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Complacent flight crew lacks coordination skills in setting altimeter in descent in holding pattern and creates a loss of separation with another aircraft in pattern.
| Attributes | |
| ACN | 135343 |
| Time | |
| Date | 199001 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : sea |
| State Reference | WA |
| Altitude | msl bound lower : 16300 msl bound upper : 17000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
| Flight Phase | other |
| Route In Use | arrival other enroute airway : zse |
| Flight Plan | IFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
| Flight Phase | other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : flight engineer pilot : atp |
| Experience | flight time last 90 days : 100 flight time total : 7000 flight time type : 1500 |
| ASRS Report | 135343 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : required legal separation non adherence : clearance other anomaly other |
| Independent Detector | atc equipment other atc equipment : unspecified other flight crewa |
| Resolutory Action | flight crew : overcame equipment problem flight crew : returned to intended course or assigned course |
| Consequence | Other |
| Miss Distance | horizontal : 18000 vertical : 300 |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Flight was cleared to descend to 17,000' and hold at depicted intersection. Flight arrived at fix at FL210, 220 IAS, called 'entering holding', turned outbnd and continued to descend. Second officer read aloud ATIS WX to which captain reset his altimeter (at FL210). Second officer did not hand up landing data card at this time because (stated later) holding time would bring up new ATIS prior to flight leaving holding. First officer (flying) noted captain reset his altimeter but elected to wait until FL180 to reset altimeter. Upon captain's resetting his altimeter, second officer initiated descent checklist. Captain and second officer 'set and cross-checked' altimeters by the checklist but did not request response from first officer because of 29.92 setting still above FL180. At FL180 first officer asked 'what's the altimeter?', looked at the captain's setting and reset his altimeter and the altitude reminder to 30.33. The second officer responded with 'altimeter cross-checked.' the aircraft leveled at 17,000 on outbnd leg noting another aircraft abeam, turning inbound apparently at the same altitude. Coincidentally to level off and seeing at the same altitude. Coincidentally to level off and seeing other aircraft, flight was given a frequency change. After check-in, captain asked controller altitude of the other aircraft and was told 16,000 at which time the controller responded that flight's altitude readout was 16,300. The captain stated to the controller that both altimeters and the altitude reminder were at exactly 17,000 with a setting of 30.33. The controller instructed flight to turn off mode C, to which the captain complied. At that point second officer held up landing data card with his finger on altimeter setting of 29.33. The captain said 'climb' and the first officer climbed back to 17,000 with all altimeter settings at 29.33. Flight advised ATC it would switch to #2 mode C. ATC asked flight what it had set in kollsman window and the captain replied '29.33.' ATC responded 'I thought that's what you earlier said you had set.' #2 mode C was switched on, ATC acknowledged a good mode C readout at 16,900 and flight continued holding, descent and approach monitored by ATC. The captain is somewhat hard of hearing and made original setting from verbal by second officer. The first officer ignored first setting of altimeter by captain and second officer because of early setting at FL210 and flying requirements of entering holding. The second officer did not note captain's error on his checklist 'cross-checked.' the first officer obtained his setting from the captain's erroneous setting. The second officer again did not cross-check first officer's setting to his printed numbers on the landing data card still on second officer desk. The first officer made a verbal exclamation at the relative high altimeter (compared to the stormy low at departure 2 days prior) but did not use any phrase 'high altimeter.' the captain and second officer did not inquire as to the nature of the first officer's exclamation.
Original NASA ASRS Text
Title: COMPLACENT FLT CREW LACKS COORD SKILLS IN SETTING ALTIMETER IN DESCENT IN HOLDING PATTERN AND CREATES A LOSS OF SEPARATION WITH ANOTHER ACFT IN PATTERN.
Narrative: FLT WAS CLRED TO DSND TO 17,000' AND HOLD AT DEPICTED INTXN. FLT ARRIVED AT FIX AT FL210, 220 IAS, CALLED 'ENTERING HOLDING', TURNED OUTBND AND CONTINUED TO DSND. S/O READ ALOUD ATIS WX TO WHICH CAPT RESET HIS ALTIMETER (AT FL210). S/O DID NOT HAND UP LNDG DATA CARD AT THIS TIME BECAUSE (STATED LATER) HOLDING TIME WOULD BRING UP NEW ATIS PRIOR TO FLT LEAVING HOLDING. F/O (FLYING) NOTED CAPT RESET HIS ALTIMETER BUT ELECTED TO WAIT UNTIL FL180 TO RESET ALTIMETER. UPON CAPT'S RESETTING HIS ALTIMETER, S/O INITIATED DSCNT CHECKLIST. CAPT AND S/O 'SET AND CROSS-CHECKED' ALTIMETERS BY THE CHECKLIST BUT DID NOT REQUEST RESPONSE FROM F/O BECAUSE OF 29.92 SETTING STILL ABOVE FL180. AT FL180 F/O ASKED 'WHAT'S THE ALTIMETER?', LOOKED AT THE CAPT'S SETTING AND RESET HIS ALTIMETER AND THE ALT REMINDER TO 30.33. THE S/O RESPONDED WITH 'ALTIMETER CROSS-CHECKED.' THE ACFT LEVELED AT 17,000 ON OUTBND LEG NOTING ANOTHER ACFT ABEAM, TURNING INBND APPARENTLY AT THE SAME ALT. COINCIDENTALLY TO LEVEL OFF AND SEEING AT THE SAME ALT. COINCIDENTALLY TO LEVEL OFF AND SEEING OTHER ACFT, FLT WAS GIVEN A FREQ CHANGE. AFTER CHECK-IN, CAPT ASKED CTLR ALT OF THE OTHER ACFT AND WAS TOLD 16,000 AT WHICH TIME THE CTLR RESPONDED THAT FLT'S ALT READOUT WAS 16,300. THE CAPT STATED TO THE CTLR THAT BOTH ALTIMETERS AND THE ALT REMINDER WERE AT EXACTLY 17,000 WITH A SETTING OF 30.33. THE CTLR INSTRUCTED FLT TO TURN OFF MODE C, TO WHICH THE CAPT COMPLIED. AT THAT POINT S/O HELD UP LNDG DATA CARD WITH HIS FINGER ON ALTIMETER SETTING OF 29.33. THE CAPT SAID 'CLIMB' AND THE F/O CLIMBED BACK TO 17,000 WITH ALL ALTIMETER SETTINGS AT 29.33. FLT ADVISED ATC IT WOULD SWITCH TO #2 MODE C. ATC ASKED FLT WHAT IT HAD SET IN KOLLSMAN WINDOW AND THE CAPT REPLIED '29.33.' ATC RESPONDED 'I THOUGHT THAT'S WHAT YOU EARLIER SAID YOU HAD SET.' #2 MODE C WAS SWITCHED ON, ATC ACKNOWLEDGED A GOOD MODE C READOUT AT 16,900 AND FLT CONTINUED HOLDING, DSCNT AND APCH MONITORED BY ATC. THE CAPT IS SOMEWHAT HARD OF HEARING AND MADE ORIGINAL SETTING FROM VERBAL BY S/O. THE F/O IGNORED FIRST SETTING OF ALTIMETER BY CAPT AND S/O BECAUSE OF EARLY SETTING AT FL210 AND FLYING REQUIREMENTS OF ENTERING HOLDING. THE S/O DID NOT NOTE CAPT'S ERROR ON HIS CHECKLIST 'CROSS-CHECKED.' THE F/O OBTAINED HIS SETTING FROM THE CAPT'S ERRONEOUS SETTING. THE S/O AGAIN DID NOT CROSS-CHECK F/O'S SETTING TO HIS PRINTED NUMBERS ON THE LNDG DATA CARD STILL ON S/O DESK. THE F/O MADE A VERBAL EXCLAMATION AT THE RELATIVE HIGH ALTIMETER (COMPARED TO THE STORMY LOW AT DEP 2 DAYS PRIOR) BUT DID NOT USE ANY PHRASE 'HIGH ALTIMETER.' THE CAPT AND S/O DID NOT INQUIRE AS TO THE NATURE OF THE F/O'S EXCLAMATION.
Data retrieved from NASA's ASRS site as of July 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.