Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
GA1382
Initial Report
Upon approach to landing at London Luton EGGW we were being vectored by Luton Director for ILS runway 25. Initially we were cleared 3000’ then given a heading to intercept and cleared approach. We, as have been trained, armed approach mode, armed VNAV and set minimums in our altitude preselect. Around the same time as we intercepted, the captain asked for flaps 3 and gear down. At this point I was monitoring the gear and my attention was away from monitoring flight instruments. Shortly later the captain said “why isn’t it stopping?” meaning why didn’t we capture the VALT of 3000’. We inadvertently went low by 600-700’. Shortly after ATC contacted us and informed us we had departed controlled airspace low; we were instructed “cleared to re-enter controlled airspace in half a mile” at glide slope intercept. We complied and the rest of the approach was normal.
CHIRP Comment
CHIRP highly commends the reporter for this candid report, which was also communicated to the reporter’s line manager. Could we all honestly say that we would have done the same? After all, they got away with it and no harm done. But, by altruistically sharing the experience, there’s an opportunity for everyone to learn and consider the human factor implications of this ‘near miss’.
It serves to remind us all how a combination of tasks and cockpit activities carried out in close succession can quickly lead to distraction and loss of focus of attention away from the flight instruments at a critical point. The reporter self-identified the key lesson as being communication and teamwork in the cockpit. The decision to configure the aircraft just when VNAV capture was expected meant that the crew became distracted from monitoring the flightpath. Avoiding selection of services at critical points for an approach is advisable to prevent such occurrences, albeit that’s sometimes easier said than done, as there may have been a valid reason that caused the flaps and gear to have been selected at that point.
Don’t forget that as well as enabling the experience to be shared through this FEEDBACK, all reports to CHIRP also contribute towards our disidentified safety database and our efforts to analyse and understand the bigger safety picture.
Key Issues relating to this report
Dirty Dozen Human Factors
The following ‘Dirty Dozen’ Human Factors elements were a key part of the CHIRP discussions about this report and are intended to provide food for thought when considering aspects that might be pertinent in similar circumstances.
Communication – Effective information flow and communication between crew members not achieved.
Teamwork – Breakdown in task prioritisation.