37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1423444 |
Time | |
Date | 201702 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | D10.TRACON |
State Reference | TX |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Super King Air 350 |
Operating Under FAR Part | Part 135 |
Flight Phase | Initial Climb |
Route In Use | Vectors |
Flight Plan | IFR |
Person 1 | |
Function | Captain |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 110 Flight Crew Total 4858 Flight Crew Type 110 |
Events | |
Anomaly | Deviation - Altitude Overshoot Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy |
Narrative:
An equipment change inside of an hour before departure; efforts to launch the flight as scheduled; a new crew pairing and a misinterpretation of a hand written note along with cockpit distractions were contributing factors to an altitude deviation during initial climb. I set the captains side altimeter just before I had to turn off avionics prior to engine start. The truncation in cockpit set up was due to passengers boarding the aircraft and to conserve battery power from prior maintenance performed on the aircraft since a start without external power was to be performed. The copilot shut the door and I began starting engines. Upon arrival of the co-pilot to the flight deck I was completing engine start and powering up avionics when he began reading the ATIS and clearance from a handwritten note laid on the pedestal. The co-pilot assumed that none of the altimeters had been set and began setting them from right to left to what he believed was the correct interpretation of my handwritten note. I was distracted with a headset malfunction on my side. My note read 29.74 and he interpreted it to read 29.24 a difference of .50 inches of mercury. He did not verify the resulting altimeter reading with field elevation or obtain positive confirmation from me nor check it against the recorded ATIS in order to clarify. A second chance for both pilots to catch the mistake would have taken place during the flight instrument check under the performance of the taxi checklist. The flight instruments were checked but I glanced at the altimeter setting and noticed the ending four and assumed nothing had changed since I set the altimeter prior to engine start. The departure was normal with the exception that ATC allowed us to level at 3000' then issued a climb to 4000' and upon reaching 4000' notified us of that the current altimeter setting was 29.74 and that we were 700' high and to descend immediately for traffic to 4000'. The co-pilot immediately changed my altimeter as I was descending and we did not experience a TA or and RA on TCAS and no traffic was observed outside that we could see. From the crews perspective there was no loss of separation. ATC issued no further instructions to call the facility manager and the balance of the flight was completed without further incident. At the conclusion of the flight I debriefed the co-pilot on the events that had transpired and over the next day or so we both had the opportunity to think about what we could have done differently to avoid the chain of events. Both of us have reviewed standard operating procedures and proper checklist operations relative to the appropriate checks prior to flight. In addition; crew pairing considerations will be taken into closer account in the future along with taking a delay when circumstances such as these encroach on sufficient time to allow for readying the aircraft for flight.
Original NASA ASRS Text
Title: B350 Captain reported an incorrect altimeter setting before departure resulted in a 700 feet overshoot on intermediate level off.
Narrative: An equipment change inside of an hour before departure; efforts to launch the flight as scheduled; a new crew pairing and a misinterpretation of a hand written note along with cockpit distractions were contributing factors to an altitude deviation during initial climb. I set the captains side altimeter just before I had to turn off avionics prior to engine start. The truncation in cockpit set up was due to passengers boarding the aircraft and to conserve battery power from prior maintenance performed on the aircraft since a start without external power was to be performed. The copilot shut the door and I began starting engines. Upon arrival of the co-pilot to the flight deck I was completing engine start and powering up avionics when he began reading the ATIS and clearance from a handwritten note laid on the pedestal. The co-pilot assumed that none of the altimeters had been set and began setting them from right to left to what he believed was the correct interpretation of my handwritten note. I was distracted with a headset malfunction on my side. My note read 29.74 and he interpreted it to read 29.24 a difference of .50 inches of mercury. He did not verify the resulting altimeter reading with field elevation or obtain positive confirmation from me nor check it against the recorded ATIS in order to clarify. A second chance for both pilots to catch the mistake would have taken place during the flight instrument check under the performance of the taxi checklist. The flight instruments were checked but I glanced at the altimeter setting and noticed the ending four and assumed nothing had changed since I set the altimeter prior to engine start. The departure was normal with the exception that ATC allowed us to level at 3000' then issued a climb to 4000' and upon reaching 4000' notified us of that the current altimeter setting was 29.74 and that we were 700' high and to descend immediately for traffic to 4000'. The co-pilot immediately changed my altimeter as I was descending and we did not experience a TA or and RA on TCAS and no traffic was observed outside that we could see. From the crews perspective there was no loss of separation. ATC issued no further instructions to call the facility manager and the balance of the flight was completed without further incident. At the conclusion of the flight I debriefed the co-pilot on the events that had transpired and over the next day or so we both had the opportunity to think about what we could have done differently to avoid the chain of events. Both of us have reviewed standard operating procedures and proper checklist operations relative to the appropriate checks prior to flight. In addition; crew pairing considerations will be taken into closer account in the future along with taking a delay when circumstances such as these encroach on sufficient time to allow for readying the aircraft for flight.
Data retrieved from NASA's ASRS site 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.