Narrative:

This is a narrative of the sequence of events that led to an altitude deviation on feb/tue/02, lhr-jfk. The altitude deviation stemmed from an inadvertent deviation from SOP. Our flight departed egll on runway 27R, wobun 2F departure. After flying at 6000 ft for approximately 10 mins, we were instructed by lhr control to turn right, climb 8000 ft. I was hand flying as we initiated a VNAV climb as we had previously briefed prior to departure. As the aircraft was climbing to 8000 ft, london control requested flight level leaving. At this point, both pilots reset their altimeters from 0093 millibars to 1013.2 millibars. The indicated altitude climbed to approximately 8450 ft. London then instructed us to descend and turn left to approximately 360 degree heading. No TCASII activations occurred. Although the transition level was briefed numerous times before takeoff, because of workload and task prioritization problems, all of us had let our situational awareness deteriorate. In retrospect, several CRM/SOP deviations can be detected and analyzed. Situational awareness: failure to reset 1013.2 millibars immediately after the controller gave the turn/climb instruction to 8000 ft. Workload management: as the PF, it would have improved my crew's performance if I had been using the autoplt. There would have been less workload on the PNF and I could have diverted more attention to the situational awareness aspects of the flight. At the time I was trying to keep my proficiency current on hand flying. In the future, I will more carefully evaluate my autoplt/hand flying options. Human factors: 1) high workload from lhr control in respect to heading changes and TA's. 2) maneuvering -- slowing ATC initiated turn to avoid cumulus clouds. 3) low pressure of 0093 millibars magnified the transition error. 4) nonstandard transition levels, depending on country, on climb, and on descent. 5) fast controller instructions. When not accustomed to foreign accent, the fast pace of instructions sometimes requires a moment to process. Many times, all 3 crew members will confer and discuss what we think we heard, before readback. Supplemental information from acn 539620: after several heading changes, the third pilot asked to rank the IRU's. Prior to selecting the FMC page, we received a clearance for a right turn and a climb to 8000 ft. I set 8000 ft into the altitude window and pointed to the altitude, and the first officer pointed as well. I went down to the FMC climb page and selected climb direct as briefed. I then selected the FMC page to rank IRU's. During this process, the controller asked for our altitude. We then noticed we had failed to set 1013 millibars out of 6000 ft. Workload management. Captain did not prioritize his workload and was using the FMC leaving the transition altitude. High workload from ATC was a factor. Human factors involved: high workload from ATC, high radio traffic from london. A different transition altitude than normal. Supplemental information from acn 539622: captain was selecting climb direct in the FMC so that first officer could use VNAV. I asked captain to pull up the position reference page so I could begin the class ii checklist prior to coast out. After a few moments in the climb, ATC queried our altitude.

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Original NASA ASRS Text

Title: AN ALTDEV OVERSHOOT OCCURS WHEN A B767-300 FLC FAILS TO RESET THEIR ALTIMETERS TO QNE WHEN LEAVING 6000 FT FOR 8000 FT ON THE DEP PROC FROM EGLL, FO.

Narrative: THIS IS A NARRATIVE OF THE SEQUENCE OF EVENTS THAT LED TO AN ALTDEV ON FEB/TUE/02, LHR-JFK. THE ALTDEV STEMMED FROM AN INADVERTENT DEV FROM SOP. OUR FLT DEPARTED EGLL ON RWY 27R, WOBUN 2F DEP. AFTER FLYING AT 6000 FT FOR APPROX 10 MINS, WE WERE INSTRUCTED BY LHR CTL TO TURN R, CLB 8000 FT. I WAS HAND FLYING AS WE INITIATED A VNAV CLB AS WE HAD PREVIOUSLY BRIEFED PRIOR TO DEP. AS THE ACFT WAS CLBING TO 8000 FT, LONDON CTL REQUESTED FLT LEVEL LEAVING. AT THIS POINT, BOTH PLTS RESET THEIR ALTIMETERS FROM 0093 MILLIBARS TO 1013.2 MILLIBARS. THE INDICATED ALT CLBED TO APPROX 8450 FT. LONDON THEN INSTRUCTED US TO DSND AND TURN L TO APPROX 360 DEG HDG. NO TCASII ACTIVATIONS OCCURRED. ALTHOUGH THE TRANSITION LEVEL WAS BRIEFED NUMEROUS TIMES BEFORE TKOF, BECAUSE OF WORKLOAD AND TASK PRIORITIZATION PROBS, ALL OF US HAD LET OUR SITUATIONAL AWARENESS DETERIORATE. IN RETROSPECT, SEVERAL CRM/SOP DEVS CAN BE DETECTED AND ANALYZED. SITUATIONAL AWARENESS: FAILURE TO RESET 1013.2 MILLIBARS IMMEDIATELY AFTER THE CTLR GAVE THE TURN/CLB INSTRUCTION TO 8000 FT. WORKLOAD MGMNT: AS THE PF, IT WOULD HAVE IMPROVED MY CREW'S PERFORMANCE IF I HAD BEEN USING THE AUTOPLT. THERE WOULD HAVE BEEN LESS WORKLOAD ON THE PNF AND I COULD HAVE DIVERTED MORE ATTN TO THE SITUATIONAL AWARENESS ASPECTS OF THE FLT. AT THE TIME I WAS TRYING TO KEEP MY PROFICIENCY CURRENT ON HAND FLYING. IN THE FUTURE, I WILL MORE CAREFULLY EVALUATE MY AUTOPLT/HAND FLYING OPTIONS. HUMAN FACTORS: 1) HIGH WORKLOAD FROM LHR CTL IN RESPECT TO HDG CHANGES AND TA'S. 2) MANEUVERING -- SLOWING ATC INITIATED TURN TO AVOID CUMULUS CLOUDS. 3) LOW PRESSURE OF 0093 MILLIBARS MAGNIFIED THE TRANSITION ERROR. 4) NONSTANDARD TRANSITION LEVELS, DEPENDING ON COUNTRY, ON CLB, AND ON DSCNT. 5) FAST CTLR INSTRUCTIONS. WHEN NOT ACCUSTOMED TO FOREIGN ACCENT, THE FAST PACE OF INSTRUCTIONS SOMETIMES REQUIRES A MOMENT TO PROCESS. MANY TIMES, ALL 3 CREW MEMBERS WILL CONFER AND DISCUSS WHAT WE THINK WE HEARD, BEFORE READBACK. SUPPLEMENTAL INFO FROM ACN 539620: AFTER SEVERAL HDG CHANGES, THE THIRD PLT ASKED TO RANK THE IRU'S. PRIOR TO SELECTING THE FMC PAGE, WE RECEIVED A CLRNC FOR A R TURN AND A CLB TO 8000 FT. I SET 8000 FT INTO THE ALT WINDOW AND POINTED TO THE ALT, AND THE FO POINTED AS WELL. I WENT DOWN TO THE FMC CLB PAGE AND SELECTED CLB DIRECT AS BRIEFED. I THEN SELECTED THE FMC PAGE TO RANK IRU'S. DURING THIS PROCESS, THE CTLR ASKED FOR OUR ALT. WE THEN NOTICED WE HAD FAILED TO SET 1013 MILLIBARS OUT OF 6000 FT. WORKLOAD MGMNT. CAPT DID NOT PRIORITIZE HIS WORKLOAD AND WAS USING THE FMC LEAVING THE TRANSITION ALT. HIGH WORKLOAD FROM ATC WAS A FACTOR. HUMAN FACTORS INVOLVED: HIGH WORKLOAD FROM ATC, HIGH RADIO TFC FROM LONDON. A DIFFERENT TRANSITION ALT THAN NORMAL. SUPPLEMENTAL INFO FROM ACN 539622: CAPT WAS SELECTING CLB DIRECT IN THE FMC SO THAT FO COULD USE VNAV. I ASKED CAPT TO PULL UP THE POS REF PAGE SO I COULD BEGIN THE CLASS II CHKLIST PRIOR TO COAST OUT. AFTER A FEW MOMENTS IN THE CLB, ATC QUERIED OUR ALT.

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.