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A B767 flight, after an all night atlantic crossing, descends below the assigned altitude when the PF sets his altimeter to inches rather than MB during the approach to egll, first officer.
| Attributes | |
| ACN | 538207 |
| Time | |
| Date | 200202 |
| Day | Mon |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : egll.airport |
| State Reference | FO |
| Altitude | msl bound lower : 4700 msl bound upper : 5000 |
| Environment | |
| Light | Dawn |
| Aircraft 1 | |
| Controlling Facilities | artcc : egll.artcc |
| Operator | common carrier : air carrier |
| Make Model Name | B767 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | descent : intermediate altitude |
| Route In Use | approach : instrument precision |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| ASRS Report | 537491 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : relief pilot |
| Qualification | pilot : atp |
| ASRS Report | 538207 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance non adherence : company policies other anomaly other |
| Independent Detector | aircraft equipment : altitude alert other flight crewa other flight crewb |
| Resolutory Action | flight crew : became reoriented flight crew : returned to assigned altitude |
| Consequence | other |
| Supplementary | |
| Problem Areas | Environmental Factor Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
We were on the downwind heading east for vectors to the ILS runway 27L at lhr. Heathrow director issued a descent to 5000 ft and gave us an altimeter setting of 998 MB since this was below the transition level. The captain who was the PNF set his altimeter correctly. The first officer who was the PF inadvertently set his altimeter to 2998 in hg. Since the first officer's altimeter read about 400 ft high the descent continued to 4700 ft. The altitude warning sounded and the captain announced 'altitude, pull up.' the first officer responded with a climb to recover the altitude. The flight continued safely without further incident. Supplemental information from acn 537491: the relief pilot and captain noticed the descent through 5000 ft and the captain instructed the PF to pull up. It was early morning with cloudy WX and we just departed the holding pattern for the approach. All system on the aircraft were working normally.
Original NASA ASRS Text
Title: A B767 FLT, AFTER AN ALL NIGHT ATLANTIC XING, DSNDS BELOW THE ASSIGNED ALT WHEN THE PF SETS HIS ALTIMETER TO INCHES RATHER THAN MB DURING THE APCH TO EGLL, FO.
Narrative: WE WERE ON THE DOWNWIND HEADING E FOR VECTORS TO THE ILS RWY 27L AT LHR. HEATHROW DIRECTOR ISSUED A DSCNT TO 5000 FT AND GAVE US AN ALTIMETER SETTING OF 998 MB SINCE THIS WAS BELOW THE TRANSITION LEVEL. THE CAPT WHO WAS THE PNF SET HIS ALTIMETER CORRECTLY. THE FO WHO WAS THE PF INADVERTENTLY SET HIS ALTIMETER TO 2998 IN HG. SINCE THE FO'S ALTIMETER READ ABOUT 400 FT HIGH THE DSCNT CONTINUED TO 4700 FT. THE ALT WARNING SOUNDED AND THE CAPT ANNOUNCED 'ALT, PULL UP.' THE FO RESPONDED WITH A CLB TO RECOVER THE ALT. THE FLT CONTINUED SAFELY WITHOUT FURTHER INCIDENT. SUPPLEMENTAL INFO FROM ACN 537491: THE RELIEF PLT AND CAPT NOTICED THE DSCNT THROUGH 5000 FT AND THE CAPT INSTRUCTED THE PF TO PULL UP. IT WAS EARLY MORNING WITH CLOUDY WX AND WE JUST DEPARTED THE HOLDING PATTERN FOR THE APCH. ALL SYS ON THE ACFT WERE WORKING NORMALLY.
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.