Narrative:

Set up: we were in a descent to be at FL150 13 NM prior to comet when ATC gave us the following instructions (ATC was narita approach): 'cleared to hold at kasmi, as published, 13000 ft, efc is 20, runway 34 in use.' as there are 2 fixes that sound alike, I confirmed the holding fix to be kasmi rather than cosmo and since kasmi was not on our route of flight, I asked to go there direct. ATC approved direct kasmi. Just approaching kasmi, ATC directed us to turn to 090 degrees and climb to 13000 ft. I replied we were turning to 090 degrees but were at 13000 ft. He again directed us to climb to 13000 ft, upon which we noticed we were at 29.92 altimeter setting rather than local altimeter of 29.32. In the confusion over the holding fix and a somewhat tight fuel situation with the efc we were given (40 mins in future), we had missed resetting our altimeter passing the transition level of 14000 ft. We started a climb as we reset our altimeter and heard ATC direct another aircraft to turn and look for us visually. I believe this aircraft was approaching us in a climb to 12000 ft. We got a TCASII TA one time as this aircraft passed 2-3 NM behind us and we leveled at 13000 ft MSL. Later (3-4 mins later) ATC asked us if we had been at 12500 ft, and I replied we had been at FL130 'standard altimeter' (29.92). Contributing factors: 1) very low altimeter (29.32). 2) unusual transition level (14000 ft). 3) clearance to a holding fix not on our route of flight. 4) clearance to 13000 ft, without giving the local altimeter with the clearance. 5) some language problems with the japanese controller. How discovered: by ATC. It appeared he discovered this early enough to keep our aircraft over 2 mi and 1000 ft separated. Corrective actions: 1) insure transition level is briefed prior to descent along with ATIS altimeter setting, especially when a low altimeter and nonstandard transition level are in use. 2) if ATC will always give the local altimeter whenever a descent to below the transition level is given, it will cue the flight crew to set it when they descend. Bottom line: this was our fault and a classic setup for an error like this. Human factors considerations: 1) fatigue. This was at the end of a 13 1/2 hour flight. Both the PF and PNF were coming off of a 2 1/2 hour rest break and the cobwebs were still evident in our thinking and performance. The other 'rest' crew were not in the cockpit and they struggled with a balky crew rest module that would not close properly. With those 2 extra pair of eyes/ears and brains in the cockpit, this might not have happened. 2) proficiency. The PF was new to the MD11 and its tricky FMS. He was having trouble loading the route of flight change, holding, efc which caused me to have to monitor his work closely and not keep up with the 'big picture.' 3) automation. The automation in this case was a hindrance to the PF as he was obviously reverting to boeing FMS programming which often won't work with MD11 FMS work. 4) communication. The japanese ATC controller gave a great deal of information (ie, route change, holding instructions, new runway in use, altitude change) without any preparation or indication of these coming. (We were the first aircraft sent to holding we heard on his frequency.) combine that with some language difficulty, 2 relatively groggy pilots in the cockpit and 2 available pilots not in the cockpit wrestling with a crew rest module, and the mix was right for this to happen. Supplemental information from acn 503409: I was in the process of briefing my copilot on our approach to the runway 16 ILS when we got our directions to hold at kasmi. My normal briefing is a 'nats' briefing. It includes NOTAMS, approach parameters and settings, terrain considerations/transition flight level and special pages (considerations). I had not gotten past the approach portion of the brief, so did not brief the copilot of the transition flight level. Supplemental information from acn 503420: of the 2 capts, I was the captain in charge. Since the second captain was in need of a leg to avoid a currency problem, I selected him to fly the first leg of our rotation. The copilot (teamed with me) awakened the resting captain. He arrived on deck a few mins later. I briefed him, and he took the left seat. Within a few mins, his copilot assumed his seat and explained that he could not stow the crew rest facility. My copilot went back to try to stow the crew rest facility. I stood behind the left seat to monitor the operation. The copilot working on the crew rest facility then asked me for help. When the situation was resolved, we returned to the cockpit. I noticed we were at 13000 ft. In a climbing turn, the TCASII sounded 'traffic, traffic' once. At the same time, the controller called our position to the other aircraft, who, after a pause, replied that he had us in sight.

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Original NASA ASRS Text

Title: POTENTIAL CONFLICT ENSUES WHEN AN MD11 FLC DSNDS 600 FT BELOW THEIR ASSIGNED ALT AFTER THEY OVERLOOK SETTING THEIR ALTIMETER TO THE LCL SETTING 5 MI N OF KASMI, FO.

Narrative: SET UP: WE WERE IN A DSCNT TO BE AT FL150 13 NM PRIOR TO COMET WHEN ATC GAVE US THE FOLLOWING INSTRUCTIONS (ATC WAS NARITA APCH): 'CLRED TO HOLD AT KASMI, AS PUBLISHED, 13000 FT, EFC IS 20, RWY 34 IN USE.' AS THERE ARE 2 FIXES THAT SOUND ALIKE, I CONFIRMED THE HOLDING FIX TO BE KASMI RATHER THAN COSMO AND SINCE KASMI WAS NOT ON OUR RTE OF FLT, I ASKED TO GO THERE DIRECT. ATC APPROVED DIRECT KASMI. JUST APCHING KASMI, ATC DIRECTED US TO TURN TO 090 DEGS AND CLB TO 13000 FT. I REPLIED WE WERE TURNING TO 090 DEGS BUT WERE AT 13000 FT. HE AGAIN DIRECTED US TO CLB TO 13000 FT, UPON WHICH WE NOTICED WE WERE AT 29.92 ALTIMETER SETTING RATHER THAN LCL ALTIMETER OF 29.32. IN THE CONFUSION OVER THE HOLDING FIX AND A SOMEWHAT TIGHT FUEL SIT WITH THE EFC WE WERE GIVEN (40 MINS IN FUTURE), WE HAD MISSED RESETTING OUR ALTIMETER PASSING THE TRANSITION LEVEL OF 14000 FT. WE STARTED A CLB AS WE RESET OUR ALTIMETER AND HEARD ATC DIRECT ANOTHER ACFT TO TURN AND LOOK FOR US VISUALLY. I BELIEVE THIS ACFT WAS APCHING US IN A CLB TO 12000 FT. WE GOT A TCASII TA ONE TIME AS THIS ACFT PASSED 2-3 NM BEHIND US AND WE LEVELED AT 13000 FT MSL. LATER (3-4 MINS LATER) ATC ASKED US IF WE HAD BEEN AT 12500 FT, AND I REPLIED WE HAD BEEN AT FL130 'STANDARD ALTIMETER' (29.92). CONTRIBUTING FACTORS: 1) VERY LOW ALTIMETER (29.32). 2) UNUSUAL TRANSITION LEVEL (14000 FT). 3) CLRNC TO A HOLDING FIX NOT ON OUR RTE OF FLT. 4) CLRNC TO 13000 FT, WITHOUT GIVING THE LCL ALTIMETER WITH THE CLRNC. 5) SOME LANGUAGE PROBS WITH THE JAPANESE CTLR. HOW DISCOVERED: BY ATC. IT APPEARED HE DISCOVERED THIS EARLY ENOUGH TO KEEP OUR ACFT OVER 2 MI AND 1000 FT SEPARATED. CORRECTIVE ACTIONS: 1) INSURE TRANSITION LEVEL IS BRIEFED PRIOR TO DSCNT ALONG WITH ATIS ALTIMETER SETTING, ESPECIALLY WHEN A LOW ALTIMETER AND NONSTANDARD TRANSITION LEVEL ARE IN USE. 2) IF ATC WILL ALWAYS GIVE THE LCL ALTIMETER WHENEVER A DSCNT TO BELOW THE TRANSITION LEVEL IS GIVEN, IT WILL CUE THE FLC TO SET IT WHEN THEY DSND. BOTTOM LINE: THIS WAS OUR FAULT AND A CLASSIC SETUP FOR AN ERROR LIKE THIS. HUMAN FACTORS CONSIDERATIONS: 1) FATIGUE. THIS WAS AT THE END OF A 13 1/2 HR FLT. BOTH THE PF AND PNF WERE COMING OFF OF A 2 1/2 HR REST BREAK AND THE COBWEBS WERE STILL EVIDENT IN OUR THINKING AND PERFORMANCE. THE OTHER 'REST' CREW WERE NOT IN THE COCKPIT AND THEY STRUGGLED WITH A BALKY CREW REST MODULE THAT WOULD NOT CLOSE PROPERLY. WITH THOSE 2 EXTRA PAIR OF EYES/EARS AND BRAINS IN THE COCKPIT, THIS MIGHT NOT HAVE HAPPENED. 2) PROFICIENCY. THE PF WAS NEW TO THE MD11 AND ITS TRICKY FMS. HE WAS HAVING TROUBLE LOADING THE RTE OF FLT CHANGE, HOLDING, EFC WHICH CAUSED ME TO HAVE TO MONITOR HIS WORK CLOSELY AND NOT KEEP UP WITH THE 'BIG PICTURE.' 3) AUTOMATION. THE AUTOMATION IN THIS CASE WAS A HINDRANCE TO THE PF AS HE WAS OBVIOUSLY REVERTING TO BOEING FMS PROGRAMMING WHICH OFTEN WON'T WORK WITH MD11 FMS WORK. 4) COM. THE JAPANESE ATC CTLR GAVE A GREAT DEAL OF INFO (IE, RTE CHANGE, HOLDING INSTRUCTIONS, NEW RWY IN USE, ALT CHANGE) WITHOUT ANY PREPARATION OR INDICATION OF THESE COMING. (WE WERE THE FIRST ACFT SENT TO HOLDING WE HEARD ON HIS FREQ.) COMBINE THAT WITH SOME LANGUAGE DIFFICULTY, 2 RELATIVELY GROGGY PLTS IN THE COCKPIT AND 2 AVAILABLE PLTS NOT IN THE COCKPIT WRESTLING WITH A CREW REST MODULE, AND THE MIX WAS RIGHT FOR THIS TO HAPPEN. SUPPLEMENTAL INFO FROM ACN 503409: I WAS IN THE PROCESS OF BRIEFING MY COPLT ON OUR APCH TO THE RWY 16 ILS WHEN WE GOT OUR DIRECTIONS TO HOLD AT KASMI. MY NORMAL BRIEFING IS A 'NATS' BRIEFING. IT INCLUDES NOTAMS, APCH PARAMETERS AND SETTINGS, TERRAIN CONSIDERATIONS/TRANSITION FLT LEVEL AND SPECIAL PAGES (CONSIDERATIONS). I HAD NOT GOTTEN PAST THE APCH PORTION OF THE BRIEF, SO DID NOT BRIEF THE COPLT OF THE TRANSITION FLT LEVEL. SUPPLEMENTAL INFO FROM ACN 503420: OF THE 2 CAPTS, I WAS THE CAPT IN CHARGE. SINCE THE SECOND CAPT WAS IN NEED OF A LEG TO AVOID A CURRENCY PROB, I SELECTED HIM TO FLY THE FIRST LEG OF OUR ROTATION. THE COPLT (TEAMED WITH ME) AWAKENED THE RESTING CAPT. HE ARRIVED ON DECK A FEW MINS LATER. I BRIEFED HIM, AND HE TOOK THE L SEAT. WITHIN A FEW MINS, HIS COPLT ASSUMED HIS SEAT AND EXPLAINED THAT HE COULD NOT STOW THE CREW REST FACILITY. MY COPLT WENT BACK TO TRY TO STOW THE CREW REST FACILITY. I STOOD BEHIND THE L SEAT TO MONITOR THE OP. THE COPLT WORKING ON THE CREW REST FACILITY THEN ASKED ME FOR HELP. WHEN THE SIT WAS RESOLVED, WE RETURNED TO THE COCKPIT. I NOTICED WE WERE AT 13000 FT. IN A CLBING TURN, THE TCASII SOUNDED 'TFC, TFC' ONCE. AT THE SAME TIME, THE CTLR CALLED OUR POS TO THE OTHER ACFT, WHO, AFTER A PAUSE, REPLIED THAT HE HAD US IN SIGHT.

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.