Date:	Monday 4 December 2023
Time:	11:04
Type:	Boeing 737 MAX 8-200
Owner/operator:	Ryanair
Registration:	EI-HET
MSN:	62310/7781
Year of manufacture:	2019
Engine model:	CFMI CFM LEAP-1B
Fatalities:	Fatalities: 0 / Occupants: 126
Other fatalities:	0
Aircraft damage:	None
Category:	Serious incident
Location:	London-Stansted Airport (STN/EGSS) -   United Kingdom
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Klagenfurt Airport (KLU/LOWK)
Destination airport:	London-Stansted Airport (STN/EGSS)
Investigating agency:	AAIB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
Ryanair flight FR1269, a Boeing 737 MAX 8-200, was involved in a level bust and loss of control event during a go-around at London Stansted Airport (STN).

On the flight from Klagenfurt Airport (KLU) to STN the captain was Pilot Flying.
During the descent to STN, the Stansted Approach/Director controller cleared the aircraft initially to descend to FL80, followed shortly thereafter to 6,000 feet amsl and subsequently to 4,000 feet.
At this point, 20 nm from touchdown, the aircraft was passing FL76 (about 6,800 ft aal) and still at 235 KIAS.
About 90 seconds later, the ATCO noticed that the aircraft was a bit high for a continuous descent arrival (CDA), possibly due to a tailwind, so the aircraft was instructed by ATC to turn slightly away from the runway in order to give it some extra track mileage. At about 15.5 track nautical miles from touchdown, as the aircraft descended through about 6,000 ft amsl (5,650 ft aal) the speedbrakes were extended for about 35 seconds until the aircraft passed through about 5,200 ft amsl. The aircraft was then instructed by ATC to establish on the localiser (LOC) and was cleared to descend to 2,000 ft amsl, before being cleared to capture the ILS for runway 22. At 12 nm, Flaps 1 was selected and the speedbrakes were extended again. The aircraft was then instructed by ATC to reduce speed to 180 KIAS. Flaps 5 was selected about 20 seconds later.

The LOC was captured at about 9 nm when the aircraft was 3,863 ft aal. At this point the glideslope (G/S) was indicating full scale deflection below the aircraft. Flaps 10 was then selected. About 30 seconds later, when the aircraft was at 7 nm, ATC instructed the aircraft to reduce its speed to 165 KIAS until 4 nm and to contact Stansted Tower.
At 6 nm, as the aircraft passed 2,650 ft aal, the landing gear was lowered, the speedbrakes were extended and Flaps 15 selected. The speedbrakes were then retracted. At this point the airspeed was 186 KIAS. At about 5 nm ATC cleared the aircraft to land. The commander then commented that “if we don’t catch it [the G/S] we’ll have to go around.” As the aircraft was passing 2,240 ft amsl, ALT/ACQ (altitude acquire) Flight Mode Annunciation (FMA) was displayed on the primary flight display (PFD) and Flaps 25 was selected. As a result, the commander set 100 ft in the mode control panel (MCP) altitude display, and selected LVL CHG. Shortly thereafter the commander said “let’s go around”.
At 1,940 ft amsl (1,579 ft aal) and 3.6 nm from touchdown, the commander initiated a go-around (GA) and the co-pilot advised ATC of this.
ATC replied, “standard missed approach”. The commander took manual control, as the A/P automatically disengaged, and followed the flight directors (F/D) that commanded 15° nose-up. The A/T advanced the thrust levers to a GA thrust of 82% N1 on each engine. The co-pilot then selected Flaps 15 and the landing gear up. Flaps 5 was then selected as the aircraft passed 2,700 ft amsl.
Shortly after, the ATCO noticed on his aerodrome traffic monitor that the aircraft was at about 3,400 ft and climbing. During a GA at Stansted the aircraft has to remain below 3,000 ft amsl; as the aircraft had now exceeded that altitude (level bust) ATC instructed the aircraft to “maintain 3,000 feet [amsl] please, 3,000 feet”, to which the copilot replied “maintaining 3,000 feet wilco”. During this time, the speed remained relatively stable at about 180 KIAS.
The commander then pitched the aircraft to about 5 to 10° nose-down, and made a nose- down trim input, to initiate a descent, during which 0.40 vertical g was recorded.
During the missed approach procedure (MAP) the aircraft reached a maximum pitch of 16° nose-up, a maximum climb rate of 4,100 fpm and an altitude of 4,030 ft amsl, before a descent was commenced, in manual flight, with the A/T engaged and GA thrust still set.
The aircraft then started a descent during which the commander noticed the MCP altitude display was set at 100 ft, so reset it to 5,600 ft. As the IAS was now increasing, the co-pilot said to the commander, “watch yourself…speed…speed”, with the first call coming at about 235 KIAS. The commander then extended the speedbrakes and manually retarded the thrust levers to idle. However, as the A/T was still engaged they advanced back to GA thrust. The commander then manually retarded the thrust levers to idle again, but they advanced again so, on the co-pilot’s suggestion, they were held at idle by the co-pilot. The commander then pitched the aircraft nose-up, during which a vertical acceleration of up to 1.89 g was recorded. Just after the recovery was initiated, the EGPWS “sink rate” and
“pull up pull up” aural and visual warnings on the PFD were annunciated. The MCP altitude display was then set to the missed approach altitude (MAA) of 3,000 ft and the A/T was then disconnected. During the descent the pitch of the aircraft reached a maximum of 17.7° nose-down, a rate of descent of -8,880 fpm, and 295 KIAS with Flaps 5 extended.
The lowest altitude recorded was 2,078 ft amsl, 1,740 ft (530 m) agl . The aircraft was subsequently recovered and stabilised in a shallow climb before it levelled at 3,000 ft amsl. The entire event occurred with the aircraft in IMC.
Once stabilised at 3,000 ft, the A/P was engaged and the flaps retracted. The A/T was then engaged. The aircraft was then radar vectored for an uneventful ILS and landing on Runway 22.


AAIB Conclusion
This serious incident occurred because the Missed Approach Altitude (MAA) was not set in the Mode Control Panel (MCP) before a go-around was performed. It was not set to the MAA because the flight crew were attempting to intercept the glideslope from above. This required the MCP selected altitude to be set to a height below the aircraft, and the MCP selected altitude was not adjusted to the MAA following the decision to go-around before it was executed.
The approach and go-around were flown in instrument metrological conditions (IMC) and hence the pilots had no external visual references. During the go-around the pilot flying was fixated on the Flight Directors and did not recognise that they did not command a level off at the MAA until it had flown through it.
The subsequent recovery manoeuvre from the level bust was probably exacerbated by the thrust levers being moved from a high-power setting to idle resulting in an excessive nose-down attitude, rate of descent and IAS for the aircraft’s configuration. Given the aircraft’s height during this descent the Enhanced Ground Proximity Warning System was triggered just after the commander had initiated a pitch up into a climb back to the MAA.
This serious incident involved a Boeing 737-8200 [MAX]. It could have occurred in any variant of the Boeing 737, or any other type of aircraft with similar autopilot and flight director systems. There have been other serious incidents, with similarities to the EI-HET that have been investigated.

EGSS 041020Z 13012KT 9999 OVC004 06/05 Q0997
EGSS 041120Z AUTO 11009KT 090V150 6000 -RA OVC003 05/05 Q0997

https://www.gov.uk/government/publications/aaib-current-field-investigations/air-accidents-investigation-branch-current-field-investigations
https://www.flightradar24.com/data/flights/fr1269#33148de2
https://globe.adsbexchange.com/?icao=4cad29&lat=51.894&lon=0.255&zoom=16.6&showTrace=2023-12-04&trackLabels×tamp=1701687848

Figure: AAIB

Date/time	Contributor	Updates
30-Jun-2024 06:15	ASN	Added
21-Nov-2024 14:55	ASN	Updated [Total occupants, Source, Narrative, Accident report, ]
21-Nov-2024 18:04	ASN	Updated [Narrative, ]
21-Nov-2024 18:07	ASN	Updated [Photo, ]