37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 225374 |
Time | |
Date | 199210 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : anc |
State Reference | AK |
Altitude | msl bound lower : 12500 msl bound upper : 13000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : anc |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 10000 flight time type : 1500 |
ASRS Report | 225374 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : far other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Both incidents involved assigned altitude deviations of greater than 300 ft while being vectored for an ILS approach. The first deviation occurred while the captain (a company check airman) was hand flying the airplane (widebody transport). We were cleared to descend and maintain 6000 ft. After I verified level at 6000 ft, I looked down at my approach plate to identify the localizer frequency. When I heard the altitude alerter chime I saw we were descending through 5700 ft. I rechked altitude displayed in the window to verify 6000 ft and then said '...altitude, where are you going?' the captain climbed back to altitude. Several days later on the same trip, the captain was hand flying the airplane and trying to brief the approach into anc airport. As we had passed FL180 and had not reset the altimeters, the altimeter setting of 29.42 put us several hundred ft below the assigned altitude first officer 13000 ft. I called for the checklist at 14000-15000 ft as the captain did not at FL180. By the time we got to the altimeter setting item we were already below the altitude. I discussed this with the flight engineer to stress the importance of proceeding with a checklist at the appropriate time, even if one has not been called for. I personally believe that both incidents were directly related to the normal age deterioration of the captain as he was nearing age 60. He needed ATC instructions repeated to him even though he was wearing a headset and missed many things said in the cockpit.
Original NASA ASRS Text
Title: FAILURE TO RESET ALTIMETER PASSING FL180.
Narrative: BOTH INCIDENTS INVOLVED ASSIGNED ALT DEVS OF GREATER THAN 300 FT WHILE BEING VECTORED FOR AN ILS APCH. THE FIRST DEV OCCURRED WHILE THE CAPT (A COMPANY CHK AIRMAN) WAS HAND FLYING THE AIRPLANE (WDB). WE WERE CLRED TO DSND AND MAINTAIN 6000 FT. AFTER I VERIFIED LEVEL AT 6000 FT, I LOOKED DOWN AT MY APCH PLATE TO IDENT THE LOC FREQ. WHEN I HEARD THE ALT ALERTER CHIME I SAW WE WERE DSNDING THROUGH 5700 FT. I RECHKED ALT DISPLAYED IN THE WINDOW TO VERIFY 6000 FT AND THEN SAID '...ALT, WHERE ARE YOU GOING?' THE CAPT CLBED BACK TO ALT. SEVERAL DAYS LATER ON THE SAME TRIP, THE CAPT WAS HAND FLYING THE AIRPLANE AND TRYING TO BRIEF THE APCH INTO ANC ARPT. AS WE HAD PASSED FL180 AND HAD NOT RESET THE ALTIMETERS, THE ALTIMETER SETTING OF 29.42 PUT US SEVERAL HUNDRED FT BELOW THE ASSIGNED ALT FO 13000 FT. I CALLED FOR THE CHKLIST AT 14000-15000 FT AS THE CAPT DID NOT AT FL180. BY THE TIME WE GOT TO THE ALTIMETER SETTING ITEM WE WERE ALREADY BELOW THE ALT. I DISCUSSED THIS WITH THE FE TO STRESS THE IMPORTANCE OF PROCEEDING WITH A CHKLIST AT THE APPROPRIATE TIME, EVEN IF ONE HAS NOT BEEN CALLED FOR. I PERSONALLY BELIEVE THAT BOTH INCIDENTS WERE DIRECTLY RELATED TO THE NORMAL AGE DETERIORATION OF THE CAPT AS HE WAS NEARING AGE 60. HE NEEDED ATC INSTRUCTIONS REPEATED TO HIM EVEN THOUGH HE WAS WEARING A HEADSET AND MISSED MANY THINGS SAID IN THE COCKPIT.
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.