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Latest revision as of 12:51, 23 July 2019

Article Information
Category: Level Bust Level Bust
Content source: SKYbrary About SKYbrary
Content control: SKYbrary About SKYbrary

Definition

Accident and Serious Incident Reports relating to accidents which involved Level Bust

The events are organised under the following sub-categories:

Accepted ATC Clearance not Followed

  • GLF5 / A319, south-eastern France, 2004 (On 16 September 2004, a loss of separation occurred over Geneva between Air France A319 and a Gulfstream 5 which commenced descent without clearance by ATC and with coordinated TCAS RAs not followed by either aircraft.)
  • B734 / MD81, en-route, Romford UK, 1996 (On 12 November 1996, a B737-400 descended below its assigned level in one of the holding patterns at London Heathrow in day IMC to within 100 feet vertically and between 680 and 820 metres horizontally of a MD-81 at its correct level, 1000 feet below. STCA prompted ATC to intervene and the 737 climbed back to its cleared level. Neither aircraft was fitted with TCAS 2 or saw the other visually.)
  • A310, vicinity Birmingham UK, 2006 (On 24 November 2006, an A310 descended significantly below cleared altitude during a radar vectored approach positioning, as a result of the flight crew's failure to set the QNH, which was unusually low.)
  • A320, en-route, north of Swansea UK, 2012 (On 7 September 2012, the crew of an Aer Lingus Airbus A320-200 mis-set their descent clearance. When discovering this as the actual cleared level was being approached, the AP was disconnected and the unduly abrupt control input made led to an injury to one of the cabin crew. The original error was attributed to ineffective flight deck monitoring and the inappropriate corrective control input to insufficient appreciation of the aerodynamic handling aspects of flight at high altitude. A Safety Recommendation to the Operator to review relevant aspects of its flight crew training was made.)
  • B763, en-route North Bay Canada, 2009 (On 19 June 2009 a Boeing 767-300 was level at FL330 in night IMC when the Captain’s altimeter and air speed indicator readings suddenly increased, the latter by 44 knots. The altimeter increase triggered an overspeed warning and the Captain reduced thrust and commenced a climb. The resultant stall warning was followed by a recovery. The Investigation found that a circuitry fault had caused erroneous indications on only the Captain’s instruments and that contrary to the applicable QRH procedure, no comparison with the First Officer’s or Standby instruments had been made. A related Operator FCOM error was also identified.)
  • B738, en-route, south south west of Brisbane Australia, 2013 (On 25 February 2013, a Boeing 737-800 about to commence descent from FL390 began to climb. By the time the crew recognised the cause and began to correct the deviation - their unintended selection of a inappropriate mode - the cleared level had been exceeded by 900 feet. During the recovery, a deviation from track occurred because the crew believed the autopilot had been re-engaged when it had not. The Investigation noted the failure to detect either error until flight path deviation occurred and attributed this to non-compliance with various operator procedures related to checking and confirmation of crew actions.)

... further results

SID Bust

  • C525 / B773, vicinity London City UK, 2009 (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 feet QNH SID Stop altitude and at 4000 feet QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300ER. The 777, on which line training was being conducted, failed to follow any of the three TCAS RAs generated. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 feet and 200 feet vertically. It was noted that the Cessna had been given a stepped climb SID.)
  • B773, vicinity Houston TX USA, 2014 (On 3 July 2014, a Boeing 777-300 departing Houston came within 200 feet vertically and 0.61nm laterally of another aircraft after climbing significantly above the Standard Instrument Departure Procedure (SID) stop altitude of 4,000 feet believing clearance was to FL310. The crew responded to ATC avoiding action to descend and then disregarded TCAS 'CLIMB' and subsequently LEVEL OFF RAs which followed. The Investigation found that an inadequate departure brief, inadequate monitoring by the augmented crew and poor communication with ATC had preceded the SID non-compliance and that the crew should have followed the TCAS RAs issued.)

Clearance Readback Error Undetected

  • B738/A319 en-route, south east of Zurich Switzerland, 2013 (On 12 April 2013, a Ryanair Boeing 737-800 took a climb clearance intended for another Ryanair aircraft on the same frequency. The aircraft for which the clearance was intended did not respond and the controller did not notice that the clearance readback had come from a different aircraft. Once the wrong aircraft began to climb, from FL360 to FL380, a TCAS RA to descend occurred due to traffic just transferred to a different frequency and at FL370. That traffic received a TCAS RA to climb. STCA was activated at the ATS Unit controlling both Ryanair aircraft.)
  • A319/B733, en-route, near Moutiers France, 2010 (On 8 July 2010 an Easyjet Airbus A319 on which line training was being conducted mis-set a descent level despite correctly reading it back and, after subsequently failing to notice an ATC re-iteration of the same cleared level, continued descent to 1000 feet below it in day VMC and into conflict with crossing traffic at that level, a Boeing 737. The 737 received and actioned a TCAS RA ‘CLIMB’ and the A319, which received only a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.)
  • E145, en-route, north east of Madrid Spain, 2011 (On 4 August 2011, a Luxair Embraer 145 flying a STAR into Madrid incorrectly read back a descent clearance to altitude 10,000 feet as being to 5,000 feet and the error was not detected by the controller. The aircraft was transferred to the next sector where the controller failed to notice that the incorrect clearance had been repeated. Shortly afterwards, the aircraft received a Hard EGPWS ‘Pull Up’ Warning and responded to it with no injury to the 47 occupants during the manoeuvre. The Investigation noted that an MSAW system was installed in the ACC concerned but was not active.)
  • C525 / B773, vicinity London City UK, 2009 (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 feet QNH SID Stop altitude and at 4000 feet QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300ER. The 777, on which line training was being conducted, failed to follow any of the three TCAS RAs generated. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 feet and 200 feet vertically. It was noted that the Cessna had been given a stepped climb SID.)
  • A320, vicinity Oslo Norway, 2008 (On 19 December 2008, an Aeroflot Airbus A320 descended significantly below its cleared and acknowledged altitude after the crew lost situational awareness at night whilst attempting to establish on the ILS at Oslo from an extreme intercept track after a late runway change and an unchallenged incorrect readback. The Investigation concluded that the response to the EGPWS warning which resulted had been “late and slow” but that the risk of CFIT was “present but not imminent”. The context for the event was considered to have been poor communications between ATC and the aircraft in respect of changes of landing runway.)

TCAS RA Response

  • DH8A/DH8C, en-route, northern Canada, 2011 (On 7 February 2011 two Air Inuit DHC8s came into head-to-head conflict en route over the eastern shoreline of Hudson Bay in non radar Class ‘A airspace when one of them deviated from its cleared level towards the other which had been assigned the level 1000 feet below. The subsequent investigation found that an inappropriate FD mode had been used to maintain the assigned level of the deviating aircraft and noted deficiencies at the Operator in both TCAS pilot training and aircraft defect reporting as well as a variation in altitude alerting systems fitted to aircraft in the DHC8 fleet.)
  • GLF5 / A319, south-eastern France, 2004 (On 16 September 2004, a loss of separation occurred over Geneva between Air France A319 and a Gulfstream 5 which commenced descent without clearance by ATC and with coordinated TCAS RAs not followed by either aircraft.)
  • C525 / B773, vicinity London City UK, 2009 (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 feet QNH SID Stop altitude and at 4000 feet QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300ER. The 777, on which line training was being conducted, failed to follow any of the three TCAS RAs generated. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 feet and 200 feet vertically. It was noted that the Cessna had been given a stepped climb SID.)
  • B773, vicinity Houston TX USA, 2014 (On 3 July 2014, a Boeing 777-300 departing Houston came within 200 feet vertically and 0.61nm laterally of another aircraft after climbing significantly above the Standard Instrument Departure Procedure (SID) stop altitude of 4,000 feet believing clearance was to FL310. The crew responded to ATC avoiding action to descend and then disregarded TCAS 'CLIMB' and subsequently LEVEL OFF RAs which followed. The Investigation found that an inadequate departure brief, inadequate monitoring by the augmented crew and poor communication with ATC had preceded the SID non-compliance and that the crew should have followed the TCAS RAs issued.)
  • A319/B733, en-route, near Moutiers France, 2010 (On 8 July 2010 an Easyjet Airbus A319 on which line training was being conducted mis-set a descent level despite correctly reading it back and, after subsequently failing to notice an ATC re-iteration of the same cleared level, continued descent to 1000 feet below it in day VMC and into conflict with crossing traffic at that level, a Boeing 737. The 737 received and actioned a TCAS RA ‘CLIMB’ and the A319, which received only a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.)

Manual Flight

  • B752, vicinity Keflavik Iceland, 2013 (On 26 February 2013, the crew of a Boeing 752 temporarily lost full control of their aircraft on a night auto-ILS approach at Keflavik when an un-commanded roll occurred during flap deployment after an earlier partial loss of normal hydraulic system pressure. The origin of the upset was found to have been a latent fatigue failure of a roll spoiler component, the effect of which had only become significant in the absence of normal hydraulic pressure and had been initially masked by autopilot authority until this was exceeded during flap deployment.)
  • F15 / E145, en-route, Bedford UK, 2005 (On 27 January 2005, two USAF-operated McDonnell Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)
  • DH8D / B772, vicinity Sydney Australia, 2016 (On 9 December 2016, a Bombardier DHC8-400 departing Sydney lost prescribed separation against an inbound Boeing 777-200 after its crew failed to ensure that the aircraft levelled as cleared at 5,000 feet and this was exceeded by 600 feet. The Investigation found that the First Officer, as Pilot Flying, had disconnected the autopilot prior to routinely changing the selected airspeed because it tended to disconnect when this was done with altitude capture mode active but had then failed to re-engage it. The Captain's lack of effective monitoring was attributed to distraction as he sought to visually acquire the conflicting traffic.)
  • A332, en-route, near Dar es Salaam Tanzania, 2012 (On 27 February 2012, the crew of an Airbus A330 en route at night and crossing the East African coast at FL360 encountered sudden violent turbulence as they flew into a convective cell not seen on their weather radar and briefly lost control as their aircraft climbed 2000 feet with resultant minor injuries to two occupants. The Investigation concluded that the isolated and rapidly developing cell had not been detected because of crew failure to make proper use of their weather radar, but noted that activation of flight envelope protection and subsequent crew action to recover control had been appropriate.)
  • B738, en-route, Arabian Sea, 2010 (On 26 May 2010, a Boeing 737-800 being operated by Air India Express on a passenger flight from Dubai UAE to Pune, India was in the cruise at night at FL370 near PARAR when a sudden high speed descent occurred without ATC clearance during which nearly 7000 feet of altitude was lost in a little over 30 seconds before recovery was made. The remainder of the flight was uneventful. Despite the abnormal pitch, pitch change and ‘g’ variation, none of the 113 occupants had been injured.)
  • DH8A/DH8C, en-route, northern Canada, 2011 (On 7 February 2011 two Air Inuit DHC8s came into head-to-head conflict en route over the eastern shoreline of Hudson Bay in non radar Class ‘A airspace when one of them deviated from its cleared level towards the other which had been assigned the level 1000 feet below. The subsequent investigation found that an inappropriate FD mode had been used to maintain the assigned level of the deviating aircraft and noted deficiencies at the Operator in both TCAS pilot training and aircraft defect reporting as well as a variation in altitude alerting systems fitted to aircraft in the DHC8 fleet.)

... further results

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For all accident reports held on SKYbrary, see the main section on Accident Reports.