Incident: Ryanair B38M at London on Dec 4th 2023, rapid descent during go around

By Simon Hradecky, created Friday, Jun 28th 2024 13:19Z, last updated Friday, Jun 28th 2024 13:19Z

A Ryanair Boeing 737-8 MAX, registration EI-HET performing flight FR-1269 from Klagenfurt (Austria) to London Stansted,EN (UK), was on final approach to Stansted's runway 22 descending through about 1900 feet MSL (1525 feet AGL) at about 145 knots over ground about 3.2 nm before the runway threshold at 11:03L (11:03Z) when the crew initiated a go around due to an unstabilized approach. The aircraft accelerated and climbed through about 4000 feet at 197 knots over ground when the aircraft began to rapidly descend to 2175 feet MSL (1825 feet AGL) within 17 seconds accelerating to 280 knots over ground, climbed and descended a second time reaching a minimum height of about 1700 feet AGL. The aircraft subsequently climbed to and stabilized at 3000 feet, positioned for another approach and landed without further incident about 12 minutes after the initiation of the go around.

The British AAIB reported they have opened an investigation stating: "High speed and high nose down pitch attitude during go-around, London Stansted."

The Irish AAIU, participating in the investigation, stated a level bust.

The airline reported an unstable approach before landing, they are cooperating with the AAIB.

Metars:
EGSS 041320Z AUTO 11009KT 090V150 5000 BR OVC003 06/05 Q0996=
EGSS 041250Z AUTO 11010KT 090V150 7000 OVC003 06/05 Q0996=
EGSS 041220Z AUTO 11010KT 080V150 7000 OVC003 06/05 Q0996=
EGSS 041150Z AUTO 11009KT 090V150 3500 BR OVC003 06/05 Q0996=
EGSS 041120Z AUTO 11009KT 090V150 6000 -RA OVC003 05/05 Q0997=
EGSS 041050Z AUTO 12010KT 6000 -RA OVC004 05/05 Q0997=
EGSS 041020Z 13012KT 9999 OVC004 06/05 Q0997=
EGSS 040950Z 13012KT 9999 OVC004 05/05 Q0997=
EGSS 040920Z AUTO 13012KT 9999 OVC004 05/04 Q0997=
EGSS 040850Z AUTO 13011KT 110V170 9999 OVC003 05/05 Q0997=

Reader Comments: (the comments posted below do not reflect the view of The Aviation Herald but represent the view of the various posters)

By j on Monday, Jul 8th 2024 12:04Z

Additional info from a German-language article about the incident: Pilot induced oscillation(?) caused by pushing the nose down too quick and too hard after the angle of approach got very high from the TOGA.

Wild Altitude and Airspeed Excursions
By Captain Crunch on Thursday, Jul 4th 2024 14:31Z

Yep.

500 ft too high at GA. It's a fairly good bet that nobody yet put the MA alt of 3000ft in the Alt Sel Window.

You can't push buttons when you are this mucked up.
Revert to a lower level of automation: Da Pilot!

Oh that's right. I forgot. Widebody Pretender says to always fly on autopilot no matter what!

Silly Me!

delayed
By aviator a on Tuesday, Jul 2nd 2024 12:29Z

just wondering, how comes it took that much time for this serious incident to being published - almost 7 months after it happened.

Weather
By Steve Roberts on Sunday, Jun 30th 2024 17:05Z

I very much doubt they were doing a non precision approach with a cloud base of 300 feet,

Goround
By Bob B license on Sunday, Jun 30th 2024 16:55Z

No mention of the fact they were 295 knots in a turn limited to 185 knots or the Flap limiting speed was grossly exceeded and the subsequent withdrawal of the aircraft whilst the flaps, slats were all removed due to the exceedances.

By John on Sunday, Jun 30th 2024 16:53Z

If it was an NPA as claimed below, then it's totally normal not to have the MAA pre selected in the MCP. It's not set until 1000' AAL on an NPA. For an ILS it would be set at GS intercept.

Unstable approach
By Largo on Sunday, Jun 30th 2024 09:25Z

Some times, I see that the temptation of rapidly comply with the go around procedure, we get ourselves into trouble. You are at 1500ft AGL, that means that you have plenty of time, to first discontinue the approach, level off, wait for the MAP, prepare for it, and execute the go around. Being so close to the GA altitude, implies a very short time to manage change of thrust, attitude, configuration and altitude selection, and even worse with this overpowered birds.

@ ducky
By Gabriel on Saturday, Jun 29th 2024 16:09Z

Go-arounds don't need to be executed at full thrust. A go around from more than 3NM out and more than 1000ft high would normally be performed at a reduced thrust that would provide a moderate climb rate.

Additionally, you should set up the go-around altitude in the "autopilot" controls. Then...
- If you fly the go around on autopilot, the autopilot will level off at 3000ft by itself, no active pilot intervention needed (other than initiating the go-around).
- If the go-around is hand flown, the flight director in the artificial horizon will provide guidance to the pilot to follow the go-around profile and level off at 3000ft.
- And in either case, you will receive an alert tone when you climb through 2250 ft (750 below the target altitude).
- Not to mention that the flying pilot has a monitoring pilot to, well, monitor and back him up.

A go around is a very basic flight maneuver. It doesn't require an extremely competent pilot. Just a minimally competent one.

@ Shirley
By Gabriel on Saturday, Jun 29th 2024 15:59Z

No plane has ever crashed after a single MCAS activation.
And I did call you Shirley!

Not pilots anymore.
By Jhon on Saturday, Jun 29th 2024 14:00Z

Children of the magenta.

By Raffim on Saturday, Jun 29th 2024 01:51Z

If it3s Boeing ain't going

AFDS mismangement
By commodore on Friday, Jun 28th 2024 23:08Z

The flight was conducting a practice non-precision approach to RW22; the MCP altitude was set to the MDA. When the crew elected to go-around, the MAA (3000) was not set. As such, the AFDS did not provide altitude capture guidance at the published MAA. Following the level bust, the PF over-corrected in their attempt to return to the correct level.

MISAP alt issue
By Av8tor on Friday, Jun 28th 2024 21:24Z

Go-arounds with very small altitude changes required, or with odd altitude requirements (like a MISAP ALT which is lower than the alt where a go-around is initiated) will regularly become very interesting sim sessions to look at. Mostly a training and awareness issue. Fly as you train and train as you fly - so more real-life scenarios must be dealt with in the sim and not just the standard hum-drum required. So maybe a little extra time spent in the sim is not so expensive after all, hey training managers?

Ducky
By Busdriver on Friday, Jun 28th 2024 19:01Z

The Go around altitude can be checked from the UKAIP or the charts if you have access to Jepp or Lido but it is 3000ft for both ends of the runway .Go -arounds with small climb segments should be part of the approach brief. I was once pnf in an empty A300-600 that went round at Brize Norton due to unreported fog . The climb segment was 1300ft and an empty A300 had 125000lb of thrust and the aircraft weight was about 220000lb. During the go-around the flaps jammed. This all happened at about 0300 in the morning. It was a very busy cockpit for a few minutes.

@Busdriver
By ducky on Friday, Jun 28th 2024 16:58Z

If it is a fact that the missed approach altitude for Runway 04 is 3,000 feet, then this would imply that at the moment the Pilot Flying activated the Go-Around buttons on the throttle quadrant, the difference between current altitude (1,900 feet and missed approach altitude 3,000 feet is only 1,100 feet!) Considering the powerful thrust output from the MAX engines coupled with the pitch attitude from go-around logic this 1,100 feet margin would be achieved in just a few seconds requiring an extremely competent pilot to execute this maneuver accurately and precisely. Another key element to this event is this: was the altitude preselect set to 3,000 feet or was it set to 4,000 feet?

By Dont Call Me Shirley on Friday, Jun 28th 2024 16:50Z

@Luca
"MCAS will only be activated once."

Yes, because the plane will be pulverized after that one activation.

lets see
By Luca on Friday, Jun 28th 2024 15:29Z

One of the fixes of MCAS according to Boeing is "MCAS will only be activated once."

But, with no information best bet might be an overshoot on the go around. Maybe there was also traffic and they had to expedite.

We will see once the investigation concludes.

By Mike on Friday, Jun 28th 2024 15:25Z

This again? Is it my impression or there is a trend going on about 737 going around pitching down? Lets not forget flydubai 737. If there is a trend please provide proper training for pilots asap.

What a horlicks
By Busdriver on Friday, Jun 28th 2024 13:46Z

The Go Around altitude at Stansted on 04 is 3000ft so we have a level bust dueing the go around which is recognised and then an expedited descent which probably led to a flap overspeed and overshooting the altitude again before they finally stabilise and go round for another attempt I would imagine that this was probably a training flight with a cadet

Dive during G/A
By John on Friday, Jun 28th 2024 13:46Z

Yo me it sounds more like a somatogravic illusion than an MCAS issue�Let�s wait and see�

@ FBW
By breizh44 on Friday, Jun 28th 2024 13:31Z

No kidding! Yes, it would. Did the "improved" MCAS screw up again? Almost sounds like it.

Weird
By FBW on Friday, Jun 28th 2024 13:26Z

It would be interesting to know what caused this.