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. Acute fatigue and ineffective crew communication meant that the pilots did not have an accurate mental picture of their situation and did not appreciate they had descended below their cleared altitude. The evidence suggested that the operator did not monitor the professional standards of the crew, or ensure its Standard Operating Procedures (SOPs) were effective and being used consistently, and that this contributed to this serious incident.
A correction was issued concerning this report regarding the aircraft type. The online version of the report was amended on 22 December 2017.
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Published 14 December 2017