Narrative:

During climb out, the flight was restr to 17000 ft. After cruising for a few mins at this altitude, we were cleared to FL230 and direct to psk. Climb was initiated and diverted attention to locating psk frequency on chart. After leveling off at FL230, 1 or 2 more step-climbs were issued to FL290. While cruising at FL290, ATC inquired about our altitude and I responded FL290, as indicated on all 3 altimeters. We were then cleared to FL310. As climb was initiated to FL310, I realized that all 3 altimeters were still set to qnh rather than qne (29.92). The altimeters were then reset to 29.92 and the flight continued climbing to FL310, where it cruised. The cause of missing the resetting of the altimeters passing FL180 was the distraction of searching for the VOR frequency, which occurred while climbing between 17000 ft and FL180. Continuing factors were: fatigue (this flight brought me within 15 mins of accumulating 30 hours in 5 days, under very adverse conditions) and, inexperienced first officer (new to the company and on the aircraft). A possible error trapping could have occurred had the controller mentioned the discrepancy in mode C (estimated at 300 ft) when we had leveled off 2 or 3 times before and after reaching FL290. His inquiry about our altitude did not trigger any suspicion since all 3 altimeters indicated the same altitude (FL290). It has been my experience in the last few yrs that ATC issues composite clrncs quite often (altitude, heading, airspeed, etc). This, combined with 4-DIGIT flight numbers, leads to confusion and adds a link to the possible error chain. Additionally, when such clrncs come at moments, when otherwise routine habit patterns are interrupted, the possibility of an untrapped error is greatly increased. Introduce to this chain fatigue and inexperience, and then we have an environment in which the human factor error reaches it greatest potential. As for this particular error (altimeter setting), I plan to rechk the setting several times after passing FL180, not only when I come through it.

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Original NASA ASRS Text

Title: B737 FLC FORGETS TO RESET THEIR ALTIMETERS AND OVERSHOT THEIR ASSIGNED ALT.

Narrative: DURING CLBOUT, THE FLT WAS RESTR TO 17000 FT. AFTER CRUISING FOR A FEW MINS AT THIS ALT, WE WERE CLRED TO FL230 AND DIRECT TO PSK. CLB WAS INITIATED AND DIVERTED ATTN TO LOCATING PSK FREQ ON CHART. AFTER LEVELING OFF AT FL230, 1 OR 2 MORE STEP-CLBS WERE ISSUED TO FL290. WHILE CRUISING AT FL290, ATC INQUIRED ABOUT OUR ALT AND I RESPONDED FL290, AS INDICATED ON ALL 3 ALTIMETERS. WE WERE THEN CLRED TO FL310. AS CLB WAS INITIATED TO FL310, I REALIZED THAT ALL 3 ALTIMETERS WERE STILL SET TO QNH RATHER THAN QNE (29.92). THE ALTIMETERS WERE THEN RESET TO 29.92 AND THE FLT CONTINUED CLBING TO FL310, WHERE IT CRUISED. THE CAUSE OF MISSING THE RESETTING OF THE ALTIMETERS PASSING FL180 WAS THE DISTR OF SEARCHING FOR THE VOR FREQ, WHICH OCCURRED WHILE CLBING BTWN 17000 FT AND FL180. CONTINUING FACTORS WERE: FATIGUE (THIS FLT BROUGHT ME WITHIN 15 MINS OF ACCUMULATING 30 HRS IN 5 DAYS, UNDER VERY ADVERSE CONDITIONS) AND, INEXPERIENCED FO (NEW TO THE COMPANY AND ON THE ACFT). A POSSIBLE ERROR TRAPPING COULD HAVE OCCURRED HAD THE CTLR MENTIONED THE DISCREPANCY IN MODE C (ESTIMATED AT 300 FT) WHEN WE HAD LEVELED OFF 2 OR 3 TIMES BEFORE AND AFTER REACHING FL290. HIS INQUIRY ABOUT OUR ALT DID NOT TRIGGER ANY SUSPICION SINCE ALL 3 ALTIMETERS INDICATED THE SAME ALT (FL290). IT HAS BEEN MY EXPERIENCE IN THE LAST FEW YRS THAT ATC ISSUES COMPOSITE CLRNCS QUITE OFTEN (ALT, HDG, AIRSPD, ETC). THIS, COMBINED WITH 4-DIGIT FLT NUMBERS, LEADS TO CONFUSION AND ADDS A LINK TO THE POSSIBLE ERROR CHAIN. ADDITIONALLY, WHEN SUCH CLRNCS COME AT MOMENTS, WHEN OTHERWISE ROUTINE HABIT PATTERNS ARE INTERRUPTED, THE POSSIBILITY OF AN UNTRAPPED ERROR IS GREATLY INCREASED. INTRODUCE TO THIS CHAIN FATIGUE AND INEXPERIENCE, AND THEN WE HAVE AN ENVIRONMENT IN WHICH THE HUMAN FACTOR ERROR REACHES IT GREATEST POTENTIAL. AS FOR THIS PARTICULAR ERROR (ALTIMETER SETTING), I PLAN TO RECHK THE SETTING SEVERAL TIMES AFTER PASSING FL180, NOT ONLY WHEN I COME THROUGH IT.

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.