Narrative:

Background information to altitude excursion: this was our first flight with the new TCAS system. During takeoff from msp to ord, at 300', we received a verbal resolution advisory (RA) to 'descend, descend now.' our book says this should not have happened. Altitude excursion: as the first officer, I was flying the approach to ord. Tower directed us to go around at about 300' due to previous landing traffic still on the runway. Approach shortly cleared us to 4000' with a new heading. Even though the traffic at ord was very busy, since I flew the approach manually, I flew the go around manually also, using a basic INS x-chk. During the go around, the captain did not want the TCAS to tell us to descend again, so he turned the TCAS system off. A short while later, after he realized he turned the transponder off, turned the transponder back on. This was enough to distract him from monitoring the altitude level off. I was making a nice, gradual level off at 4000' when the altitude alert went off. I then remembered that the altimeter I should be looking at is the third altimeter on the other side of the cockpit, and not the one in front of me. Both our altimeters are set to QFE, which is easy to forget during a critical phase of flight. Fortunately, I was already beginning the level off, so we only momentarily deviated to 400' above assigned altitude. Center did not say anything, and we did not observe any conflicting traffic. If we had not armed the altitude for 4000' and the airport elevation was much higher, the altitude deviation would have been much higher. Recommendation: have the FAA require that the altimeters in front of the captain and first officer always be set to qnh or qne as appropriate. The FAA should not allow 2 out of 3 altimeters set to the wrong setting. The FAA should make the 'third' altimeter the one that is set to QFE for those companies who insist on using such an old procedure. I'm sure this is one of many altitude excursions that are attributed to this altitude procedure, and that nothing will be done until the 'next' accident. Human factors play a big part in aviation accidents, and I feel your office can quickly and easily correct this problem.

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Original NASA ASRS Text

Title: ALT DEVIATOIN ACCOUNT QFE.

Narrative: BACKGROUND INFO TO ALT EXCURSION: THIS WAS OUR FIRST FLT WITH THE NEW TCAS SYS. DURING TKOF FROM MSP TO ORD, AT 300', WE RECEIVED A VERBAL RESOLUTION ADVISORY (RA) TO 'DSND, DSND NOW.' OUR BOOK SAYS THIS SHOULD NOT HAVE HAPPENED. ALT EXCURSION: AS THE F/O, I WAS FLYING THE APCH TO ORD. TWR DIRECTED US TO GO AROUND AT ABOUT 300' DUE TO PREVIOUS LNDG TFC STILL ON THE RWY. APCH SHORTLY CLRED US TO 4000' WITH A NEW HDG. EVEN THOUGH THE TFC AT ORD WAS VERY BUSY, SINCE I FLEW THE APCH MANUALLY, I FLEW THE GAR MANUALLY ALSO, USING A BASIC INS X-CHK. DURING THE GAR, THE CAPT DID NOT WANT THE TCAS TO TELL US TO DSND AGAIN, SO HE TURNED THE TCAS SYS OFF. A SHORT WHILE LATER, AFTER HE REALIZED HE TURNED THE XPONDER OFF, TURNED THE XPONDER BACK ON. THIS WAS ENOUGH TO DISTRACT HIM FROM MONITORING THE ALT LEVEL OFF. I WAS MAKING A NICE, GRADUAL LEVEL OFF AT 4000' WHEN THE ALT ALERT WENT OFF. I THEN REMEMBERED THAT THE ALTIMETER I SHOULD BE LOOKING AT IS THE THIRD ALTIMETER ON THE OTHER SIDE OF THE COCKPIT, AND NOT THE ONE IN FRONT OF ME. BOTH OUR ALTIMETERS ARE SET TO QFE, WHICH IS EASY TO FORGET DURING A CRITICAL PHASE OF FLT. FORTUNATELY, I WAS ALREADY BEGINNING THE LEVEL OFF, SO WE ONLY MOMENTARILY DEVIATED TO 400' ABOVE ASSIGNED ALT. CENTER DID NOT SAY ANYTHING, AND WE DID NOT OBSERVE ANY CONFLICTING TFC. IF WE HAD NOT ARMED THE ALT FOR 4000' AND THE ARPT ELEVATION WAS MUCH HIGHER, THE ALT DEVIATION WOULD HAVE BEEN MUCH HIGHER. RECOMMENDATION: HAVE THE FAA REQUIRE THAT THE ALTIMETERS IN FRONT OF THE CAPT AND F/O ALWAYS BE SET TO QNH OR QNE AS APPROPRIATE. THE FAA SHOULD NOT ALLOW 2 OUT OF 3 ALTIMETERS SET TO THE WRONG SETTING. THE FAA SHOULD MAKE THE 'THIRD' ALTIMETER THE ONE THAT IS SET TO QFE FOR THOSE COMPANIES WHO INSIST ON USING SUCH AN OLD PROC. I'M SURE THIS IS ONE OF MANY ALT EXCURSIONS THAT ARE ATTRIBUTED TO THIS ALT PROC, AND THAT NOTHING WILL BE DONE UNTIL THE 'NEXT' ACCIDENT. HUMAN FACTORS PLAY A BIG PART IN AVIATION ACCIDENTS, AND I FEEL YOUR OFFICE CAN QUICKLY AND EASILY CORRECT THIS PROB.

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.