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  • H25B, vicinity Kerry Ireland, 2015 (Synopsis: On 16 June 2015, the crew of a US-operated HS125 on a commercial air transport flight failed to continue climbing as cleared to FL200 after take off from Kerry for a transatlantic flight and instead levelled at 2000 feet on track towards higher terrain. Prompt ATC recognition of the situation and intervention to direct an immediate climb resolved the imminent CFIT risk. The Investigation found that the two pilots involved had, despite correct readback, interpreted their clearance to flight level two hundred as being to two thousand feet and then failed to seek clarification from ATC when they became confused.)
  • C525 / B773, vicinity London City UK, 2009 (Synopsis: 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.)
  • B738, en-route, south south west of Brisbane Australia, 2013 (Synopsis: 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.)
  • F15 / E145, en-route, Bedford UK, 2005 (Synopsis: 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.)
  • B744, en-route, southeast of Hong Kong SAR China, 2017 (Synopsis: On 7 April 2017, a Boeing 747-400 crew did not adjust planned speed at an anticipated holding point when the level given was higher than expected. As a consequence of this and distraction, as the new holding level was approached and the turn began, stall buffet, several stick shaker activations and pilot-induced oscillations occurred when the crew failed to follow the applicable stall warning recovery procedure. Descent below the cleared level occurred and the upset caused injuries in the passenger cabin. Whilst attributing the event to poor crew performance, the Investigation also concluded that related operator pilot training was inadequate.)
  • A319/B733, en-route, near Moutiers France, 2010 (Synopsis: 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.)