B757-200 CREW HAD MULTIPLE CIRCADIAN DISRUPTIONS CAUSING EXTREME FATIGUE. THE CREW HAD AN ALTDEV WHEN THEY DID NOT SET THEIR ALTIMETERS TO QNH AT THE TRANSITION ALT.

Date: 2004-03 · Aircraft: B757 Undifferentiated or Other Model

Anomalies: deviation-altitude-excursion-from-assigned-altitude|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-published-material-policy

Synopsis

B757-200 CREW HAD MULTIPLE CIRCADIAN DISRUPTIONS CAUSING EXTREME FATIGUE. THE CREW HAD AN ALTDEV WHEN THEY DID NOT SET THEIR ALTIMETERS TO QNH AT THE TRANSITION ALT.

Narrative

FATIGUE WAS THE PRIMARY FACTOR LEADING TO THIS EVENT. THE DUTY DAY STARTED LATE NIGHT AT XA00 IN EDDK (COLOGNE; GERMANY). BOTH CREW MEMBERS HAD EXPERIENCED MULTIPLE CIRCADIAN RHYTHM DISRUPTIONS DURING THE PREVIOUS FEW DAYS CONTRIBUTING TO CUMULATIVE FATIGUE. AFTER FLYING AN UNEVENTFUL LEG TO ESMS (MALMO; SWEDEN); THE CREW HAD TO WAIT FOR ABOUT 2 HRS BEFORE DEPARTING FOR ENGM (OSLO; NORWAY). THERE WERE NO FACILITIES FOR THE CREW IN MALMO; SO THE 2 HRS WERE SPENT IN THE COCKPIT WHILE THE ACFT WAS LOADED/UNLOADED AND SVCED. THIS WAS BTWN XD00 AND XF00 LCL TIME. BOTH CREW MEMBERS EXPRESSED THAT THIS WAIT CONTRIBUTED TO THEIR LEVEL OF FATIGUE THAT MORNING. AN ADDITIONAL COMPLICATION WAS THAT THE FLT COULDN'T ARRIVE OLSO PRIOR TO XG00 LCL. THE FLT WAS HELD UNTIL AN ETA IN OSLO OF XG05. THE FLT TO OSLO WENT SMOOTHLY AND WAS GIVEN A SERIES OF DSCNTS TO A FLT LEVEL IN THE HIGH TEENS. THE ACFT WAS THEN CLRED TO FURTHER DSND TO AN ALT OF 3000 FT AND INTERCEPT THE LOC. THE LCL ALTIMETER SETTING WAS 991 MB. DURING THAT DSCNT; THERE WAS A RWY CHANGE RESULTING IN A STRAIGHT-IN APCH AND A NEW ETA OF ABOUT XF57. THIS BRIEFLY DISTR THE CREW. THE CREW HAD COMPLETED THE APCH CHKLIST DOWN TO 'ALTIMETER;' PER COMPANY PROC; WHILE DSNDING THROUGH FL180. THE CREW DSNDED THROUGH THE TRANSITION LEVEL OF 9000 FT AND LEVELED OFF APPROX 600 FT BELOW THE ASSIGNED ALT IN VMC AND ESTABLISHED ON THE LOC OUTSIDE THE MARKER BEACON. WHEN QUESTIONED BY OSLO APCH; THE CREW IMMEDIATELY REALIZED THE ERROR; RESET THE CORRECT ALTIMETER SETTING; AND CLBED TO 3000 FT. SHORTLY AFTER LEVELING OFF; THE ACFT INTERCEPTED THE GS. AN UNEVENTFUL APCH AND LNDG FOLLOWED. SUPPLEMENTAL INFO FROM ACN 612254: AS THE FLT PROGRESSED IT BECAME CLR THAT IT WOULD ARRIVE EARLY. THE RWY LNDG DIRECTION CHANGED AND THE ACFT WAS NOW LINED UP FOR A STRAIGHT-IN APCH. THROUGHOUT THE DSCNT THE CREW WAS CONCERNED WITH THE LNDG TIME. EVERY ATTEMPT WAS BEING MADE TO SLOW THE APCH DOWN AND THE CREW BECAME DISTR BY THIS. LEVELING AT 3000 FT VMC; OSLO REQUESTED AN ALT CHK. WE IMMEDIATELY REALIZED THAT WE HAD NOT RESET THE ALTIMETERS. THE ACFT WAS AT 2400 FT.

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