37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 321300 |
Time | |
Date | 199511 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : pvd airport : bos |
State Reference | RI |
Altitude | msl bound lower : 13300 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | enroute airway : zbw |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 130 flight time total : 11000 flight time type : 800 |
ASRS Report | 321300 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 75 flight time total : 6000 flight time type : 75 |
ASRS Report | 321547 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa other other : unspecified atc |
Resolutory Action | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On descent from altitude into the bos area, we were given a level off at FL180. From ATIS, the bos altimeter setting was very low at 29.94 and we discussed it being very close to the lowest usable flight level. We were given the bos altimeter setting and cleared to 16000 ft. After calling for the in-range checklist, I set the altimeter setting of 29.94 in the standby altimeter, but put 30.44 on my primary altimeter. When reaching 16000 ft we were cleared to 14000 ft. The first officer was talking to the company on another radio and missed the level off. ZBW asked my altitude and I replied 14000 ft. The controller said I was showing 13300 ft on his scope and restated the bos altimeter setting 29.94. I then discovered my error on setting the altimeter and said I would immediately correct back to 14000 ft. The controller then gave me clearance to 13000 ft and said he wondered what I was doing when I missed the level off at 16000 ft. He said he gave me 14000 ft because he had an open altitude. He didn't know what the problem was until I missed the level off at 14000 ft as well. There appeared to be no traffic conflict and we were handed off to bos approach for the subsequent approach and landing. Conclusions: I can only attribute my error in setting the altimeter to fatigue. I had flown into mem from phx that night not expecting to go back out, but was called back to fly after arriving home, so I ended up being awake all night. I can now see how fatigue, combined with the high workload in the approach environment in 2 man electric cockpits can lead to making mistakes that are not readily picked up by just 2 crew members. My previous experience has been in 3 crew member cockpits and that extra set of eyes and ears can make up for errors that are not caught in the 2 man aircraft. In the future, I will be very careful not to put myself in the position of flying fatigued again.
Original NASA ASRS Text
Title: WRONG ALTIMETER SETTING BY PF, CAPT. FO NOT MONITORING BECAUSE HE WAS OFF THE RADIOS WITH COMPANY COM. ATC INTERVENED AND CAPT RESET ALTIMETER. FATIGUE CONTRIBUTED.
Narrative: ON DSCNT FROM ALT INTO THE BOS AREA, WE WERE GIVEN A LEVEL OFF AT FL180. FROM ATIS, THE BOS ALTIMETER SETTING WAS VERY LOW AT 29.94 AND WE DISCUSSED IT BEING VERY CLOSE TO THE LOWEST USABLE FLT LEVEL. WE WERE GIVEN THE BOS ALTIMETER SETTING AND CLRED TO 16000 FT. AFTER CALLING FOR THE IN-RANGE CHKLIST, I SET THE ALTIMETER SETTING OF 29.94 IN THE STANDBY ALTIMETER, BUT PUT 30.44 ON MY PRIMARY ALTIMETER. WHEN REACHING 16000 FT WE WERE CLRED TO 14000 FT. THE FO WAS TALKING TO THE COMPANY ON ANOTHER RADIO AND MISSED THE LEVEL OFF. ZBW ASKED MY ALT AND I REPLIED 14000 FT. THE CTLR SAID I WAS SHOWING 13300 FT ON HIS SCOPE AND RESTATED THE BOS ALTIMETER SETTING 29.94. I THEN DISCOVERED MY ERROR ON SETTING THE ALTIMETER AND SAID I WOULD IMMEDIATELY CORRECT BACK TO 14000 FT. THE CTLR THEN GAVE ME CLRNC TO 13000 FT AND SAID HE WONDERED WHAT I WAS DOING WHEN I MISSED THE LEVEL OFF AT 16000 FT. HE SAID HE GAVE ME 14000 FT BECAUSE HE HAD AN OPEN ALT. HE DIDN'T KNOW WHAT THE PROB WAS UNTIL I MISSED THE LEVEL OFF AT 14000 FT AS WELL. THERE APPEARED TO BE NO TFC CONFLICT AND WE WERE HANDED OFF TO BOS APCH FOR THE SUBSEQUENT APCH AND LNDG. CONCLUSIONS: I CAN ONLY ATTRIBUTE MY ERROR IN SETTING THE ALTIMETER TO FATIGUE. I HAD FLOWN INTO MEM FROM PHX THAT NIGHT NOT EXPECTING TO GO BACK OUT, BUT WAS CALLED BACK TO FLY AFTER ARRIVING HOME, SO I ENDED UP BEING AWAKE ALL NIGHT. I CAN NOW SEE HOW FATIGUE, COMBINED WITH THE HIGH WORKLOAD IN THE APCH ENVIRONMENT IN 2 MAN ELECTRIC COCKPITS CAN LEAD TO MAKING MISTAKES THAT ARE NOT READILY PICKED UP BY JUST 2 CREW MEMBERS. MY PREVIOUS EXPERIENCE HAS BEEN IN 3 CREW MEMBER COCKPITS AND THAT EXTRA SET OF EYES AND EARS CAN MAKE UP FOR ERRORS THAT ARE NOT CAUGHT IN THE 2 MAN ACFT. IN THE FUTURE, I WILL BE VERY CAREFUL NOT TO PUT MYSELF IN THE POS OF FLYING FATIGUED AGAIN.
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.