37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 294498 |
Time | |
Date | 199501 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : pmm |
State Reference | MI |
Altitude | msl bound lower : 14000 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : azu |
Operator | common carrier : air taxi |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 135 |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute airway : zau |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 255 flight time total : 6050 flight time type : 4000 |
ASRS Report | 294498 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 3900 flight time type : 2000 |
ASRS Report | 294742 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : far other anomaly other |
Independent Detector | other controllera |
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 |
Narrative:
Aircraft was on a flight from dtw to rfd. At the time of the incident, the pilots were in contact with ZAU. The aircraft had just passed over pmm VOR. The controller had not given the current altimeter setting when the crew checked in on the new frequency. The crew did not catch this omission. After a short period of time, the controller stated he saw the aircraft 400 ft off altitude and gave the chicago altimeter setting to them. There had been quite a change in the last 50 mi. The crew put this new altimeter setting in and the flight proceeded without incident. Factors involved in this error included the controller's initial omission of the altimeter setting and the crew's subsequent failure to catch this mistake. There were no distrs in the cockpit. Moreover, the crew was alert and no extraneous communication or activity was occurring at the time. The captain was well aware of the aircraft's position but failed to catch the mistake on the part of the controller. The crew discussed the incident at length. The captain assumed full responsibility for the error but the first officer stated he was equally responsible for failing to catch the mistake. Cockpit resource management was actively used the entire day by the crew and they both have worked well together on numerous occasions. Supplemental information from acn 294742: in retrospect, I realized that complacency was the cause for the error. The captain and I were very familiar with the route, the aircraft and each other because of our familiarity with one another, we constantly converse at altitude. Although we do not normally miss ATC calls and always practice proper cockpit resource management, we allowed our concentration to lapse.
Original NASA ASRS Text
Title: ALTIMETER SETTING WAS NOT UPDATED, AND ACFT DEVIATED FROM ASSIGNED ALT.
Narrative: ACFT WAS ON A FLT FROM DTW TO RFD. AT THE TIME OF THE INCIDENT, THE PLTS WERE IN CONTACT WITH ZAU. THE ACFT HAD JUST PASSED OVER PMM VOR. THE CTLR HAD NOT GIVEN THE CURRENT ALTIMETER SETTING WHEN THE CREW CHKED IN ON THE NEW FREQ. THE CREW DID NOT CATCH THIS OMISSION. AFTER A SHORT PERIOD OF TIME, THE CTLR STATED HE SAW THE ACFT 400 FT OFF ALT AND GAVE THE CHICAGO ALTIMETER SETTING TO THEM. THERE HAD BEEN QUITE A CHANGE IN THE LAST 50 MI. THE CREW PUT THIS NEW ALTIMETER SETTING IN AND THE FLT PROCEEDED WITHOUT INCIDENT. FACTORS INVOLVED IN THIS ERROR INCLUDED THE CTLR'S INITIAL OMISSION OF THE ALTIMETER SETTING AND THE CREW'S SUBSEQUENT FAILURE TO CATCH THIS MISTAKE. THERE WERE NO DISTRS IN THE COCKPIT. MOREOVER, THE CREW WAS ALERT AND NO EXTRANEOUS COM OR ACTIVITY WAS OCCURRING AT THE TIME. THE CAPT WAS WELL AWARE OF THE ACFT'S POS BUT FAILED TO CATCH THE MISTAKE ON THE PART OF THE CTLR. THE CREW DISCUSSED THE INCIDENT AT LENGTH. THE CAPT ASSUMED FULL RESPONSIBILITY FOR THE ERROR BUT THE FO STATED HE WAS EQUALLY RESPONSIBLE FOR FAILING TO CATCH THE MISTAKE. COCKPIT RESOURCE MGMNT WAS ACTIVELY USED THE ENTIRE DAY BY THE CREW AND THEY BOTH HAVE WORKED WELL TOGETHER ON NUMEROUS OCCASIONS. SUPPLEMENTAL INFO FROM ACN 294742: IN RETROSPECT, I REALIZED THAT COMPLACENCY WAS THE CAUSE FOR THE ERROR. THE CAPT AND I WERE VERY FAMILIAR WITH THE RTE, THE ACFT AND EACH OTHER BECAUSE OF OUR FAMILIARITY WITH ONE ANOTHER, WE CONSTANTLY CONVERSE AT ALT. ALTHOUGH WE DO NOT NORMALLY MISS ATC CALLS AND ALWAYS PRACTICE PROPER COCKPIT RESOURCE MGMNT, WE ALLOWED OUR CONCENTRATION TO LAPSE.
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.