ASN Wikibase Occurrence # 204139
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| Date: | Tuesday 15 November 2016 |
| Time: | 01:38 UTC |
| Type: |  Bombardier BD-700-1A11 Global 5000 |
| Owner/operator: | Private |
| Registration: | VP-CKM |
| MSN: | 9445 |
| Fatalities: | Fatalities: 0 / Occupants: 3 |
| Aircraft damage: | None |
| Location: | near Hong Kong-Chek Lap Kok International Airport (HKG/VHHH) -
 Hong Kong
|
| Phase: | Approach |
| Nature: | Private |
| Departure airport: | Beijing-Capital Airport (PEK/ZBAA) |
| Hong Kong-Chek Lap Kok International Airport (HKG/VHHH) | |
| Confidence Rating: |  Information is only available from news, social media or unofficial sources |
The aircraft was on an approach to runway 07L at Hong Kong International Airport and descended to 390 ft amsl at a point on the procedure where its cleared altitude was 1,700 ft amsl.
Conclusion
The aircraft’s FMS was set correctly to fly the approach and the autopilot was engaged when a descent was initiated towards 1,000 ft amsl in vertical speed mode. At 1,550 ft amsl, the commander disconnected the autopilot at approximately the same time that the co-pilot selected the target altitude to 2,000 ft amsl. The aircraft was then being flown manually with the FMS set such that, if the FD was followed without further intervention, it would have commanded a descent until the aircraft struck the surface of the sea.
It was concluded that the crew did not exchange sufficient information to share an accurate mental model of their situation and, consequently, were not aware that they had descended below their cleared altitude. Disconnecting the autopilot increased their workload, making it less likely they would regain an awareness of the situation, and made it necessary to fly the turn onto the localiser manually, which led directly to a high rate of descent and to TAWS cautions and warnings. Shortly after the first TAWS warning, the co-pilot told the commander not to descend any further. However, the commander did not respond decisively to the co-pilot’s warnings or system alerts until the aircraft was below 500 ft above the surface. Acute fatigue and a breakdown of SOPs within the flight deck led to the ineffective communication between the pilots. It was likely that the operator was not effectively monitoring the professional standards of its crews, or their use of SOPs, because it had no Chief Pilot and this made the ineffective communication more likely.
Sources:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 10-Jan-2018 16:14 | harro | Added |
| 10-Jan-2018 17:13 | harro | Updated [Time] |
Corrections or additions? ... Edit this accident description
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