Narrative:

3-man widebody transport crew experienced in europe operations reported for scheduled duty at XX30 pm EDT to fly dtw-bos, change aircraft at bos and fly bos-cph. Scheduled duty time was 12+25. Departure from bos was delayed 2+30 for aircraft maintenance. Crew departed bos with protected copenhagen arrival time of OY55 EDT. Crew had been awake for 20 hours including the entire eastern time zone night at time of landing at cph. Approach in use at cph was 22L VOR DME. Second officer (mis) copied ATIS showing altimeter setting to be 29.91, ceiling at 700' with 5 KM visibility and wind at 25-30 KTS. Transition level was 40 and 'qnh 991' was given by approach. First officer was flying approach and was cleared to initial approach altitude of 2500' on a 270 degree intercept heading, published MDA was 420'. Intercept occurred at 13 DME, and final approach fix was at 10 DME. Upon initial tower contact crew was advised of heavy rain at field. Flight directors were showing aircraft on course but CDI's were showing course to be right. Flight directors were turned off and first officer continued working to correct to VOR course. Wind at 2000' was 300/40 drift was 9L. At 1000 above MDA captain called out '1000' and shortly thereafter second officer monitoring approach (company does not supply approach charts to second officer's) called out '300 radar altitude, go around'. Missed approach was initiated in heavy rain with press altitude reading 800'. First officer flew missed approach. After missed approach captain questioned tower about altimeter setting being 29.91 and relieved confirmation. South second voice however corrected that statement to 991 millibars. Aircraft altimeters were reset from 29.91 to 991 millibars, a 640' difference. First officer flew aircraft on second approach to same runway landing without incidents. Aircraft most probably was within 160' of striking the water in a 1500 FPM rate of descent on the first approach. Contributing conditions: miscopy of ATIS. Very tired crew. 'Qnh 991' terminology. FL400 trans level during busy approach phase. No glide slope available on approach. Very strong xwinds. Heavy rain. Very low altimeter setting (29.27'). As a minimum fix for this problem, terminology should be qnh 0991 when quoting millibars or hecto pascals, 'qnh 991' is not enough! Callback conversation with reporter revealed the following: the second officer was monitoring the radio altimeter on descent and noted the disparity between it and the barometer altimeter and called out to go around just as the ground proximity warning went off so we were all coordinated on the go around. One problem on altimeter setting is that we did not receive the altimeter until about 4000' on descent. This is common in europe 6 - 4T feet on descent. So was hurried and very tired and apparently misheard the altimeter as 29.91 when they said qnh niner niner one.

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Original NASA ASRS Text

Title: FLT CREW OF WDB MISSET THEIR ALTIMETERS FOR APCH TO COPENHAGEN. ON APCH RECEIVED GPWS, EXECUTED GO AROUND. ALTIMETER WAS 991 MILLIBARS NOT 29 PT 91.

Narrative: 3-MAN WDB CREW EXPERIENCED IN EUROPE OPS REPORTED FOR SCHEDULED DUTY AT XX30 PM EDT TO FLY DTW-BOS, CHANGE ACFT AT BOS AND FLY BOS-CPH. SCHEDULED DUTY TIME WAS 12+25. DEP FROM BOS WAS DELAYED 2+30 FOR ACFT MAINT. CREW DEPARTED BOS WITH PROTECTED COPENHAGEN ARR TIME OF OY55 EDT. CREW HAD BEEN AWAKE FOR 20 HRS INCLUDING THE ENTIRE EASTERN TIME ZONE NIGHT AT TIME OF LNDG AT CPH. APCH IN USE AT CPH WAS 22L VOR DME. S/O (MIS) COPIED ATIS SHOWING ALTIMETER SETTING TO BE 29.91, CEILING AT 700' WITH 5 KM VIS AND WIND AT 25-30 KTS. TRANSITION LEVEL WAS 40 AND 'QNH 991' WAS GIVEN BY APCH. F/O WAS FLYING APCH AND WAS CLRED TO INITIAL APCH ALT OF 2500' ON A 270 DEG INTERCEPT HDG, PUBLISHED MDA WAS 420'. INTERCEPT OCCURRED AT 13 DME, AND FINAL APCH FIX WAS AT 10 DME. UPON INITIAL TWR CONTACT CREW WAS ADVISED OF HEAVY RAIN AT FIELD. FLT DIRECTORS WERE SHOWING ACFT ON COURSE BUT CDI'S WERE SHOWING COURSE TO BE RIGHT. FLT DIRECTORS WERE TURNED OFF AND F/O CONTINUED WORKING TO CORRECT TO VOR COURSE. WIND AT 2000' WAS 300/40 DRIFT WAS 9L. AT 1000 ABOVE MDA CAPT CALLED OUT '1000' AND SHORTLY THEREAFTER S/O MONITORING APCH (COMPANY DOES NOT SUPPLY APCH CHARTS TO S/O'S) CALLED OUT '300 RADAR ALT, GO AROUND'. MISSED APCH WAS INITIATED IN HEAVY RAIN WITH PRESS ALT READING 800'. F/O FLEW MISSED APCH. AFTER MISSED APCH CAPT QUESTIONED TWR ABOUT ALTIMETER SETTING BEING 29.91 AND RELIEVED CONFIRMATION. S SECOND VOICE HOWEVER CORRECTED THAT STATEMENT TO 991 MILLIBARS. ACFT ALTIMETERS WERE RESET FROM 29.91 TO 991 MILLIBARS, A 640' DIFFERENCE. F/O FLEW ACFT ON SECOND APCH TO SAME RWY LNDG WITHOUT INCIDENTS. ACFT MOST PROBABLY WAS WITHIN 160' OF STRIKING THE WATER IN A 1500 FPM RATE OF DSCNT ON THE FIRST APCH. CONTRIBUTING CONDITIONS: MISCOPY OF ATIS. VERY TIRED CREW. 'QNH 991' TERMINOLOGY. FL400 TRANS LEVEL DURING BUSY APCH PHASE. NO GLIDE SLOPE AVAILABLE ON APCH. VERY STRONG XWINDS. HEAVY RAIN. VERY LOW ALTIMETER SETTING (29.27'). AS A MINIMUM FIX FOR THIS PROBLEM, TERMINOLOGY SHOULD BE QNH 0991 WHEN QUOTING MILLIBARS OR HECTO PASCALS, 'QNH 991' IS NOT ENOUGH! CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: THE S/O WAS MONITORING THE RADIO ALTIMETER ON DESCENT AND NOTED THE DISPARITY BETWEEN IT AND THE BAROMETER ALTIMETER AND CALLED OUT TO GO AROUND JUST AS THE GND PROX WARNING WENT OFF SO WE WERE ALL COORDINATED ON THE GO AROUND. ONE PROBLEM ON ALTIMETER SETTING IS THAT WE DID NOT RECEIVE THE ALTIMETER UNTIL ABOUT 4000' ON DSCNT. THIS IS COMMON IN EUROPE 6 - 4T FEET ON DSCNT. SO WAS HURRIED AND VERY TIRED AND APPARENTLY MISHEARD THE ALTIMETER AS 29.91 WHEN THEY SAID QNH NINER NINER ONE.

Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.