37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 459095 |
Time | |
Date | 200001 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : den.airport |
State Reference | CO |
Altitude | msl bound lower : 12500 msl bound upper : 13000 |
Environment | |
Flight Conditions | Mixed |
Weather Elements | Snow |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 18500 flight time type : 9000 |
ASRS Report | 459095 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial |
Experience | flight time last 90 days : 100 flight time total : 2300 flight time type : 500 |
ASRS Report | 459360 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory |
Supplementary | |
Problem Areas | Flight Crew Human Performance Environmental Factor Company |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were assigned altitude 13000 ft. On descent through FL180, I set my altimeter to 30.58, having misread the landing data card. The altimeter should have been 29.58. This caused a 1000 ft error and as we were descending through 13500 ft, the controller advised our altitude was showing 12500 ft and reissued the correct altimeter of 29.58. I was in such a hurry to correct the altitude and the altimeter that I climbed through 13000 ft and had to correct again. On landing, I contacted the approach control supervisor and he indicated that no other traffic was involved. This was the last leg of an 11 hour day and the last flight of a long 3 week rotation and fatigue could be a casual factor. The flight engineer set 29.58 in his altimeter and wrote 29.58 on the card. During the checklist, I read 30.58 and set that in my altimeter, as did the first officer. The flight engineer did not catch the bad call. On later discussion with the crew, the flight engineer realized that when the checklist was being read, all he heard was '58' and didn't catch the rest of the call. Just goes to show that fatigue can catch you even when you are following all the procedures. I'm just glad that the rest of the system worked. The controller noticed the altitude and made the correction. We were also very lucky there was no other traffic.
Original NASA ASRS Text
Title: A DSNDING B727 FREIGHTER OVERSHOOTS ITS ASSIGNED ALT WHEN THE CREW MISSETS THE ALTIMETER AT TOO LOW A SETTING SE OF DEN, CO.
Narrative: WE WERE ASSIGNED ALT 13000 FT. ON DSCNT THROUGH FL180, I SET MY ALTIMETER TO 30.58, HAVING MISREAD THE LNDG DATA CARD. THE ALTIMETER SHOULD HAVE BEEN 29.58. THIS CAUSED A 1000 FT ERROR AND AS WE WERE DSNDING THROUGH 13500 FT, THE CTLR ADVISED OUR ALT WAS SHOWING 12500 FT AND REISSUED THE CORRECT ALTIMETER OF 29.58. I WAS IN SUCH A HURRY TO CORRECT THE ALT AND THE ALTIMETER THAT I CLBED THROUGH 13000 FT AND HAD TO CORRECT AGAIN. ON LNDG, I CONTACTED THE APCH CTL SUPVR AND HE INDICATED THAT NO OTHER TFC WAS INVOLVED. THIS WAS THE LAST LEG OF AN 11 HR DAY AND THE LAST FLT OF A LONG 3 WK ROTATION AND FATIGUE COULD BE A CASUAL FACTOR. THE FE SET 29.58 IN HIS ALTIMETER AND WROTE 29.58 ON THE CARD. DURING THE CHKLIST, I READ 30.58 AND SET THAT IN MY ALTIMETER, AS DID THE FO. THE FE DID NOT CATCH THE BAD CALL. ON LATER DISCUSSION WITH THE CREW, THE FE REALIZED THAT WHEN THE CHKLIST WAS BEING READ, ALL HE HEARD WAS '58' AND DIDN'T CATCH THE REST OF THE CALL. JUST GOES TO SHOW THAT FATIGUE CAN CATCH YOU EVEN WHEN YOU ARE FOLLOWING ALL THE PROCS. I'M JUST GLAD THAT THE REST OF THE SYS WORKED. THE CTLR NOTICED THE ALT AND MADE THE CORRECTION. WE WERE ALSO VERY LUCKY THERE WAS NO OTHER TFC.
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.