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|
Attributes | |
ACN | 599510 |
Time | |
Date | 200311 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mdw.airport |
State Reference | IL |
Altitude | msl bound lower : 2000 msl bound upper : 3000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : c90.tracon |
Operator | general aviation : corporate |
Make Model Name | Falcon 50 |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 2000 flight time type : 120 |
ASRS Report | 599510 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : undershoot non adherence : far other anomaly other |
Independent Detector | other controllerb |
Resolutory Action | controller : issued advisory flight crew : returned to original clearance flight crew : became reoriented other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On the last flight of the aircraft, nov/wed/03, the altimeter setting was unusually high, somewhere in the 30.60 inches area. The altimeter setting on the ATIS on the morning of the incident was 29.72. While setting the altimeters during the before start checks, I ignored the first 2 digits and rotated the both primary flight display pressure settings and the standby altimeter to 39.72 inches. The cabin pressure controller has an altimeter setting that reverts back to 29.92 after power down. I set it correctly to 29.72. During taxi I checked flight instruments, and compared the altimeter settings, but failed to confirm that they matched field elevation. I only checked the 3 altimeters, and did not catch that the pressure controller was set differently from the altimeters. On the mdw 4 departure, which is a vector with an initial altitude of 3000 ft, we leveled at 3000 ft which was actually 2000 ft. I checked in with departure level at 3000 ft. The controller cleared us to climb to 4000 ft. We climbed to 4000 ft. After a few mins the controller reclred us to 4000 ft. I told him we were level at 4000 ft. He said we were indicating 3000 ft, and to check the altimeter setting. That was when we realized our mistake. There was no traffic or terrain conflict. The controller was quick to catch the problem, and very understanding. I think that when I am in a rush I tend to skim over things, like one does when skimming a newspaper article to pick out the interesting parts. That morning I skimmed over the first 2 digits of the pressure and skimmed over the thousands place on the altimeters to see what I thought was the important information. Luckily that did not happen going out of an airport in mountainous terrain. It is a lesson that I will keep in mind every time I'm feeling rushed.
Original NASA ASRS Text
Title: A DA-50 FLT CREW INADVERTENTLY SET 30 PT 72 INSTEAD OF THE ACTUAL 29 PT 72, WHICH RESULTED IN THE ACFT LEVELING OFF 1000 FT LOW.
Narrative: ON THE LAST FLT OF THE ACFT, NOV/WED/03, THE ALTIMETER SETTING WAS UNUSUALLY HIGH, SOMEWHERE IN THE 30.60 INCHES AREA. THE ALTIMETER SETTING ON THE ATIS ON THE MORNING OF THE INCIDENT WAS 29.72. WHILE SETTING THE ALTIMETERS DURING THE BEFORE START CHKS, I IGNORED THE FIRST 2 DIGITS AND ROTATED THE BOTH PRIMARY FLT DISPLAY PRESSURE SETTINGS AND THE STANDBY ALTIMETER TO 39.72 INCHES. THE CABIN PRESSURE CONTROLLER HAS AN ALTIMETER SETTING THAT REVERTS BACK TO 29.92 AFTER PWR DOWN. I SET IT CORRECTLY TO 29.72. DURING TAXI I CHKED FLT INSTS, AND COMPARED THE ALTIMETER SETTINGS, BUT FAILED TO CONFIRM THAT THEY MATCHED FIELD ELEVATION. I ONLY CHKED THE 3 ALTIMETERS, AND DID NOT CATCH THAT THE PRESSURE CONTROLLER WAS SET DIFFERENTLY FROM THE ALTIMETERS. ON THE MDW 4 DEP, WHICH IS A VECTOR WITH AN INITIAL ALT OF 3000 FT, WE LEVELED AT 3000 FT WHICH WAS ACTUALLY 2000 FT. I CHKED IN WITH DEP LEVEL AT 3000 FT. THE CTLR CLRED US TO CLB TO 4000 FT. WE CLBED TO 4000 FT. AFTER A FEW MINS THE CTLR RECLRED US TO 4000 FT. I TOLD HIM WE WERE LEVEL AT 4000 FT. HE SAID WE WERE INDICATING 3000 FT, AND TO CHK THE ALTIMETER SETTING. THAT WAS WHEN WE REALIZED OUR MISTAKE. THERE WAS NO TFC OR TERRAIN CONFLICT. THE CTLR WAS QUICK TO CATCH THE PROB, AND VERY UNDERSTANDING. I THINK THAT WHEN I AM IN A RUSH I TEND TO SKIM OVER THINGS, LIKE ONE DOES WHEN SKIMMING A NEWSPAPER ARTICLE TO PICK OUT THE INTERESTING PARTS. THAT MORNING I SKIMMED OVER THE FIRST 2 DIGITS OF THE PRESSURE AND SKIMMED OVER THE THOUSANDS PLACE ON THE ALTIMETERS TO SEE WHAT I THOUGHT WAS THE IMPORTANT INFO. LUCKILY THAT DID NOT HAPPEN GOING OUT OF AN ARPT IN MOUNTAINOUS TERRAIN. IT IS A LESSON THAT I WILL KEEP IN MIND EVERY TIME I'M FEELING RUSHED.
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.