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A B737-300 crew incorrectly set a very low altimeter setting resulting in a 1000 ft error during descent.
| Attributes | |
| ACN | 649389 |
| Time | |
| Date | 200503 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : pvd.airport |
| State Reference | RI |
| Altitude | msl single value : 11000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : zny.artcc tracon : n90.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | descent : approach |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Experience | flight time last 90 days : 250 flight time total : 8000 flight time type : 8000 |
| ASRS Report | 649389 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Experience | flight time last 90 days : 200 flight time total : 6500 flight time type : 2000 |
| ASRS Report | 649391 |
| Events | |
| Anomaly | altitude deviation : undershoot non adherence : clearance non adherence : published procedure other anomaly other |
| Independent Detector | other controllera other controllerb |
| Resolutory Action | controller : issued advisory controller : issued new clearance |
| Consequence | faa : reviewed incident with flight crew |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Weather |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
En route to pvd; marginal WX being discussed; first officer obtained ATIS. He wrote down pvd altimeter as 29.80 which was set out of FL180. Clearance altitude was 11000 ft; captain flying on LNAV; aircraft leveled at 11000 ft. Nyc inquired about altitude; said they showed us low. We both checked the altimeters which read 11000 ft. Handoff to pvd approach shortly after where he gave us an altimeter of 28.90 and a descent to 10000 ft. Confirmed 28.90 and realized the '8' and '9' had been reversed. Reset altimeters and continued to pvd with eventually a divert to bwi. I feel workload combined with an altimeter setting rarely seen caused the numbers to be reversed.
Original NASA ASRS Text
Title: A B737-300 CREW INCORRECTLY SET A VERY LOW ALTIMETER SETTING RESULTING IN A 1000 FT ERROR DURING DSCNT.
Narrative: ENRTE TO PVD; MARGINAL WX BEING DISCUSSED; FO OBTAINED ATIS. HE WROTE DOWN PVD ALTIMETER AS 29.80 WHICH WAS SET OUT OF FL180. CLRNC ALT WAS 11000 FT; CAPT FLYING ON LNAV; ACFT LEVELED AT 11000 FT. NYC INQUIRED ABOUT ALT; SAID THEY SHOWED US LOW. WE BOTH CHKED THE ALTIMETERS WHICH READ 11000 FT. HDOF TO PVD APCH SHORTLY AFTER WHERE HE GAVE US AN ALTIMETER OF 28.90 AND A DSCNT TO 10000 FT. CONFIRMED 28.90 AND REALIZED THE '8' AND '9' HAD BEEN REVERSED. RESET ALTIMETERS AND CONTINUED TO PVD WITH EVENTUALLY A DIVERT TO BWI. I FEEL WORKLOAD COMBINED WITH AN ALTIMETER SETTING RARELY SEEN CAUSED THE NUMBERS TO BE REVERSED.
Data retrieved from NASA's ASRS site as of January 2009 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.