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Flight crew of B737-400 uses wrong altimeter setting on descent. Approach controller receives ground proximity alert and issues climb, repeating altimeter setting.
| Attributes | |
| ACN | 390010 |
| Time | |
| Date | 199712 |
| Day | Tue |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : btv |
| State Reference | VT |
| Altitude | msl bound lower : 5400 msl bound upper : 6000 |
| Environment | |
| Flight Conditions | IMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : btv |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | descent other |
| Route In Use | enroute : on vectors |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 196 flight time total : 12800 flight time type : 8700 |
| ASRS Report | 390010 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
I was captain of flight from phl-btv. I was PF. During descent below FL180, I put 29.82 in my altimeter. First officer at this time was talking to company on the #2 radio. When he came back up, he also put 29.82 in his altimeter. We made 2 turns in published holding at 7000 ft awaiting a snow shower to pass by the field. After departing the hold, and being vectored for an ILS runway 33 approach, we were descending through 6000 ft for 5400 ft when the approach controller announced a ground proximity alert and told us to climb immediately to 6000 ft and to check our altimeters at 28.82. We immediately started to climb, checked our altimeters and discovered our mistake. We never got a GPWS warning. I have no explanation for such a serious mistake, other than the fact that it was such an unusually low altimeter setting that day. Both the first officer and I wrote the correct altimeter setting on our note pads, and both of us misset the correct altimeter. Neither of us realized our mistake until the approach controller warned us.
Original NASA ASRS Text
Title: FLC OF B737-400 USES WRONG ALTIMETER SETTING ON DSCNT. APCH CTLR RECEIVES GND PROX ALERT AND ISSUES CLB, REPEATING ALTIMETER SETTING.
Narrative: I WAS CAPT OF FLT FROM PHL-BTV. I WAS PF. DURING DSCNT BELOW FL180, I PUT 29.82 IN MY ALTIMETER. FO AT THIS TIME WAS TALKING TO COMPANY ON THE #2 RADIO. WHEN HE CAME BACK UP, HE ALSO PUT 29.82 IN HIS ALTIMETER. WE MADE 2 TURNS IN PUBLISHED HOLDING AT 7000 FT AWAITING A SNOW SHOWER TO PASS BY THE FIELD. AFTER DEPARTING THE HOLD, AND BEING VECTORED FOR AN ILS RWY 33 APCH, WE WERE DSNDING THROUGH 6000 FT FOR 5400 FT WHEN THE APCH CTLR ANNOUNCED A GND PROX ALERT AND TOLD US TO CLB IMMEDIATELY TO 6000 FT AND TO CHK OUR ALTIMETERS AT 28.82. WE IMMEDIATELY STARTED TO CLB, CHKED OUR ALTIMETERS AND DISCOVERED OUR MISTAKE. WE NEVER GOT A GPWS WARNING. I HAVE NO EXPLANATION FOR SUCH A SERIOUS MISTAKE, OTHER THAN THE FACT THAT IT WAS SUCH AN UNUSUALLY LOW ALTIMETER SETTING THAT DAY. BOTH THE FO AND I WROTE THE CORRECT ALTIMETER SETTING ON OUR NOTE PADS, AND BOTH OF US MISSET THE CORRECT ALTIMETER. NEITHER OF US REALIZED OUR MISTAKE UNTIL THE APCH CTLR WARNED US.
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.