37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 459790 |
Time | |
Date | 200001 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | intersection : cetus |
State Reference | OH |
Altitude | msl bound lower : 13300 msl bound upper : 14000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zob.artcc |
Operator | common carrier : air carrier |
Make Model Name | DC-10 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : multi engine |
Experience | flight time last 90 days : 100 flight time total : 6000 flight time type : 800 |
ASRS Report | 459790 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 23000 flight time type : 1500 |
ASRS Report | 459946 |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : weather inflight encounter other non adherence : clearance non adherence : company policies other anomaly other |
Independent Detector | atc equipment other atc equipment : radar -- mode c other controllera |
Resolutory Action | controller : issued advisory flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | ATC Human Performance Airspace Structure Weather Flight Crew Human Performance Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Our aircraft was cleared to maintain 14000 ft MSL from a descent that started above the transition level. In accordance with company procedure, I handed the pilots a company ATIS card which had dtw ATIS which I had transcribed from our non printing ACARS screen. ACARS reported altimeter setting was 29.28 inches. The altimeter setting (erroneously) transcribed to the ATIS form was 29.98 inches. Passing through the transition level the pilots set their altimeters to 29.98 from the company ATIS form instead of the altimeter previously issued by ATC. The aircraft subsequently leveled off at 14000 ft MSL as shown on both pilots' altimeters with 29.98 set (aircraft actually at 13300 ft MSL). ATC had just mins before reported another aircraft's mode C showing altitude greater than 300 ft from assigned altitude. Then ATC asked us to 'confirm level at 14000 ft.' pilots looked at altimeters and responded 'level 14000 ft' (unaware of the incorrect altimeter setting). ATC then reported that our mode C showed an altitude other than that which was assigned (14000 ft), and asked us to 'stop squawk.' we switched xponders during the latter transmission. ATC then responded with 'roger, confirm altimeter 29.28.' following this, there was momentary confusion as to where 29.98 had come from. Both pilots immediately reset altimeters to 29.28 and realized the altitude deviation and promptly climbed to 14000 ft MSL. Initially our crew thought it might be an error with ATC's equipment. The flight crew of our flight failed to xchk the ATC altimeter setting given with our descent clearance against the altimeter setting written on the company ATIS card. The ACARS screen from which ATIS was copied is smaller than a playing card and the numbers can be difficult to read due to the close spacing of the lines. The altimeter setting was spread over 2 separate lines. I was distraction several times by normal operating procedures or requests from the pilots while I was transcribing the ATIS. When I returned my gaze to the ACARS screen, I must have focused on the 'niner' part that was spelled out. During the descent check, the altimeters are verified as part of the check, but they were verified against the erroneous information on the ATIS card. Shortly after the descent clearance, we were informed that we were going to have to enter holding for 40 mins due to WX. The workload for each crew member increased greatly and the chances of us catching our mistake before leveloff diminished. Corrective action would be to ensure all crew members verify altimeters against the ATC assigned altimeter setting. Completely abolishing the paper ATIS form would force the crew to set the altimeter off the setting given by ATC since they would have no other readily available source. ATC policy should have controller start any altitude query with 'confirm altimeter 29.92 (or current setting).' we had several exchanges before ATC restated the altimeter setting.
Original NASA ASRS Text
Title: A DC10 FLT OVERSHOOTS ITS ASSIGNED ALT WHEN THE FLC PLACES THE WRONG ALTIMETER SETTING INTO THE BAROMETRIC WINDOW S OF DTW, MI.
Narrative: OUR ACFT WAS CLRED TO MAINTAIN 14000 FT MSL FROM A DSCNT THAT STARTED ABOVE THE TRANSITION LEVEL. IN ACCORDANCE WITH COMPANY PROC, I HANDED THE PLTS A COMPANY ATIS CARD WHICH HAD DTW ATIS WHICH I HAD TRANSCRIBED FROM OUR NON PRINTING ACARS SCREEN. ACARS RPTED ALTIMETER SETTING WAS 29.28 INCHES. THE ALTIMETER SETTING (ERRONEOUSLY) TRANSCRIBED TO THE ATIS FORM WAS 29.98 INCHES. PASSING THROUGH THE TRANSITION LEVEL THE PLTS SET THEIR ALTIMETERS TO 29.98 FROM THE COMPANY ATIS FORM INSTEAD OF THE ALTIMETER PREVIOUSLY ISSUED BY ATC. THE ACFT SUBSEQUENTLY LEVELED OFF AT 14000 FT MSL AS SHOWN ON BOTH PLTS' ALTIMETERS WITH 29.98 SET (ACFT ACTUALLY AT 13300 FT MSL). ATC HAD JUST MINS BEFORE RPTED ANOTHER ACFT'S MODE C SHOWING ALT GREATER THAN 300 FT FROM ASSIGNED ALT. THEN ATC ASKED US TO 'CONFIRM LEVEL AT 14000 FT.' PLTS LOOKED AT ALTIMETERS AND RESPONDED 'LEVEL 14000 FT' (UNAWARE OF THE INCORRECT ALTIMETER SETTING). ATC THEN RPTED THAT OUR MODE C SHOWED AN ALT OTHER THAN THAT WHICH WAS ASSIGNED (14000 FT), AND ASKED US TO 'STOP SQUAWK.' WE SWITCHED XPONDERS DURING THE LATTER XMISSION. ATC THEN RESPONDED WITH 'ROGER, CONFIRM ALTIMETER 29.28.' FOLLOWING THIS, THERE WAS MOMENTARY CONFUSION AS TO WHERE 29.98 HAD COME FROM. BOTH PLTS IMMEDIATELY RESET ALTIMETERS TO 29.28 AND REALIZED THE ALTDEV AND PROMPTLY CLBED TO 14000 FT MSL. INITIALLY OUR CREW THOUGHT IT MIGHT BE AN ERROR WITH ATC'S EQUIP. THE FLC OF OUR FLT FAILED TO XCHK THE ATC ALTIMETER SETTING GIVEN WITH OUR DSCNT CLRNC AGAINST THE ALTIMETER SETTING WRITTEN ON THE COMPANY ATIS CARD. THE ACARS SCREEN FROM WHICH ATIS WAS COPIED IS SMALLER THAN A PLAYING CARD AND THE NUMBERS CAN BE DIFFICULT TO READ DUE TO THE CLOSE SPACING OF THE LINES. THE ALTIMETER SETTING WAS SPREAD OVER 2 SEPARATE LINES. I WAS DISTR SEVERAL TIMES BY NORMAL OPERATING PROCS OR REQUESTS FROM THE PLTS WHILE I WAS TRANSCRIBING THE ATIS. WHEN I RETURNED MY GAZE TO THE ACARS SCREEN, I MUST HAVE FOCUSED ON THE 'NINER' PART THAT WAS SPELLED OUT. DURING THE DSCNT CHK, THE ALTIMETERS ARE VERIFIED AS PART OF THE CHK, BUT THEY WERE VERIFIED AGAINST THE ERRONEOUS INFO ON THE ATIS CARD. SHORTLY AFTER THE DSCNT CLRNC, WE WERE INFORMED THAT WE WERE GOING TO HAVE TO ENTER HOLDING FOR 40 MINS DUE TO WX. THE WORKLOAD FOR EACH CREW MEMBER INCREASED GREATLY AND THE CHANCES OF US CATCHING OUR MISTAKE BEFORE LEVELOFF DIMINISHED. CORRECTIVE ACTION WOULD BE TO ENSURE ALL CREW MEMBERS VERIFY ALTIMETERS AGAINST THE ATC ASSIGNED ALTIMETER SETTING. COMPLETELY ABOLISHING THE PAPER ATIS FORM WOULD FORCE THE CREW TO SET THE ALTIMETER OFF THE SETTING GIVEN BY ATC SINCE THEY WOULD HAVE NO OTHER READILY AVAILABLE SOURCE. ATC POLICY SHOULD HAVE CTLR START ANY ALT QUERY WITH 'CONFIRM ALTIMETER 29.92 (OR CURRENT SETTING).' WE HAD SEVERAL EXCHANGES BEFORE ATC RESTATED THE ALTIMETER SETTING.
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.