POTENTIAL CONFLICT ENSUES WHEN AN MD11 FLC DSNDS 600 FT BELOW THEIR ASSIGNED ALT AFTER THEY OVERLOOK SETTING THEIR ALTIMETER TO THE LCL SETTING 5 MI N OF KASMI; FO.

2001-03 · NASA ASRS report 503219

Date: 2001-03 · Aircraft: MD-11 · Phase: descent

Anomalies: conflict-airborne-conflict|deviation-altitude-overshoot|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-clearance|other-flc-distr-workload

Synopsis

POTENTIAL CONFLICT ENSUES WHEN AN MD11 FLC DSNDS 600 FT BELOW THEIR ASSIGNED ALT AFTER THEY OVERLOOK SETTING THEIR ALTIMETER TO THE LCL SETTING 5 MI N OF KASMI; FO.

Narrative

SET UP: WE WERE IN A DSCNT TO BE AT FL150 13 NM PRIOR TO COMET WHEN ATC GAVE US THE FOLLOWING INSTRUCTIONS (ATC WAS NARITA APCH): 'CLRED TO HOLD AT KASMI; AS PUBLISHED; 13000 FT; EFC IS 20; RWY 34 IN USE.' AS THERE ARE 2 FIXES THAT SOUND ALIKE; I CONFIRMED THE HOLDING FIX TO BE KASMI RATHER THAN COSMO AND SINCE KASMI WAS NOT ON OUR RTE OF FLT; I ASKED TO GO THERE DIRECT. ATC APPROVED DIRECT KASMI. JUST APCHING KASMI; ATC DIRECTED US TO TURN TO 090 DEGS AND CLB TO 13000 FT. I REPLIED WE WERE TURNING TO 090 DEGS BUT WERE AT 13000 FT. HE AGAIN DIRECTED US TO CLB TO 13000 FT; UPON WHICH WE NOTICED WE WERE AT 29.92 ALTIMETER SETTING RATHER THAN LCL ALTIMETER OF 29.32. IN THE CONFUSION OVER THE HOLDING FIX AND A SOMEWHAT TIGHT FUEL SIT WITH THE EFC WE WERE GIVEN (40 MINS IN FUTURE); WE HAD MISSED RESETTING OUR ALTIMETER PASSING THE TRANSITION LEVEL OF 14000 FT. WE STARTED A CLB AS WE RESET OUR ALTIMETER AND HEARD ATC DIRECT ANOTHER ACFT TO TURN AND LOOK FOR US VISUALLY. I BELIEVE THIS ACFT WAS APCHING US IN A CLB TO 12000 FT. WE GOT A TCASII TA ONE TIME AS THIS ACFT PASSED 2-3 NM BEHIND US AND WE LEVELED AT 13000 FT MSL. LATER (3-4 MINS LATER) ATC ASKED US IF WE HAD BEEN AT 12500 FT; AND I REPLIED WE HAD BEEN AT FL130 'STANDARD ALTIMETER' (29.92). CONTRIBUTING FACTORS: 1) VERY LOW ALTIMETER (29.32). 2) UNUSUAL TRANSITION LEVEL (14000 FT). 3) CLRNC TO A HOLDING FIX NOT ON OUR RTE OF FLT. 4) CLRNC TO 13000 FT; WITHOUT GIVING THE LCL ALTIMETER WITH THE CLRNC. 5) SOME LANGUAGE PROBS WITH THE JAPANESE CTLR. HOW DISCOVERED: BY ATC. IT APPEARED HE DISCOVERED THIS EARLY ENOUGH TO KEEP OUR ACFT OVER 2 MI AND 1000 FT SEPARATED. CORRECTIVE ACTIONS: 1) INSURE TRANSITION LEVEL IS BRIEFED PRIOR TO DSCNT ALONG WITH ATIS ALTIMETER SETTING; ESPECIALLY WHEN A LOW ALTIMETER AND NONSTANDARD TRANSITION LEVEL ARE IN USE. 2) IF ATC WILL ALWAYS GIVE THE LCL ALTIMETER WHENEVER A DSCNT TO BELOW THE TRANSITION LEVEL IS GIVEN; IT WILL CUE THE FLC TO SET IT WHEN THEY DSND. BOTTOM LINE: THIS WAS OUR FAULT AND A CLASSIC SETUP FOR AN ERROR LIKE THIS. HUMAN FACTORS CONSIDERATIONS: 1) FATIGUE. THIS WAS AT THE END OF A 13 1/2 HR FLT. BOTH THE PF AND PNF WERE COMING OFF OF A 2 1/2 HR REST BREAK AND THE COBWEBS WERE STILL EVIDENT IN OUR THINKING AND PERFORMANCE. THE OTHER 'REST' CREW WERE NOT IN THE COCKPIT AND THEY STRUGGLED WITH A BALKY CREW REST MODULE THAT WOULD NOT CLOSE PROPERLY. WITH THOSE 2 EXTRA PAIR OF EYES/EARS AND BRAINS IN THE COCKPIT; THIS MIGHT NOT HAVE HAPPENED. 2) PROFICIENCY. THE PF WAS NEW TO THE MD11 AND ITS TRICKY FMS. HE WAS HAVING TROUBLE LOADING THE RTE OF FLT CHANGE; HOLDING; EFC WHICH CAUSED ME TO HAVE TO MONITOR HIS WORK CLOSELY AND NOT KEEP UP WITH THE 'BIG PICTURE.' 3) AUTOMATION. THE AUTOMATION IN THIS CASE WAS A HINDRANCE TO THE PF AS HE WAS OBVIOUSLY REVERTING TO BOEING FMS PROGRAMMING WHICH OFTEN WON'T WORK WITH MD11 FMS WORK. 4) COM. THE JAPANESE ATC CTLR GAVE A GREAT DEAL OF INFO (IE; RTE CHANGE; HOLDING INSTRUCTIONS; NEW RWY IN USE; ALT CHANGE) WITHOUT ANY PREPARATION OR INDICATION OF THESE COMING. (WE WERE THE FIRST ACFT SENT TO HOLDING WE HEARD ON HIS FREQ.) COMBINE THAT WITH SOME LANGUAGE DIFFICULTY; 2 RELATIVELY GROGGY PLTS IN THE COCKPIT AND 2 AVAILABLE PLTS NOT IN THE COCKPIT WRESTLING WITH A CREW REST MODULE; AND THE MIX WAS RIGHT FOR THIS TO HAPPEN. SUPPLEMENTAL INFO FROM ACN 503409: I WAS IN THE PROCESS OF BRIEFING MY COPLT ON OUR APCH TO THE RWY 16 ILS WHEN WE GOT OUR DIRECTIONS TO HOLD AT KASMI. MY NORMAL BRIEFING IS A 'NATS' BRIEFING. IT INCLUDES NOTAMS; APCH PARAMETERS AND SETTINGS; TERRAIN CONSIDERATIONS/TRANSITION FLT LEVEL AND SPECIAL PAGES (CONSIDERATIONS). I HAD NOT GOTTEN PAST THE APCH PORTION OF THE BRIEF; SO DID NOT BRIEF THE COPLT OF THE TRANSITION FLT LEVEL. SUPPLEMENTAL INFO FROM ACN 503420: OF THE 2 CAPTS; I WAS THE CAPT IN CHARGE. SINCE THE SECOND CAPT WAS IN NEED OF A LEG TO AVOID A CURRENCY PROB; I SELECTED HIM TO FLY THE FIRST LEG OF OUR ROTATION. THE COPLT (TEAMED WITH ME) AWAKENED THE RESTING CAPT. HE ARRIVED ON DECK A FEW MINS LATER. I BRIEFED HIM; AND HE TOOK THE L SEAT. WITHIN A FEW MINS; HIS COPLT ASSUMED HIS SEAT AND EXPLAINED THAT HE COULD NOT STOW THE CREW REST FACILITY. MY COPLT WENT BACK TO TRY TO STOW THE CREW REST FACILITY. I STOOD BEHIND THE L SEAT TO MONITOR THE OP. THE COPLT WORKING ON THE CREW REST FACILITY THEN ASKED ME FOR HELP. WHEN THE SIT WAS RESOLVED; WE RETURNED TO THE COCKPIT. I NOTICED WE WERE AT 13000 FT. IN A CLBING TURN; THE TCASII SOUNDED 'TFC; TFC' ONCE. AT THE SAME TIME; THE CTLR CALLED OUR POS TO THE OTHER ACFT; WHO; AFTER A PAUSE; REPLIED THAT HE HAD US IN SIGHT.

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

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