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Flight crew of medium large transport on descent into czyz mis-set altimeter--inadvertently overshot assigned altitude but caught error with only minor overshoot not commented on by controller.
| Attributes | |
| ACN | 111483 |
| Time | |
| Date | 198905 |
| Day | Sun |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | atc facility : czyz |
| State Reference | ON |
| Altitude | msl bound lower : 7000 msl bound upper : 9000 |
| Environment | |
| Flight Conditions | Mixed |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : czyz |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other |
| Flight Phase | descent : approach descent other |
| Route In Use | arrival star : star |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 180 flight time total : 11000 flight time type : 5000 |
| ASRS Report | 111483 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other anomaly other |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : anomaly accepted |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
| Situations | |
| Publication | Unspecified |
Narrative:
On descent for our arrival into yyz we were cleared for the linng STAR. Initially we were kept high by ZOB due to other traffic. When handed over to czyz we were subsequently cleared for the profile descent for runway 24 (approach was to 24L). We had initially reviewed the depiction page which had recently been changed in the way the altitude restrictions are displayed with concentric circles and radials and arrival fixes. Having been held up longer than we would have liked, we were now rushed to meet the altitude restrictions along with speed restrictions; while reviewing the approach, send company in range message on ACARS, complete the preliminary landing checklist and make a passenger announcement to the F/a's to prepare the cabin for arrival. It was also necessary to bring the cabin altitude down at a faster rate prior to landing. We met the 40 DME crossing restriction of between 15000 and 11000'. The next restriction was 25 DME at 9000', 250 KTS. In the rush 7000' was set in the altitude alert which was on an adjacent page for the profile to 33. In another review of the page the mistake was caught at 8500' and as we climbed back to 9000' the controller cleared us down to 8000'. The controller made no mention of the altitude deviation. These profile dscnts into toronto constantly receive complaints from pilots. During VMC conditions they require full attention of both crew members in the manual instead of outside during a critical phase of the descent, approach and landing. On some occasions you will be flying the profile for a landing to a particular runway and the controller will change the profile to a different runway adding to the potential for confusion. Pages for the profiles could display in bolder type the runway of use to prevent inadvertent mistakes.
Original NASA ASRS Text
Title: FLT CREW OF MLG ON DESCENT INTO CZYZ MIS-SET ALTIMETER--INADVERTENTLY OVERSHOT ASSIGNED ALT BUT CAUGHT ERROR WITH ONLY MINOR OVERSHOOT NOT COMMENTED ON BY CTLR.
Narrative: ON DSCNT FOR OUR ARR INTO YYZ WE WERE CLRED FOR THE LINNG STAR. INITIALLY WE WERE KEPT HIGH BY ZOB DUE TO OTHER TFC. WHEN HANDED OVER TO CZYZ WE WERE SUBSEQUENTLY CLRED FOR THE PROFILE DSCNT FOR RWY 24 (APCH WAS TO 24L). WE HAD INITIALLY REVIEWED THE DEPICTION PAGE WHICH HAD RECENTLY BEEN CHANGED IN THE WAY THE ALT RESTRICTIONS ARE DISPLAYED WITH CONCENTRIC CIRCLES AND RADIALS AND ARR FIXES. HAVING BEEN HELD UP LONGER THAN WE WOULD HAVE LIKED, WE WERE NOW RUSHED TO MEET THE ALT RESTRICTIONS ALONG WITH SPD RESTRICTIONS; WHILE REVIEWING THE APCH, SEND COMPANY IN RANGE MESSAGE ON ACARS, COMPLETE THE PRELIMINARY LNDG CHKLIST AND MAKE A PAX ANNOUNCEMENT TO THE F/A'S TO PREPARE THE CABIN FOR ARR. IT WAS ALSO NECESSARY TO BRING THE CABIN ALT DOWN AT A FASTER RATE PRIOR TO LNDG. WE MET THE 40 DME XING RESTRICTION OF BTWN 15000 AND 11000'. THE NEXT RESTRICTION WAS 25 DME AT 9000', 250 KTS. IN THE RUSH 7000' WAS SET IN THE ALT ALERT WHICH WAS ON AN ADJACENT PAGE FOR THE PROFILE TO 33. IN ANOTHER REVIEW OF THE PAGE THE MISTAKE WAS CAUGHT AT 8500' AND AS WE CLBED BACK TO 9000' THE CTLR CLRED US DOWN TO 8000'. THE CTLR MADE NO MENTION OF THE ALT DEVIATION. THESE PROFILE DSCNTS INTO TORONTO CONSTANTLY RECEIVE COMPLAINTS FROM PLTS. DURING VMC CONDITIONS THEY REQUIRE FULL ATTN OF BOTH CREW MEMBERS IN THE MANUAL INSTEAD OF OUTSIDE DURING A CRITICAL PHASE OF THE DSCNT, APCH AND LNDG. ON SOME OCCASIONS YOU WILL BE FLYING THE PROFILE FOR A LNDG TO A PARTICULAR RWY AND THE CTLR WILL CHANGE THE PROFILE TO A DIFFERENT RWY ADDING TO THE POTENTIAL FOR CONFUSION. PAGES FOR THE PROFILES COULD DISPLAY IN BOLDER TYPE THE RWY OF USE TO PREVENT INADVERTENT MISTAKES.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.