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Medevac aircraft uses wrong altimeter setting. Altitude deviation.
| Attributes | |
| ACN | 226133 |
| Time | |
| Date | 199211 |
| Day | Mon |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : anc |
| State Reference | AK |
| Altitude | msl bound lower : 13000 msl bound upper : 14000 |
| Environment | |
| Flight Conditions | IMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tower : slc |
| Operator | common carrier : air taxi |
| Make Model Name | Medium Large Transport |
| Navigation In Use | Other |
| Flight Phase | descent other |
| Route In Use | enroute airway : zan |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air taxi |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : cfi pilot : atp pilot : flight engineer |
| Experience | flight time last 90 days : 100 flight time total : 16000 flight time type : 900 |
| ASRS Report | 226133 |
| Person 2 | |
| Affiliation | company : air taxi |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
| Independent Detector | atc equipment other atc equipment : unspecified other flight crewa |
| Resolutory Action | flight crew : returned to intended course or assigned course other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
| Situations | |
| ATC Facility | procedure or policy : unspecified |
Narrative:
Medical evacuate/evacuation flight (medevac). Bet-mri. 2 pilot crew. During the flight, the medical crew was very worried about the patient's condition. The flight crew had to initiate radio calls and relay messages between the hospital and the med crew. As the flight progressed the medical crew became increasingly distressed. There was a lot of noise as the blood covered doctor yelled instructions to the nurses. This was distracting to the flight crew. Approximately 20 min prior to landing our destination airport went below landing mins (special VFR). The first officer was taking care of all ATC communication and I was talking to company and the hospital on the other radio. The first officer told me that we were cleared from FL210 to 14000. We began descent and accomplished the in range checklist. Passing FL180 we set altimeters to 29.89. The radio traffic became very busy now as we tried to coordinate our plans with the hospital. A nurse came forward to the cockpit to discuss options with the hospital. Our destination was then changed from anc to aed (elmendorf AFB). The first officer then copied the aed ATIS while I requested permission to land from base operations. We leveled at 14000 and I asked the first officer to read the aed ATIS to me. When the first officer read the local altimeter setting as 28.89 I asked him to rechk the ATIS (while I listened). The local altimeter was 28.89! I reset my altimeter and began a climb back up to 14000. I asked the first officer to notify ATC of our intentions and to turn off all non-ATC communication radios. We proceeded to aed and landed. Post-flight: when I asked the first officer how he could have missed the low altimeter setting. He replied 'the ATIS at mri lacked the normal phraseology, altimeter low low 28.89.' contributing factors: fatigue - - the first officer was out of his normal sleep cycle. He was filling in while the full time night medevac first officer was on time off. We had flown another flight several nights before and the first officer said that he hadn't done well with all the schedule swapping. I also had not slept more than several hours in the previous day or so. Although we were legal to fly as the FARS are concerned we were fatigued. Phraseology: I learned in a conversation later that day with an ATC controller that the use of the phrase 'altimeter low low' is no longer required when reporting abnormally low altimeter settings (pretty stupid, huh?). I believe that, if the first officer had heard 'low low' this altitude deviation would not have happened. Aircraft confign: the communication radios used by the medical team are in the cockpit. The medical crew member must kneel between the pilot seats, talk on a hand microphone, and listen on the overhead speaker. This system works quite well normally, but during times of high cockpit workload it can be very distracting. We, of course, only allow this kind of communication to go on above 10000 ft. There is no cockpit door to isolate the flight crew from the noise and chaos that happens in the back of the airplane during a medical emergency.
Original NASA ASRS Text
Title: MEDEVAC ACFT USES WRONG ALTIMETER SETTING. ALTDEV.
Narrative: MEDICAL EVAC FLT (MEDEVAC). BET-MRI. 2 PLT CREW. DURING THE FLT, THE MEDICAL CREW WAS VERY WORRIED ABOUT THE PATIENT'S CONDITION. THE FLC HAD TO INITIATE RADIO CALLS AND RELAY MESSAGES BTWN THE HOSPITAL AND THE MED CREW. AS THE FLT PROGRESSED THE MEDICAL CREW BECAME INCREASINGLY DISTRESSED. THERE WAS A LOT OF NOISE AS THE BLOOD COVERED DOCTOR YELLED INSTRUCTIONS TO THE NURSES. THIS WAS DISTRACTING TO THE FLC. APPROX 20 MIN PRIOR TO LNDG OUR DEST ARPT WENT BELOW LNDG MINS (SPECIAL VFR). THE FO WAS TAKING CARE OF ALL ATC COM AND I WAS TALKING TO COMPANY AND THE HOSPITAL ON THE OTHER RADIO. THE FO TOLD ME THAT WE WERE CLRED FROM FL210 TO 14000. WE BEGAN DSCNT AND ACCOMPLISHED THE IN RANGE CHKLIST. PASSING FL180 WE SET ALTIMETERS TO 29.89. THE RADIO TFC BECAME VERY BUSY NOW AS WE TRIED TO COORDINATE OUR PLANS WITH THE HOSPITAL. A NURSE CAME FORWARD TO THE COCKPIT TO DISCUSS OPTIONS WITH THE HOSPITAL. OUR DEST WAS THEN CHANGED FROM ANC TO AED (ELMENDORF AFB). THE FO THEN COPIED THE AED ATIS WHILE I REQUESTED PERMISSION TO LAND FROM BASE OPS. WE LEVELED AT 14000 AND I ASKED THE FO TO READ THE AED ATIS TO ME. WHEN THE FO READ THE LCL ALTIMETER SETTING AS 28.89 I ASKED HIM TO RECHK THE ATIS (WHILE I LISTENED). THE LCL ALTIMETER WAS 28.89! I RESET MY ALTIMETER AND BEGAN A CLB BACK UP TO 14000. I ASKED THE FO TO NOTIFY ATC OF OUR INTENTIONS AND TO TURN OFF ALL NON-ATC COM RADIOS. WE PROCEEDED TO AED AND LANDED. POST-FLT: WHEN I ASKED THE FO HOW HE COULD HAVE MISSED THE LOW ALTIMETER SETTING. HE REPLIED 'THE ATIS AT MRI LACKED THE NORMAL PHRASEOLOGY, ALTIMETER LOW LOW 28.89.' CONTRIBUTING FACTORS: FATIGUE - - THE FO WAS OUT OF HIS NORMAL SLEEP CYCLE. HE WAS FILLING IN WHILE THE FULL TIME NIGHT MEDEVAC FO WAS ON TIME OFF. WE HAD FLOWN ANOTHER FLT SEVERAL NIGHTS BEFORE AND THE FO SAID THAT HE HADN'T DONE WELL WITH ALL THE SCHEDULE SWAPPING. I ALSO HAD NOT SLEPT MORE THAN SEVERAL HRS IN THE PREVIOUS DAY OR SO. ALTHOUGH WE WERE LEGAL TO FLY AS THE FARS ARE CONCERNED WE WERE FATIGUED. PHRASEOLOGY: I LEARNED IN A CONVERSATION LATER THAT DAY WITH AN ATC CTLR THAT THE USE OF THE PHRASE 'ALTIMETER LOW LOW' IS NO LONGER REQUIRED WHEN RPTING ABNORMALLY LOW ALTIMETER SETTINGS (PRETTY STUPID, HUH?). I BELIEVE THAT, IF THE FO HAD HEARD 'LOW LOW' THIS ALTDEV WOULD NOT HAVE HAPPENED. ACFT CONFIGN: THE COM RADIOS USED BY THE MEDICAL TEAM ARE IN THE COCKPIT. THE MEDICAL CREW MEMBER MUST KNEEL BTWN THE PLT SEATS, TALK ON A HAND MIKE, AND LISTEN ON THE OVERHEAD SPEAKER. THIS SYS WORKS QUITE WELL NORMALLY, BUT DURING TIMES OF HIGH COCKPIT WORKLOAD IT CAN BE VERY DISTRACTING. WE, OF COURSE, ONLY ALLOW THIS KIND OF COM TO GO ON ABOVE 10000 FT. THERE IS NO COCKPIT DOOR TO ISOLATE THE FLC FROM THE NOISE AND CHAOS THAT HAPPENS IN THE BACK OF THE AIRPLANE DURING A MEDICAL EMER.
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.