Narrative:

I was the first officer and was responsible for computer entries and radio communication. We were cleared out of FL230 to 10000 ft by tokyo center. We were given a crossing restriction of at or below 15000 ft at melon intersection. In short order, we were given revised clearance to 11000 ft then handed off to tokyo narita approach who then gave a clearance to hold at aries intersection. We were perhaps 20 DME from the fix. An already busy arrival was made more so by the following factors: 1) WX - thunderstorms, turbulence. Captain was closely monitoring radar. 2) WX at destination - reported at mins. Crew during descent was discussing possible divert to oshka. International officer fell out of loop while getting oshka WX and monitoring ATIS. New ATIS indicated runway change. 3) I was overly occupied with computer duties - holding, new arrival, new approach. I did not monitor descent closely enough. 4) language - the controller was difficult to understand. I required repeats of several of the transmissions. I also had to ask for efc. 5) we were descended late - captain elected to hand fly the aircraft to make the crossing restriction. The automatic pilot off alarm distracted me for a few moments at a critical time about 17000 ft (TA 14000 ft). I had completed the descent checklist to 18000 ft (or trans altitude). After the autoplt off alarm I went back to the computer and was so engaged when narita approach told us we were below altitude and to climb and turn. The captain reacted immediately. We had failed to reset altimeters from 29.92 to 29.19 at transition altitude. Nobody was thinking descent checklist. It is extremely difficult to maintain cockpit awareness and scan in FMC aircraft when rapid change is required. Particularly with the head down keypad. Contributing factors: 1) high workload aircraft with relatively low time crew descending into area of heavy WX. 2) last min holding instructions took the first officer out of the loop while reprogramming the computer. 3) I now backing first officer up on getting the transition altitude checklist completed. 4) captain not doublechking to see that all the checklist items had been completed. Lessons to be learned: 1) all crew members need to insure checklist is complete (including the one who is flying). 2) all crew members need to be in the loop during approach, particularly when WX, language differences, and last min clrncs could complicate the approach.

Google
 

Original NASA ASRS Text

Title: ACR FLC IN NEW MODEL WDB HAS ALT DEV ALT OVERSHOT ALT EXCURSION DUE TO WRONG ALTIMETER SETTING.

Narrative: I WAS THE FO AND WAS RESPONSIBLE FOR COMPUTER ENTRIES AND RADIO COM. WE WERE CLRED OUT OF FL230 TO 10000 FT BY TOKYO CENTER. WE WERE GIVEN A XING RESTRICTION OF AT OR BELOW 15000 FT AT MELON INTXN. IN SHORT ORDER, WE WERE GIVEN REVISED CLRNC TO 11000 FT THEN HANDED OFF TO TOKYO NARITA APCH WHO THEN GAVE A CLRNC TO HOLD AT ARIES INTXN. WE WERE PERHAPS 20 DME FROM THE FIX. AN ALREADY BUSY ARR WAS MADE MORE SO BY THE FOLLOWING FACTORS: 1) WX - TSTMS, TURB. CAPT WAS CLOSELY MONITORING RADAR. 2) WX AT DEST - RPTED AT MINS. CREW DURING DSCNT WAS DISCUSSING POSSIBLE DIVERT TO OSHKA. INTL OFFICER FELL OUT OF LOOP WHILE GETTING OSHKA WX AND MONITORING ATIS. NEW ATIS INDICATED RWY CHANGE. 3) I WAS OVERLY OCCUPIED WITH COMPUTER DUTIES - HOLDING, NEW ARR, NEW APCH. I DID NOT MONITOR DSCNT CLOSELY ENOUGH. 4) LANGUAGE - THE CTLR WAS DIFFICULT TO UNDERSTAND. I REQUIRED REPEATS OF SEVERAL OF THE TRANSMISSIONS. I ALSO HAD TO ASK FOR EFC. 5) WE WERE DSNDED LATE - CAPT ELECTED TO HAND FLY THE ACFT TO MAKE THE XING RESTRICTION. THE AUTO PLT OFF ALARM DISTRACTED ME FOR A FEW MOMENTS AT A CRITICAL TIME ABOUT 17000 FT (TA 14000 FT). I HAD COMPLETED THE DSCNT CHKLIST TO 18000 FT (OR TRANS ALT). AFTER THE AUTOPLT OFF ALARM I WENT BACK TO THE COMPUTER AND WAS SO ENGAGED WHEN NARITA APCH TOLD US WE WERE BELOW ALT AND TO CLB AND TURN. THE CAPT REACTED IMMEDIATELY. WE HAD FAILED TO RESET ALTIMETERS FROM 29.92 TO 29.19 AT TRANSITION ALT. NOBODY WAS THINKING DSCNT CHKLIST. IT IS EXTREMELY DIFFICULT TO MAINTAIN COCKPIT AWARENESS AND SCAN IN FMC ACFT WHEN RAPID CHANGE IS REQUIRED. PARTICULARLY WITH THE HEAD DOWN KEYPAD. CONTRIBUTING FACTORS: 1) HIGH WORKLOAD ACFT WITH RELATIVELY LOW TIME CREW DSNDING INTO AREA OF HVY WX. 2) LAST MIN HOLDING INSTRUCTIONS TOOK THE FO OUT OF THE LOOP WHILE REPROGRAMMING THE COMPUTER. 3) I NOW BACKING FO UP ON GETTING THE TRANSITION ALT CHKLIST COMPLETED. 4) CAPT NOT DOUBLECHKING TO SEE THAT ALL THE CHKLIST ITEMS HAD BEEN COMPLETED. LESSONS TO BE LEARNED: 1) ALL CREW MEMBERS NEED TO INSURE CHKLIST IS COMPLETE (INCLUDING THE ONE WHO IS FLYING). 2) ALL CREW MEMBERS NEED TO BE IN THE LOOP DURING APCH, PARTICULARLY WHEN WX, LANGUAGE DIFFERENCES, AND LAST MIN CLRNCS COULD COMPLICATE THE APCH.

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.