37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 261148 |
Time | |
Date | 199401 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : orf |
State Reference | VA |
Altitude | msl bound lower : 2600 msl bound upper : 3000 |
Environment | |
Flight Conditions | Mixed |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : orf |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach descent other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 20000 flight time type : 100 |
ASRS Report | 261148 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Got a frequency handoff descending through 19000 ft (where we normally reset altimeters, turn on landing lights, then call for in range checklist). Tired, up all night flying the freight. Normally the PF calls for the checklist. If he fails to I'll call for at 18000 ft. In any case we did not reset altimeters and did not do the 'in range' checklist. Further we flying into a deep low resulting in being about 700 ft low. 300 ft to 400 ft below the assigned 3000 ft, approach control called saying he showed us about 300 ft low. We instantly realized what had happened, reset the altimeters as we initiated a climb back to the assigned altitude, ran the 'in range' and shortly after the before landing checklists. The rest of the flight was uneventful. While my inattn caused the incident (along with my first officer and so) I feel the root cause was poor sleep over the past several days. While air carrier teaches sleep help during cockpit resource management it does little good when you then go to noisy hotels with rooms that aren't dark. It would take considerably more company involvement to correct this. As long as 'back side of the clock' flying exists, so will this problem. In this case I felt fairly good when I went to work, but after a gso-ind leg and a 3 hour layover, I was feeling tired. Then a leg to tys and another hour on the ground and really felt tired. One further item. Orf was supposed to have freezing rain. In fact, the WX was good with the ground in sight throughout the descent. I believe this lulled me into relaxing - and contributed to the incident.
Original NASA ASRS Text
Title: ALT BUST.
Narrative: GOT A FREQ HDOF DSNDING THROUGH 19000 FT (WHERE WE NORMALLY RESET ALTIMETERS, TURN ON LNDG LIGHTS, THEN CALL FOR IN RANGE CHKLIST). TIRED, UP ALL NIGHT FLYING THE FREIGHT. NORMALLY THE PF CALLS FOR THE CHKLIST. IF HE FAILS TO I'LL CALL FOR AT 18000 FT. IN ANY CASE WE DID NOT RESET ALTIMETERS AND DID NOT DO THE 'IN RANGE' CHKLIST. FURTHER WE FLYING INTO A DEEP LOW RESULTING IN BEING ABOUT 700 FT LOW. 300 FT TO 400 FT BELOW THE ASSIGNED 3000 FT, APCH CONTROL CALLED SAYING HE SHOWED US ABOUT 300 FT LOW. WE INSTANTLY REALIZED WHAT HAD HAPPENED, RESET THE ALTIMETERS AS WE INITIATED A CLB BACK TO THE ASSIGNED ALT, RAN THE 'IN RANGE' AND SHORTLY AFTER THE BEFORE LANDING CHKLISTS. THE REST OF THE FLT WAS UNEVENTFUL. WHILE MY INATTN CAUSED THE INCIDENT (ALONG WITH MY FO AND SO) I FEEL THE ROOT CAUSE WAS POOR SLEEP OVER THE PAST SEVERAL DAYS. WHILE ACR TEACHES SLEEP HELP DURING COCKPIT RESOURCE MGMNT IT DOES LITTLE GOOD WHEN YOU THEN GO TO NOISY HOTELS WITH ROOMS THAT AREN'T DARK. IT WOULD TAKE CONSIDERABLY MORE COMPANY INVOLVEMENT TO CORRECT THIS. AS LONG AS 'BACK SIDE OF THE CLOCK' FLYING EXISTS, SO WILL THIS PROB. IN THIS CASE I FELT FAIRLY GOOD WHEN I WENT TO WORK, BUT AFTER A GSO-IND LEG AND A 3 HR LAYOVER, I WAS FEELING TIRED. THEN A LEG TO TYS AND ANOTHER HR ON THE GND AND REALLY FELT TIRED. ONE FURTHER ITEM. ORF WAS SUPPOSED TO HAVE FREEZING RAIN. IN FACT, THE WX WAS GOOD WITH THE GND IN SIGHT THROUGHOUT THE DSCNT. I BELIEVE THIS LULLED ME INTO RELAXING - AND CONTRIBUTED TO THE INCIDENT.
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.