2011-06 · NASA ASRS report 954901
During a period of very low atmospheric pressure; a B767ER flight crew suffered a significant low altitude deviation when they failed to set QNH as they descended below the Transition Level while flying the ARTIP 2C LNAV/VNAV transition to the EHAM 18R ILS.
We were on the arrival phase; Norku 2A and then cleared via the ARTIP 2C transition; 18R AMS. The arrival has several 'at or above' altitudes; which we edited to hard altitudes (enhancing VNAV performance). Approach checklist was called and partially accomplished at approximately 10;000 FT. We held the checklist due to the Transition Level being 4;500 FT. ATC descended us to FL70; the first published alt on the arrival. We were unsure if we were cleared for the transition/approach due to unfamiliar phraseology. As we left FL70; heading toward the next waypoint; requiring FL60; I asked the pilot not flying if we were cleared for the approach/altitudes. The pilot not flying asked ATC to confirm; and they said we were; and the pilot not flying read back; 'Cleared for the approach; with the altitudes.' We made final; appropriate settings on MCP; preparing to transition from LNAV to 'APP' mode. After reassuring that we were cleared for the approach I entered 2;000 FT in the altitude window; corresponding to glide slope intercept. I flew the approach in LNAV/VNAV; with speed intervening. All of this took less the sixty seconds to transpire; but we missed the change to local QNH at FL4.5; resulting in a 500 foot (low due to extremely low QNH setting) error at subsequent 4;000 FT; 3;400 FT; and 2;000 FT step downs. As the aircraft leveled at 2;000 FT and as we were selecting 'APP' (from LNAV/VNAV); Approach Control said; 'We show you below the glide slope.' This did not register immediately as significant; as we SHOULD be just below the glideslope at that point. They followed with; 'We show you 500 FT low.' All three of us immediately saw and corrected our QNH setting; and we were indeed approximately 1;500 FT MSL. The pilot not flying apologized and acknowledged our 'QNH error' They said 'no problem; contact the Tower'. At the switch to Tower they said; 'We show you on the glide slope now; you are cleared to land; runway 18R.' The remainder of the approach and landing was uneventful. I have always been a stickler for standardization and timely checklist compliance. And after nearly seventeen years of 'standardization' in the US (Local altimeter settings passing FL180); the European 'standard' got me. My error has little or no defense. In virtually every international destination; Approach Control ALWAYS clears us to an altitude in feet; with local QNH setting; when descending us below the Transition Altitude. Not Amsterdam Approach. Frequently; we don't even know the landing runway; when we accomplish our Approach Checklist at or near 10;000 FT. We frequently respond; '1013 now; altimeters to go;' leaving the checklist unfinished. I hope I will be able to pass along this experience and 'Lessons Learned' from my error; to every flight crew I fly with. I cannot think of a 'one procedure' fix; considering the variations from country to country. I am sure there is a reason; but it sure would be helpful if Europe could standardize its transition level/altitude and make it a level not in a high work load environment. Perhaps all we can do is stress LACK of continuity in international flying; and make the variety of approach scenarios an integral part of out Threat Management briefings.
During the VNAV descent; local QNH was not set from 29.92 (1013.2 Hp) to QNH. Local altimeter at the time was 0996 HP or 29.41. The flight proceeded from NARIX to the final approach fix. On final to intercept the ILS; altimeters read 2;000 FT. Approach called and asked us to verify altitude. I immediately announced; 'check QNH;' realizing what had happened; the pilot flying and pilot not flying adjusted their altimeters and it showed us 500 FT low.The approach checklist seems to be more tailored for a transition level of 18;000 FT. We complete the approach checklist earlier on; as trained; when in ICAO environments; but the checklist is technically not completed until transition level is reached and QNH set.This set up had everything in place to present a challenge. That being level offs within 1;000 FT of each other and an altimeter reset which instantly shaved 500 FT from actual. I believe that the North American IFR environment is MUCH SAFER with a standard transition level of 18;000 FT and maybe someday; especially for the developed nations; they too will catch up and stop these transition level 'moving targets.'
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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