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Barometric Pressure Setting Advisory Tool (BAT)
- 1 Description
- 2 Objective
- 3 Background
- 4 Technological Enablers
- 5 Barometric Pressure Setting Advisory Tool Description
- 6 Procedures
- 7 Implementation
- 8 Safety Impact of BPS Monitoring
- 9 Related Articles
- 10 Accidents and Incidents
- 11 Further Reading
- 12 NATS Programme Contacts
The Barometric Pressure Setting Advisory Tool is designed to provide an advisory warning to Terminal Control Approach controllers where there is a significant difference (greater than 6 hPa) from the London QNH. The BAT tool applies only to arrival aircraft at or below the transition altitude and works with both multi-radar tracking (MRT) and single radar information source.
A study conducted by NATS of aircraft flying within the London TMA has highlighted some operator anomalies in the setting of flight deck BPS. It was established that a clear majority of flight crews change altimeter settings in a timely manner in accordance with ICAO Procedures for Air Navigation Services - Aircraft Operations (PANS-OPS). However, there were recorded a few examples of errant behaviour. The risk of level deviations caused by altimeter setting errors is highest when the atmospheric pressure is low and the risk is significant when the pressure in the London TMA is forecast to be less than 996 hPa.
Mode S Enhanced Surveillance (EHS) transponders may automatically provide particular flight deck parameters to air traffic systems that have not been used previously by ATC. The Mode S EHS technology makes it possible for aircraft to downlink the flight deck altimeter setting in the form of a Mode S parameter known as Barometric Pressure Setting (BPS).
Mode S BPS data is provided by a large proportion of flights in European terminal airspaces and the NATS study has shown this data to be of a very high integrity in the majority of cases. There are, however, some known problems with data supplied by some aircraft when above the transition altitude, which precludes its use by ATC. Nevertheless, although the provision of Mode S BPS is not mandated, NATS considers that the downlinked data is of sufficient integrity to be used by ATC for aircraft descending below the transition altitude and that this will contribute to the prevention of level busts by inbound aircraft.
Barometric Pressure Setting Advisory Tool Description
The tool is designed to follow these principles of operation:
- A route filter is applied such that only arrivals to specific airports are eligible. For Phase One these filters are for Heathrow, Northolt, London City & Biggin Hill.
- The Mode S Selected Altitude (SFL) and the current level (Mode C) are compared to ensure that the arrival aircraft intends to remain below the Transition Altitude.
- Mode S BPS is down-linked from aircraft. The BPS must be 6mb or more different to the London QNH and SFL data must be available
- Other criteria are applied to give flight crews the maximum amount of time to change altimeter settings without unduly risking a nuisance potential level bust indication.
The tool is NOT intended to:
- Alert on departure aircraft (apart from positioning flights that stay below the Transition Altitude). This is due to issues with incorrect data provided by certain aircraft - the last selected QNH rather than standard pressure is downlinked when operating above the Transition Altitude.
- Alert above the transition altitude (e.g. aircraft entering a terminal hold).
- Support aircraft that do not provide both Mode S SFL and Mode S BPS (approximately 80% of aircraft in the TMA provide both types of data).
- Provide an advisory to TMA positions.
The BAT advisory comprises a two tone yellow pulse of the level field (as displayed below). The BAT advisory is not acknowledged and does not appear in the Vertical Stack List (VSL). STCA takes precedence over the BAT advisory and the actual BPS value downlinked is displayed in the Mode S Data window. In the radar image below the Mode A code is displayed on line one of the track label and is usually converted to the aircraft callsign on the controller’s radar display. Line two contains the current level, the destination code and the selected altitude. The BPS advisory is shown on the target with the Mode A code of 7735, the level field will pulse yellow on the ATC display. The Mode S data window shows the actual BPS being down-linked.
Responsibilities for use of the tool
- The response to a BAT advisory is not a mandatory task for controllers, although it is encouraged for early identification of possible level busts.
- The use of BAT is not a substitute for RT read-back, which remains a mandatory controller task.
- Where a BAT advisory indicates a variation with the QNH provided by ATC, controllers must not state the incorrect QNH value which can be observed in the Mode S Data Window on the radar display.
- Controllers to complete a STAR report for any BAT advisory / resolution where safety may have been compromised but use a comments folder for all other occasions where BAT was used.
Where controllers choose to query the discrepancy, the phraseology to be used is:
“(Callsign), Check Altimeter Setting, QNH xxx” - where xxx is the local QNH being utilised
Notwithstanding the above, if an aircraft is in conflict with another, the priority is to resolve the confliction. If appropriate, avoiding action should be issued prior to confirming the correct QNH. Where sufficient time exists, the use of the following phraseology may be used to query the altimeter setting used by the aircrew:
“(Callsign) Report QNH”
This will enable flight crew to check selected pressure setting, irrespective of any BAT Advisory or QNH data displayed in the Mode S Data Window.
- Issue with very low provision of BPS data from all airlines passed by a specific aircraft type. Fix being discussed with operators.
- Possible that after aircrew are challenged, BAT advisory persists. ATC is not expected to repeat challenge.
- Emergency code selected (e.g. 7500) – the Track Data Block flashes whereas associated BAT advisory will pulse.
- STCA will alert and clear BAT advisory. If STCA acknowledged / finishes, BAT advisory will immediate resume.
- Will support positioning flights below Transition Altitude as long as in check area and correct destination code.
- From 25th November 2010, BPS data will be automatically down linked from all compliant aircraft to ATC workstations within the London Terminal Control Centre at Swanwick covering arrivals at Heathrow, Northolt, London City and Biggin Hill.
- From 10th March 2011 - BAT for Terminal Control Stansted and Terminal Control Luton for arrivals to Stansted and Luton will be implanted.
- Late spring 2011 – BAT will be implemented for Terminal Control Gatwick for arrivals to Gatwick and Redhill.
Safety Impact of BPS Monitoring
The UK CAA and NATS wish to highlight the positive safety impact that the downlinking of BPS will have on the prevention of Level Busts. Operators are to advise their aircrew that for LTMA arrivals that are cleared to descend below the Transition Altitude, the down linked BPS will be automatically monitored. Where the ground system indicates that the down linked BPS is outside a specified range, ATC at the London Terminal Control Centre may issue the correct QNH on more than one occasion as a reminder to the pilot.
When ATC pass a reminder of the QNH, it is anticipated that the pilot monitoring will cross check the altimeter settings.
- Level Bust in Holding Patterns
- Transition Altitude/Level
- Altimeter Pressure Setting
- Altimeter Setting Procedures
- Minimum Sector Altitude
Accidents and Incidents
Events in which the incorrect altimeter pressure setting was either a cause or contributing factor in a Level Bust or CFIT/near CFIT:
- SW4, New Plymouth New Zealand, 2009 (CFIT RE HF) (The visual approach at destination was rushed and unstable with the distraction of a minor propeller speed malfunction and with un-actioned GPWS warnings caused by excessive sink and terrain closure rates. After a hard touchdown close to the beginning of the runway, directional control was lost and the aircraft left the runway to the side before continuing parallel to it for the rest of the landing roll.)
- A306, East Midlands UK, 2011 (LOC AW HF) (On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.)
- E190, En route, Eastern Kavango Namibia, 2013 (CFIT HF) (On 29 November 2013, during the cruise at FL380 and without advising ATC, the aircraft commander of a Mozambique Airlines Embraer 190 initiated what initial evidence indicates was an intentional descent without any prior announcement whilst the First Officer had temporarily left the flight deck. The AP remained engaged, the thrust was set to flight idle and the speed brakes were extended. The aircraft was commanded to continue descend at near to Vmo by means of the manual input of successively lower selected altitudes until the final one was below ground level. The Investigation is continuing.)
- B734, vicinity Lyon France, 2010 (CFIT HF) (On 7 September 2010, a Turkish operated Boeing 737-400 flew a non precision approach at Lyon Saint-Exupéry in IMC significantly below the procedure vertical profile throughout and only made a go around when instructed to do so by ATC following an MSAW activation. The minimum recorded radio height was 250 feet at 1.4nm from the runway threshold.)
- SU95, manoeuvring near Jakarta Indonesia, 2012 (CFIT HF FIRE) (On 9 May 2012, a Sukhoi RRJ-95 on a manufacturer-operated demonstration flight out of Jakarta descended below the promulgated safe altitude and, after TAWS alerts and warnings had been ignored, impacted terrain in level flight which resulted in the destruction of the aeroplane and death of all 45 occupants. The Investigation concluded that that the operating crew were unaware that their descent would take them below some of the terrain in the area until the alerts started and then assumed they had been triggered by an incorrect database and switched the equipment off.)
- A320, Khartoum Sudan, 2005 (WX CFIT HF) (On 11 March 2005, an Airbus A321-200 operated by British Mediterranean Airways, executed two unstable approaches below applicable minima in a dust storm to land in Khartoum Airport, Sudan. The crew were attempting a third approach when they received information from ATC that visibility was below the minimum required for the approach and they decided to divert to Port Sudan where the A320 landed without further incident.)
- DHC6, vicinity Oksibil Indonesia, 2009 (CFIT WX HF) (On 2 August 2009 a DHC-6 being operated by Merpati Nusantara Airlines on a scheduled domestic passenger flight from Sentani to Oksibil in West Papua in daylight and on a VFR Flight Plan was in collision with terrain 6nm from destination resulting in the destruction of the aircraft and the death of all 15 occupants.)
- MD83, vicinity Paris Orly France, 1997 (CFIT HF) (On 23 November 1997, a McDonald Douglas MD 83 being operated by AOM French Airlines on a scheduled passenger flight from Marseille to Paris Orly made an unintended premature descent almost to terrain impact at 4nm from the destination runway in day IMC before a go around was commenced. A subsequent approach was uneventful and a normal landing ensued. There was no damage to the aircraft or injury to the occupants.)
- B733, vicinity Helsinki Finland, 2008 (LB CFIT HF) (On 26 March 2008, a Ukraine International Airlines’ Boeing 737-300 being vectored by ATC to the ILS at destination Helsinki in IMC descended below its cleared altitude and came close to a telecommunications mast. ATC noticed the deviation and instructed a climb. The investigation attributed the non-compliance with the accepted descent clearance to the failure of the flight crew to operate in accordance with SOPs. The ability of ATC safety systems as installed and configured at the time of the occurrence was also noted.)
- D328, Sumburgh UK, 2006 (CFIT HF) (On 11 June 2006, a Dornier 328 operated by City Star Airlines whilst positioning in marginal visibility for a day approach at Sumburgh, Shetland Isles UK, and having incorrectly responded to TAWS Class A warnings/alerts by not gaining safe altitude, came to close proximity with terrain . The approach was continued and a safe landing was made at the airport.)
- EC55, en-route, Hong Kong China, 2003 (HF CFIT) (On 26 August 2003, at night, a Eurocopter EC155, operated by Hong Kong Government Flight Service (GFS), performing a casualty evacuation mission (casevac), impacted the elevated terrain in Tung Chung Gap near Hong Kong International airport.)
- MD83, vicinity Dublin Airport, Ireland, 2007 (CFIT HF) (On 16 August 2007, during a non-precision approach to RWY34 at Dublin airport, the flight crew of a MD83 misidentified the lights of a 16-storey hotel at Santry Cross as those of the runway approach lighting system. The aircraft deviated to the left of the approach course and descended below the Minimum Descent Altitude (MDA) without proper visual recognition of the runway in use. A go-around was initiated as soon as ATC corrective clearance was issued.)
- A320, vicinity Bahrain Airport, Kingdom of Bahrain, 2000 (CFIT HF) (On 23 August 2000, a Gulf Air Airbus A320 flew at speed into the sea during an intended dark night go around at Bahrain and all 143 occupants were killed. It was subsequently concluded that, although a number of factors created the scenario in which the accident could occur, the most plausible explanation for both the descent and the failure to recover from it was the focus on the airspeed indication at the expense of the ADI and the effect of somatogravic illusion on the recently promoted Captain which went unchallenged by his low-experience First Officer.)
- MD83, vicinity Nantes France, 2004 (HF CFIT) (On 21 March 2004, an MD-83 operated by Luxor Air, performed an unstabilised non-precision approach (NPA) to runway 21 at Nantes Atlantique airport, at night and under IMC conditions, which resulted in near-CFIT and a go around contrary to the standard missed approach procedure.)
- B738, vicinity Cork Ireland, 2006 (CFIT HF) (On 4 June 2006, a Boeing 737-800 being operated by Ryanair on a passenger flight from London Stansted to Cork became too high to land off a day visual approach and requested a right hand orbit to reposition. This positioning was flown too close to terrain with TAWS alert triggered prior to a second approach to a successful landing.)
- B734, Amsterdam Netherlands, 2010 (BS CFIT LOC HF) (On 6 June 2010, a Boeing 737-400 being operated by Atlas Blue, a wholly owned subsidiary of Royal Air Maroc, on a passenger flight from Amsterdam to Nador, Morocco encountered a flock of geese just after becoming airborne from runway 18L in day VMC close to sunset and lost most of the thrust on the left engine following bird ingestion. A MAYDAY was declared and a minimal single engine climb out was followed by very low level visual manoeuvring not consistently in accordance with ATC radar headings before the aircraft landed back on runway 18R just over 9 minutes later.)
- B738, vicinity London Stansted UK, 2011 (CFIT HF) (On 13 March 2011, a Turkish Airlines’ Boeing 737-800 stopped climb shortly after take off after misreading the SID chart. After levelling at 450 feet agl, it continued following the lateral part of the SID only until ATC re-iterated the requirement to climb after resolving a temporary loss of contact due to an un-instructed premature frequency change. It was found that the crew had received but apparently not responded to an EGPWS ‘PULL UP’ Warning. It was concluded that there was an opportunity to improve the clarity of UK SID charts to aid pilots with limited English language skills.)
- EC25, vicinity ETAP Central offshore platform, North Sea UK (CFIT HF) (On 18 February 2009, the crew of Eurocopter EC225 LP Super Puma attempting to make an approach to a North Sea offshore platform in poor visibility at night lost meaningful visual reference and a sea impact followed. All occupants escaped from the helicopter and were subsequently rescued. The investigation concluded that the accident probably occurred because of the effects of oculogravic and somatogravic illusions combined with both pilots being focused on the platform and not monitoring the flight instruments.)
- A320, vicinity Glasgow UK, 2008 (CFIT HF) (An Airbus A322 being operated by British Airways on a scheduled passenger flight from London Heathrow to Glasgow was being radar vectored in day IMC towards an ILS approach to runway 23 at destination when an EGPWS Mode 2 Hard Warning was received and the prescribed response promptly initiated by the flight crew with a climb to MSA.)
- B732, vicinity Resolute Bay Canada, 2011 (CFIT HF FIRE) (On 20 August 2011, a First Air Boeing 737-200 making an ILS approach to Resolute Bay struck a hill east of the designated landing runway in IMC and was destroyed. An off-track approach was attributed to the aircraft commander’s failure to recognise the effects of his inadvertent interference with the AP ILS capture mode and the subsequent loss of shared situational awareness on the flight deck. The approach was also continued when unstabilised and the Investigation concluded that the poor CRM and SOP compliance demonstrated on the accident flight were representative of a wider problem at the operator.)
- T154, vicinity Smolensk Russian Federation, 2010 (CFIT HF WX FIRE) (On 10 April 2010, a Polish Air Force Tupolev Tu-154M on a pre-arranged VIP flight into Smolensk Severny failed to adhere to landing minima during a non precision approach with thick fog reported and after ignoring a TAWS ‘PULL UP’ Warning in IMC continued descent off track and into the ground. All of the Contributory Factors to the pilot error cause found by the Investigation related to the operation of the aircraft in a range of respects including a failure by the crew to obtain adequate weather information for the intended destination prior to and during the flight.)
- T154, vicinity Svalbard Norway, 1996 (CFIT HF) (On 29 August 1996, a Tu-154, crashed after misflying an off-set LLZ non-precision approach to Svalbard Longyear airport, Norway, in IMC.)
- DH8D, Vicinity Exeter UK, 2010 (CFIT LB AW HF) (On 11 September 2010, a DHC8-400 being operated by Flybe on a scheduled passenger flight from Bergerac France to Exeter failed to level as cleared during the approach at destination in day VMC and continued a premature descent without the awareness of either pilot due to distraction following a minor system malfunction until an EGPWS ‘PULL UP’ Hard Warning occurred following which a recovery climb was initiated. There were no abrupt manoeuvres and no injuries to any of the 53 occupants.)
- LJ35, vicinity Masset BC Canada, 1995 (CFIT HF) (On 11 January 1995, a Learjet 35, crashed into the sea while conducting an NDB approach to Masset, British Columbia, Canada. The most probable cause was considered to be a miss-set altimeter.)
- C185, Smithers BC Canada, 2000 (CFIT) (On 27 September 2000, a Cessna 185, struck a snow covered hillside, probably while in controlled flight, en-route from Smithers BC, Canada.)
- MD11, vicinity East Midlands UK, 2005 (LB HF) (On 3 December 2005, the crew of a MD-11 freighter failed to set the (very low) QNH for a night approach, due to distraction, and as a result descended well below the cleared altitude given by ATC for the intercept heading for the ILS at Nottingham East Midlands airport, UK.)
- B733, vicinity Chambery France, 2010 (CFIT LOC HF) (On 7 February 2010, a Boeing 737-300 being operated by Jet2 on a scheduled passenger flight from Leeds/Bradford UK to Chambery France was making an ILS approach to runway 18 at destination in day IMC when a Mode 2 EGPWS ‘Terrain, Pull Up’ Warning occurred. A climb was immediately initiated to VMC on top and a second ILS approach was then made uneventfully. Despite extreme pitch during the early stages of the pull up climb, none if the 109 occupants, all secured for landing, were injured.)
- A320, vicinity Sochi Russian Federation, 2006 (HF CFIT) (On 3 May 2006, an Airbus 320 operated by Armavia Airlines at night and in instrument meteorological conditions (IMC) mismanaged a go around and crashed into the Black Sea near Sochi Airport, Russia.)
- BE20/SF34, Vicinity Stornoway UK, 2011 (LB LOS HF) (On 31 December 2011 a USAF C12 Beech King Air descended 700 feet below the cleared outbound altitude on a procedural non precision approach to Stornoway in uncontrolled airspace in IMC and also failed to fly the procedure correctly. As a result it came into conflict with a Saab 340 inbound on the same procedure. The Investigation found that the C12 crew had interpreted the QNH given by ATC as 990 hPa as 29.90 inches, the subscale setting units used in the USA. The Saab 340 pilot saw the opposite direction traffic on TCAS and descended early to increase separation.)
- A310, vicinity Birmingham UK, 2006 (LB CFIT HF) (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.)
- A109, vicinity London Heliport London UK, 2013 (CFIT FIRE HF WX) (On 16 January 2013, an Augusta 109E helicopter positioning by day on an implied (due to adverse weather conditions) SVFR clearance collided with a crane attached to a tall building under construction. It and associated debris fell to street level and the pilot and a pedestrian were killed and several others on the ground injured. It was concluded that the pilot had not seen the crane or seen it too late to avoid whilst flying by visual reference in conditions which had become increasingly challenging. The Investigation recommended improvements in the regulatory context in which the accident had occurred.)
- FA20, vicinity Narsarsuaq Greenland, 2001 (CFIT HF) (On 5 August 2001, a Dassault Falcon 20, operated by Naske Air, on a non-scheduled international cargo flight, crashed on the final approach to runway 07 at Narsarsuaq, Greenland (BGBW), the aircraft impacting mountainous terrain 4.5 NM SW of the aerodrome.)
- B743, vicinity Won Guam Airport, Guam, 1997 (CFIT HF WX) (On 6 August 1997, Korean Air flight 801, a Boeing 747-300, crashed at night at Nimitz Hill, 3 miles southwest of Won Guam International Airport, Agana, Guam while on final approach for runway 6 Left. Of the 254 persons on board, 228 were killed, and 23 passengers and 3 flight attendants survived the accident with serious injuries.)
- E145, en route, north east of Madrid Spain, 2011 (CFIT LB HF AGC) (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.)
- B738, vicinity Memmingen Germany, 2012 (CFIT HF) (On 23 September 2012 a Ryanair Boeing 737-800 made a premature descent to 450 feet agl in day VMC whilst turning right onto visual finals for runway 24 at Memmingen after the FMS selected altitude had been set to a figure only 44 feet above runway threshold elevation of 2052 feet amsl. EGPWS Alerts of ‘Sink Rate’ and ‘Caution Terrain’ prompted initiation of a go around which, as it was initiated, was accompanied by a an EGPWS ‘TERRAIN PULL UP’ warning. The go around and a second successful approach to runway 24 were uneventful. The Investigation is not yet complete.)
- S61, vicinity Bødo Norway, 2008 (CFIT HF WX) (On 24 February 2008, a Sikorsky S-61N being operated by British International Helicopters on a passenger flight from Værøy to Bødo attempted a visual approach at destination in day IMC and came close to unseen terrain before accepting an offer of assistance from ATC to achieve an ILS approach to runway 07 without further event. None of the 18 occupants were injured.)
- AT43, vicinity Pristina Kosovo, 1999 (CFIT HF FIRE) (On 12 November 1999, a French-registered ATR 42-300 being operated by Italian airline Si Fly on a passenger charter flight from Rome to Pristina was positioning for approach at destination in day IMC when it hit terrain and was destroyed, killing all 24 occupants. A post crash fire broke out near the fuel tanks after the impact.)
- P46T, vicinity Son Bonet Palma de Mallorca Spain, 2002 (HF AI CFIT) (On 19 December 2002, a Piper PA-46 Malibu, after takeoff from Son Bonet Aerodrome, penetrated the control zone (CTR) of Palma de Mallorca tower. The pilot was instructed to leave the CTR and the aircraft headed towards mountainous terrain to the north of the island where the flight conditions were below the VFR minimum. In level flight the aircraft impacted terrain at an altitude of 2000 ft killing all three occupants.)
- DH8A, vicinity Palmerston North New Zealand, 1995 (CFIT HF AW) (On 9 June 1995 a de Havilland DHC-8-100 collided with terrain some 16 km east of Palmerston North aerodrome while carrying out a daytime instrument approach. The airplane departed Auckland as scheduled Ansett New Zealand flight 703 to Palmerston North airport.)
- B752, vicinity Cali Colombia, 1995 (CFIT HF FIRE) (On 20 December 1995, an American Airlines Boeing 757-200 inbound to Cali, Colombia made a rushed descent towards final approach at destination and the crew lost positional awareness whilst manoeuvring in night VMC. After the crew failed to stow the fully deployed speed brakes when responding to a GPWS ‘PULL UP’ Warning, the aircraft impacted terrain and was destroyed with only four seriously injured survivors from the 163 occupants surviving the impact. The accident was attributed entirely to poor flight management on the part of the operating flight crew, although issues related to the FMS were found to have contributed to this.)
- B762, vicinity Busan Korea, 2002 (CFIT HF) (On 15 April 2002, during daytime in poor visibility conditions, a Boeing 767-200 operated by Air China crashed during a circling approach, on Mt. Dotdae located 4.6 km north of runway 18R threshold at Busan/Gimhae International Airport at an elevation of 204m AMSL.)
- SW4, vicinity Lockhart River Queensland Australia, 2005 (CFIT HF) (On 7 May 2005, a Fairchild Aircraft Inc. SA227-DC Metro 23 aircraft, was being operated by Transair on an IFR flight from Bamaga to Cairns, with an intermediate stop at Lockhart River, Queensland. The aircraft impacted terrain approximately 11 km north-west of the Lockhart River aerodrome and was destroyed by the impact forces and an intense, fuel-fed, post-impact fire.)
- B773, vicinity Melbourne Australia, 2011 (CFIT HF) (On 24 July 2011, a Thai Airways International Boeing 777-300 descended below the safe altitude on a night non-precision approach being flown at Melbourne and then failed to commence the go around instructed by ATC because of this until the instruction had been repeated. The Investigation concluded that the aircraft commander monitoring the automatic approach flown by the First Officer had probably experienced ‘automation surprise’ in respect of the effects of an unexpected FMS mode change and had thereafter failed to monitor the descent of the aircraft with a selected FMS mode which was not normally used for approach.)
- CRJ1, vicinity Brest France, 2003 (CFIT HF FIRE) (On 22 June 2003, a Bombardier CRJ100 being operated by Brit Air flew an inaccurate night ILS approach and impacted terrain over a mile from the runway during an attempted unsuccessful go-around at Brest Guipavas Airport.)
- FA50, vicinity London City UK, 2010 (CFIT LB HF) (On 21 January 2010, a Mystere Falcon 50 being operated by TAG Aviation on a positioning flight from Biggin Hill to London City in day VMC began a descent at a high rate below its cleared altitude of 2000 ft amsl because the aircraft commander believed, on the basis of external visual cues, that the aircraft was on a final approach track for Runway 27 at destination when in fact it was downwind for Runway 09. After an alert from ATC as the aircraft passed 900 ft agl at a rate of descent of approximately 2200 fpm, recovery to a normal landing on Runway 09 was achieved.)
- B738, vicinity Denpasar Bali Indonesia, 2013 (CFIT HF) (On 13 April 2013, a Lion Air Boeing 737-800 flew a day non precision approach to runway 09 at Bali (Denpasar) and after encountering deteriorating visibility conditions continued below MDA before impacting the sea short of the intended landing runway after a go around had been called following the EGPWS ‘Twenty’ call. The aircraft broke up on impact but there was no fire and all 108 occupants survived with only 4 sustaining serious injury. An investigation is continuing.)
- RJ1H, vicinity Zurich Switzerland, 2001 (CFIT FIRE HF) (On 24 November 2001, a Crossair Avro RJ100 making a night non precision approach to Zurich violated approach minima and subsequently impacted terrain whilst making a delayed attempt to initiate a go around. The aircraft was destroyed by the impact and post crash fire and 24 of the 33 occupants were killed. The Investigation attributed the crash to the crew deliberately continuing descent below MDA without having acquired the prescribed visual reference. Both crew pairing and aspects of the crew as individuals were identified as the context.)
- C550, vicinity Cagliari Sardinia Italy, 2004 (CFIT HF) (On 24 February 2004, a Cessna 550 inbound to Cagliari at night requested and was approved for a visual approach without crew awareness of the surrounding terrain. It was subsequently destroyed by terrain impact and a resultant fire during descent and all occupants were killed. The Investigation concluded that the accident was the consequence of the way the crew conducted the flight in the absence of adequate visual references and with the possibility of a ‘black hole’ effect. It was also noted that the aircraft was not fitted, nor required to be fitted, with TAWS.)
- A320, vicinity Oslo Norway, 2008 (CFIT LB HF AGC) (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.)
- C30J, en-route, northern Sweden 2012 (CFIT HF FIRE) (On 15 March 2012, a Royal Norwegian Air Force C130J-30 Hercules en route on a positioning transport flight from northern Norway to northern Sweden crossed the border, descended into uncontrolled airspace below MSA and entered IMC. Shortly after levelling at FL 070, it flew into the side of a 6608 foot high mountain. The Investigation concluded that although the direct cause was the actions of the crew, Air Force procedures supporting the operation were deficient. It also found that the ATC service provided had been contrary to regulations and attributed this to inadequate controller training.)
- … further results
"Pressure altimeter setting error" is not in the list of possible values (Into water, Into terrain, Into obstruction, No Visual Reference, Lateral Navigation Error, Vertical navigation error, VFR flight plan, IFR flight plan) for this property.