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|
Attributes | |
ACN | 718676 |
Time | |
Date | 200612 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | navaid : gsh.vortac |
State Reference | IN |
Altitude | msl bound lower : 22000 msl bound upper : 23000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zob.artcc tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | DC-8 70 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp pilot : instrument pilot : multi engine |
Experience | flight time last 90 days : 150 flight time total : 14000 flight time type : 7000 |
ASRS Report | 718676 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : atp pilot : commercial pilot : flight engineer pilot : cfi pilot : multi engine |
Experience | flight time last 90 days : 167 flight time total : 13667 flight time type : 6450 |
ASRS Report | 718905 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
En route from toledo express via direct gsh VOR; captain flying. We were cleared to FL220 and told that we could expect higher when clear of traffic passing off our right side. We reported the traffic in sight and watched it pass behind us. At FL180 both pilots reset altimeters and called out 'set 29.92.' at FL217 on the captain's altimeter; the copilot remarked that the cleared altitude was FL220 which the captain acknowledged. The copilot then stated that there was an altitude discrepancy between the altimeters and that his altimeter was indicating FL227; 1000 ft higher than the captain's altimeter. The flight engineer noticed that the captain's altimeter was set to 28.92 instead of 29.92. Just as the captain corrected his altimeter and began a descent; ZAU called and asked what our altitude was and told FL227. Center then cleared us to FL230. The captain should have set his altimeter correctly and checked the copilot's altimeter for agreement. The copilot did not notice the altitude deviation on his altimeter until we were 700 ft high and the flight engineer should have checked that the 2 altimeters were set and that they agreed. The main factor contributing to this incident was fatigue. This was a night freight flight and although the crew had been on duty for only 2 hours they were into their 18TH hour of the day with another 5 hours to go until the next rest period.
Original NASA ASRS Text
Title: DC8-70 FLT CREW OVERSHOOTS THEIR CLRED ALT BECAUSE THE CAPT'S ALT WAS INCORRECTLY SET.
Narrative: ENRTE FROM TOLEDO EXPRESS VIA DIRECT GSH VOR; CAPT FLYING. WE WERE CLRED TO FL220 AND TOLD THAT WE COULD EXPECT HIGHER WHEN CLR OF TFC PASSING OFF OUR R SIDE. WE RPTED THE TFC IN SIGHT AND WATCHED IT PASS BEHIND US. AT FL180 BOTH PLTS RESET ALTIMETERS AND CALLED OUT 'SET 29.92.' AT FL217 ON THE CAPT'S ALTIMETER; THE COPLT REMARKED THAT THE CLRED ALT WAS FL220 WHICH THE CAPT ACKNOWLEDGED. THE COPLT THEN STATED THAT THERE WAS AN ALT DISCREPANCY BTWN THE ALTIMETERS AND THAT HIS ALTIMETER WAS INDICATING FL227; 1000 FT HIGHER THAN THE CAPT'S ALTIMETER. THE FE NOTICED THAT THE CAPT'S ALTIMETER WAS SET TO 28.92 INSTEAD OF 29.92. JUST AS THE CAPT CORRECTED HIS ALTIMETER AND BEGAN A DSCNT; ZAU CALLED AND ASKED WHAT OUR ALT WAS AND TOLD FL227. CTR THEN CLRED US TO FL230. THE CAPT SHOULD HAVE SET HIS ALTIMETER CORRECTLY AND CHKED THE COPLT'S ALTIMETER FOR AGREEMENT. THE COPLT DID NOT NOTICE THE ALTDEV ON HIS ALTIMETER UNTIL WE WERE 700 FT HIGH AND THE FE SHOULD HAVE CHKED THAT THE 2 ALTIMETERS WERE SET AND THAT THEY AGREED. THE MAIN FACTOR CONTRIBUTING TO THIS INCIDENT WAS FATIGUE. THIS WAS A NIGHT FREIGHT FLT AND ALTHOUGH THE CREW HAD BEEN ON DUTY FOR ONLY 2 HRS THEY WERE INTO THEIR 18TH HR OF THE DAY WITH ANOTHER 5 HRS TO GO UNTIL THE NEXT REST PERIOD.
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.