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Aircraft 'Y' flight crew misinterpreted altimeter setting and entered holding pattern at wrong altitude.
| Attributes | |
| ACN | 295670 |
| Time | |
| Date | 199502 |
| Day | Sat |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | atc facility : jfk |
| State Reference | NY |
| Altitude | msl bound lower : 12000 msl bound upper : 12000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zny |
| Operator | common carrier : air carrier |
| Make Model Name | B767 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | other |
| Route In Use | arrival other |
| Flight Plan | IFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | B747 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | other |
| Route In Use | arrival other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| ASRS Report | 295670 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument |
| Events | |
| Anomaly | altitude deviation : overshoot conflict : nmac non adherence : required legal separation non adherence : far non adherence : clearance other anomaly other |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera other flight crewa |
| Resolutory Action | controller : issued new clearance flight crew : took evasive action other |
| Consequence | Other |
| Miss Distance | vertical : 100 |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Our flight was holding 45 mi northeast of jfk at 12000 ft. Altimeter setting 28.95, VFR on top. TCASII issued warning followed by an RA, dive, and full red on bottom of ivsi. I pushed nose over to comply and first officer immediately thereafter saw a foreign air carrier 747 out his side window. He told me we were in no danger and that I could regain the 100 ft I had lost. ZNY then asked foreign air carrier its altitude, foreign air carrier responded 13000 ft and there's a us air carrier very close to us. ZNY then asked foreign air carrier its altimeter setting and he responded 29.95, as he had read it back. At that point we were changed to another frequency and exited the hold. The low altimeter setting, along with a crew using english as a second language, in my mind, was the cause of this potentially disastrous situation. I am also puzzled by the late call from center and wonder why the alert they supposedly receive with a 300 ft altitude deviation didn't result in a more timely warning. I recommend that whenever the altimeter is below 29.xx it should be mandatory that ctrs read out settings in the following fashion. Altimeter 28.90, repeat 28.90, readback altimeter. At this time they should be particularly vigilant about hearing the readback as they gave it. Thank you for your attention.
Original NASA ASRS Text
Title: ACFT 'Y' FLC MISINTERPRETED ALTIMETER SETTING AND ENTERED HOLDING PATTERN AT WRONG ALT.
Narrative: OUR FLT WAS HOLDING 45 MI NE OF JFK AT 12000 FT. ALTIMETER SETTING 28.95, VFR ON TOP. TCASII ISSUED WARNING FOLLOWED BY AN RA, DIVE, AND FULL RED ON BOTTOM OF IVSI. I PUSHED NOSE OVER TO COMPLY AND FO IMMEDIATELY THEREAFTER SAW A FOREIGN ACR 747 OUT HIS SIDE WINDOW. HE TOLD ME WE WERE IN NO DANGER AND THAT I COULD REGAIN THE 100 FT I HAD LOST. ZNY THEN ASKED FOREIGN ACR ITS ALT, FOREIGN ACR RESPONDED 13000 FT AND THERE'S A U.S. ACR VERY CLOSE TO US. ZNY THEN ASKED FOREIGN ACR ITS ALTIMETER SETTING AND HE RESPONDED 29.95, AS HE HAD READ IT BACK. AT THAT POINT WE WERE CHANGED TO ANOTHER FREQ AND EXITED THE HOLD. THE LOW ALTIMETER SETTING, ALONG WITH A CREW USING ENGLISH AS A SECOND LANGUAGE, IN MY MIND, WAS THE CAUSE OF THIS POTENTIALLY DISASTROUS SIT. I AM ALSO PUZZLED BY THE LATE CALL FROM CTR AND WONDER WHY THE ALERT THEY SUPPOSEDLY RECEIVE WITH A 300 FT ALTDEV DIDN'T RESULT IN A MORE TIMELY WARNING. I RECOMMEND THAT WHENEVER THE ALTIMETER IS BELOW 29.XX IT SHOULD BE MANDATORY THAT CTRS READ OUT SETTINGS IN THE FOLLOWING FASHION. ALTIMETER 28.90, REPEAT 28.90, READBACK ALTIMETER. AT THIS TIME THEY SHOULD BE PARTICULARLY VIGILANT ABOUT HEARING THE READBACK AS THEY GAVE IT. THANK YOU FOR YOUR ATTN.
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.