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Air carrier medium large transport altitude deviation because the flight crew failed to set qnh passing 18000 ft. Altitude error resulted in a TCASII RA for traffic 2-3 NM away.
| Attributes | |
| ACN | 200320 |
| Time | |
| Date | 199201 |
| Day | Mon |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : hcm |
| State Reference | VA |
| Altitude | msl bound lower : 28000 msl bound upper : 28800 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zla |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | enroute airway : zdc |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 15000 |
| ASRS Report | 200320 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : flight engineer pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 6500 flight time type : 2000 |
| ASRS Report | 200162 |
| Events | |
| Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
| Resolutory Action | flight crew : returned to intended course or assigned course |
| Consequence | Other |
| Miss Distance | horizontal : 21000 vertical : 1000 |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Flight from dca to mia, crew did not set qnh at FL180, due to distrs, multiple heading changes and step climbs with level off at FL180, 20, 22, 26, 28. Altimeter was left at 30.58. At FL280 center gave us a climb to 310, at 28800 on our incorrect atl center said return to FL280. We then received a TCASII RA for a 2500 ft rate descent, we descended to our FL280 then discovered error and returned to FL280 with 29.92 set. (We had a visual on traffic at our 11 O'clock and about FL290).
Original NASA ASRS Text
Title: ACR MLG ALTDEV BECAUSE THE FLC FAILED TO SET QNH PASSING 18000 FT. ALT ERROR RESULTED IN A TCASII RA FOR TFC 2-3 NM AWAY.
Narrative: FLT FROM DCA TO MIA, CREW DID NOT SET QNH AT FL180, DUE TO DISTRS, MULTIPLE HDG CHANGES AND STEP CLBS WITH LEVEL OFF AT FL180, 20, 22, 26, 28. ALTIMETER WAS LEFT AT 30.58. AT FL280 CTR GAVE US A CLB TO 310, AT 28800 ON OUR INCORRECT ATL CTR SAID RETURN TO FL280. WE THEN RECEIVED A TCASII RA FOR A 2500 FT RATE DSCNT, WE DSNDED TO OUR FL280 THEN DISCOVERED ERROR AND RETURNED TO FL280 WITH 29.92 SET. (WE HAD A VISUAL ON TFC AT OUR 11 O'CLOCK AND ABOUT FL290).
Data retrieved from NASA's ASRS site as of July 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.