Narrative:

During preflight activities, the altitude alerter was inadvertently set to 5000 ft as initial level off altitude. The pre departure clearance (pre departure clearance) came very late, just prior to pushback via the aircraft ACARS printer. Due to its arrival at pushback, a very busy time, withheld checklist items were completed. 'Transponder', which I remember xchking against the pre departure clearance, and 'navigation radios' which the initial routing of the iah 338 degree radial I also remember xchking with the pre departure clearance, however, I also responded with 5000 ft by reference to the altitude alerter, not xchking it against the pre departure clearance! Here was our problem. Our clearance was only to 4000 ft. The takeoff briefing at the end of the runway was 'runway heading to maintain 5000 ft' shortly after takeoff while in a large left turn the first officer noted an aircraft approximately 1200 ft above us in our climb path. (TCASII equipped aircraft and there was a lot of WX in the area). By the time the first officer advised me, then told the tower of a possible conflict, (mentioning less than 1000 vertical separation) our TCASII gave a TA, having reduced the rate of climb as the situation developed, I (PF) immediately leveled the aircraft. At this same time the tower told us 'maintain 4000 ft.' being at 4300 ft we descended to 4000 stating we had not confirmed 4000 ft earlier. At this time we learned of our error. After lengthy checks, reviewing the SID, and flight papers, neither the first officer nor I can determine when 5000 was set into the altitude alert. We do know that time was short when we returned to the cockpit. Turn-around time was quick, there was a lot of WX along the iah-dfw route and delays going into dfw. Upon cockpit preparation, there was the late pre departure clearance, coming at pushback, a period of duty saturation! But, not a time to rush. It is probably during this busy time period that 5000 ft was inadvertently set, or that possibly it was not reset from the arrival cleanup. Contributing factors might be that this was occurring during the last leg of a day flying 8 hours, 11 1/2 hours after hotel pick up. Also the lack of any guidance from the SID. Neither a published altitude, nor any navigational procedure. It is my duty to check the altitude set in the altitude alert during the preflight checklist. It is the correct and effective procedure that both the first officer and myself failed to xchk the assigned altitude. A reminder from the tower as part of the normal clearance during takeoff might be helpful. I.e. 'Cleared for takeoff, maintain runway heading and 4000 ft'. Also a more timely change to departure, as when switching frequencys the altitude leaving and altitude climbing/descending to are announced. I can only say that an alert first officer who provided very timely information to both me and the controller, prevented a very potentially accident. The TCASII too was most helpful, as it provided the information and probably would have followed with an 'RA' to us had we not stopped our ascent. Supplemental information from air carrier 199611: additionally, had there been a more expeditious handoff to departure (3 mins 29 seconds in IMC), we would have checked in with departure, reported climbing to 5000 ft which would have been another xchk that may have prevented this incident from occurring. I feel an altitude on the takeoff clearance (especially with no expect altitude on the SID in a data link clearance delivery environment) would be an additional safety measure.

Google
 

Original NASA ASRS Text

Title: ACR RECEIVES PRE DEP CLRNC VERY LATE. ENTER WRONG ALT IN ALT ALERT WINDOW. TCASII TA.

Narrative: DURING PREFLT ACTIVITIES, THE ALT ALERTER WAS INADVERTENTLY SET TO 5000 FT AS INITIAL LEVEL OFF ALT. THE PDC (PRE DEP CLRNC) CAME VERY LATE, JUST PRIOR TO PUSHBACK VIA THE ACFT ACARS PRINTER. DUE TO ITS ARR AT PUSHBACK, A VERY BUSY TIME, WITHHELD CHKLIST ITEMS WERE COMPLETED. 'TRANSPONDER', WHICH I REMEMBER XCHKING AGAINST THE PDC, AND 'NAV RADIOS' WHICH THE INITIAL RTING OF THE IAH 338 DEG RADIAL I ALSO REMEMBER XCHKING WITH THE PDC, HOWEVER, I ALSO RESPONDED WITH 5000 FT BY REF TO THE ALT ALERTER, NOT XCHKING IT AGAINST THE PDC! HERE WAS OUR PROBLEM. OUR CLRNC WAS ONLY TO 4000 FT. THE TKOF BRIEFING AT THE END OF THE RWY WAS 'RWY HDG TO MAINTAIN 5000 FT' SHORTLY AFTER TKOF WHILE IN A LARGE L TURN THE FO NOTED AN ACFT APPROX 1200 FT ABOVE US IN OUR CLB PATH. (TCASII EQUIPPED ACFT AND THERE WAS A LOT OF WX IN THE AREA). BY THE TIME THE FO ADVISED ME, THEN TOLD THE TWR OF A POSSIBLE CONFLICT, (MENTIONING LESS THAN 1000 VERT SEPARATION) OUR TCASII GAVE A TA, HAVING REDUCED THE RATE OF CLB AS THE SITUATION DEVELOPED, I (PF) IMMEDIATELY LEVELED THE ACFT. AT THIS SAME TIME THE TWR TOLD US 'MAINTAIN 4000 FT.' BEING AT 4300 FT WE DSNDED TO 4000 STATING WE HAD NOT CONFIRMED 4000 FT EARLIER. AT THIS TIME WE LEARNED OF OUR ERROR. AFTER LENGTHY CHKS, REVIEWING THE SID, AND FLT PAPERS, NEITHER THE FO NOR I CAN DETERMINE WHEN 5000 WAS SET INTO THE ALT ALERT. WE DO KNOW THAT TIME WAS SHORT WHEN WE RETURNED TO THE COCKPIT. TURN-AROUND TIME WAS QUICK, THERE WAS A LOT OF WX ALONG THE IAH-DFW RTE AND DELAYS GOING INTO DFW. UPON COCKPIT PREPARATION, THERE WAS THE LATE PDC, COMING AT PUSHBACK, A PERIOD OF DUTY SATURATION! BUT, NOT A TIME TO RUSH. IT IS PROBABLY DURING THIS BUSY TIME PERIOD THAT 5000 FT WAS INADVERTENTLY SET, OR THAT POSSIBLY IT WAS NOT RESET FROM THE ARR CLEANUP. CONTRIBUTING FACTORS MIGHT BE THAT THIS WAS OCCURRING DURING THE LAST LEG OF A DAY FLYING 8 HRS, 11 1/2 HRS AFTER HOTEL PICK UP. ALSO THE LACK OF ANY GUIDANCE FROM THE SID. NEITHER A PUBLISHED ALT, NOR ANY NAVIGATIONAL PROC. IT IS MY DUTY TO CHK THE ALT SET IN THE ALT ALERT DURING THE PREFLT CHKLIST. IT IS THE CORRECT AND EFFECTIVE PROC THAT BOTH THE FO AND MYSELF FAILED TO XCHK THE ASSIGNED ALT. A REMINDER FROM THE TWR AS PART OF THE NORMAL CLRNC DURING TKOF MIGHT BE HELPFUL. I.E. 'CLRED FOR TKOF, MAINTAIN RWY HDG AND 4000 FT'. ALSO A MORE TIMELY CHANGE TO DEP, AS WHEN SWITCHING FREQS THE ALT LEAVING AND ALT CLBING/DSNDING TO ARE ANNOUNCED. I CAN ONLY SAY THAT AN ALERT FO WHO PROVIDED VERY TIMELY INFO TO BOTH ME AND THE CTLR, PREVENTED A VERY POTENTIALLY ACCIDENT. THE TCASII TOO WAS MOST HELPFUL, AS IT PROVIDED THE INFO AND PROBABLY WOULD HAVE FOLLOWED WITH AN 'RA' TO US HAD WE NOT STOPPED OUR ASCENT. SUPPLEMENTAL INFO FROM ACR 199611: ADDITIONALLY, HAD THERE BEEN A MORE EXPEDITIOUS HDOF TO DEP (3 MINS 29 SECONDS IN IMC), WE WOULD HAVE CHKED IN WITH DEP, RPTED CLBING TO 5000 FT WHICH WOULD HAVE BEEN ANOTHER XCHK THAT MAY HAVE PREVENTED THIS INCIDENT FROM OCCURRING. I FEEL AN ALT ON THE TKOF CLRNC (ESPECIALLY WITH NO EXPECT ALT ON THE SID IN A DATA LINK CLRNC DELIVERY ENVIRONMENT) WOULD BE AN ADDITIONAL SAFETY MEASURE.

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.