37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 319427 |
Time | |
Date | 199510 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : pwe |
State Reference | NE |
Altitude | msl bound lower : 16500 msl bound upper : 17000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zkc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival other arrival star : star enroute airway : zkc enroute other |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Route In Use | enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 150 flight time total : 20000 flight time type : 1800 |
ASRS Report | 319427 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 11000 flight time type : 4000 |
ASRS Report | 319286 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : published procedure non adherence : required legal separation non adherence : clearance non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 18000 vertical : 500 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On arrival into mci, navigating the kayuu 3 STAR arrival and descending through about 18300 ft MSL, the TCASII issued a TA at our 12 O'clock position low. Our aircraft was descending at about 2000 FPM, therefore the TA was followed by an RA within seconds to monitor vertical speed. Our attention was directed to the target intruder's relative position and we determined that we would level 500 ft above him at 17000 ft MSL. Therefore we continued our descent at a reduced rate and leveled off at 17000 ft MSL on assigned altitude. As we were approaching 17000 ft the captain asked the center controller about the other aircraft since there was no mention earlier about traffic from ATC. Center replied that there was traffic level at 16000 ft at which time I realized that we haven't changed the altimeter to the local setting of 29.41 yet. At this time we were within 100 ft of level off, therefore 500 ft below our true altitude of 17000 ft. We immediately reset our altimeters and climbed up to 17000 ft. I saw the other aircraft pass off our right and below, never getting within 500 ft of us. Just prior to the situation I was the first officer and PNF was out of the loop and off frequency getting the mci ATIS. I was off an extended period of time due to large amount of NOTAMS included in the ATIS on taxiway closures that required me to listen to the tape a couple times. During that time the captain informed me that he was given an expedite descent clearance through FL190 to level at 17000 ft. Once below FL190 he was issued a frequency change. The captain just finished checking in with the new controller when I came back into the loop. It was at this time that we received the TA/RA from the TCASII system, which distracted us from our normal procedural flow to set our altimeters and call out 18000 ft on a descent. Then the situation occurred that I stated earlier. It is obvious that this situation occurred because we didn't reset our altimeters, but I feel there are other underlying factors. Pilots should not have to listen to half the information that end up on ATIS tapes. I feel that most NOTAMS are there just to meet some legal requirement to cover somebody. Taxiway closures don't need to be on ATIS, ground control only needs to give specific instructions and with those instructions mention that a certain taxiway is closed. Also, frequency changes within 1000 ft of FL180 is one more factor that can break normal thought patterns, not saying this is an excuse, but this is time I feel it was a factor since the TA/RA was involved. The RA was telling us to monitor vertical speed and this time indicating not to descend. When we figured out that we were going to have 500 ft vertical separation from the target the captain continued descent at a reduced rate to level off. We were assuming the target was VFR at 16500 ft below the WX we were in at the time. I feel another reason we didn't level off based on the RA is that we are getting desensitized to the TCASII alerts in the B737-300. On numerous occasions especially when we are climbing towards a level aircraft, we get TA/RA's because we are climbing at such a rapid rate. When we get a TA/RA at these times, we check vertical separation and confirm that we are indeed going to level off prior to the other aircraft's altitude and continue to our altitude. I think here we subconsciously did this. I'm watching this in the future. As far as altimeter setting procedures, now we wait until we are approaching or at 18000 ft to reset. Maybe a procedure should be used that when an aircraft is cleared from a flight level to below 18000 ft, the local pressure should be set when leaving altitude or if already descending, set, when clearance is received to an altitude below flight levels. Also, personally, I am going to make a conscious effort to get ATIS information earlier so I will be in the loop during most of the descent especially around the transition altitude.
Original NASA ASRS Text
Title: POTENTIAL CONFLICT, OPPOSITE DIRECTION TFC. WRONG ALTIMETER SETTING DSNDING THROUGH FL180. DSCNT PROC EXPEDITED DSCNT.
Narrative: ON ARR INTO MCI, NAVING THE KAYUU 3 STAR ARR AND DSNDING THROUGH ABOUT 18300 FT MSL, THE TCASII ISSUED A TA AT OUR 12 O'CLOCK POS LOW. OUR ACFT WAS DSNDING AT ABOUT 2000 FPM, THEREFORE THE TA WAS FOLLOWED BY AN RA WITHIN SECONDS TO MONITOR VERT SPD. OUR ATTN WAS DIRECTED TO THE TARGET INTRUDER'S RELATIVE POS AND WE DETERMINED THAT WE WOULD LEVEL 500 FT ABOVE HIM AT 17000 FT MSL. THEREFORE WE CONTINUED OUR DSCNT AT A REDUCED RATE AND LEVELED OFF AT 17000 FT MSL ON ASSIGNED ALT. AS WE WERE APCHING 17000 FT THE CAPT ASKED THE CTR CTLR ABOUT THE OTHER ACFT SINCE THERE WAS NO MENTION EARLIER ABOUT TFC FROM ATC. CTR REPLIED THAT THERE WAS TFC LEVEL AT 16000 FT AT WHICH TIME I REALIZED THAT WE HAVEN'T CHANGED THE ALTIMETER TO THE LCL SETTING OF 29.41 YET. AT THIS TIME WE WERE WITHIN 100 FT OF LEVEL OFF, THEREFORE 500 FT BELOW OUR TRUE ALT OF 17000 FT. WE IMMEDIATELY RESET OUR ALTIMETERS AND CLBED UP TO 17000 FT. I SAW THE OTHER ACFT PASS OFF OUR R AND BELOW, NEVER GETTING WITHIN 500 FT OF US. JUST PRIOR TO THE SIT I WAS THE FO AND PNF WAS OUT OF THE LOOP AND OFF FREQ GETTING THE MCI ATIS. I WAS OFF AN EXTENDED PERIOD OF TIME DUE TO LARGE AMOUNT OF NOTAMS INCLUDED IN THE ATIS ON TXWY CLOSURES THAT REQUIRED ME TO LISTEN TO THE TAPE A COUPLE TIMES. DURING THAT TIME THE CAPT INFORMED ME THAT HE WAS GIVEN AN EXPEDITE DSCNT CLRNC THROUGH FL190 TO LEVEL AT 17000 FT. ONCE BELOW FL190 HE WAS ISSUED A FREQ CHANGE. THE CAPT JUST FINISHED CHKING IN WITH THE NEW CTLR WHEN I CAME BACK INTO THE LOOP. IT WAS AT THIS TIME THAT WE RECEIVED THE TA/RA FROM THE TCASII SYS, WHICH DISTRACTED US FROM OUR NORMAL PROCEDURAL FLOW TO SET OUR ALTIMETERS AND CALL OUT 18000 FT ON A DSCNT. THEN THE SIT OCCURRED THAT I STATED EARLIER. IT IS OBVIOUS THAT THIS SIT OCCURRED BECAUSE WE DIDN'T RESET OUR ALTIMETERS, BUT I FEEL THERE ARE OTHER UNDERLYING FACTORS. PLTS SHOULD NOT HAVE TO LISTEN TO HALF THE INFO THAT END UP ON ATIS TAPES. I FEEL THAT MOST NOTAMS ARE THERE JUST TO MEET SOME LEGAL REQUIREMENT TO COVER SOMEBODY. TXWY CLOSURES DON'T NEED TO BE ON ATIS, GND CTL ONLY NEEDS TO GIVE SPECIFIC INSTRUCTIONS AND WITH THOSE INSTRUCTIONS MENTION THAT A CERTAIN TXWY IS CLOSED. ALSO, FREQ CHANGES WITHIN 1000 FT OF FL180 IS ONE MORE FACTOR THAT CAN BREAK NORMAL THOUGHT PATTERNS, NOT SAYING THIS IS AN EXCUSE, BUT THIS IS TIME I FEEL IT WAS A FACTOR SINCE THE TA/RA WAS INVOLVED. THE RA WAS TELLING US TO MONITOR VERT SPD AND THIS TIME INDICATING NOT TO DSND. WHEN WE FIGURED OUT THAT WE WERE GOING TO HAVE 500 FT VERT SEPARATION FROM THE TARGET THE CAPT CONTINUED DSCNT AT A REDUCED RATE TO LEVEL OFF. WE WERE ASSUMING THE TARGET WAS VFR AT 16500 FT BELOW THE WX WE WERE IN AT THE TIME. I FEEL ANOTHER REASON WE DIDN'T LEVEL OFF BASED ON THE RA IS THAT WE ARE GETTING DESENSITIZED TO THE TCASII ALERTS IN THE B737-300. ON NUMEROUS OCCASIONS ESPECIALLY WHEN WE ARE CLBING TOWARDS A LEVEL ACFT, WE GET TA/RA'S BECAUSE WE ARE CLBING AT SUCH A RAPID RATE. WHEN WE GET A TA/RA AT THESE TIMES, WE CHK VERT SEPARATION AND CONFIRM THAT WE ARE INDEED GOING TO LEVEL OFF PRIOR TO THE OTHER ACFT'S ALT AND CONTINUE TO OUR ALT. I THINK HERE WE SUBCONSCIOUSLY DID THIS. I'M WATCHING THIS IN THE FUTURE. AS FAR AS ALTIMETER SETTING PROCS, NOW WE WAIT UNTIL WE ARE APCHING OR AT 18000 FT TO RESET. MAYBE A PROC SHOULD BE USED THAT WHEN AN ACFT IS CLRED FROM A FLT LEVEL TO BELOW 18000 FT, THE LCL PRESSURE SHOULD BE SET WHEN LEAVING ALT OR IF ALREADY DSNDING, SET, WHEN CLRNC IS RECEIVED TO AN ALT BELOW FLT LEVELS. ALSO, PERSONALLY, I AM GOING TO MAKE A CONSCIOUS EFFORT TO GET ATIS INFO EARLIER SO I WILL BE IN THE LOOP DURING MOST OF THE DSCNT ESPECIALLY AROUND THE TRANSITION ALT.
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.