Narrative:

We were descending into sfo, I was the PF and ATC had us at 320 KTS or greater. About mod on the MOD2 arrival we were given a descent to 17000 ft and a holding clearance at cedes. This caught us by surprise as we believed that the request for a faster than normal speed meant that we were leading the traffic flow into sfo. The captain, PNF, became busy programming the FMS, communicating to the passenger and the company (on ACARS) and verifying with me the holding clearance and proper pattern to be flown. We were IMC with engine alpa 1100 on, which requires a minimum N1 power setting that is higher than idle. As we descended through FL180, I looked at the ATIS for the current altimeter setting. I noted 30.06, set my altimeter to and announced 30.06, to which the captain acknowledged and set his altimeter to 30.06. At this point we were cleared to 14000 ft, before arriving at 17000 ft. Unknown at this point was the fact that I had noted the wrong value for the altimeter. The ATIS setting was actually 29.54 which resulted in an approximately error of 500 ft of altitude. As we descended through 15000 ft the controller questioned us about our altitude. He noted us 500 ft low. We responded that we had already been cleared to 14000 ft, not 15000 ft, to which he concurred and said it was his mistake. This was significant in that it reassured us that everything was okay. Looking back through it is now apparent that we all missed a very significant clue that we were on the wrong altimeter setting. Through the remainder of the flight no controller mentioned altitude deviation to us. We were eventually cleared to cross cedes at 11000 ft, which we did exactly, but we were actually at 10500 ft (unknown to us, of course). We cannot explain why at this point the controller did not query us about our latitude. We were then cleared to 8000 ft while being vectored to the final approach course. Traffic was called out to us at 7000 ft yet the only traffic we saw on TCASII was indicating 7500 ft. (We assume now that the TCASII error was from our erroneously set altimeters.) we were descending very slowly due to the N1 setting required for engine alpha 1100. Fortunately, this kept us from ever getting down to a cleared altitude before we received clearance to a further lower altitude. This fact caused us by chance to cross over the above mentioned traffic at an indicated altitude of 8500 ft. Due to the confusion of the controller issued traffic and the TCASII we elected to stay at 8500 ft until clear of this target. Sometimes you do things just to be extra safe and in this case it helped us maintain a 1000 ft separation from this target even though we had the potential for a loss of altitude separation. Eventually, we were given clearance for the final approach intercept along with clearance for the approach and a 4000 ft crossing restr and dumba. Again, since we were always 'high' due to engine alpha 1100, we intercepted the GS well before dumba and tracked it normally to the runway. We discovered our altimeter setting error at 1000 ft RA when I didn't hear the appropriate 1000 ft for call from the captain. The confusion led to the discovery of the discrepancy between the actual altimeter setting and the one we were using. Landing and taxi in were normal at least. The workload was very high at this time due to the unexpected holding clearance, night IMC, heavy communications, and for me a lack of recent time in the 767. (Referring to my logbook, I flew 9 total legs in the last yr on the 767, with the most recent experience 2 full months prior to this flight. All other flying was on the 757.) I make note of this because I found myself having to concentrate more on flying due to the subtle differences of the 767 from the 757. Even with the autoplt engaged I felt just that little bit more pressure due not only to a higher N1 setting for a descent, but also the basis 'feel' between the 767 and 757. These factors may have helped me to misread the ATIS altimeter setting and cause us as a crew not to discover our error until much later in the flight. The higher than normal N1 settings (causing us to be higher than normal at various stages of the approach transition) probably prevented us from actually being in an altitude deviation situation except for the cedes crossing and the 'traffic' crossing described above. Unfortunately, the checklist did not help us find our error in this situation. In conclusion, the one thing that stands out above all others lies in how transcribing the ATIS might be standardized. The 30.06 altimeter setting we used was actually the wind speed and direction and was written 3006. In my mind this was a reasonable setting versus something like 1806 (180 degrees at 6 KTS) which could not be mistaken for an altimeter setting. The altimeter setting was written 954, however, when I write down an ATIS I have the habit of writing 29.54. Therefore, I was looking for a 4 digit number. Additionally, I write ATIS winds thus: '300 degrees/6,' which again cannot be mistaken for an altimeter setting. I realize this may be a small consideration, but after this experience, I believe that this mistake has probably occurred many times before and will happen many times again. Our scenario was particularly acute due to the very low altimeter. Had the actual setting been 29.85, I may not be writing this report now. Supplemental information from acn 292601: during this busy period we passed through FL180, the transition altitude, and the first officer, realizing I was otherwise engaged, read the ATIS and advised altimeter 30.06, approach descent checklist, unfortunately misreading the information and reading the wind speed and direction as a (perfectly logical) altimeter setting. Since I was involved in other tasks and I expect because I had written the information at least 10 mins earlier and had dealt with dozens if not hundreds of other numbers since doing so, I took the message as received, dialed in 30.06 in both the standby altimeter and my own and thus the scenario for what followed was in place. The thing that concerns us most is that neither of us can think of a fault in our cockpit discipline which could be corrected in order to preclude future events of this type. Especially in a 2-MAN cockpit the sort of support between crew members exhibited by the first officer in reminding of altimeter settings is not only common but absolutely necessary, especially when the workload gets demanding as it did this night. As a matter of fact, I was mentally patting myself on the back as we descended on the GS as to how professionally we had handled the exigencies of this arrival -- right up to the time the first officer called our runway 28R in sight cleared to land -- 500 ft high! I do have one suggestion for procedural change which might prove of value, however. As it is now, the company has no SOP format for the display of ATIS information. Although a space is provided on the FLIP cards it is merely that-a space. The matter in which data is entered is similar but slightly different from pilot to pilot. We all eventually develop an 'individual' SOP for this important task. Perhaps the company would be well advised to reproduce the FLIP cards so that a format is printed on them for the basic WX information. In the interim, an SOP format for ATIS display could be implemented so that there is a uniform standard from pilot to pilot.

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Original NASA ASRS Text

Title: WRONG ALTIMETER SETTING CREATES A POTENTIAL FOR ALTDEVS ALT OVERSHOT IN DSCNT PROC.

Narrative: WE WERE DSNDING INTO SFO, I WAS THE PF AND ATC HAD US AT 320 KTS OR GREATER. ABOUT MOD ON THE MOD2 ARR WE WERE GIVEN A DSCNT TO 17000 FT AND A HOLDING CLRNC AT CEDES. THIS CAUGHT US BY SURPRISE AS WE BELIEVED THAT THE REQUEST FOR A FASTER THAN NORMAL SPD MEANT THAT WE WERE LEADING THE TFC FLOW INTO SFO. THE CAPT, PNF, BECAME BUSY PROGRAMMING THE FMS, COMMUNICATING TO THE PAX AND THE COMPANY (ON ACARS) AND VERIFYING WITH ME THE HOLDING CLRNC AND PROPER PATTERN TO BE FLOWN. WE WERE IMC WITH ENG ALPA 1100 ON, WHICH REQUIRES A MINIMUM N1 PWR SETTING THAT IS HIGHER THAN IDLE. AS WE DSNDED THROUGH FL180, I LOOKED AT THE ATIS FOR THE CURRENT ALTIMETER SETTING. I NOTED 30.06, SET MY ALTIMETER TO AND ANNOUNCED 30.06, TO WHICH THE CAPT ACKNOWLEDGED AND SET HIS ALTIMETER TO 30.06. AT THIS POINT WE WERE CLRED TO 14000 FT, BEFORE ARRIVING AT 17000 FT. UNKNOWN AT THIS POINT WAS THE FACT THAT I HAD NOTED THE WRONG VALUE FOR THE ALTIMETER. THE ATIS SETTING WAS ACTUALLY 29.54 WHICH RESULTED IN AN APPROX ERROR OF 500 FT OF ALT. AS WE DSNDED THROUGH 15000 FT THE CTLR QUESTIONED US ABOUT OUR ALT. HE NOTED US 500 FT LOW. WE RESPONDED THAT WE HAD ALREADY BEEN CLRED TO 14000 FT, NOT 15000 FT, TO WHICH HE CONCURRED AND SAID IT WAS HIS MISTAKE. THIS WAS SIGNIFICANT IN THAT IT REASSURED US THAT EVERYTHING WAS OKAY. LOOKING BACK THROUGH IT IS NOW APPARENT THAT WE ALL MISSED A VERY SIGNIFICANT CLUE THAT WE WERE ON THE WRONG ALTIMETER SETTING. THROUGH THE REMAINDER OF THE FLT NO CTLR MENTIONED ALTDEV TO US. WE WERE EVENTUALLY CLRED TO CROSS CEDES AT 11000 FT, WHICH WE DID EXACTLY, BUT WE WERE ACTUALLY AT 10500 FT (UNKNOWN TO US, OF COURSE). WE CANNOT EXPLAIN WHY AT THIS POINT THE CTLR DID NOT QUERY US ABOUT OUR LAT. WE WERE THEN CLRED TO 8000 FT WHILE BEING VECTORED TO THE FINAL APCH COURSE. TFC WAS CALLED OUT TO US AT 7000 FT YET THE ONLY TFC WE SAW ON TCASII WAS INDICATING 7500 FT. (WE ASSUME NOW THAT THE TCASII ERROR WAS FROM OUR ERRONEOUSLY SET ALTIMETERS.) WE WERE DSNDING VERY SLOWLY DUE TO THE N1 SETTING REQUIRED FOR ENGINE ALPHA 1100. FORTUNATELY, THIS KEPT US FROM EVER GETTING DOWN TO A CLRED ALT BEFORE WE RECEIVED CLRNC TO A FURTHER LOWER ALT. THIS FACT CAUSED US BY CHANCE TO CROSS OVER THE ABOVE MENTIONED TFC AT AN INDICATED ALT OF 8500 FT. DUE TO THE CONFUSION OF THE CTLR ISSUED TFC AND THE TCASII WE ELECTED TO STAY AT 8500 FT UNTIL CLR OF THIS TARGET. SOMETIMES YOU DO THINGS JUST TO BE EXTRA SAFE AND IN THIS CASE IT HELPED US MAINTAIN A 1000 FT SEPARATION FROM THIS TARGET EVEN THOUGH WE HAD THE POTENTIAL FOR A LOSS OF ALT SEPARATION. EVENTUALLY, WE WERE GIVEN CLRNC FOR THE FINAL APCH INTERCEPT ALONG WITH CLRNC FOR THE APCH AND A 4000 FT XING RESTR AND DUMBA. AGAIN, SINCE WE WERE ALWAYS 'HIGH' DUE TO ENGINE ALPHA 1100, WE INTERCEPTED THE GS WELL BEFORE DUMBA AND TRACKED IT NORMALLY TO THE RWY. WE DISCOVERED OUR ALTIMETER SETTING ERROR AT 1000 FT RA WHEN I DIDN'T HEAR THE APPROPRIATE 1000 FT FOR CALL FROM THE CAPT. THE CONFUSION LED TO THE DISCOVERY OF THE DISCREPANCY BTWN THE ACTUAL ALTIMETER SETTING AND THE ONE WE WERE USING. LNDG AND TAXI IN WERE NORMAL AT LEAST. THE WORKLOAD WAS VERY HIGH AT THIS TIME DUE TO THE UNEXPECTED HOLDING CLRNC, NIGHT IMC, HVY COMS, AND FOR ME A LACK OF RECENT TIME IN THE 767. (REFERRING TO MY LOGBOOK, I FLEW 9 TOTAL LEGS IN THE LAST YR ON THE 767, WITH THE MOST RECENT EXPERIENCE 2 FULL MONTHS PRIOR TO THIS FLT. ALL OTHER FLYING WAS ON THE 757.) I MAKE NOTE OF THIS BECAUSE I FOUND MYSELF HAVING TO CONCENTRATE MORE ON FLYING DUE TO THE SUBTLE DIFFERENCES OF THE 767 FROM THE 757. EVEN WITH THE AUTOPLT ENGAGED I FELT JUST THAT LITTLE BIT MORE PRESSURE DUE NOT ONLY TO A HIGHER N1 SETTING FOR A DSCNT, BUT ALSO THE BASIS 'FEEL' BTWN THE 767 AND 757. THESE FACTORS MAY HAVE HELPED ME TO MISREAD THE ATIS ALTIMETER SETTING AND CAUSE US AS A CREW NOT TO DISCOVER OUR ERROR UNTIL MUCH LATER IN THE FLT. THE HIGHER THAN NORMAL N1 SETTINGS (CAUSING US TO BE HIGHER THAN NORMAL AT VARIOUS STAGES OF THE APCH TRANSITION) PROBABLY PREVENTED US FROM ACTUALLY BEING IN AN ALTDEV SIT EXCEPT FOR THE CEDES XING AND THE 'TFC' XING DESCRIBED ABOVE. UNFORTUNATELY, THE CHKLIST DID NOT HELP US FIND OUR ERROR IN THIS SIT. IN CONCLUSION, THE ONE THING THAT STANDS OUT ABOVE ALL OTHERS LIES IN HOW TRANSCRIBING THE ATIS MIGHT BE STANDARDIZED. THE 30.06 ALTIMETER SETTING WE USED WAS ACTUALLY THE WIND SPD AND DIRECTION AND WAS WRITTEN 3006. IN MY MIND THIS WAS A REASONABLE SETTING VERSUS SOMETHING LIKE 1806 (180 DEGS AT 6 KTS) WHICH COULD NOT BE MISTAKEN FOR AN ALTIMETER SETTING. THE ALTIMETER SETTING WAS WRITTEN 954, HOWEVER, WHEN I WRITE DOWN AN ATIS I HAVE THE HABIT OF WRITING 29.54. THEREFORE, I WAS LOOKING FOR A 4 DIGIT NUMBER. ADDITIONALLY, I WRITE ATIS WINDS THUS: '300 DEGS/6,' WHICH AGAIN CANNOT BE MISTAKEN FOR AN ALTIMETER SETTING. I REALIZE THIS MAY BE A SMALL CONSIDERATION, BUT AFTER THIS EXPERIENCE, I BELIEVE THAT THIS MISTAKE HAS PROBABLY OCCURRED MANY TIMES BEFORE AND WILL HAPPEN MANY TIMES AGAIN. OUR SCENARIO WAS PARTICULARLY ACUTE DUE TO THE VERY LOW ALTIMETER. HAD THE ACTUAL SETTING BEEN 29.85, I MAY NOT BE WRITING THIS RPT NOW. SUPPLEMENTAL INFO FROM ACN 292601: DURING THIS BUSY PERIOD WE PASSED THROUGH FL180, THE TRANSITION ALT, AND THE FO, REALIZING I WAS OTHERWISE ENGAGED, READ THE ATIS AND ADVISED ALTIMETER 30.06, APCH DSCNT CHKLIST, UNFORTUNATELY MISREADING THE INFO AND READING THE WIND SPD AND DIRECTION AS A (PERFECTLY LOGICAL) ALTIMETER SETTING. SINCE I WAS INVOLVED IN OTHER TASKS AND I EXPECT BECAUSE I HAD WRITTEN THE INFO AT LEAST 10 MINS EARLIER AND HAD DEALT WITH DOZENS IF NOT HUNDREDS OF OTHER NUMBERS SINCE DOING SO, I TOOK THE MESSAGE AS RECEIVED, DIALED IN 30.06 IN BOTH THE STANDBY ALTIMETER AND MY OWN AND THUS THE SCENARIO FOR WHAT FOLLOWED WAS IN PLACE. THE THING THAT CONCERNS US MOST IS THAT NEITHER OF US CAN THINK OF A FAULT IN OUR COCKPIT DISCIPLINE WHICH COULD BE CORRECTED IN ORDER TO PRECLUDE FUTURE EVENTS OF THIS TYPE. ESPECIALLY IN A 2-MAN COCKPIT THE SORT OF SUPPORT BTWN CREW MEMBERS EXHIBITED BY THE FO IN REMINDING OF ALTIMETER SETTINGS IS NOT ONLY COMMON BUT ABSOLUTELY NECESSARY, ESPECIALLY WHEN THE WORKLOAD GETS DEMANDING AS IT DID THIS NIGHT. AS A MATTER OF FACT, I WAS MENTALLY PATTING MYSELF ON THE BACK AS WE DSNDED ON THE GS AS TO HOW PROFESSIONALLY WE HAD HANDLED THE EXIGENCIES OF THIS ARR -- RIGHT UP TO THE TIME THE FO CALLED OUR RWY 28R IN SIGHT CLRED TO LAND -- 500 FT HIGH! I DO HAVE ONE SUGGESTION FOR PROCEDURAL CHANGE WHICH MIGHT PROVE OF VALUE, HOWEVER. AS IT IS NOW, THE COMPANY HAS NO SOP FORMAT FOR THE DISPLAY OF ATIS INFO. ALTHOUGH A SPACE IS PROVIDED ON THE FLIP CARDS IT IS MERELY THAT-A SPACE. THE MATTER IN WHICH DATA IS ENTERED IS SIMILAR BUT SLIGHTLY DIFFERENT FROM PLT TO PLT. WE ALL EVENTUALLY DEVELOP AN 'INDIVIDUAL' SOP FOR THIS IMPORTANT TASK. PERHAPS THE COMPANY WOULD BE WELL ADVISED TO REPRODUCE THE FLIP CARDS SO THAT A FORMAT IS PRINTED ON THEM FOR THE BASIC WX INFO. IN THE INTERIM, AN SOP FORMAT FOR ATIS DISPLAY COULD BE IMPLEMENTED SO THAT THERE IS A UNIFORM STANDARD FROM PLT TO PLT.

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.