37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 809746 |
Time | |
Date | 200810 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 9000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B717 (Formerly MD-95) |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 809746 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Leveling at 9000 ft; ATC instructed us to slow to 180 KTS. We extended the slats only to find we had not done the in-range checklist and; thus; had an inaccurate altimeter setting. The correct altimeter was 30.37 and we still had 29.92 set. We had been given several altitude assignments and had probably leveled off several hundred ft off on each while descending. ATC did not call us on any of them or give us a number to call and; as far as we could tell; no conflicts presented. We didn't get any TCAS alerts on any other traffic. Event occurred for several reasons. Both pilots were on the last day of a 4 day trip with an early wake-up; despite the fact that the first day show time had been late afternoon. So there was a disruption of circadian rhythm. I could not get to sleep the night before (especially since our duty-off time the first night of the trip had been very late!); so I had less than 8 hours rest; but did not feel fatigued prior to the flight. Also; ATC was evidently training new controllers and there were excessive (I feel) speed adjustments; changes of altitude; and heading changes; causing task saturation. We forgot to do the in-range checklist; and to reset the altimeters until passing through 10000 ft MSL. Scheduling could help by not constructing pairings that check in the first day in the late afternoon; and the last day very early. We (pilots) need to be more proactive about getting the in-range as soon as we pass FL180 on the descent. We also need to be cognizant that ATC is doing a lot of training.
Original NASA ASRS Text
Title: B717-200 FLIGHT CREW FAILS TO PERFORM APPROACH-DESCENT CHECKLIST AND LEVEL OFF LOW DUE TO MIS-SET ALTIMETER.
Narrative: LEVELING AT 9000 FT; ATC INSTRUCTED US TO SLOW TO 180 KTS. WE EXTENDED THE SLATS ONLY TO FIND WE HAD NOT DONE THE IN-RANGE CHKLIST AND; THUS; HAD AN INACCURATE ALTIMETER SETTING. THE CORRECT ALTIMETER WAS 30.37 AND WE STILL HAD 29.92 SET. WE HAD BEEN GIVEN SEVERAL ALT ASSIGNMENTS AND HAD PROBABLY LEVELED OFF SEVERAL HUNDRED FT OFF ON EACH WHILE DSNDING. ATC DID NOT CALL US ON ANY OF THEM OR GIVE US A NUMBER TO CALL AND; AS FAR AS WE COULD TELL; NO CONFLICTS PRESENTED. WE DIDN'T GET ANY TCAS ALERTS ON ANY OTHER TFC. EVENT OCCURRED FOR SEVERAL REASONS. BOTH PLTS WERE ON THE LAST DAY OF A 4 DAY TRIP WITH AN EARLY WAKE-UP; DESPITE THE FACT THAT THE FIRST DAY SHOW TIME HAD BEEN LATE AFTERNOON. SO THERE WAS A DISRUPTION OF CIRCADIAN RHYTHM. I COULD NOT GET TO SLEEP THE NIGHT BEFORE (ESPECIALLY SINCE OUR DUTY-OFF TIME THE FIRST NIGHT OF THE TRIP HAD BEEN VERY LATE!); SO I HAD LESS THAN 8 HRS REST; BUT DID NOT FEEL FATIGUED PRIOR TO THE FLT. ALSO; ATC WAS EVIDENTLY TRAINING NEW CTLRS AND THERE WERE EXCESSIVE (I FEEL) SPD ADJUSTMENTS; CHANGES OF ALT; AND HDG CHANGES; CAUSING TASK SATURATION. WE FORGOT TO DO THE IN-RANGE CHKLIST; AND TO RESET THE ALTIMETERS UNTIL PASSING THROUGH 10000 FT MSL. SCHEDULING COULD HELP BY NOT CONSTRUCTING PAIRINGS THAT CHK IN THE FIRST DAY IN THE LATE AFTERNOON; AND THE LAST DAY VERY EARLY. WE (PLTS) NEED TO BE MORE PROACTIVE ABOUT GETTING THE IN-RANGE AS SOON AS WE PASS FL180 ON THE DSCNT. WE ALSO NEED TO BE COGNIZANT THAT ATC IS DOING A LOT OF TRAINING.
Data retrieved from NASA's ASRS site as of May 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.