Flight Crew Altitude Breach During Approach

No fatalities • 23 km SSW Brisbane Airport, Queensland

An aircraft descended below its cleared altitude of 3,000 ft during the approach phase due to increased pilot workload and loss of situational awareness.

What happened

During the approach and landing phase, the flight crew experienced a significant increase in workload following an error with the altitude selector. The pilot flying (PF) failed to properly depress the selector and subsequently neglected to verify the flight mode annunciation (FMA) for the required change. This error led to a substantial loss of situational awareness regarding the aircraft's descent profile, specifically concerning the aircraft's altitude relative to its distance from the runway.

Driven by a preconception that the aircraft needed to avoid being high on the approach profile, the PF initiated a descent that breached the required altitude limit of 3,000 ft. This altitude was mandatory to maintain until the aircraft was established on final approach. The crew identified the deviation and began leveling the aircraft at approximately 2,000 ft shortly before air traffic control (ATC) notified them of the altitude breach.

The investigation

The investigation focused on the crew's management of the approach and the execution of monitoring duties. It was noted that while the pilot monitoring (PM) had not previously flown this specific approach, the monitoring role was not effectively performed. The investigation examined how the combination of high workload and the failure to verify flight mode changes contributed to the loss of descent profile awareness.

Probable cause

The breach of the altitude limit was caused by a loss of situational awareness regarding the descent profile, driven by high workload and a failure to verify flight mode changes, alongside a preoccupation with maintaining a specific approach path.

Frequently asked questions

What happened in the 2017-11-18 The Boeing Company 777-319ER accident near 23 km SSW Brisbane Airport, Queensland?

An aircraft descended below its cleared altitude of 3,000 ft during the approach phase due to increased pilot workload and loss of situational awareness.

Were there any fatalities in the 2017-11-18 The Boeing Company 777-319ER accident?

No fatalities were recorded in this accident.

What aircraft was involved and where did it happen?

The accident on 2017-11-18 involved a The Boeing Company 777-319ER, registration ZK-OKN, operated by Air New Zealand, at 23 km SSW Brisbane Airport, Queensland.

What was the probable cause of the accident?

The breach of the altitude limit was caused by a loss of situational awareness regarding the descent profile, driven by high workload and a failure to verify flight mode changes, alongside a preoccupation with maintaining a specific approach path.

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