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Wrong altimeter setting. Flight crew forgot to set altimeters to qnh descending out of 18000 ft. Approach controller didn't give an altimeter setting with descent clearance.
| Attributes | |
| ACN | 336470 |
| Time | |
| Date | 199605 |
| Day | Sun |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | atc facility : ord |
| State Reference | IL |
| Altitude | msl bound lower : 8700 msl bound upper : 9000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : ord tower : atl |
| Operator | common carrier : air carrier |
| Make Model Name | B767-200 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | cruise other descent other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| ASRS Report | 336470 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| ASRS Report | 336211 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance 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:
Approach control advised may/xx/96, that he read our altitude as 8700 ft. He was correct. We had 29.92 altimeter setting instead of 29.59. We reset correctly and climbed to 9000 ft. There were no conflicts or other actions taken. TCASII was operating normally. There are reasons for errors made but to learn from mistakes you must realize they are mistakes. This event should not have happened. The copilot was flying and descending through FL180 and was distracted by a 'not on intercept heading' message on the CDU screen and I think the controller did not pass the current altimeter setting to us. This is an important cue. A tired crew returning from europe and different altimeter procedures did not complete their descent checklist at FL180 and reset the altimeters. The lesson is -- checklist! Checklist! Checklist! It saves you from the always present distractions.
Original NASA ASRS Text
Title: WRONG ALTIMETER SETTING. FLC FORGOT TO SET ALTIMETERS TO QNH DSNDING OUT OF 18000 FT. APCH CTLR DIDN'T GIVE AN ALTIMETER SETTING WITH DSCNT CLRNC.
Narrative: APCH CTL ADVISED MAY/XX/96, THAT HE READ OUR ALT AS 8700 FT. HE WAS CORRECT. WE HAD 29.92 ALTIMETER SETTING INSTEAD OF 29.59. WE RESET CORRECTLY AND CLBED TO 9000 FT. THERE WERE NO CONFLICTS OR OTHER ACTIONS TAKEN. TCASII WAS OPERATING NORMALLY. THERE ARE REASONS FOR ERRORS MADE BUT TO LEARN FROM MISTAKES YOU MUST REALIZE THEY ARE MISTAKES. THIS EVENT SHOULD NOT HAVE HAPPENED. THE COPLT WAS FLYING AND DSNDING THROUGH FL180 AND WAS DISTRACTED BY A 'NOT ON INTERCEPT HDG' MESSAGE ON THE CDU SCREEN AND I THINK THE CTLR DID NOT PASS THE CURRENT ALTIMETER SETTING TO US. THIS IS AN IMPORTANT CUE. A TIRED CREW RETURNING FROM EUROPE AND DIFFERENT ALTIMETER PROCS DID NOT COMPLETE THEIR DSCNT CHKLIST AT FL180 AND RESET THE ALTIMETERS. THE LESSON IS -- CHKLIST! CHKLIST! CHKLIST! IT SAVES YOU FROM THE ALWAYS PRESENT DISTRACTIONS.
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.