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Barometric Pressure Setting Advisory Tool (BAT)

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Category: Level Bust Level Bust
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Description

Barometric Pressure Setting Advisory Tool (BAT) is a tool developed by NATS to identify significant QNH setting errors based on downlinked Mode S Barometric Pressure Setting (BPS) data.

Objective

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.

Background

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.

Technological Enablers

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

Operation

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.

Coverage

BAT Coverage as of 25 Nov. 2010

Visual Representation

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.

Visual representation of the BAT

Procedures

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.

Phraseology

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.

Specifics

  • 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.

Implementation

  • 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.

Related Articles

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:

  • A332, vicinity Tripoli Libya, 2010 (CFIT HF FIRE) (On 12 May 2010, an Afriqiyah Airways Airbus A330 making a daylight go around from a non precision approach at Tripoli which had been discontinued after visual reference was not obtained at MDA did not sustain the initially established IMC climb and, following flight crew control inputs attributed to the effects of somatogravic illusion and poor CRM, descended rapidly into the ground with a high vertical and forward speed, The aircraft was destroyed by impact forces and the consequent fire and all but one of the 104 occupants were killed.)
  • DH8D, vicinity Edinburgh UK, 2008 (LB CFIT HF) (On 23 December 2008, a DHC8-400 being operated by Flybe on a scheduled passenger flight from Southampton to Edinburgh continued descent below its cleared altitude of 2100ft in day VMC prior to and then whilst tracking the ILS LLZ for Runway 23 at destination. It remained below the ILS GS until the ATC GND Controller, who had no formal responsibility for this phase of flight but was positioned alongside the TWR Controller, observed that aircraft had descended to within 800 ft of local terrain approximately 5 nm from the runway threshold. The flight crew appeared unaware of this when making a ‘Finals’ call to TWR at 5.5 nm and so the Controller queried the descent. The aircraft was then levelled to achieve 600ft agl at 4nm from the threshold and an uneventful landing subsequently followed.)
  • 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.)
  • 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.)
  • E190, En route, Eastern Kavango Namibia, 2013 (CFIT INT) (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.)
  • 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.)
  • 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.)
  • 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.)
  • A320, vicinity Addis Ababa Ethiopia, 2003 (CFIT) (On 31 March 2003, an A320, operated by British Mediterranean AW, narrowly missed colliding with terrain during a non-precision approach to Addis Ababa, Ethiopia.)
  • 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.)
  • GLF4, vicinity Kerry Ireland, 2009 (CFIT HF) (On 13 July 2009, a Gulfstream IV being operated by Indian operator Asia Aviation on a private flight from Kerry to Luton with one passenger on board in day IMC suffered a left main windshield failure shortly after take off and elected to make a return to land. Having received an ATC clearance to do so, it then failed to follow it and began a steep descent approximately 6 nm to the south of the airport towards high ground. When ATC became aware of this, an urgent instruction to climb was given and eventually the return was completed.)
  • 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.)
  • B733, vicinity Manchester UK, 1997 (LB CFIT HF) (On 1 August 1997, an Air Malta B737, descending for an approach into Manchester UK in poor weather, descended significantly below the cleared and correctly acknowledged altitude, below MSA.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • A310, vicinity Abidjan Ivory Coast, 2000 (CFIT HF) (On 30 January 2000, an Airbus 310 took off from Abidjan (Ivory Coast) at night bound for Lagos, Nigeria then Nairobi, Kenya. Thirty-three seconds after take-off, the airplane crashed into the Atlantic Ocean, 1.5 nautical miles south of the runway at Abidjan Airport. 169 persons died and 10 were injured in the accident.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • BE20, vicinity Gallatin Field MT USA, 2007 (CFIT HF) (On February 6, 2007, a Beech 200 King Air, being operated by Metro Aviation on an EMS positioning flight from Great Falls MT to Gallatin Field MT, collided at night in VMC with mountainous terrain approximately 13 nm north-northwest of the intended destination shortly after advising that the airport was in sight and requesting and obtaining permission for a visual approach.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • A333, vicinity Wom Guam Airport, Guam, 2002 (CFIT HF) (On 16 December 2002, approximately 1735 UTC, an Airbus A330-330, operating as Philippine Airlines flight 110, struck power lines while executing a localizer-only Instrument Landing System (ILS) approach to runway 6L at A.B. Pat Won Guam International Airport, Agana, Guam. Instrument meteorological conditions prevailed during the approach. Following a ground proximity warning system (GPWS) alert, the crew executed a missed approach and landed successfully after a second approach to the airport.)
  • 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.)
  • B738, En route, east of Asahikawa Japan, 2010 (CFIT HF) (On 26 October 2010, an All Nippon Boeing 737-800 was radar vectored towards mountainous terrain and simultaneously given descent clearance to an altitude which was 5000 feet below the applicable MVA whilst in IMC without full flight crew awareness. Two TAWS ‘PULL UP’ hard warnings occurred in quick succession as a result. The flight crew responses were as prescribed and the subsequent investigation found that the closest recorded proximity to terrain had been 655 feet. It was established that the controller had ‘forgotten’ about MVA.)
  • DHC6, En route, Mount Elizabeth Antarctica, 2013 (CFIT HF) (On 23 January 2013, a Canadian-operated DHC6 on day VFR positioning flight in Antarctica was found to have impacted terrain under power and whilst climbing at around the maximum rate possible. The evidence assembled by the Investigation indicated that this probably occurred following entry into IMC at an altitude below that of terrain in the vicinity having earlier set course en route direct to the intended destination. The aircraft was destroyed and there were no survivors.)
  • 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.)
  • 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.)
  • DHC6, En route, Arghakhanchi Western Nepal, 2014 (CFIT FIRE HF WX) (On 16 February 2014 a Nepal Airlines DHC6 attempting a diversion on a VFR flight which had encountered adverse weather impacted terrain at an altitude of over 7000 feet in a mountainous area after intentionally entering cloud following a decision to divert due to weather incompatible with VFR. The aircraft was destroyed and all 18 occupants were killed. The Investigation attributed the accident to loss of situational awareness by the aircraft commander and inadequate crew co-operation in responding to the prevailing weather conditions.)
  • 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.)
  • 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.)
  • DHC6, vicinity Kokoda Papua New Guinea, 2009 (CFIT HF) (On 11 August 2009, a De Havilland Canada DHC-6-300 being operated by Airlines PNG on a scheduled domestic passenger flight from Port Moresby to Kokoda impacted terrain in day IMC while transiting the Kokoda Gap, approximately 6nm south east of the intended destination. The aircraft was destroyed by impact forces and all 13 occupants were killed.)
  • 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.)
  • 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.)
  • … 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.

Further Reading

HindSight

UK NATS

EUROCONTROL

NATS Programme Contacts