Report on "serious incident" during Ryanair flight released

LONDON - A Ryanair Boeing 737 MAX discontinued an unstable approach into Standsted Airport. During the go around procedure the aircraft entered a steep descent exceeding the speed limit for its current setup. Ryanair amended its discontinued approach procedures in the wake of the incident.

The UK Air Accident Investigation Branch (AAIB) released its final report on a 4 December 2023 mishap involving a Boeing 737 MAX 8200 of Ryanair.

"After an unstable ILS approach, a manually flown go-around (GA) was initiated at 1,940 ft amsl and 3.6 nm from touchdown," the AAIB states. "During the approach the mode control panel altitude display was set to 100 ft, but not reset to the missed approach altitude (MAA), prior to the GA being commenced."

Mid go-around the aircraft "committed a level bust as it climbed through the MAA of 3,000 ft amsl". The pilot flying than pitched the aircraft down to enter a descent from a maximum altitude 4,030 ft amsl.

"During the descent the aircraft reached a nose-down attitude of 17.7° and 295 KIAS, with Flaps 5 extended before a recovery and climb was initiated, during which its lowest recorded height was 1,740 ft agl", the AAIB concludes. After the recovery was commenced the ground proximity warning sounded through the cockpit.

"Prior to the (go-around) the MAA was not checked by either pilot" and during the maneuver the pilot flying was "fixated on the flight directors and expected them to command the aircraft to level off," according to the report.

According to the AAIB there have been several "serious incidents which occurred during go-arounds" in the past with "similar factors" to that were found in this investigation involving EI-HET. "Although EI-HET is a Boeing 737-8200 (MAX), the incident could have occurred in any variant of the Boeing 737, or any other type of aircraft with similar autopilot and flight director systems."

As a result of this "serious incident" Ryanair has taken additional safety actions including informing its pilots about this event and introducing a new Discontinued Approach procedure.