Event Details


Title:Altitude excursion, Boeing 737-300, 9H-ABT
Micro summary:This Boeing 737-300 diverted from its clearance by 1400' and 600' under MSA on approach.
Event Time:1997-08-01 at 0943 UTC
File Name:1997-08-01-UK.pdf
Publishing Agency:Aircraft Accident Investigation Board (AAIB)
Publishing Country:United Kingdom
Report number:EW/C97/8/3
Pages:4
Site of event:On approach to Manchester
Departure:Malta International Airport (Luqa Airport), Malta
Destination:Birmingham International Airport, West Midlands, England
Airplane Type(s):Boeing 737-300
Flight Phase:Approach
Registration(s):9H-ABT
Operator(s):Air Malta
Type of flight:Revenue
Occupants:100
Fatalities:0
Serious Injuries:0
Minor/Non-Injured:100
Other Injuries:0
Executive Summary:The crew were operating a scheduled flight, as AMC 202, from Malta to Manchester. For the first part of the flight, the first officer was the handling pilot. However, the forecast weather at Manchester indicated that Low Visibility Procedures (LVP) would be required and, in accordance with company procedures, this would require the commander in the left seat to be the handling pilot. Therefore, towards the end of the cruise, the commander took over the handling duties and the first officer assumed the normal non-handling duties including the radio monitoring and response. Prior to flight, the commander had confirmed the serviceability of the aircraft and noted that there were no 'Carried Forward Defects' in the Technical Log; additionally, he had also confirmed that both the first officer and himself were qualified to carry out the expected LVP approach. Throughout the flight, the aircraft was fully serviceable.

Before descent, the crew obtained the airport weather information and the commander briefed for the expected approach to Runway 24 at Manchester. Information 'X', timed at 0850 hrs, confirmed the landing runway as 24 and described the weather as follows: "Surface wind 220°/06 kt, visibility 2,500 metres in drizzle, cloud broken at 100 feet and overcast at 300 feet, temperature and dew point 16°C, QNH 1011 mb and a wet runway." During the descent, the crew were instructed to enter the 'Hold' at 'Dayne' and, while in the 'Hold', were transferred to Manchester Director on frequency 121.350 MHz at 0936 hrs. On initial contact,the crew confirmed their cleared level as FL 70 and this was acknowledged by the controller together with the message that they would shortly be leaving the 'Hold'.

Then, at 0937 hrs, the controller passed three separate messages to AMC 202: the first was to fly at a speed of 180 kt, the second was to descend to FL 50 and the third was to cancel the 'Hold' and to turn right onto 010°. All these messages were passed clearly and acknowledged correctly by the crew. At 0940 hrs, the crew reported level at FL 50. Shortly afterwards, the controller passed two further messages to AMC 202. The first was: "AMC202 reduce to 160 kt and maintain until at four DME"; this was acknowledged as: "160 kt till four DME AMC 202". Then, the controller transmitted: "202 correct descend to altitude four thousand feet QNH 1011"; the crew replied: "Four thousand feet on QNH 1011 AMC 202". Within the cockpit, the clearance to an altitude was the prompt for the crew to action their 'Approach checks'. At 0942 hrs, the controller turned the aircraft left onto a heading of 335°M and this was acknowledged correctly. Then, at 0943, the controller noted from his radar display that AMC 202 was indicating at a altitude lower than cleared and immediately asked the crew to confirm their altitude. When AMC 202 stated that they were: "Passing two thousand four hundred feet", the controller promptly replied: "AMC 202 climb to three thousand feet immediately your cleared level was four thousand feet". The crew responded immediately with an application of power coincident with their radio acknowledgement. Thereafter, the controller advised them that the minimum safe altitude in their immediate area was three thousand feet and gave them radar vectors to intercept the ILS. The aircraft landed uneventfully shortly afterwards.
Learning Keywords:Operations - Altitude Excursion
Close match:Midair collision, Accident occurring July 1, 2002 involving a Boeing 757-200 and Tupolev Tu-154M
A serious incident which occurred on 30 January 1998, in the airspace 10 NM east of Stockholm/Arlanda airport between the aircraft with registry YL-BAN and SE-DUR
Proximity incident, Infraction of minimum separation between the aircraft G-KATA and OY-CNP in the airspace above Malmö/ Sturup airport, M County, on the 22nd of August 2002
Loss of separation west of Helsinki-Vantaa airport on 22.1.2003
Loss of separation over BALTI on 6.9.2002
Loss of Separation East of Turku Airport on 23.10.2002
Near-miss between an Airbus A310, AP-BED and a Boeing 737-600, LN-RPK
AIRPROX, Embraer EMB-145EU vs. Two McDonnell Douglas F-15Es
Turbulence injuries, Airbus A300B4-605R, G-MONR
Loss of altitude while maneuvering on approach, Boeing 727-2H3, C-GYFA
Loss of altitude following takeoff, Airbus A310, 5Y-BFT, 8 November 1998 at 2048 hrs
Crash into terrain, West Coast Airlines, Inc., DC-9, N9101, Near Wemme, Oregon, October 1, 1966
In-flight upset, Trans World Airlines, Inc., Boeing 727-31, N840TW, near Saginaw, Michigan, April 4, 1979
Loss of separation south east of Helsinki-Vantaa, Finland on 11.1.2002
Altimeter setting error and altitude excursion, McDonnell Douglas MD-11, N701GC, December 3, 2005
Descent beneath glide slope, Boeing 747-412, 4X-ELS, January 10, 2006

 




Accident Reports on DVD, Copyright © 2006 by Flight Simulation Systems, LLC.  All Rights Reserved.
 All referenced trademarks are the property of their respective owners.
www.fss.aero