37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 721200 |
Time | |
Date | 200612 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : anc.vor |
State Reference | AK |
Altitude | msl single value : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zan.artcc tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | descent : intermediate altitude |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : flight engineer pilot : atp pilot : cfi |
Experience | flight time last 90 days : 180 flight time total : 14000 flight time type : 8000 |
ASRS Report | 721200 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Fatigue is the underlying issue here. Start of pattern was 11 hours late; reported for trip (was not notified of delay). This put sleep pattern 15 hours out of sync. Unable to sleep prior to departure on this reported flight. Accumulated sleep loss pattern affected the last several hours of flight. Small tasks were difficult. We all missed the wrong altimeter setting that was set during checklist. Altimeter was set at 29.90 and the actual setting should have been 29.00. ATC pointed out the error; there was no traffic conflict. Next time will call in fatigued if known future sleep pattern will be hard to recover from; even if not tired at time of pattern departure. Human performance -- failure to cross verification error; and xchking of setting -- poor monitoring; with such a low altimeter setting wished ATC would have emphasized this low setting after descending below 18000 ft.
Original NASA ASRS Text
Title: FLT CREW RPTS ERRORS CAUSED BY FATIGUE AFTER 11 HR DEP DELAY.
Narrative: FATIGUE IS THE UNDERLYING ISSUE HERE. START OF PATTERN WAS 11 HRS LATE; RPTED FOR TRIP (WAS NOT NOTIFIED OF DELAY). THIS PUT SLEEP PATTERN 15 HRS OUT OF SYNC. UNABLE TO SLEEP PRIOR TO DEP ON THIS RPTED FLT. ACCUMULATED SLEEP LOSS PATTERN AFFECTED THE LAST SEVERAL HRS OF FLT. SMALL TASKS WERE DIFFICULT. WE ALL MISSED THE WRONG ALTIMETER SETTING THAT WAS SET DURING CHKLIST. ALTIMETER WAS SET AT 29.90 AND THE ACTUAL SETTING SHOULD HAVE BEEN 29.00. ATC POINTED OUT THE ERROR; THERE WAS NO TFC CONFLICT. NEXT TIME WILL CALL IN FATIGUED IF KNOWN FUTURE SLEEP PATTERN WILL BE HARD TO RECOVER FROM; EVEN IF NOT TIRED AT TIME OF PATTERN DEP. HUMAN PERFORMANCE -- FAILURE TO CROSS VERIFICATION ERROR; AND XCHKING OF SETTING -- POOR MONITORING; WITH SUCH A LOW ALTIMETER SETTING WISHED ATC WOULD HAVE EMPHASIZED THIS LOW SETTING AFTER DSNDING BELOW 18000 FT.
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.