B767-200 FLC FAILS TO SET ALTIMETER FOR APCH TO LAND. DSCNT BELOW ASSIGNED.

Date: 1995-08 · Aircraft: B767-200

Anomalies: deviation-discrepancy-procedural-published-material-policy|inflight-event-encounter-cftt-cfit|other-unspecified

Synopsis

B767-200 FLC FAILS TO SET ALTIMETER FOR APCH TO LAND. DSCNT BELOW ASSIGNED.

Narrative

I WOULD LIKE TO FOLLOW UP WITH A MORE DETAILED RPT LATER AS I HAVE TIME TO DIGEST ALL THE DETAILS AND FACTORS INVOLVED; THUS A SHORT SYNOPSIS FOLLOWS. SIT: ARPT CLOSED FOR 40 MINS DUE TO TSTM. 2 SEPARATE HOLDING PATTERNS. CLRNC LIMIT FIXES A FACTOR; WX ON ROUTING AND ON VECTORS A FACTOR; UNFAMILIAR HOLDING FIXES A FACTOR; ATC LANGUAGE; EQUIP A FACTOR. BOTTOM LINE: WORKLOAD LEVEL INTENSE. ESSENTIALLY WE HAD TO VECTOR OURSELVES AROUND WX TO ALIGN OURSELVES WITH FINAL APCH. ALT ASSIGNMENTS ARE IN METERS AND IN QFE; REQUIRING A DOUBLE CONVERSION. AS PF; I TOOK RESPONSIBILITY FOR NAVING AROUND WX WITH RESPECT TO FINAL APCH. PNF WORKED RADIOS; MANY DISTRS. I CALLED FOR APCH CHK WHICH INCLUDES SETTING OF ALTIMETERS AS LAST ITEM. LOW TRANSITION LEVEL OF 1500 METERS AT THIS ARPT. RADIO CALL DISTRACTED PNF FROM COMPLETING CHKLIST AND I WAS TOO BUSY TO CATCH IT. ALTIMETERS WERE NOT SET TO QFE AND WE DSNDED TO 1660 FT APCH ALT WITH ALTIMETER SETTING AT 1013 MILLIBARS VERSUS QFE 977. WE WERE 900 TO 1000 FT LOW/700 TO 800 FT AGL LEVEL WHEN CALL FROM APCH CTL CORRECTED ERROR. STILL IMC AT THAT ALT. IMMEDIATE CORRECTION. REMAINDER OF APCH LNDG UNEVENTFUL. CAUSE: LACK OF DISCIPLINE IN NOT COMPLETING CHKLIST. SOLUTION: I CANNOT ANY LONGER BE CERTAIN THAT PNF WILL COMPLETE HIS ASSIGNED TASKS. I WILL NEED TO INCREASE MY MONITORING OF HIS ACTIONS. GIVEN THE WORKLOAD ON THIS APCH; I DON'T YET SEE HOW I'LL BE ABLE TO ADD THIS TO MY WORKLOAD; BUT I WILL HAVE TO FIND A WAY. MAJOR PROB: QFE; METERS AND LOW TRANSITION LEVEL ARE POTENTIAL ACCIDENT WAITING TO HAPPEN. THIS WAS POTENTIALLY VERY SCARY. THE 'WHAT IFS' ON THIS APCH ARE EXTREMELY DISCONCERTING AND HAVE GIVEN ME GREAT PAUSE.

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