<< >> NASA ASRS Report 336470, May 1996

Wrong altimeter setting. Flight crew forgot to set altimeters to qnh descending out of 18000 ft. Approach controller didn't give an altimeter setting with descent clearance.

Attributes
ACN	336470
Time
Date	199605
Day	Sun
Local Time Of Day	1201 To 1800
Place
Locale Reference	atc facility : ord
State Reference	IL
Altitude	msl bound lower : 8700 msl bound upper : 9000
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : ord tower : atl
Operator	common carrier : air carrier
Make Model Name	B767-200
Operating Under FAR Part	Part 121
Navigation In Use	Other Other
Flight Phase	cruise other descent other
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
ASRS Report	336470
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : atp
ASRS Report	336211
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:

Approach control advised may/xx/96, that he read our altitude as 8700 ft. He was correct. We had 29.92 altimeter setting instead of 29.59. We reset correctly and climbed to 9000 ft. There were no conflicts or other actions taken. TCASII was operating normally. There are reasons for errors made but to learn from mistakes you must realize they are mistakes. This event should not have happened. The copilot was flying and descending through FL180 and was distracted by a 'not on intercept heading' message on the CDU screen and I think the controller did not pass the current altimeter setting to us. This is an important cue. A tired crew returning from europe and different altimeter procedures did not complete their descent checklist at FL180 and reset the altimeters. The lesson is -- checklist! Checklist! Checklist! It saves you from the always present distractions.

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Original NASA ASRS Text

Title: WRONG ALTIMETER SETTING. FLC FORGOT TO SET ALTIMETERS TO QNH DSNDING OUT OF 18000 FT. APCH CTLR DIDN'T GIVE AN ALTIMETER SETTING WITH DSCNT CLRNC.

Narrative: APCH CTL ADVISED MAY/XX/96, THAT HE READ OUR ALT AS 8700 FT. HE WAS CORRECT. WE HAD 29.92 ALTIMETER SETTING INSTEAD OF 29.59. WE RESET CORRECTLY AND CLBED TO 9000 FT. THERE WERE NO CONFLICTS OR OTHER ACTIONS TAKEN. TCASII WAS OPERATING NORMALLY. THERE ARE REASONS FOR ERRORS MADE BUT TO LEARN FROM MISTAKES YOU MUST REALIZE THEY ARE MISTAKES. THIS EVENT SHOULD NOT HAVE HAPPENED. THE COPLT WAS FLYING AND DSNDING THROUGH FL180 AND WAS DISTRACTED BY A 'NOT ON INTERCEPT HDG' MESSAGE ON THE CDU SCREEN AND I THINK THE CTLR DID NOT PASS THE CURRENT ALTIMETER SETTING TO US. THIS IS AN IMPORTANT CUE. A TIRED CREW RETURNING FROM EUROPE AND DIFFERENT ALTIMETER PROCS DID NOT COMPLETE THEIR DSCNT CHKLIST AT FL180 AND RESET THE ALTIMETERS. THE LESSON IS -- CHKLIST! CHKLIST! CHKLIST! IT SAVES YOU FROM THE ALWAYS PRESENT DISTRACTIONS.

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.