37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 576513 |
Time | |
Date | 200303 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | navaid : las.vortac |
State Reference | NV |
Altitude | msl single value : 6100 |
Environment | |
Flight Conditions | Mixed |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | DC-10 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach descent : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 2000 flight time total : 14000 flight time type : 3000 |
ASRS Report | 576513 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far non adherence : company policies non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment : msaw atc equipment other atc equipment : radar aircraft equipment : gpws other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued alert flight crew : took evasive action flight crew : became reoriented |
Supplementary | |
Problem Areas | Flight Crew Human Performance FAA Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Level at 6100 ft MSL approaching boulder city VORTAC, GPWS activated. Simultaneously, ATC advised to check altitude. We spotted top of terrain through break in overcast. ATC advised altimeter setting of 29.66. We had set 29.96, which would place us 300 ft lower than indicated. Contributing factors: 1) crew fatigue. We had less than 3 hours sleep in previous 24 hours, time of day was XA30. 2) when I listened to ATIS, tape quality sounded poor. Flight engineer wrote down altimeter setting on card and crew set all 3 altimeters to incorrect setting. 3) possibility that ATIS was recorded in error. New ATIS made after landing. 4) crew familiarity with route. GPWS alerts very common when vectored to boulder city VOR and we tend to ignore GPWS warning. The major cause was fatigue. Must we crash and kill 350 people to get the FAA to update flight and duty time rules for international supplemental operations?
Original NASA ASRS Text
Title: DC10-30 CREW GOT A GPWS TERRAIN WARNING AND SIMULTANEOUSLY WAS ISSUED AN MSAW ALERT.
Narrative: LEVEL AT 6100 FT MSL APCHING BOULDER CITY VORTAC, GPWS ACTIVATED. SIMULTANEOUSLY, ATC ADVISED TO CHK ALT. WE SPOTTED TOP OF TERRAIN THROUGH BREAK IN OVCST. ATC ADVISED ALTIMETER SETTING OF 29.66. WE HAD SET 29.96, WHICH WOULD PLACE US 300 FT LOWER THAN INDICATED. CONTRIBUTING FACTORS: 1) CREW FATIGUE. WE HAD LESS THAN 3 HRS SLEEP IN PREVIOUS 24 HRS, TIME OF DAY WAS XA30. 2) WHEN I LISTENED TO ATIS, TAPE QUALITY SOUNDED POOR. FE WROTE DOWN ALTIMETER SETTING ON CARD AND CREW SET ALL 3 ALTIMETERS TO INCORRECT SETTING. 3) POSSIBILITY THAT ATIS WAS RECORDED IN ERROR. NEW ATIS MADE AFTER LNDG. 4) CREW FAMILIARITY WITH RTE. GPWS ALERTS VERY COMMON WHEN VECTORED TO BOULDER CITY VOR AND WE TEND TO IGNORE GPWS WARNING. THE MAJOR CAUSE WAS FATIGUE. MUST WE CRASH AND KILL 350 PEOPLE TO GET THE FAA TO UPDATE FLT AND DUTY TIME RULES FOR INTL SUPPLEMENTAL OPS?
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.