Flight crew of a B767-200 overshot climb altitude due to forgetting to reset altimeters passing thro...

Attributes
ACN	387777
Time
Date	199712
Day	Fri
Local Time Of Day	0601 To 1200
Place
Locale Reference	atc facility : cfb
State Reference	NY
Altitude	msl bound lower : 19000 msl bound upper : 19320
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	artcc : zny tower : dfw
Operator	common carrier : air carrier
Make Model Name	B767-300 and 300 ER
Operating Under FAR Part	Part 121
Navigation In Use	Other Other
Flight Phase	climbout : intermediate altitude
Route In Use	enroute airway : j95
Flight Plan	IFR
Aircraft 2
Make Model Name	Commercial Fixed Wing
Operating Under FAR Part	other : unknown
Flight Phase	cruise other
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	other other : other pilot : flight engineer pilot : cfi pilot : atp
Experience	flight time last 90 days : 150 flight time total : 11000 flight time type : 501
ASRS Report	387777
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : commercial pilot : instrument
Events
Anomaly	altitude deviation : overshoot conflict : airborne less severe non adherence : far non adherence : clearance other anomaly other
Independent Detector	aircraft equipment other aircraft equipment : unspecified other flight crewa
Resolutory Action	flight crew : returned to assigned altitude other
Consequence	Other
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Aircraft was level at 17000 ft. Another aircraft was south of our position by 3-5 mi, paralleling our course and at the same altitude. Our aircraft was experiencing moderate chop. At approximately AB40 local time, our flight was cleared to climb to FL190. The PF initiated the climb via selection of VNAV. At approximately 17600 ft, we received a traffic alert from the aircraft's TCASII system. The intruding aircraft (perceived) or potentially conflicting aircraft was displayed on both left and right ehsi's which were in map mode. The altitude of the other aircraft was displayed as FL196. We began actively searching for the aircraft which was at 12 O'clock and 3-5 mi. I advised ATC immediately of the traffic alert. Our initial rate of climb was a little over 2000 FPM. ATC responded that target aircraft was at FL200. Our display continued to display FL196. First officer slowed the rate of climb and we continued to scan for traffic. As we approached leveloff at FL190, I observed that the altimeters had not been reset to 29.92 and immediately called 'altimeter setting.' both pilots changed altimeters from 29.53 to 29.92. As I dialed in the correct setting, I became aware that the eventual altitude would exceed FL190, and began pushing the control forward and advised the first officer to descend immediately. Maximum altitude observed on first officer's altimeter was 19280 ft. Maximum altitude observed on captain's altimeter ws 19320 ft. Deviation was momentary in duration. Causal factor: flight crew failed to set correct altimeter setting for airspace. Contributing factors: task management, distraction from task by traffic alert, failure of crew to understand TCASII display is dependent upon altimeter settings in use. Combination of traffic, altimeter change, high initial rate of climb (set off alert) combined to create a human error. Probability of similar event occurring to subject crew approaching nil.

Original NASA ASRS Text

Title: FLC OF A B767-200 OVERSHOT CLB ALT DUE TO FORGETTING TO RESET ALTIMETERS PASSING THROUGH FL180. A TCASII ALERT OF AN ACFT 600 FT ABOVE THEIR ASSIGNED ALT, WHICH ATC ADVISED WAS 1000 FT, CAUSED THE CAPT TO RECHK THEIR ALTIMETER SETTINGS AND FIND THEIR ERROR. THE FLYING FO IMMEDIATELY DSNDED TO ASSIGNED ALT.

Narrative: ACFT WAS LEVEL AT 17000 FT. ANOTHER ACFT WAS S OF OUR POS BY 3-5 MI, PARALLELING OUR COURSE AND AT THE SAME ALT. OUR ACFT WAS EXPERIENCING MODERATE CHOP. AT APPROX AB40 LCL TIME, OUR FLT WAS CLRED TO CLB TO FL190. THE PF INITIATED THE CLB VIA SELECTION OF VNAV. AT APPROX 17600 FT, WE RECEIVED A TFC ALERT FROM THE ACFT'S TCASII SYS. THE INTRUDING ACFT (PERCEIVED) OR POTENTIALLY CONFLICTING ACFT WAS DISPLAYED ON BOTH L AND R EHSI'S WHICH WERE IN MAP MODE. THE ALT OF THE OTHER ACFT WAS DISPLAYED AS FL196. WE BEGAN ACTIVELY SEARCHING FOR THE ACFT WHICH WAS AT 12 O'CLOCK AND 3-5 MI. I ADVISED ATC IMMEDIATELY OF THE TFC ALERT. OUR INITIAL RATE OF CLB WAS A LITTLE OVER 2000 FPM. ATC RESPONDED THAT TARGET ACFT WAS AT FL200. OUR DISPLAY CONTINUED TO DISPLAY FL196. FO SLOWED THE RATE OF CLB AND WE CONTINUED TO SCAN FOR TFC. AS WE APCHED LEVELOFF AT FL190, I OBSERVED THAT THE ALTIMETERS HAD NOT BEEN RESET TO 29.92 AND IMMEDIATELY CALLED 'ALTIMETER SETTING.' BOTH PLTS CHANGED ALTIMETERS FROM 29.53 TO 29.92. AS I DIALED IN THE CORRECT SETTING, I BECAME AWARE THAT THE EVENTUAL ALT WOULD EXCEED FL190, AND BEGAN PUSHING THE CTL FORWARD AND ADVISED THE FO TO DSND IMMEDIATELY. MAX ALT OBSERVED ON FO'S ALTIMETER WAS 19280 FT. MAX ALT OBSERVED ON CAPT'S ALTIMETER WS 19320 FT. DEV WAS MOMENTARY IN DURATION. CAUSAL FACTOR: FLC FAILED TO SET CORRECT ALTIMETER SETTING FOR AIRSPACE. CONTRIBUTING FACTORS: TASK MGMNT, DISTR FROM TASK BY TFC ALERT, FAILURE OF CREW TO UNDERSTAND TCASII DISPLAY IS DEPENDENT UPON ALTIMETER SETTINGS IN USE. COMBINATION OF TFC, ALTIMETER CHANGE, HIGH INITIAL RATE OF CLB (SET OFF ALERT) COMBINED TO CREATE A HUMAN ERROR. PROBABILITY OF SIMILAR EVENT OCCURRING TO SUBJECT CREW APCHING NIL.

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.