37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 689301 |
Time | |
Date | 200603 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : ave.vortac |
State Reference | CA |
Altitude | msl bound lower : 34800 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa.artcc tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 150 flight time total : 13000 flight time type : 8000 |
ASRS Report | 689301 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 110 flight time total : 12000 flight time type : 6000 |
ASRS Report | 689570 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : undershoot non adherence : far non adherence : published procedure non adherence : clearance |
Independent Detector | other controllerb |
Resolutory Action | controller : issued alert flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Climbing out of oak at 10000 ft; we noticed that the right engine bleed valve appeared closed. We then started troubleshooting the problem; referring to the QRH and MEL. We checked the circuit breakers and cycled the bleed; iso; and pack switches in attempt to open the stuck bleed valve. During our troubleshooting; we missed the 18000 ft checklist and forgot to reset our altimeters to 29.92. We were initially cleared to FL410. After reviewing the MEL and ATC ride reports; I elected to level off at FL350 since the cabin pressure was ok at that altitude. Shortly after leveloff; ATC asked if we were level at FL350; he showed us 200 ft low. We then noticed our altimeter setting 30.18 and reset 29.92; climbed to FL350. ATC then confirmed we were at FL350. I did not note any traffic conflicts nor did center indicate any. We continued to our next city and MEL'ed the pack. My mistake during the troubleshooting was that no one was primarily flying the aircraft and that we both were trying to troubleshoot. I should have given the aircraft to the first officer to fly while I reviewed the MEL and QRH. We would not have missed the altimeter reset had someone stayed tuned to flying the aircraft.
Original NASA ASRS Text
Title: WHILE TROUBLESHOOTING A BLEED VALVE PROB; B737-700 CREW FORGETS TO RESET ALTIMETERS AT 18000 FT RESULTING IN ALTDEV UPON LEVELOFF.
Narrative: CLBING OUT OF OAK AT 10000 FT; WE NOTICED THAT THE R ENG BLEED VALVE APPEARED CLOSED. WE THEN STARTED TROUBLESHOOTING THE PROB; REFERRING TO THE QRH AND MEL. WE CHKED THE CIRCUIT BREAKERS AND CYCLED THE BLEED; ISO; AND PACK SWITCHES IN ATTEMPT TO OPEN THE STUCK BLEED VALVE. DURING OUR TROUBLESHOOTING; WE MISSED THE 18000 FT CHKLIST AND FORGOT TO RESET OUR ALTIMETERS TO 29.92. WE WERE INITIALLY CLRED TO FL410. AFTER REVIEWING THE MEL AND ATC RIDE RPTS; I ELECTED TO LEVEL OFF AT FL350 SINCE THE CABIN PRESSURE WAS OK AT THAT ALT. SHORTLY AFTER LEVELOFF; ATC ASKED IF WE WERE LEVEL AT FL350; HE SHOWED US 200 FT LOW. WE THEN NOTICED OUR ALTIMETER SETTING 30.18 AND RESET 29.92; CLBED TO FL350. ATC THEN CONFIRMED WE WERE AT FL350. I DID NOT NOTE ANY TFC CONFLICTS NOR DID CTR INDICATE ANY. WE CONTINUED TO OUR NEXT CITY AND MEL'ED THE PACK. MY MISTAKE DURING THE TROUBLESHOOTING WAS THAT NO ONE WAS PRIMARILY FLYING THE ACFT AND THAT WE BOTH WERE TRYING TO TROUBLESHOOT. I SHOULD HAVE GIVEN THE ACFT TO THE FO TO FLY WHILE I REVIEWED THE MEL AND QRH. WE WOULD NOT HAVE MISSED THE ALTIMETER RESET HAD SOMEONE STAYED TUNED TO FLYING THE ACFT.
Data retrieved from NASA's ASRS site as of January 2009 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.