37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 423079 |
Time | |
Date | 199812 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : air |
State Reference | OH |
Altitude | msl bound lower : 27700 msl bound upper : 28000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : on vectors enroute airway : zob |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 225 flight time total : 4000 flight time type : 250 |
ASRS Report | 423079 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : undershoot other anomaly other |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Air Traffic Incident | Pilot Deviation |
Narrative:
Center advised we were showing 300 ft low. Altimeters were still set at 30.27 vice 29.92. We were initially cleared to 17000 ft. Subsequently we received clearance to FL230, along with vectors for traffic and routing. Eventually cleared to FL280. During the lower altitude climbs -- bottom line -- the climb checklist (which resets altimeters) was not accomplished. For my part, I missed it because my habit pattern of holding the checklist card in my hand until the climb checklist is accomplished was broken. I put it away to assist in copying instructions, etc, during the high workload departure. In the future, if I put it down, I will put it where it is a 'nuisance' until I complete it. This incident impressed upon me the value of, and inherent risks, associated with 'habit patterns.' it was a valuable lesson learned. Fortunately, the altimeter difference (30.27 vice 29.92) only resulted in a 300 ft deviation.
Original NASA ASRS Text
Title: FLC OF A B757 FORGOT TO RESET THEIR ALTIMETER DURING CLB, PASSING FL180, CAUSING A 300 FT UNDERSHOOT AT CRUISE ALT. ARTCC RADAR CTLR INTERVENED AND ADVISED OF LOW INDICATED ALT.
Narrative: CTR ADVISED WE WERE SHOWING 300 FT LOW. ALTIMETERS WERE STILL SET AT 30.27 VICE 29.92. WE WERE INITIALLY CLRED TO 17000 FT. SUBSEQUENTLY WE RECEIVED CLRNC TO FL230, ALONG WITH VECTORS FOR TFC AND ROUTING. EVENTUALLY CLRED TO FL280. DURING THE LOWER ALT CLBS -- BOTTOM LINE -- THE CLB CHKLIST (WHICH RESETS ALTIMETERS) WAS NOT ACCOMPLISHED. FOR MY PART, I MISSED IT BECAUSE MY HABIT PATTERN OF HOLDING THE CHKLIST CARD IN MY HAND UNTIL THE CLB CHKLIST IS ACCOMPLISHED WAS BROKEN. I PUT IT AWAY TO ASSIST IN COPYING INSTRUCTIONS, ETC, DURING THE HIGH WORKLOAD DEP. IN THE FUTURE, IF I PUT IT DOWN, I WILL PUT IT WHERE IT IS A 'NUISANCE' UNTIL I COMPLETE IT. THIS INCIDENT IMPRESSED UPON ME THE VALUE OF, AND INHERENT RISKS, ASSOCIATED WITH 'HABIT PATTERNS.' IT WAS A VALUABLE LESSON LEARNED. FORTUNATELY, THE ALTIMETER DIFFERENCE (30.27 VICE 29.92) ONLY RESULTED IN A 300 FT DEV.
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.