No fatalities

2017-11-18: The Boeing Company 777-319ER (ZK-OKN) — Air New Zealand — 23 km SSW Brisbane Airport, Queensland

23 km SSW Brisbane Airport, Queensland

On November 18, 2017, a The Boeing Company 777-319ER (registration ZK-OKN) operated by Air New Zealand was involved in an aviation accident near 23 km SSW Brisbane Airport, Queensland. No fatalities were reported. Investigators recorded the probable cause as: The pilot flying's failure to press the altitude selector properly and then check that the required flight mode change occurred on the Flight Mode Annunciator (FMA), which increased workload and led to loss of descent profile awareness and a preconception… This summary draws on records from the Australian Transport Safety Bureau (ATSB); 8 related events involving the same aircraft type or operator are linked below.

Sourcesthe Australian Transport Safety Bureau (ATSB)Primary reportUpdated 1779789113Data APIEditorial standards
Aircraft registered ZK-OKN
Aircraft registered ZK-OKN. Photo: Phillip Capper from Wellington, New Zealand / CC BY 2.0, via Wikimedia Commons

During an approach, the pilot flying did not properly press the altitude selector and failed to verify the flight mode change, leading to increased workload and loss of situational awareness, resulting in a descent below the required 3,000 ft clearance limit. The pilot monitoring's oversight was ineffective.

Approach and Landing Workload

The approach and landing phases are recognized as periods of elevated workload. This workload can escalate significantly when unexpected errors occur, compounding the challenges faced by the flight crew.

Altitude Selector Error

The pilot flying (PF) did not press the altitude selector correctly and subsequently failed to check that the intended flight mode change had been registered on the Flight Mode Annunciator (FMA). This oversight led to a substantial increase in the PF's workload as the approach progressed.

Loss of Situational Awareness

As a result of the higher workload, the PF lost awareness of the aircraft's descent profile, particularly the relationship between altitude and distance to the landing point. This loss of situational awareness was compounded by a preconception that the aircraft should not become high on the profile during positioning for final approach.

Descent Below Clearance Limit

The combination of diminished descent profile awareness and the preconceived notion led the PF to initiate a descent below the published altitude limit of 3,000 ft, which was required to be maintained until the aircraft was established on final approach. The PF recognized the error and began leveling the aircraft just before air traffic control (ATC) notified the flight crew that they had breached the descent clearance limit.

Pilot Monitoring Role

The pilot monitoring (PM) has a responsibility to maintain awareness of the PF's actions and the aircraft's flight profile relative to altitude clearances and approach procedure limitations. Although the PM had not flown this particular approach before, the monitoring duties during the approach were not effectively executed.

Probable cause

The pilot flying's failure to press the altitude selector properly and then check that the required flight mode change occurred on the Flight Mode Annunciator (FMA), which increased workload and led to loss of descent profile awareness and a preconception that the aircraft should not get high on profile, resulting in a descent below the 3,000 ft altitude limit.