37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 97654 |
Time | |
Date | 198811 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : crl |
State Reference | MI |
Altitude | msl bound lower : 9000 msl bound upper : 1000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent other |
Route In Use | enroute airway : zob |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain |
Qualification | pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 15000 flight time type : 12000 |
ASRS Report | 97654 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
En route cmh-dtw, fairly short leg. First officer flying. I did in range checklist which calls for pilots to verbally state setting and xchk each other. I stated 29.85 and crosschecked his. He did the same. I was calling in range to company in dtw when ATC asked our altitude. He answered them, '10000',' assigned altitude. They said, 'check your altimeters.' I then looked at the sheet where I wrote the ATIS information down. Altimeter setting that I wrote down was 28.85, but we both had set 29.85. Consequently we were cruising at 9000' but indicating 10000'. We immediately climbed up. ATC said nothing else. Neither did we. It is a fairly rushed leg. I think we were keeping our speed up for ATC. I did the inrange check as soon as we began our descent from 22000'. I must have simply misstated the unusually low altimeter setting to one more normal. In cmh the altimeter setting was 29.02 or something like that. So the change was marked from 29.92, but not so much from cmh. Neither the first officer nor myself believe it happened because I rushed the checklist. I said loudly and pointedly what I thought it was--and checked to see we set it. I think it happened because I did not recognize the unusual nature of the setting and reverted to more familiar settings during the checklist. This failure to recognize may have been caused by high workload at time and also an underdeveloped appreciation for altimeter settings importance due to rarity of such vast differences. Callback conversation with reporter revealed the following: reporter states both he and first officer shocked when realized mistake. Had not recognized extreme low pressure when heard ATIS. In briefing learned that dtw WX was ok, just high overcast. Did not pay much attention to dtw, put focus on stl where knew would have to make instrument approach. Heard setting correctly, wrote it down correctly and simply set altimeter with more normal numbers.
Original NASA ASRS Text
Title: ALT DEVIATION, WRONG ALTIMETER SETTING.
Narrative: ENRTE CMH-DTW, FAIRLY SHORT LEG. F/O FLYING. I DID IN RANGE CHKLIST WHICH CALLS FOR PLTS TO VERBALLY STATE SETTING AND XCHK EACH OTHER. I STATED 29.85 AND XCHKED HIS. HE DID THE SAME. I WAS CALLING IN RANGE TO COMPANY IN DTW WHEN ATC ASKED OUR ALT. HE ANSWERED THEM, '10000',' ASSIGNED ALT. THEY SAID, 'CHK YOUR ALTIMETERS.' I THEN LOOKED AT THE SHEET WHERE I WROTE THE ATIS INFO DOWN. ALTIMETER SETTING THAT I WROTE DOWN WAS 28.85, BUT WE BOTH HAD SET 29.85. CONSEQUENTLY WE WERE CRUISING AT 9000' BUT INDICATING 10000'. WE IMMEDIATELY CLBED UP. ATC SAID NOTHING ELSE. NEITHER DID WE. IT IS A FAIRLY RUSHED LEG. I THINK WE WERE KEEPING OUR SPD UP FOR ATC. I DID THE INRANGE CHK AS SOON AS WE BEGAN OUR DSCNT FROM 22000'. I MUST HAVE SIMPLY MISSTATED THE UNUSUALLY LOW ALTIMETER SETTING TO ONE MORE NORMAL. IN CMH THE ALTIMETER SETTING WAS 29.02 OR SOMETHING LIKE THAT. SO THE CHANGE WAS MARKED FROM 29.92, BUT NOT SO MUCH FROM CMH. NEITHER THE F/O NOR MYSELF BELIEVE IT HAPPENED BECAUSE I RUSHED THE CHKLIST. I SAID LOUDLY AND POINTEDLY WHAT I THOUGHT IT WAS--AND CHKED TO SEE WE SET IT. I THINK IT HAPPENED BECAUSE I DID NOT RECOGNIZE THE UNUSUAL NATURE OF THE SETTING AND REVERTED TO MORE FAMILIAR SETTINGS DURING THE CHKLIST. THIS FAILURE TO RECOGNIZE MAY HAVE BEEN CAUSED BY HIGH WORKLOAD AT TIME AND ALSO AN UNDERDEVELOPED APPRECIATION FOR ALTIMETER SETTINGS IMPORTANCE DUE TO RARITY OF SUCH VAST DIFFERENCES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: RPTR STATES BOTH HE AND F/O SHOCKED WHEN REALIZED MISTAKE. HAD NOT RECOGNIZED EXTREME LOW PRESSURE WHEN HEARD ATIS. IN BRIEFING LEARNED THAT DTW WX WAS OK, JUST HIGH OVCST. DID NOT PAY MUCH ATTN TO DTW, PUT FOCUS ON STL WHERE KNEW WOULD HAVE TO MAKE INSTRUMENT APCH. HEARD SETTING CORRECTLY, WROTE IT DOWN CORRECTLY AND SIMPLY SET ALTIMETER WITH MORE NORMAL NUMBERS.
Data retrieved from NASA's ASRS site as of August 2007 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.