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Altimeter setting rule not followed in descent procedure out of FL180. Altitude deviation altitude overshot in descent.
| Attributes | |
| ACN | 228157 |
| Time | |
| Date | 199212 |
| Day | Tue |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : pdx |
| State Reference | OR |
| Altitude | msl bound lower : 4500 msl bound upper : 5000 |
| Environment | |
| Flight Conditions | IMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : pdx |
| Operator | general aviation : corporate |
| Make Model Name | Light Transport, Low Wing, 2 Turbojet Eng |
| Flight Phase | cruise other descent other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | Other |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : cfi pilot : atp |
| Experience | flight time last 90 days : 80 flight time total : 3400 flight time type : 80 |
| ASRS Report | 228157 |
| Person 2 | |
| Affiliation | Other |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : commercial |
| 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 |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Busy and somewhat fatigued, we were descending into pdx for approach dealing with icing and avoiding areas of heavier precipitation on our WX radar. We had been in the clouds from mid twenties altitude wise. Prior to that we were briefing approach and readying the aircraft for descent through icing. Thinking far enough ahead we ran all checklists. I think upon reaching 18000 ft, busy with icing and WX, we overlooked running the 18000 ft items of the checklist and neither of us caught the fact the altimeters had not been set to I believe 29.54. Only after the controller called us asking if we were level at 5000 ft and he was showing 4500 ft did I immediately initiate a climb and reset the altimeter. I compliment the controller and have become much more critical of myself regarding 18000 ft awareness, which I thought was sufficient awareness. Because of its criticalness, I have instituted not only 18000 ft check, but 2 more checks: one at initial altitude above or below 18000 ft, example: '16000 ft on 29.54 inches' set and on initial vector for approach on procedure turn inbound, example: 5000 ft on 29.54 set. The nature of our business is that a simple little number in a window can mean the difference between a pleasant ride and disaster.
Original NASA ASRS Text
Title: ALTIMETER SETTING RULE NOT FOLLOWED IN DSCNT PROC OUT OF FL180. ALTDEV ALT OVERSHOT IN DSCNT.
Narrative: BUSY AND SOMEWHAT FATIGUED, WE WERE DSNDING INTO PDX FOR APCH DEALING WITH ICING AND AVOIDING AREAS OF HEAVIER PRECIPITATION ON OUR WX RADAR. WE HAD BEEN IN THE CLOUDS FROM MID TWENTIES ALT WISE. PRIOR TO THAT WE WERE BRIEFING APCH AND READYING THE ACFT FOR DSCNT THROUGH ICING. THINKING FAR ENOUGH AHEAD WE RAN ALL CHKLISTS. I THINK UPON REACHING 18000 FT, BUSY WITH ICING AND WX, WE OVERLOOKED RUNNING THE 18000 FT ITEMS OF THE CHKLIST AND NEITHER OF US CAUGHT THE FACT THE ALTIMETERS HAD NOT BEEN SET TO I BELIEVE 29.54. ONLY AFTER THE CTLR CALLED US ASKING IF WE WERE LEVEL AT 5000 FT AND HE WAS SHOWING 4500 FT DID I IMMEDIATELY INITIATE A CLB AND RESET THE ALTIMETER. I COMPLIMENT THE CTLR AND HAVE BECOME MUCH MORE CRITICAL OF MYSELF REGARDING 18000 FT AWARENESS, WHICH I THOUGHT WAS SUFFICIENT AWARENESS. BECAUSE OF ITS CRITICALNESS, I HAVE INSTITUTED NOT ONLY 18000 FT CHK, BUT 2 MORE CHKS: ONE AT INITIAL ALT ABOVE OR BELOW 18000 FT, EXAMPLE: '16000 FT ON 29.54 INCHES' SET AND ON INITIAL VECTOR FOR APCH ON PROC TURN INBOUND, EXAMPLE: 5000 FT ON 29.54 SET. THE NATURE OF OUR BUSINESS IS THAT A SIMPLE LITTLE NUMBER IN A WINDOW CAN MEAN THE DIFFERENCE BTWN A PLEASANT RIDE AND DISASTER.
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.