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An air carrier B757 flight crew forgot to reset all of their altimeters and the autoplt, referencing the misset altimeter, climbed above their assigned altitude.
| Attributes | |
| ACN | 398287 |
| Time | |
| Date | 199803 |
| Day | Mon |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | atc facility : fuz |
| State Reference | TX |
| Altitude | msl bound lower : 21000 msl bound upper : 21250 |
| Environment | |
| Flight Conditions | IMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : zfw tower : oak |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | cruise other |
| Flight Plan | IFR |
| Person 1 | |
| 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 : 15000 flight time type : 4100 |
| ASRS Report | 398287 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| ASRS Report | 398280 |
| Events | |
| Anomaly | altitude deviation : excursion from assigned altitude inflight encounter : weather inflight encounter other non adherence : clearance non adherence : published procedure other anomaly other |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera other flight crewa |
| Resolutory Action | none taken : detected after the fact other other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
On leveloff FL210 (autoplt engaged in proximity of thunderstorm and moderate turbulence) autoplt overshot altitude by +/-100 ft. Autoplt was disengaged and aircraft flown by hand to FL210. Autoplt was re-engaged and aircraft began climb again. ATC queried us about our altitude and called traffic at FL220. We noted center altimeter was not reset to 29.92 (still reading dfw local altimeter setting). We reset center altimeter, disconnected autoplt again, and hand flew back to FL210. No evasive action was taken by either aircraft and the other air carrier advised ATC they had visual contact with our aircraft. Probable cause: failure to accomplish climb checklist as per SOP. Both captain and first officer altimeters were properly reset to 29.92, but center was not. Contributing factors: thunderstorm avoidance and moderate turbulence distracting factors. 3 hour ground delay awaiting departure release for WX (thunderstorms). I thought altitude overshoot was due to moderate turbulence initially.
Original NASA ASRS Text
Title: AN ACR B757 FLC FORGOT TO RESET ALL OF THEIR ALTIMETERS AND THE AUTOPLT, REFING THE MISSET ALTIMETER, CLBED ABOVE THEIR ASSIGNED ALT.
Narrative: ON LEVELOFF FL210 (AUTOPLT ENGAGED IN PROX OF TSTM AND MODERATE TURB) AUTOPLT OVERSHOT ALT BY +/-100 FT. AUTOPLT WAS DISENGAGED AND ACFT FLOWN BY HAND TO FL210. AUTOPLT WAS RE-ENGAGED AND ACFT BEGAN CLB AGAIN. ATC QUERIED US ABOUT OUR ALT AND CALLED TFC AT FL220. WE NOTED CTR ALTIMETER WAS NOT RESET TO 29.92 (STILL READING DFW LCL ALTIMETER SETTING). WE RESET CTR ALTIMETER, DISCONNECTED AUTOPLT AGAIN, AND HAND FLEW BACK TO FL210. NO EVASIVE ACTION WAS TAKEN BY EITHER ACFT AND THE OTHER ACR ADVISED ATC THEY HAD VISUAL CONTACT WITH OUR ACFT. PROBABLE CAUSE: FAILURE TO ACCOMPLISH CLB CHKLIST AS PER SOP. BOTH CAPT AND FO ALTIMETERS WERE PROPERLY RESET TO 29.92, BUT CTR WAS NOT. CONTRIBUTING FACTORS: TSTM AVOIDANCE AND MODERATE TURB DISTRACTING FACTORS. 3 HR GND DELAY AWAITING DEP RELEASE FOR WX (TSTMS). I THOUGHT ALT OVERSHOOT WAS DUE TO MODERATE TURB INITIALLY.
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.