37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 381080 |
Time | |
Date | 199709 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : nrt |
State Reference | FO |
Altitude | msl bound lower : 10500 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zma |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | descent other |
Route In Use | enroute airway : rjtg |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 75 flight time total : 6500 flight time type : 250 |
ASRS Report | 381080 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence other other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were approaching the narita airport outside tokyo, at the end of an international flight that started in anchorage. Our flight had been delayed as a tropical storm passed through the tokyo area hours before. The WX was rapidly improving, becoming VFR with gusty winds. Approaching nrt, we were cleared from FL160 to FL110, passing through the transition level of FL140. It had already been mentioned in the approach briefing, the importance of setting the local altimeter of 29.39 passing through FL140. Just after starting descent from FL160, approach control gave us holding instructions at kamsi intersection. The holding instructions created confusion, because kamsi intersection was not located on our current route of flight. The other concern was determining how long we could hold before proceeding to our alternate. During the descent from FL160 to FL110 the crew's attention was focused on determining kamsi intersection location, proper holding procedures, proper holding speed and length of time we could hold. As we leveled at 11000 ft this work had been completed and we were properly heading toward kamsi and slowing with a 25 min window of fuel to hold with prior to heading to our alternate osaka, I was level at 11000 ft for approximately 4 mins when I realized we all had missed the transition level. The altimeter read 29.92 not 29.39. Our altitude was actually 10500 ft. I immediately reset the altimeter and climbed to 11000 ft. There was never any mention from approach control about the altitude deviation. The aircraft landed without further incident. The focusing on the holding instruction which were not expected, during a critical phase of descent, could have created a far more serious altitude incursion.
Original NASA ASRS Text
Title: FLC OF A WDB FORGOT TO RESET ALTIMETER ON DSCNT RESULTING IN OVERSHOOTING ASSIGNED APCH ALT. FLC RECOGNIZED THEIR ERROR AND CLBED BACK TO CORRECT ALT WITHOUT ATC INTERVENTION.
Narrative: WE WERE APCHING THE NARITA ARPT OUTSIDE TOKYO, AT THE END OF AN INTL FLT THAT STARTED IN ANCHORAGE. OUR FLT HAD BEEN DELAYED AS A TROPICAL STORM PASSED THROUGH THE TOKYO AREA HRS BEFORE. THE WX WAS RAPIDLY IMPROVING, BECOMING VFR WITH GUSTY WINDS. APCHING NRT, WE WERE CLRED FROM FL160 TO FL110, PASSING THROUGH THE TRANSITION LEVEL OF FL140. IT HAD ALREADY BEEN MENTIONED IN THE APCH BRIEFING, THE IMPORTANCE OF SETTING THE LCL ALTIMETER OF 29.39 PASSING THROUGH FL140. JUST AFTER STARTING DSCNT FROM FL160, APCH CTL GAVE US HOLDING INSTRUCTIONS AT KAMSI INTXN. THE HOLDING INSTRUCTIONS CREATED CONFUSION, BECAUSE KAMSI INTXN WAS NOT LOCATED ON OUR CURRENT RTE OF FLT. THE OTHER CONCERN WAS DETERMINING HOW LONG WE COULD HOLD BEFORE PROCEEDING TO OUR ALTERNATE. DURING THE DSCNT FROM FL160 TO FL110 THE CREW'S ATTN WAS FOCUSED ON DETERMINING KAMSI INTXN LOCATION, PROPER HOLDING PROCS, PROPER HOLDING SPD AND LENGTH OF TIME WE COULD HOLD. AS WE LEVELED AT 11000 FT THIS WORK HAD BEEN COMPLETED AND WE WERE PROPERLY HEADING TOWARD KAMSI AND SLOWING WITH A 25 MIN WINDOW OF FUEL TO HOLD WITH PRIOR TO HEADING TO OUR ALTERNATE OSAKA, I WAS LEVEL AT 11000 FT FOR APPROX 4 MINS WHEN I REALIZED WE ALL HAD MISSED THE TRANSITION LEVEL. THE ALTIMETER READ 29.92 NOT 29.39. OUR ALT WAS ACTUALLY 10500 FT. I IMMEDIATELY RESET THE ALTIMETER AND CLBED TO 11000 FT. THERE WAS NEVER ANY MENTION FROM APCH CTL ABOUT THE ALTDEV. THE ACFT LANDED WITHOUT FURTHER INCIDENT. THE FOCUSING ON THE HOLDING INSTRUCTION WHICH WERE NOT EXPECTED, DURING A CRITICAL PHASE OF DSCNT, COULD HAVE CREATED A FAR MORE SERIOUS ALT INCURSION.
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.