Narrative:

Russian ATC kept aircraft high on STAR (KS25L) for traffic; then vectored north of runway to lose altitude. Altitude changes were rapid; and crew workload was high; compounded by metric conversion and controller accent. ATC directed speed reduction from 250 KTS to minimum approach speed (180 KTS) while in turning descent to a 90 degree localizer intercept (ILS runway 25L). I (the PF) extended speed brakes and extended flaps on speed schedule to 20 degrees; resulting in a descent rate of approximately 2000 FPM. Simultaneously; altitude assignments continued rapidly in 1000 ft increments from 3300 M (9900 ft) above the transition level of 1500 M to 600 M (1800 ft). Concurrently; aircraft descended into solid layer at 1200 M (3600 ft). Crew had briefed transition altitude and QFE (984 millibars) at 3300 M and set the standby altimeter to QFE. All 3 pilots were distraction by late ATC clearance for localizer intercept (aircraft overshot localizer by full deflection); simultaneous clearance to 600 M and approach clearance as IMC was encountered; and thus failed to see QFE as aircraft passed through 1500 M. Standards instructor training for russian airspace includes an admonition not to set QFE until aircraft actually descends below transition altitude as a leveloff at that altitude would be in qnh; not QFE; and could be hundreds of ft off; and captain had briefed this standard previously on flight. As aircraft encountered VMC at 700 M (2000 ft AGL); I retracted speed brakes; then clicked off autoplt and autothrottle (as I had briefed). Instantly thereafter; all 3 crew realized aircraft was low on glide path; and ATC queried as to whether we were utilizing QFE. I looked immediately at TCAS repeater on my vsi and saw traffic at 3 NM ahead and 200 ft below (traffic on ILS approach). I immediately added significant power (throttles approximately 75%); and raised nose approximately 5 degrees for a smooth climb back to glide path. I noticed speed increasing and called for flap retraction; but was consumed with conflicting information from flight director; which indicated a descent to 600 M QFE (about 400 ft below glide path); and the fact that aircraft re-encountered IMC. Captain got flaps to 5 degrees; but was distraction as well in situational awareness. Airspeed continued to 250 KTS before I had aircraft up to glide path altitude. Immediately I reduced throttles for airspeed reduction and directed gear down; and flaps extended back on schedule for landing speed. VMC was re-attained; and we maintained visual separation with landing traffic. The remainder of the approach and landing were normal. Upon shutdown; the crew wrote the aircraft up for a flap overspd. The altitude deviation was caused by crew workload saturation; resulting in a single; critical; missed step -- the transition to QFE. If one of the 3 crew had caught this item; this incident would not have occurred. No pilot was negligent -- all were performing their duties to the best of their ability. Unfortunately; the rapidity of scan requirements coupled with the unusual nature of operating in a qnh-QFE metric environment overloaded us. The flap overspd was caused by a momentary loss of situational awareness on all 3 pilots' behalf. The relief pilot noticed the overspd first. I; the PF; was overwhelmed by 1) uncertainty as to the threat presented by the traffic 200 ft below; 2) the tendency to follow bad flight director information; and 3) re-entry into IMC. In terms of training; I had not experienced this situation before -- suddenly; the aircraft was in jeopardy of a major altitude deviation at low altitude and a possible midair threat; yet I perceived semi-consciously that a major correction (maximum power and attitude) would be inappropriate for the correction of the flight path. Thus; my response was an inappropriate composite of an aggressive and smooth recovery. I am trained and confident in my procedure for a TCAS RA or a CFIT incident; but have not experienced a situation that involved both of these elements yet did not actually present a crisis threat to the aircraft. I would suggest having air crews actually practice a similar event in a simulator in order to develop the skill of not overcompensating when the situation does not dictate such. I suppose it was a likewise overcompensation for arelatively insignificant deviation in flight path that caused the demise of air carrier flight X over jamaica; ny; in 2001. I have learned a valuable lesson.

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Original NASA ASRS Text

Title: B767-300 EXPERIENCES ALTDEV ON ARR TO UUEE. RECOVERY RESULTS IN FLAP OVERSPD.

Narrative: RUSSIAN ATC KEPT ACFT HIGH ON STAR (KS25L) FOR TFC; THEN VECTORED N OF RWY TO LOSE ALT. ALT CHANGES WERE RAPID; AND CREW WORKLOAD WAS HIGH; COMPOUNDED BY METRIC CONVERSION AND CTLR ACCENT. ATC DIRECTED SPD REDUCTION FROM 250 KTS TO MINIMUM APCH SPD (180 KTS) WHILE IN TURNING DSCNT TO A 90 DEG LOC INTERCEPT (ILS RWY 25L). I (THE PF) EXTENDED SPD BRAKES AND EXTENDED FLAPS ON SPD SCHEDULE TO 20 DEGS; RESULTING IN A DSCNT RATE OF APPROX 2000 FPM. SIMULTANEOUSLY; ALT ASSIGNMENTS CONTINUED RAPIDLY IN 1000 FT INCREMENTS FROM 3300 M (9900 FT) ABOVE THE TRANSITION LEVEL OF 1500 M TO 600 M (1800 FT). CONCURRENTLY; ACFT DSNDED INTO SOLID LAYER AT 1200 M (3600 FT). CREW HAD BRIEFED TRANSITION ALT AND QFE (984 MILLIBARS) AT 3300 M AND SET THE STANDBY ALTIMETER TO QFE. ALL 3 PLTS WERE DISTR BY LATE ATC CLRNC FOR LOC INTERCEPT (ACFT OVERSHOT LOC BY FULL DEFLECTION); SIMULTANEOUS CLRNC TO 600 M AND APCH CLRNC AS IMC WAS ENCOUNTERED; AND THUS FAILED TO SEE QFE AS ACFT PASSED THROUGH 1500 M. STANDARDS INSTRUCTOR TRAINING FOR RUSSIAN AIRSPACE INCLUDES AN ADMONITION NOT TO SET QFE UNTIL ACFT ACTUALLY DSNDS BELOW TRANSITION ALT AS A LEVELOFF AT THAT ALT WOULD BE IN QNH; NOT QFE; AND COULD BE HUNDREDS OF FT OFF; AND CAPT HAD BRIEFED THIS STANDARD PREVIOUSLY ON FLT. AS ACFT ENCOUNTERED VMC AT 700 M (2000 FT AGL); I RETRACTED SPD BRAKES; THEN CLICKED OFF AUTOPLT AND AUTOTHROTTLE (AS I HAD BRIEFED). INSTANTLY THEREAFTER; ALL 3 CREW REALIZED ACFT WAS LOW ON GLIDE PATH; AND ATC QUERIED AS TO WHETHER WE WERE UTILIZING QFE. I LOOKED IMMEDIATELY AT TCAS REPEATER ON MY VSI AND SAW TFC AT 3 NM AHEAD AND 200 FT BELOW (TFC ON ILS APCH). I IMMEDIATELY ADDED SIGNIFICANT PWR (THROTTLES APPROX 75%); AND RAISED NOSE APPROX 5 DEGS FOR A SMOOTH CLB BACK TO GLIDE PATH. I NOTICED SPD INCREASING AND CALLED FOR FLAP RETRACTION; BUT WAS CONSUMED WITH CONFLICTING INFO FROM FLT DIRECTOR; WHICH INDICATED A DSCNT TO 600 M QFE (ABOUT 400 FT BELOW GLIDE PATH); AND THE FACT THAT ACFT RE-ENCOUNTERED IMC. CAPT GOT FLAPS TO 5 DEGS; BUT WAS DISTR AS WELL IN SITUATIONAL AWARENESS. AIRSPD CONTINUED TO 250 KTS BEFORE I HAD ACFT UP TO GLIDE PATH ALT. IMMEDIATELY I REDUCED THROTTLES FOR AIRSPD REDUCTION AND DIRECTED GEAR DOWN; AND FLAPS EXTENDED BACK ON SCHEDULE FOR LNDG SPD. VMC WAS RE-ATTAINED; AND WE MAINTAINED VISUAL SEPARATION WITH LNDG TFC. THE REMAINDER OF THE APCH AND LNDG WERE NORMAL. UPON SHUTDOWN; THE CREW WROTE THE ACFT UP FOR A FLAP OVERSPD. THE ALTDEV WAS CAUSED BY CREW WORKLOAD SATURATION; RESULTING IN A SINGLE; CRITICAL; MISSED STEP -- THE TRANSITION TO QFE. IF ONE OF THE 3 CREW HAD CAUGHT THIS ITEM; THIS INCIDENT WOULD NOT HAVE OCCURRED. NO PLT WAS NEGLIGENT -- ALL WERE PERFORMING THEIR DUTIES TO THE BEST OF THEIR ABILITY. UNFORTUNATELY; THE RAPIDITY OF SCAN REQUIREMENTS COUPLED WITH THE UNUSUAL NATURE OF OPERATING IN A QNH-QFE METRIC ENVIRONMENT OVERLOADED US. THE FLAP OVERSPD WAS CAUSED BY A MOMENTARY LOSS OF SITUATIONAL AWARENESS ON ALL 3 PLTS' BEHALF. THE RELIEF PLT NOTICED THE OVERSPD FIRST. I; THE PF; WAS OVERWHELMED BY 1) UNCERTAINTY AS TO THE THREAT PRESENTED BY THE TFC 200 FT BELOW; 2) THE TENDENCY TO FOLLOW BAD FLT DIRECTOR INFO; AND 3) RE-ENTRY INTO IMC. IN TERMS OF TRAINING; I HAD NOT EXPERIENCED THIS SITUATION BEFORE -- SUDDENLY; THE ACFT WAS IN JEOPARDY OF A MAJOR ALTDEV AT LOW ALT AND A POSSIBLE MIDAIR THREAT; YET I PERCEIVED SEMI-CONSCIOUSLY THAT A MAJOR CORRECTION (MAX PWR AND ATTITUDE) WOULD BE INAPPROPRIATE FOR THE CORRECTION OF THE FLT PATH. THUS; MY RESPONSE WAS AN INAPPROPRIATE COMPOSITE OF AN AGGRESSIVE AND SMOOTH RECOVERY. I AM TRAINED AND CONFIDENT IN MY PROC FOR A TCAS RA OR A CFIT INCIDENT; BUT HAVE NOT EXPERIENCED A SITUATION THAT INVOLVED BOTH OF THESE ELEMENTS YET DID NOT ACTUALLY PRESENT A CRISIS THREAT TO THE ACFT. I WOULD SUGGEST HAVING AIR CREWS ACTUALLY PRACTICE A SIMILAR EVENT IN A SIMULATOR IN ORDER TO DEVELOP THE SKILL OF NOT OVERCOMPENSATING WHEN THE SITUATION DOES NOT DICTATE SUCH. I SUPPOSE IT WAS A LIKEWISE OVERCOMPENSATION FOR ARELATIVELY INSIGNIFICANT DEV IN FLT PATH THAT CAUSED THE DEMISE OF ACR FLT X OVER JAMAICA; NY; IN 2001. I HAVE LEARNED A VALUABLE LESSON.

Data retrieved from NASA's ASRS site as of January 2009 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.