Narrative:

I was the PF and the captain was the pilot monitoring. We were in a descent with LNAV/VNAV and the autoplt engaged. We had started our descent out of our cruising level (FL260) to comply with SID restrs/ATC clearance. WX at destination was reported to be marginal but not excessively challenging. I called for and we completed the approach checklist at FL180 down to 'altimeters.' at that point; we both discussed the transition level of 5000 ft (it also had been previously briefed and discussed by both of us on the approach brief) and the qnh setting of 1002 millibars. We leveled at 11000 ft (ATC clearance). We then began getting vectors and several dscnts (heading select/flight level change with autoplt) for the ILS runway 26L into lfpg. We were on vectors and speed restrs for a very extended somewhat modified base approaching the airport from the east. We were given a descent to 7000 ft and were probably at about 20 track mi from touchdown. We were on a vector to intercept the final approach course outside the extended centerline fix of the approach. We were approximately 5 mi from the intercept when we were given 1) a modified dogleg turn to intercept the final approach course inside the center fix; 2) a descent to 4000 ft; and 3) clearance for the approach. We approached the final approach course; we leveled at 4000 ft. After about 10-15 seconds; I noticed the altimeter still said qnh 1013. I immediately alerted the captain and we reset our altimeters to 1002 millibars and climbed back to 4000 ft. We were no more than 210 ft off our assigned altitude. The published approach has the minimum altitude of 3000 ft inside the 11 DME fix on the final approach course. We were inside 11 mi; but not quite on the final approach course. It is amazing how this altimeter change could have been missed by both of us on this approach; especially after briefing it and discussing it several times. The only possible things that I can think of that could have contributed to this situation are: 1) being given several clrncs/actions at the same time by ATC; 2) being preoccupied with monitoring the descent profile; 3) being at the end of a relatively long duty day (on duty time 9.7 hours at time of occurrence); 4) being the last in a succession of 4 10 hour 40+ duty days intra-europe with the previous 4 layovers all being only 12-13 hours (and probably less due to transportation from the airport to the hotel); 5) being the 7TH day of an 11 day pairing; and 6) anticipation of a long 72 hour weekend layover. In summary. I know many pilots including myself have flown and continue to fly these schedules and duty times on a routine basis. I don't remember feeling fatigued; but I think I must have been somewhat. I think that is one of the insidious manifestations of fatigue -- sometimes you can be fatigued and not even know it. For some reason on this flight there was a breakdown in all of the system checks and balances. We followed every procedure perfectly to the letter with the exception of not setting the new qnh when we passed through the transition level. In the future; I will discuss possible fatigue implications and maintain extra special vigilance in every flight regime when my crew and I are in a situation of long duty days and successive short layovers.

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Original NASA ASRS Text

Title: A FATIGUED FLT CREW FAILS TO RESET ALTIMETERS AT TRANSITION LEVEL ON ARR TO LFPG.

Narrative: I WAS THE PF AND THE CAPT WAS THE PLT MONITORING. WE WERE IN A DSCNT WITH LNAV/VNAV AND THE AUTOPLT ENGAGED. WE HAD STARTED OUR DSCNT OUT OF OUR CRUISING LEVEL (FL260) TO COMPLY WITH SID RESTRS/ATC CLRNC. WX AT DEST WAS RPTED TO BE MARGINAL BUT NOT EXCESSIVELY CHALLENGING. I CALLED FOR AND WE COMPLETED THE APCH CHKLIST AT FL180 DOWN TO 'ALTIMETERS.' AT THAT POINT; WE BOTH DISCUSSED THE TRANSITION LEVEL OF 5000 FT (IT ALSO HAD BEEN PREVIOUSLY BRIEFED AND DISCUSSED BY BOTH OF US ON THE APCH BRIEF) AND THE QNH SETTING OF 1002 MILLIBARS. WE LEVELED AT 11000 FT (ATC CLRNC). WE THEN BEGAN GETTING VECTORS AND SEVERAL DSCNTS (HDG SELECT/FLT LEVEL CHANGE WITH AUTOPLT) FOR THE ILS RWY 26L INTO LFPG. WE WERE ON VECTORS AND SPD RESTRS FOR A VERY EXTENDED SOMEWHAT MODIFIED BASE APCHING THE ARPT FROM THE E. WE WERE GIVEN A DSCNT TO 7000 FT AND WERE PROBABLY AT ABOUT 20 TRACK MI FROM TOUCHDOWN. WE WERE ON A VECTOR TO INTERCEPT THE FINAL APCH COURSE OUTSIDE THE EXTENDED CTRLINE FIX OF THE APCH. WE WERE APPROX 5 MI FROM THE INTERCEPT WHEN WE WERE GIVEN 1) A MODIFIED DOGLEG TURN TO INTERCEPT THE FINAL APCH COURSE INSIDE THE CTR FIX; 2) A DSCNT TO 4000 FT; AND 3) CLRNC FOR THE APCH. WE APCHED THE FINAL APCH COURSE; WE LEVELED AT 4000 FT. AFTER ABOUT 10-15 SECONDS; I NOTICED THE ALTIMETER STILL SAID QNH 1013. I IMMEDIATELY ALERTED THE CAPT AND WE RESET OUR ALTIMETERS TO 1002 MILLIBARS AND CLBED BACK TO 4000 FT. WE WERE NO MORE THAN 210 FT OFF OUR ASSIGNED ALT. THE PUBLISHED APCH HAS THE MINIMUM ALT OF 3000 FT INSIDE THE 11 DME FIX ON THE FINAL APCH COURSE. WE WERE INSIDE 11 MI; BUT NOT QUITE ON THE FINAL APCH COURSE. IT IS AMAZING HOW THIS ALTIMETER CHANGE COULD HAVE BEEN MISSED BY BOTH OF US ON THIS APCH; ESPECIALLY AFTER BRIEFING IT AND DISCUSSING IT SEVERAL TIMES. THE ONLY POSSIBLE THINGS THAT I CAN THINK OF THAT COULD HAVE CONTRIBUTED TO THIS SITUATION ARE: 1) BEING GIVEN SEVERAL CLRNCS/ACTIONS AT THE SAME TIME BY ATC; 2) BEING PREOCCUPIED WITH MONITORING THE DSCNT PROFILE; 3) BEING AT THE END OF A RELATIVELY LONG DUTY DAY (ON DUTY TIME 9.7 HRS AT TIME OF OCCURRENCE); 4) BEING THE LAST IN A SUCCESSION OF 4 10 HR 40+ DUTY DAYS INTRA-EUROPE WITH THE PREVIOUS 4 LAYOVERS ALL BEING ONLY 12-13 HRS (AND PROBABLY LESS DUE TO TRANSPORTATION FROM THE ARPT TO THE HOTEL); 5) BEING THE 7TH DAY OF AN 11 DAY PAIRING; AND 6) ANTICIPATION OF A LONG 72 HR WEEKEND LAYOVER. IN SUMMARY. I KNOW MANY PLTS INCLUDING MYSELF HAVE FLOWN AND CONTINUE TO FLY THESE SCHEDULES AND DUTY TIMES ON A ROUTINE BASIS. I DON'T REMEMBER FEELING FATIGUED; BUT I THINK I MUST HAVE BEEN SOMEWHAT. I THINK THAT IS ONE OF THE INSIDIOUS MANIFESTATIONS OF FATIGUE -- SOMETIMES YOU CAN BE FATIGUED AND NOT EVEN KNOW IT. FOR SOME REASON ON THIS FLT THERE WAS A BREAKDOWN IN ALL OF THE SYS CHKS AND BALS. WE FOLLOWED EVERY PROC PERFECTLY TO THE LETTER WITH THE EXCEPTION OF NOT SETTING THE NEW QNH WHEN WE PASSED THROUGH THE TRANSITION LEVEL. IN THE FUTURE; I WILL DISCUSS POSSIBLE FATIGUE IMPLICATIONS AND MAINTAIN EXTRA SPECIAL VIGILANCE IN EVERY FLT REGIME WHEN MY CREW AND I ARE IN A SITUATION OF LONG DUTY DAYS AND SUCCESSIVE SHORT LAYOVERS.

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.