Neos B738 at Bristol on Jun 1st 2019, descended below safe height on approach and again on go around
Last Update: April 23, 2020 / 20:27:24 GMT/Zulu time
Incident Facts
Date of incident
Jun 1, 2019
Classification
Report
Airline
Neos
Flight number
NO-830
Departure
Verona, Italy
Destination
Bristol, United Kingdom
Aircraft Registration
I-NEOT
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
The AAIB released their bulletin releasing following conclusion:
Flying a shortened routing led to a rushed and unstable approach which did not follow the correct vertical flightpath. This was observed by ATC who instructed the aircraft to go around. The crew found themselves performing a go-around unexpectedly but did not know why they had been required to do so. The go-around was conducted with a mis-set altitude on the MCP, and neither crew member noticed for a significant period that the aircraft was descending during the manoeuvre.
Crews should always be ready to perform a go-around because there can be many reasons why they might have to, either internal or external to the aircraft, such as on instruction from ATC.
The AAIB reported at the time of the incident approach control to Bristol was staffed by a trainee under supervision by an experienced controller. The ILS for runway 27 was not available due to works in progress, NOTAMs hat been issued informing the crew to expect the RNAV (GNSS) approach to runway 27.
The AAIB analysed:
The incident began when the crew accepted a shortened routing offered by Bristol Approach. This meant the aircraft was above FL100 with less than 25 nm to run to touchdown. Whilst the trainee controller clearly had good intentions in offering the crew the routing, a more experienced controller might not have considered it appropriate given the speed and height of I-NEOT. However, it is the responsibility of the crew to accept or decline any shortcut offered having assessed whether it is suitable. It remains the prerogative of the crew to ask for extra track miles to touchdown any time they consider the current distance to be too short.
As a result of the shorter routing, I-NEOT had too little distance to descend and reduce speed ready for the approach. The speed of the aircraft over ELROV was 61 kt above the procedure limiting speed. As a result, the crew were unable to make use of the VNAV mode of the AFDS and the approach was begun in LVL CHG. Descending down the approach in LVL CHG meant the crew were unable to reset to go-around altitude as directed in the operator’s procedures. Had they done so the aircraft would have climbed straight away because the autopilot was engaged.
I-NEOT did not meet the stable approach criteria laid out in the operator’s Operations Manual and, in these circumstances, the operator’s procedures required the crew to go around. However, the passing of the stable approach barrier went unmentioned by the crew and was followed shortly afterwards by ATC instructing them to go-around.
The instruction to I-NEOT to go-around was based on an instinctive reaction from the tower controller who considered that the aircraft was dangerously positioned in accordance with MATS Part 1. Whilst the crew were not expecting it and could not understand the reason for it, all crews must be prepared to perform a go-around at any time during an approach. In this event, the fact that the MCP altitude remained set at the approach minima rather than the missed approach altitude caused a significant deviation from a normal go-around with the aircraft descending, unnoticed by either crew member, for a significant period. The controller and the crew members realised almost simultaneously that there was a problem and the aircraft began to climb. During the initial go-around the aircraft descended below 500 ft agl.
The crew experienced a technical issue with VNAV after the go-around which meant they were unable to fly the second approach using this mode. However, this issue was not the cause of VNAV disconnecting at the start of the first approach. That was caused by the significant excess speed that the aircraft had at the start of the approach. Regardless of the reason for the disengagement, all crews should be aware that automatic modes will not always be operational and alternatives or reversions, should they be available, should be discussed before the approach begins.
Incident Facts
Date of incident
Jun 1, 2019
Classification
Report
Airline
Neos
Flight number
NO-830
Departure
Verona, Italy
Destination
Bristol, United Kingdom
Aircraft Registration
I-NEOT
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
This article is published under license from Avherald.com. © of text by Avherald.com.
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