37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 495500 |
Time | |
Date | 200012 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : dqo.vortac |
State Reference | DE |
Altitude | msl bound lower : 12000 msl bound upper : 12530 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zny.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | descent : holding |
Route In Use | arrival star : minks 2 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : multi engine pilot : instrument |
Experience | flight time last 90 days : 90 flight time total : 9500 flight time type : 3500 |
ASRS Report | 495500 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : atp pilot : multi engine pilot : instrument |
Experience | flight time last 90 days : 240 flight time total : 8000 flight time type : 1500 |
ASRS Report | 495299 |
Events | |
Anomaly | altitude deviation : undershoot non adherence : clearance non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued alert flight crew : returned to assigned altitude flight crew : became reoriented |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Did not change altimeter from 29.92 to local altimeter (30.45) when descending below FL180. This placed aircraft at 12400 ft in holding pattern at stefe vice 12000 ft assigned. Brought to pilot's attention by ATC. No mention of traffic conflict by ATC, no indication of traffic conflict on TCASII. While at FL260, assigned to cross somto at 13000 ft. During descent, new instructions given to cross stefe at 12000 ft or as close as possible to 12000 ft and hold, as published, at stefe. Although first officer was flying, I, as the captain, failed to note the altimeter change going through FL180. Captain's attention was given to notifying company and passenger at hold, finding stefe on the arrival chart and ensuring navaids were properly set up for the hold. I, as the captain, should have done a better job of prioritizing actions. ATC noted that we were 400 ft above assigned altitude (12400 ft). There was no mention of a traffic conflict. The fault rests solely with the cockpit crew. Supplemental information from acn 495299: I asked the captain to call ATC and ask if we were going to have to cross the somto intersection at 13000 ft as indicated on the STAR. Our present position/altitude was going to make the crossing difficult. Frequency congestion made it difficult to get an answer from ATC. The failure to reset the altimeters was a result of too many things happening at one time. The late descent started the situation and the subsequent holding instructions and the briefing on how to hold, fuel, etc, as well as trying to make a rapid descent, led to forgetting a relatively simple task of resetting altimeters. This was a flight crew error due to a high workload environment.
Original NASA ASRS Text
Title: B737-200 CREW HAD ALT UNDERSHOOT IN ZNY CLASS E AIRSPACE.
Narrative: DID NOT CHANGE ALTIMETER FROM 29.92 TO LCL ALTIMETER (30.45) WHEN DSNDING BELOW FL180. THIS PLACED ACFT AT 12400 FT IN HOLDING PATTERN AT STEFE VICE 12000 FT ASSIGNED. BROUGHT TO PLT'S ATTN BY ATC. NO MENTION OF TFC CONFLICT BY ATC, NO INDICATION OF TFC CONFLICT ON TCASII. WHILE AT FL260, ASSIGNED TO CROSS SOMTO AT 13000 FT. DURING DSCNT, NEW INSTRUCTIONS GIVEN TO CROSS STEFE AT 12000 FT OR AS CLOSE AS POSSIBLE TO 12000 FT AND HOLD, AS PUBLISHED, AT STEFE. ALTHOUGH FO WAS FLYING, I, AS THE CAPT, FAILED TO NOTE THE ALTIMETER CHANGE GOING THROUGH FL180. CAPT'S ATTN WAS GIVEN TO NOTIFYING COMPANY AND PAX AT HOLD, FINDING STEFE ON THE ARR CHART AND ENSURING NAVAIDS WERE PROPERLY SET UP FOR THE HOLD. I, AS THE CAPT, SHOULD HAVE DONE A BETTER JOB OF PRIORITIZING ACTIONS. ATC NOTED THAT WE WERE 400 FT ABOVE ASSIGNED ALT (12400 FT). THERE WAS NO MENTION OF A TFC CONFLICT. THE FAULT RESTS SOLELY WITH THE COCKPIT CREW. SUPPLEMENTAL INFO FROM ACN 495299: I ASKED THE CAPT TO CALL ATC AND ASK IF WE WERE GOING TO HAVE TO CROSS THE SOMTO INTXN AT 13000 FT AS INDICATED ON THE STAR. OUR PRESENT POS/ALT WAS GOING TO MAKE THE XING DIFFICULT. FREQ CONGESTION MADE IT DIFFICULT TO GET AN ANSWER FROM ATC. THE FAILURE TO RESET THE ALTIMETERS WAS A RESULT OF TOO MANY THINGS HAPPENING AT ONE TIME. THE LATE DSCNT STARTED THE SIT AND THE SUBSEQUENT HOLDING INSTRUCTIONS AND THE BRIEFING ON HOW TO HOLD, FUEL, ETC, AS WELL AS TRYING TO MAKE A RAPID DSCNT, LED TO FORGETTING A RELATIVELY SIMPLE TASK OF RESETTING ALTIMETERS. THIS WAS A FLC ERROR DUE TO A HIGH WORKLOAD ENVIRONMENT.
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.