37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 597476 |
Time | |
Date | 200310 |
Day | Wed |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : unv.airport |
State Reference | PA |
Altitude | msl bound lower : 2940 msl bound upper : 4000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Turbulence |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zny.artcc |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : cfi |
Experience | flight time last 90 days : 250 flight time total : 3500 flight time type : 2000 |
ASRS Report | 597476 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : far non adherence : company policies non adherence : clearance other anomaly other 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 controller : issued new clearance controller : provided flight assist flight crew : took evasive action none taken : detected after the fact other |
Miss Distance | vertical : 85 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were descending into the sce area and had been placed on a vector by the center controller to enter a right downwind for an ILS approach. The captain had received the WX, including altimeter setting and had called the station to inform them of our arrival. While the captain was aft, I got a clearance to descend to 4000 ft and received what I believed to be an altimeter setting of 30.33 inches from the controller. I read back both the altitude and altimeter setting and began my descent. As I leveled off at 4000 ft I began a speed reduction to 200 KIAS. As the airspeed slowed, a warning started going off that I misinterped as a low airspeed warning. We were also confirming we were at 200 KIAS and confused by the warning. I noticed the radar altimeter said 900 ft AGL. I brought this to the captain's attention and we were both confused. At that time the controller told us to climb and maintain 4000 ft. I stated we were at 4000 ft and he again issued a climb. At that point, I was doubtful of my position so I disengaged the autoplt and began a climb to a higher, unknown altitude. Several moments later, we received a 'terrain, terrain' warning from the enhanced GPWS. I then applied maximum thrust and performed the CFIT escape maneuver. We eventually leveled at approximately 9000 ft. At this point we were trying to ascertain what happened. We then looked on the paper that had the WX for sce and saw an altimeter of 29.27 inches, not 30.33 inches. We were over 1 inch off, which would have been over 1000 ft. The highest terrain in our area was approximately 2800 ft MSL, and we were probably at approximately 3000 ft MSL. This had been a long duty day for us with many delays due to WX. We were over 2 hours late, fatigued and combine that with minimal ATC resources, a wrong altimeter setting was set in. I do not honestly know if this was pilot error or controller error. Callback conversation with reporter revealed the following information: the crew was on the last leg of a 14 hour duty day, operating on the back side of the clock, at 0 dark 30 mins. Reporter commented that they were 'dragging.' the aircraft is equipped with a low speed warning system in addition to a stick shaker. This is the warning the first officer thought he had. The aircraft is equipped with egpws. The first thing egpws does is have a vertical profile map pop into the moving map display. The first officer said this did not register with him. The ZNY controller first told the crew to climb and maintain 4000 ft. Since the crew thought they were already at 4000 ft they did nothing. Only after the controller told the crew to climb, in an exited voice, did the first officer start a climb. The crew has not been contacted by anyone about this incident. The crew did not report the incident to anyone.
Original NASA ASRS Text
Title: CL-65 CREW CAME WITHIN 85 FT OF AN ANTENNA DSNDING INTO UNV. THE FLYING FO MISSET HIS ALTIMETER 1 PT 06 INCHES, AND THE CAPT WAS CONTACTING THE COMPANY WITH NON PERTINENT INFO, LEAVING THE FO TO FLY SOLO. EGPWS AND ATC MSAW WARNINGS WERE GIVEN. THE CREW DID NOT KNOW WHAT THE EGPWS WARNING WAS.
Narrative: WE WERE DSNDING INTO THE SCE AREA AND HAD BEEN PLACED ON A VECTOR BY THE CTR CTLR TO ENTER A R DOWNWIND FOR AN ILS APCH. THE CAPT HAD RECEIVED THE WX, INCLUDING ALTIMETER SETTING AND HAD CALLED THE STATION TO INFORM THEM OF OUR ARR. WHILE THE CAPT WAS AFT, I GOT A CLRNC TO DSND TO 4000 FT AND RECEIVED WHAT I BELIEVED TO BE AN ALTIMETER SETTING OF 30.33 INCHES FROM THE CTLR. I READ BACK BOTH THE ALT AND ALTIMETER SETTING AND BEGAN MY DSCNT. AS I LEVELED OFF AT 4000 FT I BEGAN A SPD REDUCTION TO 200 KIAS. AS THE AIRSPD SLOWED, A WARNING STARTED GOING OFF THAT I MISINTERPED AS A LOW AIRSPD WARNING. WE WERE ALSO CONFIRMING WE WERE AT 200 KIAS AND CONFUSED BY THE WARNING. I NOTICED THE RADAR ALTIMETER SAID 900 FT AGL. I BROUGHT THIS TO THE CAPT'S ATTN AND WE WERE BOTH CONFUSED. AT THAT TIME THE CTLR TOLD US TO CLB AND MAINTAIN 4000 FT. I STATED WE WERE AT 4000 FT AND HE AGAIN ISSUED A CLB. AT THAT POINT, I WAS DOUBTFUL OF MY POS SO I DISENGAGED THE AUTOPLT AND BEGAN A CLB TO A HIGHER, UNKNOWN ALT. SEVERAL MOMENTS LATER, WE RECEIVED A 'TERRAIN, TERRAIN' WARNING FROM THE ENHANCED GPWS. I THEN APPLIED MAX THRUST AND PERFORMED THE CFIT ESCAPE MANEUVER. WE EVENTUALLY LEVELED AT APPROX 9000 FT. AT THIS POINT WE WERE TRYING TO ASCERTAIN WHAT HAPPENED. WE THEN LOOKED ON THE PAPER THAT HAD THE WX FOR SCE AND SAW AN ALTIMETER OF 29.27 INCHES, NOT 30.33 INCHES. WE WERE OVER 1 INCH OFF, WHICH WOULD HAVE BEEN OVER 1000 FT. THE HIGHEST TERRAIN IN OUR AREA WAS APPROX 2800 FT MSL, AND WE WERE PROBABLY AT APPROX 3000 FT MSL. THIS HAD BEEN A LONG DUTY DAY FOR US WITH MANY DELAYS DUE TO WX. WE WERE OVER 2 HRS LATE, FATIGUED AND COMBINE THAT WITH MINIMAL ATC RESOURCES, A WRONG ALTIMETER SETTING WAS SET IN. I DO NOT HONESTLY KNOW IF THIS WAS PLT ERROR OR CTLR ERROR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CREW WAS ON THE LAST LEG OF A 14 HR DUTY DAY, OPERATING ON THE BACK SIDE OF THE CLOCK, AT 0 DARK 30 MINS. RPTR COMMENTED THAT THEY WERE 'DRAGGING.' THE ACFT IS EQUIPPED WITH A LOW SPD WARNING SYS IN ADDITION TO A STICK SHAKER. THIS IS THE WARNING THE FO THOUGHT HE HAD. THE ACFT IS EQUIPPED WITH EGPWS. THE FIRST THING EGPWS DOES IS HAVE A VERT PROFILE MAP POP INTO THE MOVING MAP DISPLAY. THE FO SAID THIS DID NOT REGISTER WITH HIM. THE ZNY CTLR FIRST TOLD THE CREW TO CLB AND MAINTAIN 4000 FT. SINCE THE CREW THOUGHT THEY WERE ALREADY AT 4000 FT THEY DID NOTHING. ONLY AFTER THE CTLR TOLD THE CREW TO CLB, IN AN EXITED VOICE, DID THE FO START A CLB. THE CREW HAS NOT BEEN CONTACTED BY ANYONE ABOUT THIS INCIDENT. THE CREW DID NOT RPT THE INCIDENT TO ANYONE.
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.