Date: 4th December 2023
Location: London Stansted Airport, United Kingdom
Aircraft: Boeing 737-8 MAX, registration EI-HET
Flight Number: FR-1269
Operator: Ryanair
Flight Route: Klagenfurt (Austria) to London Stansted (UK)
Passengers: Undisclosed
Crew: 2
Summary of Events
On 4th December 2023, Ryanair Flight FR-1269, a Boeing 737-8 MAX, initiated a go-around during its final approach to Runway 22 at London Stansted Airport due to an unstabilized approach. During the go-around, the aircraft underwent a rapid descent, reaching a rate of descent of 8,880 feet per minute and an airspeed of 295 knots. The aircraft briefly descended to 1,740 feet above ground level (AGL) before the crew successfully recovered and stabilized at 3,000 feet. The aircraft subsequently repositioned and landed safely without further incident.
The British Air Accidents Investigation Branch (AAIB) classified the occurrence as a serious incident. Their final bulletin, released on 21st November 2024, highlighted procedural errors, high workload, and startle factors as the primary contributors to the incident.
Aircraft and Crew Information
The Boeing 737-8 MAX, registration EI-HET, is a modern variant of the 737 series equipped with advanced avionics and safety systems. At the time of the incident, the aircraft was operating under instrument meteorological conditions (IMC) with no external visual references.
The flight crew consisted of two experienced pilots familiar with both the aircraft and the operational environment at Stansted. However, the sequence of events during the approach and go-around revealed lapses in procedural adherence and situational awareness under high workload conditions.
Sequence of Events
1. Initial Approach:
The aircraft was conducting a radar-vectored Category I ILS approach to Runway 22 in IMC. At approximately 9 nautical miles (nm) from the runway threshold, the aircraft was 1,000 feet above the glideslope. The crew attempted to capture the glideslope from above, contrary to standard practice.
2. Unstabilized Approach:
By 4 nm, the crew realized they were unable to stabilize the approach. The pilot flying (PF) set the Mode Control Panel (MCP) altitude to 100 feet instead of the Missed Approach Altitude (MAA) of 3,000 feet. This critical error was not identified before the go-around.
3. Go-Around Execution:
At 3.6 nm and 1,940 feet above mean sea level (AMSL), the crew initiated a go-around. The MCP altitude setting of 100 feet caused the flight directors to continue commanding a climb without leveling off at 3,000 feet. The PF fixated on the flight directors, leading to a level bust.
4. Rapid Descent:
After overshooting the MAA, the PF initiated a corrective descent. Excessive nose-down pitch (17.7°) and power adjustments resulted in an 8,880 feet per minute descent rate and a minimum altitude of 1,740 feet AGL.
5. Recovery and Stabilization:
The Enhanced Ground Proximity Warning System (EGPWS) activated as the commander initiated recovery. The aircraft stabilized at 3,000 feet and subsequently landed safely at Stansted following a second approach.
AAIB Findings
1. Missed Approach Altitude (MAA) Not Set:
The MCP altitude was set incorrectly during the approach and not updated before the go-around. This error resulted in flight director guidance that did not correspond to the required level-off altitude.
2. High Workload and Fixation:
The PF’s fixation on the flight directors and the high workload during the approach and go-around contributed to delayed recognition of the altitude error and inadequate situational awareness.
3. Inappropriate Control Inputs:
During the descent, the PF’s inputs, combined with idle thrust and nose-down trim, exacerbated the rapid descent. These actions were likely influenced by startle factors and workload.
4. Lack of Communication:
The crew did not adequately share their mental models or intentions during the approach, leading to misaligned expectations and delayed corrective actions.
5. Operator Procedures:
While the operator’s procedures required the MAA to be set during glideslope interception, there was no explicit guidance for setting it when capturing the glideslope from above.
Conclusions
The Ryanair Flight FR-1269 serious incident resulted from procedural errors, high workload, and the failure to set the MAA during the approach. The crew’s inability to stabilize the approach and execute a coordinated go-around in IMC underscores the critical importance of effective communication, procedural adherence, and training for complex scenarios.
The incident demonstrates that even advanced systems like the Boeing 737-8 MAX’s autopilot and flight directors are vulnerable to human error when fundamental procedures are not followed.
Recommendations
1. Enhanced Training for Go-Around Procedures:
Airlines should provide simulator-based training focused on go-around scenarios, including handling level busts, high workload, and startle factors.
2. Procedural Reinforcement:
Operators should update standard operating procedures (SOPs) to explicitly address altitude setting requirements when capturing a glideslope from above.
3. Improved Crew Resource Management (CRM):
Flight crews should be trained to share mental models and intentions throughout all phases of flight, particularly during high-stress situations like unstable approaches.
4. Automation and Alerting Improvements:
Aircraft manufacturers should consider enhancing flight director and MCP alerting systems to provide clearer guidance in scenarios where the MCP altitude is inconsistent with operational requirements.
5. EGPWS Awareness:
Airlines should reinforce EGPWS recovery training, emphasizing timely responses to warnings as a critical safety barrier.
Safety Lessons and Industry Impact
This incident highlights the complexity of managing high-workload situations during instrument approaches and go-arounds. The findings emphasize the need for rigorous adherence to procedures, effective communication, and robust training to prevent similar occurrences.
The lessons learned are relevant not only to Ryanair but also to other operators using advanced aircraft systems, underscoring the universal importance of procedural discipline in modern aviation.
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