Introduction
On 8 March 2024, a Ryanair Boeing 737-8 MAX, registration EI-HGG, operating flight FR-2467 from Szczecin, Poland to London Stansted, UK, experienced a level bust following a go-around on final approach to Runway 04. The aircraft descended 600 feet below its cleared altitude after the captain took control, unaware that the autopilot (A/P) and autothrottle (A/T) were disengaged.
The flight crew corrected the altitude deviation and proceeded for a second approach, landing safely without further incident. The UK Air Accidents Investigation Branch (AAIB) investigated the event, determining that improper control handover procedures contributed to the level bust.
Sequence of Events
Final Approach and Go-Around Initiation
• FR-2467 was on a routine ILS approach to Stansted’s Runway 04, flown by the first officer as pilot flying (PF).
• Weather conditions were favourable, with winds 080° at 15 knots, and visibility was clear.
• At 500 feet radio altitude, the autopilot and autothrottle were disengaged, with the approach continuing manually.
• As the aircraft descended to 240 feet, airspeed dropped below VREF and the aircraft drifted above the glideslope.
• The captain, serving as pilot monitoring (PM), determined that the aircraft would land deep and called for a go-around at approximately 15 feet AGL.
• The first officer initiated the go-around manually, climbing to 3,000 feet in accordance with the published missed approach procedure (MAP).
Altitude Deviation During Handover
• After stabilizing at 3,000 feet, the crew communicated with air traffic control (ATC) and confirmed readiness for a second approach.
• The first officer agreed to continue flying the approach, and the captain took control for setting up the Flight Management Computer (FMC).
• During the handover, the first officer failed to inform the captain that the autopilot (A/P) and autothrottle (A/T) remained disengaged.
• Shortly thereafter, the aircraft began descending unknowingly, losing 600 feet before the captain noticed the altitude deviation.
• The captain corrected the descent, re-engaged the autopilot and autothrottle, and stabilized the aircraft back at 3,000 feet.
Potential Conflict with Other Traffic
• At the time of the altitude deviation, a helicopter was operating VFR at 2,000 feet outside controlled airspace inbound to Stansted.
• ATC had cleared the helicopter into the Stansted Controlled Traffic Region (CTR) not above 2,000 feet, but neither the aircraft nor the helicopter were in immediate conflict.
• The controller, occupied with coordinating a departing aircraft, did not notice the level bust at the time.
Second Approach and Landing
• Following the altitude correction, the captain assumed control for the remainder of the flight.
• The second approach was executed without further issues, and the aircraft landed safely on Runway 04.
Investigation Findings and Analysis
1. Improper Handover Procedures
• During the transition of control, the first officer failed to inform the captain that the autopilot and autothrottle were disengaged.
• This led to the aircraft descending below the assigned altitude before the captain realized the deviation.
• The captain was monitoring the first officer’s actions rather than the aircraft’s flight path, contributing to the delay in noticing the descent.
2. Lack of Immediate ATC Intervention
• The controller was engaged in coordinating another departure and did not detect the level bust in real-time.
• While no immediate conflict with other aircraft occurred, improved ATC monitoring could have provided earlier detection and correction of the deviation.
3. Flight Crew Workload and Situational Awareness
• The workload during the missed approach phase may have distracted the flight crew from confirming all aircraft systems were properly set.
• The absence of an autopilot callout meant that the aircraft remained in manual control, increasing the likelihood of altitude deviations.
Safety Implications and Recommendations
1. Enhanced Crew Procedures for Control Handover
• Clear verbal confirmation of flight system engagement must be part of handover procedures.
• Before assuming control, the receiving pilot should verify the autopilot and autothrottle status.
2. Improved Monitoring of Aircraft Automation
• Pilots should maintain situational awareness of aircraft automation modes at all times, especially during dynamic flight phases like missed approaches.
• Pre-landing and go-around briefings should reinforce the importance of confirming automation status before transitioning to new flight phases.
3. ATC Oversight of Altitude Deviations
• Controllers should be trained to detect and address altitude deviations promptly, particularly in busy airspace like Stansted.
• Implementation of advanced monitoring tools could improve real-time detection of unexpected altitude changes.
Conclusion
The Ryanair Boeing 737-8 MAX flight FR-2467 experienced a level bust of 600 feet during a go-around at London Stansted due to an improper control handover where the autopilot and autothrottle remained disengaged without the captain’s awareness.
The crew corrected the altitude deviation, and the aircraft landed safely on the second approach. The UK AAIB investigation highlighted the need for improved handover procedures and automation awareness to prevent similar occurrences.
No aircraft or personnel were harmed, and there was no immediate conflict with other air traffic. However, enhanced ATC monitoring and flight crew standard operating procedures (SOPs) are recommended to mitigate future risks.
The incident serves as a reminder of the importance of thorough flight crew communication, situational awareness, and automation management during go-around procedures.
Disclaimer
“This report is based on available investigation data as of 13 March 2025. While every effort has been made to ensure accuracy, the completeness of details cannot be guaranteed. If you are the rightful owner of any referenced materials and wish for them to be removed, please email takedown@cockpitking.com.”
