 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
An air carrier B737 flight crew depart with the captain's altimeter set to QFE versus qnh. Flight crew overshot their altitude by approximately 700 ft.
| Attributes | |
| ACN | 371610 |
| Time | |
| Date | 199706 |
| Day | Tue |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : pit |
| State Reference | PA |
| Altitude | msl bound lower : 5000 msl bound upper : 5700 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : pit |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other |
| Flight Phase | climbout : intermediate altitude ground : preflight |
| Route In Use | departure other departure sid : sid |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 210 flight time total : 15000 flight time type : 9000 |
| ASRS Report | 371610 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 175 flight time total : 18600 flight time type : 4600 |
| ASRS Report | 371608 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : far non adherence : published procedure |
| Independent Detector | other controllera other flight crewa |
| Resolutory Action | flight crew : returned to assigned altitude none taken : detected after the fact |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
On first leg of trip maintenance needed to perform engine runup. This check required setting altimeter on captain's side to QFE. On before start check captain nor first officer did not notice captain's altimeter was set 1000 ft low. On departure we were cleared to 5000 ft. All prescribed altitude awareness procedures were followed. When captain called 4000 ft for 5000 ft, first officer didn't notice on his altimeter that aircraft was at 5000 ft already. ATC asked first officer 'confirm altitude.' first officer responded '5000 ft' then realized altitude deviation. First officer brought it to captain's attention and deviation was then corrected. Ways to prevent this mistake could be: 1) have maintenance place switches in position they found them when returning to crew or line operations. 2) expand altitude awareness to entail pointing at altimeter settings on preflight checks. Supplemental information from acn 371608: captain's altimeter set to QFE as part of procedure. Subsequent cockpit setup and checklist was conducted very quickly and I failed to catch the altimeter setting of 28.88 vice qnh of 29.88.
Original NASA ASRS Text
Title: AN ACR B737 FLC DEPART WITH THE CAPT'S ALTIMETER SET TO QFE VERSUS QNH. FLC OVERSHOT THEIR ALT BY APPROX 700 FT.
Narrative: ON FIRST LEG OF TRIP MAINT NEEDED TO PERFORM ENG RUNUP. THIS CHK REQUIRED SETTING ALTIMETER ON CAPT'S SIDE TO QFE. ON BEFORE START CHK CAPT NOR FO DID NOT NOTICE CAPT'S ALTIMETER WAS SET 1000 FT LOW. ON DEP WE WERE CLRED TO 5000 FT. ALL PRESCRIBED ALT AWARENESS PROCS WERE FOLLOWED. WHEN CAPT CALLED 4000 FT FOR 5000 FT, FO DIDN'T NOTICE ON HIS ALTIMETER THAT ACFT WAS AT 5000 FT ALREADY. ATC ASKED FO 'CONFIRM ALT.' FO RESPONDED '5000 FT' THEN REALIZED ALTDEV. FO BROUGHT IT TO CAPT'S ATTN AND DEV WAS THEN CORRECTED. WAYS TO PREVENT THIS MISTAKE COULD BE: 1) HAVE MAINT PLACE SWITCHES IN POS THEY FOUND THEM WHEN RETURNING TO CREW OR LINE OPS. 2) EXPAND ALT AWARENESS TO ENTAIL POINTING AT ALTIMETER SETTINGS ON PREFLT CHKS. SUPPLEMENTAL INFO FROM ACN 371608: CAPT'S ALTIMETER SET TO QFE AS PART OF PROC. SUBSEQUENT COCKPIT SETUP AND CHKLIST WAS CONDUCTED VERY QUICKLY AND I FAILED TO CATCH THE ALTIMETER SETTING OF 28.88 VICE QNH OF 29.88.
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.