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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Altitude overshot during an attempted VMC approach by a B767 flight crew when the crew forgets to reset their altimeters from qne to local qnh going through the 5500 ft transition level for ILS runway 25 at ebbr, first officer.
| Attributes | |
| ACN | 563856 |
| Time | |
| Date | 200210 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : ebbr.airport |
| State Reference | FO |
| Altitude | msl bound lower : 1500 msl bound upper : 2000 |
| Aircraft 1 | |
| Controlling Facilities | tracon : ebbr.tracon tower : zzz.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B767 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | descent : approach |
| Flight Plan | IFR |
| Aircraft 2 | |
| Controlling Facilities | tracon : ebbr.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | Commercial Fixed Wing |
| Operating Under FAR Part | Part 121 |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| ASRS Report | 563856 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | aircraft equipment problem : critical altitude deviation : overshoot inflight encounter : weather non adherence : company policies non adherence : published procedure non adherence : clearance other anomaly other anomaly other |
| Independent Detector | atc equipment other atc equipment : radar mode c other controllera |
| Resolutory Action | controller : issued alert flight crew : returned to assigned altitude flight crew : became reoriented |
| Consequence | other |
| Supplementary | |
| Problem Areas | Environmental Factor Flight Crew Human Performance Weather Aircraft Airspace Structure |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
On approach to runway 25L at bru with multiple erroneous indications due to an air ground sensor failure. I was avoiding icing by expediting through an opening in a broken layer between 6000 ft and 4000 ft. Over bru, our clearance was from FL80 to 2000 ft. Transition level was 5500 ft. I was focused on getting the aircraft through the broken layer and failed to reset my altimeters. ATC pointed out traffic to us as we passed 4500 ft. We did not see it visually, but had it on TCASII. It was at 2000 ft at our 9 O'clock position and passed well behind us. Both pilots were looking for the traffic as we passed through 4000 ft. At 3500 ft, I could see the field and we were always in VFR conditions. ATC cleared us to intercept the localizer for runway 25L. ATC instructed us to maintain 2000 ft until established on the ILS to runway 25L. This call coincided with the radio altimeter call at 2500 ft. We intercepted the ILS at about 2300 ft. I was leveling at 2000 ft when ATC instructed us to climb to 2000 ft and reset our altimeters. I climbed to 2000 ft and reset altimeters. Our failure to set the appropriate altimeter setting led us to about 500 ft low. We used proper procedure to set and verify MCP altitudes. I believe workload induced by multiple erroneous indications in the cockpit due to air ground sensor failure, avoiding icing, and the traffic calls from ATC, all contributed to our failure to set the altimeters. We were in VFR at all times.
Original NASA ASRS Text
Title: ALT OVERSHOT DURING AN ATTEMPTED VMC APCH BY A B767 FLC WHEN THE CREW FORGETS TO RESET THEIR ALTIMETERS FROM QNE TO LCL QNH GOING THROUGH THE 5500 FT TRANSITION LEVEL FOR ILS RWY 25 AT EBBR, FO.
Narrative: ON APCH TO RWY 25L AT BRU WITH MULTIPLE ERRONEOUS INDICATIONS DUE TO AN AIR GND SENSOR FAILURE. I WAS AVOIDING ICING BY EXPEDITING THROUGH AN OPENING IN A BROKEN LAYER BTWN 6000 FT AND 4000 FT. OVER BRU, OUR CLRNC WAS FROM FL80 TO 2000 FT. TRANSITION LEVEL WAS 5500 FT. I WAS FOCUSED ON GETTING THE ACFT THROUGH THE BROKEN LAYER AND FAILED TO RESET MY ALTIMETERS. ATC POINTED OUT TFC TO US AS WE PASSED 4500 FT. WE DID NOT SEE IT VISUALLY, BUT HAD IT ON TCASII. IT WAS AT 2000 FT AT OUR 9 O'CLOCK POS AND PASSED WELL BEHIND US. BOTH PLTS WERE LOOKING FOR THE TFC AS WE PASSED THROUGH 4000 FT. AT 3500 FT, I COULD SEE THE FIELD AND WE WERE ALWAYS IN VFR CONDITIONS. ATC CLRED US TO INTERCEPT THE LOC FOR RWY 25L. ATC INSTRUCTED US TO MAINTAIN 2000 FT UNTIL ESTABLISHED ON THE ILS TO RWY 25L. THIS CALL COINCIDED WITH THE RADIO ALTIMETER CALL AT 2500 FT. WE INTERCEPTED THE ILS AT ABOUT 2300 FT. I WAS LEVELING AT 2000 FT WHEN ATC INSTRUCTED US TO CLB TO 2000 FT AND RESET OUR ALTIMETERS. I CLBED TO 2000 FT AND RESET ALTIMETERS. OUR FAILURE TO SET THE APPROPRIATE ALTIMETER SETTING LED US TO ABOUT 500 FT LOW. WE USED PROPER PROC TO SET AND VERIFY MCP ALTS. I BELIEVE WORKLOAD INDUCED BY MULTIPLE ERRONEOUS INDICATIONS IN THE COCKPIT DUE TO AIR GND SENSOR FAILURE, AVOIDING ICING, AND THE TFC CALLS FROM ATC, ALL CONTRIBUTED TO OUR FAILURE TO SET THE ALTIMETERS. WE WERE IN VFR AT ALL TIMES.
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.