FLC OF WDB ACR ACFT FAILED TO RESET ALTIMETER DURING DSCNT RESULTING IN OVERSHOOT OF ASSIGNED ALT.

Date: 1993-03 · Aircraft: Widebody; Low Wing; 4 Turbojet Eng

Anomalies: deviation-altitude-overshoot|deviation-discrepancy-procedural-clearance|other-unspecified

Synopsis

FLC OF WDB ACR ACFT FAILED TO RESET ALTIMETER DURING DSCNT RESULTING IN OVERSHOOT OF ASSIGNED ALT.

Narrative

APCHING ANC AT 35000 FT; DSCNT WAS INITIATED BY ATC APPROX 120 DME SE OF ANC. THROUGH SEVERAL STEPDOWNS WE WERE ULTIMATELY CLRED TO 10000 FT. PASSING 18000 FT 'APCH CHK' WAS CALLED FOR AND ACCOMPLISHED TO 'THE LINE.' TOWARD THE LAST PART OF THE CHKLIST; ATC CALLED WITH ANOTHER STEPDOWN AND BROKE THE CONTINUITY OF THE CHKLIST WHICH BROKE THE INSTINCTIVE 'FLOW' WHICH WOULD HAVE INCLUDED THE ALTIMETER AT THAT POINT. WE CONTINUED DSCNT TOWARD 10000 FT; WHEN AT APPROX 10500 FT MY FO REALIZED THE ALTIMETERS HAD NOT BEEN RESET AND CALLED IT TO MY ATTN. LEVEL OFF WAS INITIATED; ALTIMETERS RESET AND CLBED BACK TO 10000 FT. THE ALTIMETER IN ANC WAS 28.66 AT THE TIME AND COULD HAVE RESULTED IN AN EXCURSION OF NEARLY 1300 FT. WE ACTUALLY WENT DOWN TO ABOUT 9400 FT MOMENTARILY. AN ALERT ATC CTLR CAUGHT THE EXCURSION ABOUT THE SAME TIME AS THE FO CALLED OUT THE ALTIMETER SETTING. THIS INCIDENT HAS SEVERAL CONTRIBUTING FACTORS SUCH AS: FATIGUE; SINCE THE CREW HAD BEEN UP MOST OF THE NIGHT AND IN THE AIR FOR NEARLY 7 HRS; THE COM INTERRUPTION WHICH BROKE THE 'OLD HABITS;' BUT PRIMARILY THE CHANGE IN THE CHKLIST AND OPERATING PROCS WHICH WERE RECEIVED BY THE CREW AT CHK IN FOR THIS FLT. THE OPERATING REVISION WAS IN THE NEIGHBORHOOD OF 100 PAGES WITH A CHANGE IN THE CHKLIST WHICH INVOLVED A COMPLETE CHANGE OF CHKLIST PHILOSOPHY IN THE 'APCH CHK' PORTION OF THE DOCUMENT. THE NEW CHKLIST PLACED 'ALTIMETERS' BELOW THE LINE WHICH IS A PART OF THE CHKLIST TRADITIONALLY COMPLETED WHEN CLRED FOR THE APCH AND SET UP FOR THE APCH. THE NEW CHKLIST USED 'THE LINE' TO DIFFERENTIATE BTWN ITEMS ON THE CHKLIST COMPLETED OUT OF 18000 FT AND THE ALTIMETER SETTING WHICH IN INTL OPS AREN'T NECESSARILY RESET AT 18000 FT.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.