DC10-30 ACFT DURING CLB FROM FOREIGN ARPT; PF; FO; FORGOT TO CHANGE ALTIMETER AT TRANSITION ALT AND THUS CLBED ABOVE ASSIGNED ALT.

Date: 1997-05 · Aircraft: DC-10 30 · Phase: climb

Anomalies: conflict-airborne-conflict|deviation-altitude-overshoot|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy|other-unspecified

Synopsis

DC10-30 ACFT DURING CLB FROM FOREIGN ARPT; PF; FO; FORGOT TO CHANGE ALTIMETER AT TRANSITION ALT AND THUS CLBED ABOVE ASSIGNED ALT.

Narrative

WE DEPARTED MANCHESTER; ENGLAND; ARPT IN A DC10-30 FOR AN EMPTY (CREW ONLY) FERRY TO LONDON GATWICK ARPT. THE CAPT WAS STILL A HIGH MINIMUMS CAPT AND WAS ALLOWED THE TKOF AND DEP. WE WERE AT 1500 FT AND PER ICAO NOISE ABATEMENT PROCS; I CALLED FOR CLB THRUST. CLB THRUST WAS SELECTED BY PNF; HOWEVER; N1 WAS NOT SELECTED IN ORDER TO INITIATE CLB THRUST. THE TRANSITION ALT WAS 6000 FT MSL AND I FAILED TO SET 1013 MILLIBARS IN THE ALTIMETER BASE WINDOW. ON PROFILE AT BUGGED SPD; I CALLED FOR SLATS RETRACT AND CLB CHKLIST. THE AUTOPLT WAS ON AT 12000 FT MSL AS INDICATED ON THE INCORRECTLY SET ALTIMETER. WE WERE CLRED TO FL150 FT THEN FURTHER TO FL190. THE ALT FL190 WAS SET AND ARMED IN THE ALT WINDOW I WAS DISTR BY NAV WHILE THE PNF WAS ON THE RADIO. AT FL188 THE FE QUESTIONED WHAT ALT WE WERE CLRED TO. I LOOKED AT THE ALTIMETER AND FMA TO REALIZE THE AUTOPLT WAS CLBING THROUGH FL190. I IMMEDIATELY PUSHED THE YOKE OVER AND TRIMMED TO DISCONNECT THE AUTOPLT. THE CLB WAS STOPPED AT FL194 AND I DSNDED TO FL190. AS WE LEVELED AT FL190; WE RECEIVED AN RA FOR A CLB IN CONJUNCTION WITH A CTLR HDG CHANGE TO 270 DEGS FROM PREVIOUS HDG OF 190 DEGS. I INITIATED IMMEDIATE TURN TO 270 DEGS AS THE RA SUBSIDED. THE CHAIN OF ERRORS WAS QUITE OBVIOUS AS I SAT AND WROTE THEM DOWN: CLB PWR NOT BEING SELECTED; WHICH I SHOULD HAVE CAUGHT IN THE FMA. THE 1013 MILLIBARS NOT SELECTED AT 6000 FT MSL BY MYSELF; AND WHICH MY MISTAKE SHOULD HAVE BEEN CAUGHT BY THE ENGINEER IN RUNNING THE CLB CHKLIST. THE AUTOPLT NOT READING ALT CAPTURE; WHICH SHOULD HAVE BEEN CAUGHT BY ME SOONER. NOT ALLOWING MYSELF TO BE DISTR DURING SUCH A PHASE OF FLT. I SHOULD HAVE OVERRIDDEN THE AUTOPLT SOONER. AND; MY FAULT OF RELYING ON THE AUTOPLT AND NOT POSITIVELY MONITORING IT. I SHOULD HAVE SELECTED SPD MODE ON THE FMS AND SLOWED THE CLB TO 1000 FPM AT 2000 FT BELOW ASSIGNED ALT; ALL IN HINDSIGHT. DEFINITE CONTRIBUTING FACTORS: 1) CLB PWR NOT SELECTED. 2) 1013 MILLIBARS NOT BEING SET 6000 FT MSL. 3) 1013 MILLIBARS NOT CAUGHT IN CLB CHKLIST. 4) MY DISTR FROM MY FLYING DUTIES. 5) EXCESSIVE RATE OF CLB COULD HAVE CAUSED AUTOPLT'S FAULTY CAPTURE OF ALT.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.