37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 565356 |
Time | |
Date | 200211 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : egll.airport |
State Reference | FO |
Altitude | msl bound lower : 3700 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : egll.tracon |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Experience | flight time type : 3481 |
ASRS Report | 565356 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Experience | flight time type : 4941 |
ASRS Report | 565523 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance non adherence : far |
Independent Detector | other controllerb |
Resolutory Action | controller : issued advisory flight crew : returned to assigned altitude flight crew : became reoriented |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On descent into egll, cleared out of flight levels to 4000 ft (local altimeter setting 1001 MB). Crew forgot to reset altimeters and leveled at FL040 (1013 MB) which was actually 3700 ft -- 300 ft low. Error was first noticed and immediately corrected when ATC questioned our altitude, asked us to check our altimeter setting, and said he showed us at 3700 ft. Supplemental information from acn 565523: the setting of qne was unintentionally not set and this lack of action was missed by all 3 pilots in the cockpit. Action was taken to correct altitude, ie, set altimeter 1001 MB. Approach was continued without further incidence. All SOP's were followed. Contributing factors: frequency congestion and all nighter fatigue.
Original NASA ASRS Text
Title: ATC NOTES AN ALT OVERSHOOT ULTIMATELY ATTRIBUTED TO INCORRECT SETTING OF THE ALTIMETER.
Narrative: ON DSCNT INTO EGLL, CLRED OUT OF FLT LEVELS TO 4000 FT (LCL ALTIMETER SETTING 1001 MB). CREW FORGOT TO RESET ALTIMETERS AND LEVELED AT FL040 (1013 MB) WHICH WAS ACTUALLY 3700 FT -- 300 FT LOW. ERROR WAS FIRST NOTICED AND IMMEDIATELY CORRECTED WHEN ATC QUESTIONED OUR ALT, ASKED US TO CHK OUR ALTIMETER SETTING, AND SAID HE SHOWED US AT 3700 FT. SUPPLEMENTAL INFO FROM ACN 565523: THE SETTING OF QNE WAS UNINTENTIONALLY NOT SET AND THIS LACK OF ACTION WAS MISSED BY ALL 3 PLTS IN THE COCKPIT. ACTION WAS TAKEN TO CORRECT ALT, IE, SET ALTIMETER 1001 MB. APCH WAS CONTINUED WITHOUT FURTHER INCIDENCE. ALL SOP'S WERE FOLLOWED. CONTRIBUTING FACTORS: FREQ CONGESTION AND ALL NIGHTER FATIGUE.
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.