to 24 hour 7 day a week call with duty starting when called and Part 91 when the patient is not on board; leading to shifts in excess of 18 hours.
Fatigue; as a result of erratic scheduling practices; may have contributed to an altitude deviation for a single pilot King Air ambulance Captain.