37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 810179 |
Time | |
Date | 200810 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : egll.airport |
State Reference | FO |
Altitude | msl bound lower : 4640 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B777-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 145 flight time total : 20000 flight time type : 2000 |
ASRS Report | 810179 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 240 flight time total : 14000 flight time type : 680 |
ASRS Report | 810178 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : overshoot non adherence : clearance |
Independent Detector | other flight crewa other flight crewb other other : 3 |
Resolutory Action | flight crew : overcame equipment problem flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Airspace Structure |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Descending to 5000 ft during vectors for approach while on autoplt. Momentary altitude deviation occurred and descended to approximately 4640 ft when autoplt did not capture 5000 ft. The reason for the failure to capture appears to be my late action to reset altimeter to the local setting of 993 milibars. The PNF called out the altimeter setting and I missed the call due to radio traffic. He called it out again and I reset my altimeter at approximately same time as autoplt should have captured 5000 ft. Distrs consulting the lhr constant descent approach chart and using vertical speed 1200 ft down rather than flch contributed to the problem. Should have taken advantage of the relief pilot and had her consult the cda graph so I could pay more attention to flying the aircraft. Supplemental information from acn 810178: contributing factors were the amount of time lapsed between the start of the approach descent checklist and finally reaching the transition level (almost 30 mins); and the low altimeter setting. Supplemental information from acn 809961: all 3 of us looked at the constant descent chart to arrive at an appropriate descent rate. I believe the preoccupation with this new constant descent approach; was the primary factor in not getting the altimeter set at the appropriate time. I have only flown into heathrow a few times since the emphasis on the constant descent approach started; but I have yet to see anyone not sacrifice some portion of aircraft control in an attempt to keep a constant descent. The constant descent approach forces pilots to use the autoplts in modes that are not the norm. The captain had appropriately discussed that FL8000 was the lowest usable flight level because of the low altimeter; but we didn't discuss ensuring altimeter change to 993 MB early enough to prevent this altitude deviation.
Original NASA ASRS Text
Title: FAILURE OF CAPTAIN TO RESET HIS ALTIMETER AT THE TRANSITION LEVEL RESULTS IN ALTITUDE DEVIATION INBOUND TO EGLL.
Narrative: DSNDING TO 5000 FT DURING VECTORS FOR APCH WHILE ON AUTOPLT. MOMENTARY ALTDEV OCCURRED AND DSNDED TO APPROX 4640 FT WHEN AUTOPLT DID NOT CAPTURE 5000 FT. THE REASON FOR THE FAILURE TO CAPTURE APPEARS TO BE MY LATE ACTION TO RESET ALTIMETER TO THE LCL SETTING OF 993 MILIBARS. THE PNF CALLED OUT THE ALTIMETER SETTING AND I MISSED THE CALL DUE TO RADIO TFC. HE CALLED IT OUT AGAIN AND I RESET MY ALTIMETER AT APPROX SAME TIME AS AUTOPLT SHOULD HAVE CAPTURED 5000 FT. DISTRS CONSULTING THE LHR CONSTANT DSCNT APCH CHART AND USING VERT SPD 1200 FT DOWN RATHER THAN FLCH CONTRIBUTED TO THE PROB. SHOULD HAVE TAKEN ADVANTAGE OF THE RELIEF PLT AND HAD HER CONSULT THE CDA GRAPH SO I COULD PAY MORE ATTN TO FLYING THE ACFT. SUPPLEMENTAL INFO FROM ACN 810178: CONTRIBUTING FACTORS WERE THE AMOUNT OF TIME LAPSED BTWN THE START OF THE APCH DSCNT CHKLIST AND FINALLY REACHING THE TRANSITION LEVEL (ALMOST 30 MINS); AND THE LOW ALTIMETER SETTING. SUPPLEMENTAL INFO FROM ACN 809961: ALL 3 OF US LOOKED AT THE CONSTANT DSCNT CHART TO ARRIVE AT AN APPROPRIATE DSCNT RATE. I BELIEVE THE PREOCCUPATION WITH THIS NEW CONSTANT DSCNT APCH; WAS THE PRIMARY FACTOR IN NOT GETTING THE ALTIMETER SET AT THE APPROPRIATE TIME. I HAVE ONLY FLOWN INTO HEATHROW A FEW TIMES SINCE THE EMPHASIS ON THE CONSTANT DSCNT APCH STARTED; BUT I HAVE YET TO SEE ANYONE NOT SACRIFICE SOME PORTION OF ACFT CTL IN AN ATTEMPT TO KEEP A CONSTANT DSCNT. THE CONSTANT DSCNT APCH FORCES PLTS TO USE THE AUTOPLTS IN MODES THAT ARE NOT THE NORM. THE CAPT HAD APPROPRIATELY DISCUSSED THAT FL8000 WAS THE LOWEST USABLE FLT LEVEL BECAUSE OF THE LOW ALTIMETER; BUT WE DIDN'T DISCUSS ENSURING ALTIMETER CHANGE TO 993 MB EARLY ENOUGH TO PREVENT THIS ALTDEV.
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.