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Flight crew of advanced large transport were involved in programming route changes into their FMC and neglected to set their altimeter to standard setting at FL180.
| Attributes | |
| ACN | 128698 |
| Time | |
| Date | 198911 |
| Day | Thu |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | atc facility : det |
| State Reference | MI |
| Altitude | msl bound lower : 23000 msl bound upper : 23500 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zob tower : sdf |
| Operator | common carrier : air carrier |
| Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other Other |
| Flight Phase | climbout : intermediate altitude cruise other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : flight engineer pilot : instrument pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 60 flight time total : 5000 flight time type : 500 |
| ASRS Report | 128698 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument |
| Experience | flight time last 90 days : 150 flight time total : 4500 flight time type : 200 |
| ASRS Report | 128678 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : far non adherence : clearance |
| Independent Detector | other controllera |
| Resolutory Action | flight crew : overcame equipment problem flight crew : became reoriented |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
The new procedures became effective on nov/xx/89 for the detroit area. Many of the new airways and intersections and even the detroit VOR (dxo) was not in the data base of the FMC. This caused a very high workload in the cockpit. During the climb, because of the workload, the altimeter was not set to 29.92 at 18,000. We leveled at FL230 with 29.39 set in the altimeter. Center said we were 500' high and the error was immediately corrected.
Original NASA ASRS Text
Title: FLT CREW OF ADVANCED LGT WERE INVOLVED IN PROGRAMMING ROUTE CHANGES INTO THEIR FMC AND NEGLECTED TO SET THEIR ALTIMETER TO STANDARD SETTING AT FL180.
Narrative: THE NEW PROCS BECAME EFFECTIVE ON NOV/XX/89 FOR THE DETROIT AREA. MANY OF THE NEW AIRWAYS AND INTERSECTIONS AND EVEN THE DETROIT VOR (DXO) WAS NOT IN THE DATA BASE OF THE FMC. THIS CAUSED A VERY HIGH WORKLOAD IN THE COCKPIT. DURING THE CLIMB, BECAUSE OF THE WORKLOAD, THE ALTIMETER WAS NOT SET TO 29.92 AT 18,000. WE LEVELED AT FL230 WITH 29.39 SET IN THE ALTIMETER. CENTER SAID WE WERE 500' HIGH AND THE ERROR WAS IMMEDIATELY CORRECTED.
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.