37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 398700 |
Time | |
Date | 199804 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lhr |
State Reference | FO |
Altitude | msl bound lower : 7000 msl bound upper : 7200 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lhr |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | enroute airway : lhr |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 13000 flight time type : 1400 |
ASRS Report | 398700 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to assigned altitude other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On departure, initial altitude limit was 6000 ft with a qnh of 991HPA. Use of hpa was not a factor. We were cleared to level FL070, did not reset to qne and climbed through FL070. The crew of a captain and 2 ATP/type rated first officer's were familiar with the airplane and operational area. The transition altitude of 6000 ft and the low qnh were noted during the pre-start briefing. I was handling the radios with one first officer flying and the other first officer monitoring. As the first officer started to level at 6000 ft, ATC cleared '...fly heading 290 degrees and climb to level FL070.' the first officer continued the climb, which is considerably less than a 1000 ft climb. To confuse matters, I misunderstood and read back, '...heading 290 degrees, FL270.' ATC immediately corrected this and I made a correct readback. By now we were at 7000 ft (not FL070). ATC soon called, '...check your altimeter,' and we took immediate corrective action. Some causal factors: 1) obviously, the crew failed to reset the altimeters. 2) the new clearance arrived during the leveloff maneuver at the transition altitude. 3) the actual vertical change was relatively small. A more common clearance from 6000 ft would be FL130, so the resetting of the altimeter would not be so urgent. 4) I misunderstood the clearance which was distracting and time consuming. Corrections: 1) increased emphasis on transition during briefing and instituting verbal calls approaching and leaving transition altitude. 2) on a larger scale, convince states to establish a common transition altitude above the 'busy' altitudes.
Original NASA ASRS Text
Title: WDB ACFT DEPARTING AND CLBING FROM LHR, ALTIMETERS SET TO QNH. FLC CLRED TO FL070, USING QNE, BUT THEY FORGOT TO RESET THE ALTIMETERS AND OVERSHOT ASSIGNED ALT. CTLR QUERIED THEIR ALT AND THEY CORRECTED.
Narrative: ON DEP, INITIAL ALT LIMIT WAS 6000 FT WITH A QNH OF 991HPA. USE OF HPA WAS NOT A FACTOR. WE WERE CLRED TO LEVEL FL070, DID NOT RESET TO QNE AND CLBED THROUGH FL070. THE CREW OF A CAPT AND 2 ATP/TYPE RATED FO'S WERE FAMILIAR WITH THE AIRPLANE AND OPERATIONAL AREA. THE TRANSITION ALT OF 6000 FT AND THE LOW QNH WERE NOTED DURING THE PRE-START BRIEFING. I WAS HANDLING THE RADIOS WITH ONE FO FLYING AND THE OTHER FO MONITORING. AS THE FO STARTED TO LEVEL AT 6000 FT, ATC CLRED '...FLY HDG 290 DEGS AND CLB TO LEVEL FL070.' THE FO CONTINUED THE CLB, WHICH IS CONSIDERABLY LESS THAN A 1000 FT CLB. TO CONFUSE MATTERS, I MISUNDERSTOOD AND READ BACK, '...HDG 290 DEGS, FL270.' ATC IMMEDIATELY CORRECTED THIS AND I MADE A CORRECT READBACK. BY NOW WE WERE AT 7000 FT (NOT FL070). ATC SOON CALLED, '...CHK YOUR ALTIMETER,' AND WE TOOK IMMEDIATE CORRECTIVE ACTION. SOME CAUSAL FACTORS: 1) OBVIOUSLY, THE CREW FAILED TO RESET THE ALTIMETERS. 2) THE NEW CLRNC ARRIVED DURING THE LEVELOFF MANEUVER AT THE TRANSITION ALT. 3) THE ACTUAL VERT CHANGE WAS RELATIVELY SMALL. A MORE COMMON CLRNC FROM 6000 FT WOULD BE FL130, SO THE RESETTING OF THE ALTIMETER WOULD NOT BE SO URGENT. 4) I MISUNDERSTOOD THE CLRNC WHICH WAS DISTRACTING AND TIME CONSUMING. CORRECTIONS: 1) INCREASED EMPHASIS ON TRANSITION DURING BRIEFING AND INSTITUTING VERBAL CALLS APCHING AND LEAVING TRANSITION ALT. 2) ON A LARGER SCALE, CONVINCE STATES TO ESTABLISH A COMMON TRANSITION ALT ABOVE THE 'BUSY' ALTS.
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.