37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 436210 |
Time | |
Date | 199905 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : abr.airport |
State Reference | SD |
Altitude | msl bound lower : 15600 msl bound upper : 20000 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Thunderstorm |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zmp.artcc |
Operator | common carrier : charter |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Operating Under FAR Part | Part 135 |
Navigation In Use | other |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zmp.artcc |
Make Model Name | Gates Learjet Corp Undifferentiated or Other Model |
Flight Phase | climbout : intermediate altitude |
Person 1 | |
Affiliation | company : charter |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 50 flight time total : 2650 |
ASRS Report | 436210 |
Person 2 | |
Affiliation | company : charter |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 40 flight time total : 6250 flight time type : 35 |
ASRS Report | 436219 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : far non adherence : clearance non adherence : published procedure |
Independent Detector | aircraft equipment : tcas other controllera other flight crewa other flight crewb other other : 4 |
Resolutory Action | flight crew : returned to original clearance |
Miss Distance | horizontal : 12000 vertical : 1400 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were advised by ATC to obtain current WX at our destination and to inform him when we had completed that task. I and the first officer agreed that he would obtain the WX and I would monitor center frequency and continue flying the aircraft. Shortly after the first officer began getting the WX, ATC amended an earlier clearance and instructed us to descend from FL200 to 16000 ft. They also advised us of opposite direction traffic at 11 O'clock position and 10 mi climbing to 15000 ft. I accepted the descent clearance and began descending using the autoplt. I set the altitude select at 16000 ft and descended at approximately 1800 FPM. To my best recollection I was not given a current altimeter setting with the amended clearance from ATC. Simultaneously I began searching for the traffic at my 11 O'clock position. As the autoplt started to level off at 16000 ft my first officer completed obtaining the abr WX and set his altimeter. It was immediately noted that I was descending through 16000 ft. I had the traffic in sight and initiated a climb and asked the first officer to reset my altimeter. ATC advised us that we were 400 ft low and the traffic had deviated because of TCASII alert. Contributing factors included: descending towards a climbing aircraft on roughly a reciprocal bearing to our course. An extremely deep low pressure system contributed to higher than normal altimeter error, 29.92 set versus 29.16 actual. High cockpit workload, monitoring radar, 1 pilot getting WX at destination because center was too busy, looking for traffic, deviating for WX and an initiated descent and amended clearance. Possible crew fatigue as they had been called out at XX40 that morning. CRM, as a responsibility of the captain, should have been better.
Original NASA ASRS Text
Title: FAILURE BY SMT FLC TO SET ALTIMETER DSNDING THROUGH FL180 RESULTS IN ALT OVERSHOOT WHICH TRIGGERS TCASII ALERT IN ANOTHER ACFT.
Narrative: WE WERE ADVISED BY ATC TO OBTAIN CURRENT WX AT OUR DEST AND TO INFORM HIM WHEN WE HAD COMPLETED THAT TASK. I AND THE FO AGREED THAT HE WOULD OBTAIN THE WX AND I WOULD MONITOR CTR FREQ AND CONTINUE FLYING THE ACFT. SHORTLY AFTER THE FO BEGAN GETTING THE WX, ATC AMENDED AN EARLIER CLRNC AND INSTRUCTED US TO DSND FROM FL200 TO 16000 FT. THEY ALSO ADVISED US OF OPPOSITE DIRECTION TFC AT 11 O'CLOCK POS AND 10 MI CLBING TO 15000 FT. I ACCEPTED THE DSCNT CLRNC AND BEGAN DSNDING USING THE AUTOPLT. I SET THE ALT SELECT AT 16000 FT AND DSNDED AT APPROX 1800 FPM. TO MY BEST RECOLLECTION I WAS NOT GIVEN A CURRENT ALTIMETER SETTING WITH THE AMENDED CLRNC FROM ATC. SIMULTANEOUSLY I BEGAN SEARCHING FOR THE TFC AT MY 11 O'CLOCK POS. AS THE AUTOPLT STARTED TO LEVEL OFF AT 16000 FT MY FO COMPLETED OBTAINING THE ABR WX AND SET HIS ALTIMETER. IT WAS IMMEDIATELY NOTED THAT I WAS DSNDING THROUGH 16000 FT. I HAD THE TFC IN SIGHT AND INITIATED A CLB AND ASKED THE FO TO RESET MY ALTIMETER. ATC ADVISED US THAT WE WERE 400 FT LOW AND THE TFC HAD DEVIATED BECAUSE OF TCASII ALERT. CONTRIBUTING FACTORS INCLUDED: DSNDING TOWARDS A CLBING ACFT ON ROUGHLY A RECIPROCAL BEARING TO OUR COURSE. AN EXTREMELY DEEP LOW PRESSURE SYS CONTRIBUTED TO HIGHER THAN NORMAL ALTIMETER ERROR, 29.92 SET VERSUS 29.16 ACTUAL. HIGH COCKPIT WORKLOAD, MONITORING RADAR, 1 PLT GETTING WX AT DEST BECAUSE CTR WAS TOO BUSY, LOOKING FOR TFC, DEVIATING FOR WX AND AN INITIATED DSCNT AND AMENDED CLRNC. POSSIBLE CREW FATIGUE AS THEY HAD BEEN CALLED OUT AT XX40 THAT MORNING. CRM, AS A RESPONSIBILITY OF THE CAPT, SHOULD HAVE BEEN BETTER.
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.