37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 986121 |
Time | |
Date | 201112 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZFW.ARTCC |
State Reference | TX |
Aircraft 1 | |
Make Model Name | C17 |
Operating Under FAR Part | Part 91 |
Flight Phase | Descent |
Route In Use | Direct |
Flight Plan | IFR |
Person 1 | |
Function | Pilot Not Flying Captain |
Qualification | Flight Crew Instrument Flight Crew Multiengine |
Experience | Flight Crew Last 90 Days 120 Flight Crew Total 6900 Flight Crew Type 2800 |
Events | |
Anomaly | Conflict Airborne Conflict Deviation - Altitude Overshoot Deviation - Procedural Clearance Deviation - Track / Heading All Types |
Miss Distance | Horizontal 24000 Vertical 700 |
Narrative:
We were returning from an eight day mission overseas. We were on the second leg of the day; from bgr to tik; having already flown from etad to bgr. Our final leg was to take us from tik to tcm for mission termination at the end of a 24 hour flight duty period. At bgr; the copilot was responsible for loading the flight plan into the mission computer. She mistakenly omitted the gulli 1 STAR as filed. She hadn't loaded the STAR because she thought it was dependent on the landing runway; and since we hadn't known which runway tik was using; she had left the STAR out. Instead; she programmed tul direct tik. I failed to notice her mistake. Approaching tul; we began our enroute descent. After tul the controller asked us if we were proceeding to gulli. I stated no; we were direct to tik. At that time our clearance was to descend from FL240 to 16;000. Shortly after; as we were descending through 22;000; the controller amended our clearance to stop descent at FL200 and began to call out traffic at FL190. Both the pilot flying and the pilot not flying had set the local altimeter when cleared to 16;000 and neither caught our mistake when we were directed to level at FL200. As a result we were 300 ft low based on a TA with the conflicting traffic.both of us knew the proper procedure for resetting when passing through transition level however; having just dealt with numerous; varying international altimetry protocols our technique had become to reset the altimeter when cleared to an altitude in feet. As the pilot not flying; when approach cleared us to 16;000 I reached down to dial in the local altimeter. I noticed the pilot flying doing the same; and considered telling her to remain on 29.92 until transition; but did not; thinking it wouldn't be material. When told to level at FL200 for traffic; we began searching for the traffic; and neglected to reset the altimeter. Contributing factors were complacency. After a somewhat complex mission with numerous weather; maintenance and operational challenges (in the past 72 hours we had transited two airfields in hostile territory; and had logged combat) it was a relief to be back in the us on the last legs home. The weather was clear; the winds were light; and there didn't seem to be much other traffic. I should have been more persistent with the controller as to whether he needed us to go to gulli; but assumed that since I told him we were proceeding to tik; and he didn't direct us otherwise; that direct to tik was okay.corrective actions are to always have a second crewmember verify the mission computer flight plan; and to set altimeter settings in accordance with established procedures.
Original NASA ASRS Text
Title: A fatigued C-17 flight crew failed to program their filed STAR at the conclusion of their route and a track deviation and a traffic conflict resulted. A contributing factor was their failure to reset their altimeters back to QNE when ATC canceled their previous descent clearance to 16;000 MSL and assigned a flight level above the transition altitude to provide separation with traffic that ultimately generated a TCAS RA due; in part; to the 300 FT altitude error which resulted.
Narrative: We were returning from an eight day mission overseas. We were on the second leg of the day; from BGR to TIK; having already flown from ETAD to BGR. Our final leg was to take us from TIK to TCM for mission termination at the end of a 24 hour flight duty period. At BGR; the copilot was responsible for loading the flight plan into the mission computer. She mistakenly omitted the GULLI 1 STAR as filed. She hadn't loaded the STAR because she thought it was dependent on the landing runway; and since we hadn't known which runway TIK was using; she had left the STAR out. Instead; she programmed TUL direct TIK. I failed to notice her mistake. Approaching TUL; we began our enroute descent. After TUL the Controller asked us if we were proceeding to GULLI. I stated no; we were direct to TIK. At that time our clearance was to descend from FL240 to 16;000. Shortly after; as we were descending through 22;000; the Controller amended our clearance to stop descent at FL200 and began to call out traffic at FL190. Both the pilot flying and the pilot not flying had set the local altimeter when cleared to 16;000 and neither caught our mistake when we were directed to level at FL200. As a result we were 300 FT low based on a TA with the conflicting traffic.Both of us knew the proper procedure for resetting when passing through transition level however; having just dealt with numerous; varying international altimetry protocols our technique had become to reset the altimeter when cleared to an altitude in feet. As the pilot not flying; when Approach cleared us to 16;000 I reached down to dial in the local altimeter. I noticed the pilot flying doing the same; and considered telling her to remain on 29.92 until transition; but did not; thinking it wouldn't be material. When told to level at FL200 for traffic; we began searching for the traffic; and neglected to reset the altimeter. Contributing factors were complacency. After a somewhat complex mission with numerous weather; maintenance and operational challenges (in the past 72 hours we had transited two airfields in hostile territory; and had logged combat) it was a relief to be back in the US on the last legs home. The weather was clear; the winds were light; and there didn't seem to be much other traffic. I should have been more persistent with the Controller as to whether he needed us to go to GULLI; but assumed that since I told him we were proceeding to TIK; and he didn't direct us otherwise; that direct to TIK was okay.Corrective actions are to always have a second crewmember verify the mission computer flight plan; and to set altimeter settings in accordance with established procedures.
Data retrieved from NASA's ASRS site as of April 2012 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.