37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 702999 |
Time | |
Date | 200607 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : phx.airport |
State Reference | AZ |
Altitude | msl single value : 28000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zab.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 289 flight time type : 2900 |
ASRS Report | 702999 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : overshoot non adherence : clearance non adherence : far |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory flight crew : returned to assigned altitude flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The aircraft was towed away from the gate by maintenance on originating flight. We waited for the aircraft or a replacement to return to our gate. Approximately 10 mins prior to scheduled push; the aircraft was returned to the gate. 4 mechanics; the gate agent; provisioning; flight attendants; the captain and I were all in the flight deck/jetway for approximately 10 mins. I went outside to do the walkaround due to being unable to gain access to the flight deck. Upon my return; all of the previously mentioned persons were still discussing a problem concerning egt with the plane. When the captain and I finally had access to the flight deck the gate agent started the boarding process. My flight deck preflight and flows were interrupted at least 5 times by various people (mechanics; gate agent; flight attendants asking questions; etc) I had to stop and start my flow 3 times. I finally started over from the beginning to make sure I had not missed anything. Upon obtaining the current ATIS I set my altimeter to the correct setting; noting field elevation by the relative position of the altimeter dial needle. It was pointing at approximately 1120 ft -- normal for phx. We completed all checklists and briefing per standard and pushed from the gate approximately 15 mins late. Engine start; taxi; takeoff and climb were all normal. We had several intermediate leveloff altitudes on our climb to assigned altitude of FL280. Phx departure; nor ZAB did not comment about our altitude until we changed frequencys and leveled off at FL280. After approximately 2 mins at cruise the ZAB controller inquired about our altitude. I read back that we were level at FL280. Controller said they were showing FL290. Upon looking closely at my altimeter; I noticed that it was set to 28.92! The captain noticed this at the same time and began an immediate descent down 1000 ft while we both reset our altimeters to 29.92. I apologized to the controller. There was no traffic in sight on TCAS or visually. We proceeded without further incident. In my experience as a pilot I have never seen an altimeter setting off by exactly 1000 ft. Upon my xchk of the altimeter; I failed to look closely at the readout on the thousands window in the face of the gauge; instead; assuming that it was correct due to the needle pointing at what I thought was field elevation. It was an early wake up and show sign-in; a late plane with maintenance issues; way too many distrs going on all the way up to the push. I was rushed on my flows and even though I did it twice; I still missed the altimeter setting -- 28.xx looks a lot like 29.xx. If the setting had been 30.xx I am sure we would have seen the difference. Lesson learned -- be cautious and careful. Suspect everything!
Original NASA ASRS Text
Title: MIS-SET ALTIMETERS ON B737-300 RESULT IN EXACTLY 1000 FOOT ERROR AT LEVELOFF.
Narrative: THE ACFT WAS TOWED AWAY FROM THE GATE BY MAINT ON ORIGINATING FLT. WE WAITED FOR THE ACFT OR A REPLACEMENT TO RETURN TO OUR GATE. APPROX 10 MINS PRIOR TO SCHEDULED PUSH; THE ACFT WAS RETURNED TO THE GATE. 4 MECHS; THE GATE AGENT; PROVISIONING; FLT ATTENDANTS; THE CAPT AND I WERE ALL IN THE FLT DECK/JETWAY FOR APPROX 10 MINS. I WENT OUTSIDE TO DO THE WALKAROUND DUE TO BEING UNABLE TO GAIN ACCESS TO THE FLT DECK. UPON MY RETURN; ALL OF THE PREVIOUSLY MENTIONED PERSONS WERE STILL DISCUSSING A PROB CONCERNING EGT WITH THE PLANE. WHEN THE CAPT AND I FINALLY HAD ACCESS TO THE FLT DECK THE GATE AGENT STARTED THE BOARDING PROCESS. MY FLT DECK PREFLT AND FLOWS WERE INTERRUPTED AT LEAST 5 TIMES BY VARIOUS PEOPLE (MECHS; GATE AGENT; FLT ATTENDANTS ASKING QUESTIONS; ETC) I HAD TO STOP AND START MY FLOW 3 TIMES. I FINALLY STARTED OVER FROM THE BEGINNING TO MAKE SURE I HAD NOT MISSED ANYTHING. UPON OBTAINING THE CURRENT ATIS I SET MY ALTIMETER TO THE CORRECT SETTING; NOTING FIELD ELEVATION BY THE RELATIVE POS OF THE ALTIMETER DIAL NEEDLE. IT WAS POINTING AT APPROX 1120 FT -- NORMAL FOR PHX. WE COMPLETED ALL CHKLISTS AND BRIEFING PER STANDARD AND PUSHED FROM THE GATE APPROX 15 MINS LATE. ENG START; TAXI; TKOF AND CLB WERE ALL NORMAL. WE HAD SEVERAL INTERMEDIATE LEVELOFF ALTS ON OUR CLB TO ASSIGNED ALT OF FL280. PHX DEP; NOR ZAB DID NOT COMMENT ABOUT OUR ALT UNTIL WE CHANGED FREQS AND LEVELED OFF AT FL280. AFTER APPROX 2 MINS AT CRUISE THE ZAB CTLR INQUIRED ABOUT OUR ALT. I READ BACK THAT WE WERE LEVEL AT FL280. CTLR SAID THEY WERE SHOWING FL290. UPON LOOKING CLOSELY AT MY ALTIMETER; I NOTICED THAT IT WAS SET TO 28.92! THE CAPT NOTICED THIS AT THE SAME TIME AND BEGAN AN IMMEDIATE DSCNT DOWN 1000 FT WHILE WE BOTH RESET OUR ALTIMETERS TO 29.92. I APOLOGIZED TO THE CTLR. THERE WAS NO TFC IN SIGHT ON TCAS OR VISUALLY. WE PROCEEDED WITHOUT FURTHER INCIDENT. IN MY EXPERIENCE AS A PLT I HAVE NEVER SEEN AN ALTIMETER SETTING OFF BY EXACTLY 1000 FT. UPON MY XCHK OF THE ALTIMETER; I FAILED TO LOOK CLOSELY AT THE READOUT ON THE THOUSANDS WINDOW IN THE FACE OF THE GAUGE; INSTEAD; ASSUMING THAT IT WAS CORRECT DUE TO THE NEEDLE POINTING AT WHAT I THOUGHT WAS FIELD ELEVATION. IT WAS AN EARLY WAKE UP AND SHOW SIGN-IN; A LATE PLANE WITH MAINT ISSUES; WAY TOO MANY DISTRS GOING ON ALL THE WAY UP TO THE PUSH. I WAS RUSHED ON MY FLOWS AND EVEN THOUGH I DID IT TWICE; I STILL MISSED THE ALTIMETER SETTING -- 28.XX LOOKS A LOT LIKE 29.XX. IF THE SETTING HAD BEEN 30.XX I AM SURE WE WOULD HAVE SEEN THE DIFFERENCE. LESSON LEARNED -- BE CAUTIOUS AND CAREFUL. SUSPECT EVERYTHING!
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.