37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 541805 |
Time | |
Date | 200203 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | intersection : bisig |
State Reference | FO |
Altitude | msl single value : 40000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | cruise : enroute altitude change |
Route In Use | enroute airway : a582.airway |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 12000 flight time type : 8000 |
ASRS Report | 541805 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : far non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : altimeter other controllera |
Resolutory Action | controller : issued advisory none taken : detected after the fact other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
En route sbound A-582. Prior to sakon, received clearance to climb and maintain FL390. Leveled at FL390, reported FL390 at sakon. Reclred to FL400 for direction of flight entering reduced vertical separation minimums airspace. Climbed to FL400. After leveloff, first officer's altimeter read 40010 ft. Captain's read 39965 ft. At bisig, and subsequently at elmas, captain prepared position reports for those fixes. Glancing up at his altimeter, he saw 39965 ft indicated and read it as FL390, which was also the same altitude as his preceding position report at sakon. FL390 then was written in on the flight plan and the position reports were read to manila radio as FL390. Several mins passed before manila radio called back to confirm the altitude. The captain then realized the error and clarified to ATC that the flight was indeed level FL400 and had been level at FL400 at bisig and elmas and that the FL390 report at those fixes had been in error. Factors contributing to the error were distraction due to meal service in the cockpit and the electronic altimeter display. Unlike most altimeters, the electronic altimeter does not employ a rotating drum in its digital readout. Consequently, the thousands display at 39990 ft looks identical to the thousands display at 39000 ft. Both electronic and rotating drum type altimeters are used within the fleet. I have encountered this type of 'read error' several times before this occurrence.
Original NASA ASRS Text
Title: B747-200 CAPT RPTED THE ACFT ALT IN ERROR IN THE POS RPT TO RPMM.
Narrative: ENRTE SBOUND A-582. PRIOR TO SAKON, RECEIVED CLRNC TO CLB AND MAINTAIN FL390. LEVELED AT FL390, RPTED FL390 AT SAKON. RECLRED TO FL400 FOR DIRECTION OF FLT ENTERING REDUCED VERT SEPARATION MINIMUMS AIRSPACE. CLBED TO FL400. AFTER LEVELOFF, FO'S ALTIMETER READ 40010 FT. CAPT'S READ 39965 FT. AT BISIG, AND SUBSEQUENTLY AT ELMAS, CAPT PREPARED POS RPTS FOR THOSE FIXES. GLANCING UP AT HIS ALTIMETER, HE SAW 39965 FT INDICATED AND READ IT AS FL390, WHICH WAS ALSO THE SAME ALT AS HIS PRECEDING POS RPT AT SAKON. FL390 THEN WAS WRITTEN IN ON THE FLT PLAN AND THE POS RPTS WERE READ TO MANILA RADIO AS FL390. SEVERAL MINS PASSED BEFORE MANILA RADIO CALLED BACK TO CONFIRM THE ALT. THE CAPT THEN REALIZED THE ERROR AND CLARIFIED TO ATC THAT THE FLT WAS INDEED LEVEL FL400 AND HAD BEEN LEVEL AT FL400 AT BISIG AND ELMAS AND THAT THE FL390 RPT AT THOSE FIXES HAD BEEN IN ERROR. FACTORS CONTRIBUTING TO THE ERROR WERE DISTR DUE TO MEAL SVC IN THE COCKPIT AND THE ELECTRONIC ALTIMETER DISPLAY. UNLIKE MOST ALTIMETERS, THE ELECTRONIC ALTIMETER DOES NOT EMPLOY A ROTATING DRUM IN ITS DIGITAL READOUT. CONSEQUENTLY, THE THOUSANDS DISPLAY AT 39990 FT LOOKS IDENTICAL TO THE THOUSANDS DISPLAY AT 39000 FT. BOTH ELECTRONIC AND ROTATING DRUM TYPE ALTIMETERS ARE USED WITHIN THE FLEET. I HAVE ENCOUNTERED THIS TYPE OF 'READ ERROR' SEVERAL TIMES BEFORE THIS OCCURRENCE.
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.