Narrative:

Fatigue was the primary factor leading to this event. The duty day started late night at XA00 in eddk (cologne, germany). Both crew members had experienced multiple circadian rhythm disruptions during the previous few days contributing to cumulative fatigue. After flying an uneventful leg to esms (malmo, sweden), the crew had to wait for about 2 hours before departing for engm (oslo, norway). There were no facilities for the crew in malmo, so the 2 hours were spent in the cockpit while the aircraft was loaded/unloaded and svced. This was between XD00 and XF00 local time. Both crew members expressed that this wait contributed to their level of fatigue that morning. An additional complication was that the flight couldn't arrive olso prior to XG00 local. The flight was held until an ETA in oslo of XG05. The flight to oslo went smoothly and was given a series of dscnts to a flight level in the high teens. The aircraft was then cleared to further descend to an altitude of 3000 ft and intercept the localizer. The local altimeter setting was 991 MB. During that descent, there was a runway change resulting in a straight-in approach and a new ETA of about XF57. This briefly distraction the crew. The crew had completed the approach checklist down to 'altimeter,' per company procedure, while descending through FL180. The crew descended through the transition level of 9000 ft and leveled off approximately 600 ft below the assigned altitude in VMC and established on the localizer outside the marker beacon. When questioned by oslo approach, the crew immediately realized the error, reset the correct altimeter setting, and climbed to 3000 ft. Shortly after leveling off, the aircraft intercepted the GS. An uneventful approach and landing followed. Supplemental information from acn 612254: as the flight progressed it became clear that it would arrive early. The runway landing direction changed and the aircraft was now lined up for a straight-in approach. Throughout the descent the crew was concerned with the landing time. Every attempt was being made to slow the approach down and the crew became distraction by this. Leveling at 3000 ft VMC, oslo requested an altitude check. We immediately realized that we had not reset the altimeters. The aircraft was at 2400 ft.

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Original NASA ASRS Text

Title: B757-200 CREW HAD MULTIPLE CIRCADIAN DISRUPTIONS CAUSING EXTREME FATIGUE. THE CREW HAD AN ALTDEV WHEN THEY DID NOT SET THEIR ALTIMETERS TO QNH AT THE TRANSITION ALT.

Narrative: FATIGUE WAS THE PRIMARY FACTOR LEADING TO THIS EVENT. THE DUTY DAY STARTED LATE NIGHT AT XA00 IN EDDK (COLOGNE, GERMANY). BOTH CREW MEMBERS HAD EXPERIENCED MULTIPLE CIRCADIAN RHYTHM DISRUPTIONS DURING THE PREVIOUS FEW DAYS CONTRIBUTING TO CUMULATIVE FATIGUE. AFTER FLYING AN UNEVENTFUL LEG TO ESMS (MALMO, SWEDEN), THE CREW HAD TO WAIT FOR ABOUT 2 HRS BEFORE DEPARTING FOR ENGM (OSLO, NORWAY). THERE WERE NO FACILITIES FOR THE CREW IN MALMO, SO THE 2 HRS WERE SPENT IN THE COCKPIT WHILE THE ACFT WAS LOADED/UNLOADED AND SVCED. THIS WAS BTWN XD00 AND XF00 LCL TIME. BOTH CREW MEMBERS EXPRESSED THAT THIS WAIT CONTRIBUTED TO THEIR LEVEL OF FATIGUE THAT MORNING. AN ADDITIONAL COMPLICATION WAS THAT THE FLT COULDN'T ARRIVE OLSO PRIOR TO XG00 LCL. THE FLT WAS HELD UNTIL AN ETA IN OSLO OF XG05. THE FLT TO OSLO WENT SMOOTHLY AND WAS GIVEN A SERIES OF DSCNTS TO A FLT LEVEL IN THE HIGH TEENS. THE ACFT WAS THEN CLRED TO FURTHER DSND TO AN ALT OF 3000 FT AND INTERCEPT THE LOC. THE LCL ALTIMETER SETTING WAS 991 MB. DURING THAT DSCNT, THERE WAS A RWY CHANGE RESULTING IN A STRAIGHT-IN APCH AND A NEW ETA OF ABOUT XF57. THIS BRIEFLY DISTR THE CREW. THE CREW HAD COMPLETED THE APCH CHKLIST DOWN TO 'ALTIMETER,' PER COMPANY PROC, WHILE DSNDING THROUGH FL180. THE CREW DSNDED THROUGH THE TRANSITION LEVEL OF 9000 FT AND LEVELED OFF APPROX 600 FT BELOW THE ASSIGNED ALT IN VMC AND ESTABLISHED ON THE LOC OUTSIDE THE MARKER BEACON. WHEN QUESTIONED BY OSLO APCH, THE CREW IMMEDIATELY REALIZED THE ERROR, RESET THE CORRECT ALTIMETER SETTING, AND CLBED TO 3000 FT. SHORTLY AFTER LEVELING OFF, THE ACFT INTERCEPTED THE GS. AN UNEVENTFUL APCH AND LNDG FOLLOWED. SUPPLEMENTAL INFO FROM ACN 612254: AS THE FLT PROGRESSED IT BECAME CLR THAT IT WOULD ARRIVE EARLY. THE RWY LNDG DIRECTION CHANGED AND THE ACFT WAS NOW LINED UP FOR A STRAIGHT-IN APCH. THROUGHOUT THE DSCNT THE CREW WAS CONCERNED WITH THE LNDG TIME. EVERY ATTEMPT WAS BEING MADE TO SLOW THE APCH DOWN AND THE CREW BECAME DISTR BY THIS. LEVELING AT 3000 FT VMC, OSLO REQUESTED AN ALT CHK. WE IMMEDIATELY REALIZED THAT WE HAD NOT RESET THE ALTIMETERS. THE ACFT WAS AT 2400 FT.

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.