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A B727 crew, on approach to den, overshot an assigned altitude, while missing the localizer intercept, spawning a stern reminder from ATC.
| Attributes | |
| ACN | 541347 |
| Time | |
| Date | 200203 |
| Day | Thu |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : den.airport |
| State Reference | CO |
| Altitude | msl bound lower : 7100 msl bound upper : 7500 |
| Environment | |
| Flight Conditions | IMC |
| Weather Elements | Fog Snow |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : d01.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B727 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | ils localizer & glide slope : 35l |
| Flight Phase | descent : approach descent other |
| Route In Use | approach : instrument precision |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : flight engineer |
| Experience | flight time last 90 days : 100 flight time total : 9000 flight time type : 4000 |
| ASRS Report | 541347 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot inflight encounter : weather non adherence : far non adherence : published procedure non adherence : clearance other spatial deviation |
| Independent Detector | other controllera other flight crewa other flight crewb other other : 3 |
| Resolutory Action | controller : issued alert controller : issued new clearance flight crew : returned to assigned altitude |
| Consequence | faa : reviewed incident with flight crew other |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Aircraft Weather |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
I was the captain of flight to den on mar/thu/02. The first officer was the PF on this leg. We were on a right base leg, in IMC, being radar vectored for an ILS approach to runway 35L, dia. Den approach control cleared us to descend from 8000 ft MSL to 7500 ft, and a right turn from heading 270 degrees to heading 320 degrees, which was an intercept heading for the ILS final approach course. During the turn and descent, the so noticed that the 'altitude reference' bug on the first officer's barometric altimeter did not appear to be set to the published decision ht of 5631 ft MSL. The first officer turned the knob on the altimeter to set the internal bug to 5361 ft. We all noticed that when the knob was turned, the hundreds of ft needle on the altimeter began moving in conjunction with the knob. I became involved at that point helping the first officer with the local barometric pressure setting in order to returning the altimeter to the correct barometric setting. At this point, all 3 crew members were distraction by the incorrect altimeter setting, and we descended through our assigned altitude of 7500 ft MSL. We noticed the altitude deviation passing through 7200 ft, and initiated an immediate climb back to 7500 ft. The aircraft continued to descend to the lowest altitude of 7100 ft before its inertia was arrested and it began to cob. Shortly after the climb had begun, approach control sternly reminded us that our assigned altitude was 7500 ft. I responded that we were 'correcting.' we returned to 7500 ft and continued the approach. While we were concentrating on setting the altimeter back to the correct setting and climbing back to our assigned altitude, we were late completing the turn to the final approach heading, flew through the localizer and were issued another heading of 020 degrees to reintercept the localizer course. The approach and landing were completed without further incident. When the climb to our assigned altitude had begun, we broke out of the clouds and I was able to determine that we were not in immediate danger of impacting terrain, but I do not know if our deviation placed us in too close proximity of another aircraft. I suspect that was not the case. I believe that this deviation was caused by the total lack of standardization of the type and location of the flight instruments/cockpit controls in the fleet of B727 aircraft.
Original NASA ASRS Text
Title: A B727 CREW, ON APCH TO DEN, OVERSHOT AN ASSIGNED ALT, WHILE MISSING THE LOC INTERCEPT, SPAWNING A STERN REMINDER FROM ATC.
Narrative: I WAS THE CAPT OF FLT TO DEN ON MAR/THU/02. THE FO WAS THE PF ON THIS LEG. WE WERE ON A R BASE LEG, IN IMC, BEING RADAR VECTORED FOR AN ILS APCH TO RWY 35L, DIA. DEN APCH CTL CLRED US TO DSND FROM 8000 FT MSL TO 7500 FT, AND A R TURN FROM HDG 270 DEGS TO HDG 320 DEGS, WHICH WAS AN INTERCEPT HDG FOR THE ILS FINAL APCH COURSE. DURING THE TURN AND DSCNT, THE SO NOTICED THAT THE 'ALT REF' BUG ON THE FO'S BAROMETRIC ALTIMETER DID NOT APPEAR TO BE SET TO THE PUBLISHED DECISION HT OF 5631 FT MSL. THE FO TURNED THE KNOB ON THE ALTIMETER TO SET THE INTERNAL BUG TO 5361 FT. WE ALL NOTICED THAT WHEN THE KNOB WAS TURNED, THE HUNDREDS OF FT NEEDLE ON THE ALTIMETER BEGAN MOVING IN CONJUNCTION WITH THE KNOB. I BECAME INVOLVED AT THAT POINT HELPING THE FO WITH THE LCL BAROMETRIC PRESSURE SETTING IN ORDER TO RETURNING THE ALTIMETER TO THE CORRECT BAROMETRIC SETTING. AT THIS POINT, ALL 3 CREW MEMBERS WERE DISTR BY THE INCORRECT ALTIMETER SETTING, AND WE DSNDED THROUGH OUR ASSIGNED ALT OF 7500 FT MSL. WE NOTICED THE ALTDEV PASSING THROUGH 7200 FT, AND INITIATED AN IMMEDIATE CLB BACK TO 7500 FT. THE ACFT CONTINUED TO DSND TO THE LOWEST ALT OF 7100 FT BEFORE ITS INERTIA WAS ARRESTED AND IT BEGAN TO COB. SHORTLY AFTER THE CLB HAD BEGUN, APCH CTL STERNLY REMINDED US THAT OUR ASSIGNED ALT WAS 7500 FT. I RESPONDED THAT WE WERE 'CORRECTING.' WE RETURNED TO 7500 FT AND CONTINUED THE APCH. WHILE WE WERE CONCENTRATING ON SETTING THE ALTIMETER BACK TO THE CORRECT SETTING AND CLBING BACK TO OUR ASSIGNED ALT, WE WERE LATE COMPLETING THE TURN TO THE FINAL APCH HDG, FLEW THROUGH THE LOC AND WERE ISSUED ANOTHER HDG OF 020 DEGS TO REINTERCEPT THE LOC COURSE. THE APCH AND LNDG WERE COMPLETED WITHOUT FURTHER INCIDENT. WHEN THE CLB TO OUR ASSIGNED ALT HAD BEGUN, WE BROKE OUT OF THE CLOUDS AND I WAS ABLE TO DETERMINE THAT WE WERE NOT IN IMMEDIATE DANGER OF IMPACTING TERRAIN, BUT I DO NOT KNOW IF OUR DEV PLACED US IN TOO CLOSE PROX OF ANOTHER ACFT. I SUSPECT THAT WAS NOT THE CASE. I BELIEVE THAT THIS DEV WAS CAUSED BY THE TOTAL LACK OF STANDARDIZATION OF THE TYPE AND LOCATION OF THE FLT INSTS/COCKPIT CTLS IN THE FLEET OF B727 ACFT.
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.