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
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
Operator(s):Air Malta
Type of flight:Revenue
Serious Injuries:0
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
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