37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 720835 |
Time | |
Date | 200612 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : rorg.artcc |
State Reference | FO |
Altitude | msl single value : 33000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : rorg.artcc tower : phl.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
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 : 97 flight time total : 8900 flight time type : 836 |
ASRS Report | 720835 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 75 flight time total : 8900 flight time type : 700 |
ASRS Report | 720833 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Aircraft Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Flying FL330; in cruise with autoplt 1; I reached up to adjust the glare shield panel floodlights. This knob is adjacent to and similar in shape to the altimeter adjustment knob. I mistakenly rotated the altimeter adjustment knob; and subsequently heard the altitude tone and voice. Upon hearing that; I instinctively clicked off the autoplt and chased the altitude; manually correcting to the assigned altitude. The airplane; obviously; hadn't moved; but I corrected to a baro setting of 1026; which gave us a 700 ft altitude error. I immediately caught on to that; and subsequently pulled the altimeter knob; resetting the standard altimeter and I was then able to correct to the proper altitude. After I was back on altitude; I told naha ATC exactly what happened; and there was no other traffic in the area. Contributing factors to this error were as follows: some element of fatigue; and the design of the panel; neither of which are issues that can be addressed. We'll learn from the mistake and move on. This flight is a late departure out of hong kong; and I was not able to get a lot of rest in the hotel due to a noisy neighbor. To add to that; crew scheduling interrupted the little sleep I did get with some unrelated request.
Original NASA ASRS Text
Title: AN MD11 CAPT ON AN OVERWATER FLT SLEWED THE ALTIMETER ADJUSTMENT KNOB WHEN TRYING TO ADJUST LIGHTING; CAUSING A MOMENTARY ALT EXCURSION.
Narrative: FLYING FL330; IN CRUISE WITH AUTOPLT 1; I REACHED UP TO ADJUST THE GLARE SHIELD PANEL FLOODLIGHTS. THIS KNOB IS ADJACENT TO AND SIMILAR IN SHAPE TO THE ALTIMETER ADJUSTMENT KNOB. I MISTAKENLY ROTATED THE ALTIMETER ADJUSTMENT KNOB; AND SUBSEQUENTLY HEARD THE ALT TONE AND VOICE. UPON HEARING THAT; I INSTINCTIVELY CLICKED OFF THE AUTOPLT AND CHASED THE ALT; MANUALLY CORRECTING TO THE ASSIGNED ALT. THE AIRPLANE; OBVIOUSLY; HADN'T MOVED; BUT I CORRECTED TO A BARO SETTING OF 1026; WHICH GAVE US A 700 FT ALT ERROR. I IMMEDIATELY CAUGHT ON TO THAT; AND SUBSEQUENTLY PULLED THE ALTIMETER KNOB; RESETTING THE STANDARD ALTIMETER AND I WAS THEN ABLE TO CORRECT TO THE PROPER ALT. AFTER I WAS BACK ON ALT; I TOLD NAHA ATC EXACTLY WHAT HAPPENED; AND THERE WAS NO OTHER TFC IN THE AREA. CONTRIBUTING FACTORS TO THIS ERROR WERE AS FOLLOWS: SOME ELEMENT OF FATIGUE; AND THE DESIGN OF THE PANEL; NEITHER OF WHICH ARE ISSUES THAT CAN BE ADDRESSED. WE'LL LEARN FROM THE MISTAKE AND MOVE ON. THIS FLT IS A LATE DEP OUT OF HONG KONG; AND I WAS NOT ABLE TO GET A LOT OF REST IN THE HOTEL DUE TO A NOISY NEIGHBOR. TO ADD TO THAT; CREW SCHEDULING INTERRUPTED THE LITTLE SLEEP I DID GET WITH SOME UNRELATED REQUEST.
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.