Boeing 737-376, VH-TAX

199902511

Safety Action

Local safety action

As a result of this investigation, the operator issued a safety notice to flight crew advising the circumstances of the occurrence, and emphasising the need for sterile flight deck requirements during critical phases of flight.

Summary

The Departures North radar controller was radar vectoring a Boeing 737 (B737) for a right downwind leg to runway 34R and had instructed the crew to descend to 7,000 ft, which was correctly read back. Subsequently, the controller observed the mode C altitude radar display for the aircraft indicating that it was descending through 6,400 ft. The controller requested that the crew confirm the assigned altitude and was advised that they had been assigned 5,000 ft. The controller instructed the crew to climb the aircraft to 7,000 ft. There was no infringement of separation standards; however, the B737 was being vectored to overfly a De Havilland Twin Otter, and vertical separation standards were being applied.

An investigation by the operator established that the pilot in command (PIC) had selected 5,000 ft in error, and that a cross-check of the altitude setting by the co-pilot had been obscured by sun reflections on the instrument panel. The PIC believed that he may have overheard the assignment of 5,000 ft to the crew of another aircraft at the time he was resetting the altitude indicator. At the same time, the purser entered the cockpit and this action may have distracted the PIC so that he only remembered the last altitude transmitted, and not that actually assigned to his aircraft.

Occurrence summary

Investigation number 199902511
Occurrence date 01/01/1995
Location 22 km N Sydney, (VOR)
State New South Wales
Report release date 01/02/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-TAX
Serial number 23489
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane, QLD
Destination Sydney, NSW
Damage Nil