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Level Bust

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Article Information
Category: Level Bust Level Bust
Content source: SKYbrary SKYbrary
Content control: EUROCONTROL EUROCONTROL

Definition

A level bust is defined as: Any unauthorised vertical deviation of more than 300 feet from an ATC flight clearance. Within RVSM airspace this limit is reduced to 200 feet.(EUROCONTROL - HEIDI)

Definitions applied by other organisations are similar but sometimes refer to a deviation of 300 feet or more.

The level bust issue only relates to aircraft in controlled airspace or a designated ATZ outside controlled airspace, under ATC control, radar or procedural.

Description

A level bust occurs when an aircraft fails to fly at the level to which it has been cleared, regardless of whether actual loss of separation from other aircraft or the ground results. Level busts are also known as Altitude Deviations.

A Level Bust can result in Loss of Separation between aircraft or between an aircraft and the ground (CFIT).

Level busts are becoming less dangerous because improvements in technology such as better STCA and Mode S have improved the ability of controllers to safely manage any consequent loss of separation. Furthermore, the availability and proper use of [ACAS] provides a final safety net which significantly reduces the risk of a [Mid-Air Collision], and TAWS has also reduced the risk of a level bust resulting in a CFIT accident.

The move to Flexible Use Airspace (FUA), and the absence of ACAS on many military aircraft and the high perfornance of many military jet aircraft, means that the consequences of level busts involving military aircraft are more difficult to manage.

A potential loss of separation resulting from the ATCO assigning an inappropriate altitude or flight level in a flight clearance does not constitute a level bust because no deviation from the flight clearance occurs.


Types of Level Bust

  • aircraft both accepts a clearance and sets/records it correctly but then does not follow it [flight management error (usual) or technical fault(rarely)]
  • aircraft accepts a clearance correctly but then sets it incorrectly without the error being picked up by the crew [flight management error]
  • aircraft reads back clearance incorrectly and this error is not picked up by ATC so it is then recorded/set and followed [ATC error]
  • aircraft is unable to react fast enough to a late reclearance and passes through new cleared level [ATC error]
Levelbust2.jpg
  • aircraft follows clearance with the wrong altimeter sub scale setting [flight management error]
Levelbust3.jpg
  • aircraft departs cleared flight level without clearance to do so [flight management error]
Levelbust1.jpg

Effects

  • Collision with an obstacle or the ground (Controlled Flight Into Terrain), especially as a result of having the wrong altimeter sub-scale setting. This can happen when an aircraft descends in a low pressure area with standard pressure (1013) set.
  • Injury, especially to cabin crew or passengers, occasioned by violent manoeuvres to avoid collision with other aircraft or the ground.

Defences

  • Standard Operating Procedures, both on the flight deck and in the ATCU, which detail procedures to be followed to reduce the chance of level bust.
    • Flight deck routines on Multicrew aircraft should include procedures for cross-checking/confirming cleared altitude, readback, and altitude set on FMS by the monitoring crew members, and include calls of "1000 feet to go" and "approaching level".
  • Onboard aircraft equipment designed to warn of potential collision with other aircraft (ACAS/TCAS) or with the ground (GPWS or EGPWS).
  • Ground-based equipment designed to warn of potential collision with other aircraft, such as STCA, or provide more information on intentions of the aircraft (e.g. Mode S)

Typical Scenarios

  • Air-ground communications, for example:
    • The pilot mishears the level clearance, the pilot does not read back the clearance and the ATCO does not challenge the absence of a read-back;
    • The pilot reads back an incorrect level but the ATCO does not hear the erroneous read-back and does not correct the pilot’s read-back; or,
    • The pilot accepts a level clearance intended for another aircraft (call-sign confusion).
  • Pilot-induced situations, for example:
    • One pilot off frequency when clearance given by ATC and although reading it back correctly then mis-sets it on the FMS.
    • PNF fails to spot that PF has set FL110 on the FMS not the FL100 that PNF has (correctly) read back to ATC.
    • Flight crew used to a 6000ft Transition Altitude set up a SID for a departure from an airport which has a 3000ft Transition Altitude and then fail, with a low barometric pressure, to change to standardpressure setting (1013) quickly enough.
    • Uncertainty between two flight crew about a clearance given is resolved by reading back what they think it was to see if ATC then correct them. ATC don’t notice and it is not correct. [ATC hear-back error but flight crew should have asked for the clearance again not guessed it]
    • A military fast jet without ACAS but with Mode C/S exceeds its correctly acknowledged climb clearance and very rapidly causes multiple civil transport RA sequences at three different successive flight levels which, because of the fast jet's rate of climb, all consist of RAs which change too quickly to be capable of actioning.
    • the pilot understands and reads back the correct altitude or flight level but selects an incorrect altitude or flight level because of confusion of numbers with another element of the message (e.g. speed, heading or flight number), Expectation of another altitude or flight level, or Interruption or Distraction. [proper cross checking procedures on a multicrew flight deck shuld mitigate against these]
  • Aircraft technical equipment designed to prevent a Level Bust (e.g. autopilot or altitude alert) does not operate as designed.

Contributory Factors

Factors which contribute to the risk of a level bust occurring:

Factors which increase the risk of collision following a level bust:

Solutions

Further Reading

EUROCONTROL

EUROCONTROL has produced a wide range of valuable material raising awareness of, and addresssing the causes of, the Level Bust issue, including Safety Letters, an important series of briefing notes (also part of the Level Bust Toolkit), a number of articles in HindSight Magazine, an Action Plan, Posters and more. For a complete list of material available on the SKYbrary Bookshelf, see the article Level Bust Products.

Further information is available at the EUROCONTROL Level Bust web-site: http://www.eurocontrol.int/safety/public/standard_page/Level_bust.html

Airbus Briefing Notes

UKCAA

UK NATS

The Levelbest web-site http://www.levelbust.com/ contains much valuable information including articles and posters from a wide range of sources which may be down-loaded.