HONG KONG SPECIAL ADMINISTRATIVE REGION

PEOPLE'S REPUBLIC OF CHINA
AERONAUTICAL INFORMATION SERVICE
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AIC
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+852 2910 1180 AIR TRAFFIC MANAGEMENT DIVISION
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AFS
VHHHYOYX
CIVIL AVIATION DEPARTMENT
22 November 2013
EMAIL aic@cad.gov.hk HONG KONG INTERNATIONAL AIRPORT

Prevention of Level Busts
1.

Introduction

1.1

A level bust is an unauthorised vertical deviation of more than 300 ft* from the level
assigned by ATC (* within RVSM airspace this limit is reduced to 200 ft).

It can occur at

any phase of a flight, but is most common within a Terminal Area (TMA) because of the
number of level changes that are required in the arrival and departure phases of flight.
˄ˁ˅ʳ ʳ ʳ The ATC separation system relies on the accurate communication of vertical/lateral
clearances and the exact execution of those clearances by the pilot responsible for the safety
performance of the flight. The process of safely managing the vertical profile of an
aircraft is complex whereby the pilot flies the aircraft and the controller manages the
separation between the flights in his/her area of responsibility.
1.3

There are opportunities for error each time an exchange of information is performed.
Therefore it is vital that good R/T discipline is practised by both pilots and controllers alike.
It is important that all parties involved should improve their awareness of R/T techniques,
develop best practices and ensure that they are followed accordingly.

2.

Level Bust Overview

2.1

A level bust could take place at any stage of flight and can result in loss of separation
between aircraft or between aircraft and terrain.

The consequence could be a major

separation infringement or just a report of wrong altitude/level. However each case
deserves no less than a full inquiry into the actual cause(s) and all other contributing factors
to prevent a recurrence.
2.2

There are many causal factors involved in level bust situations, the following are some
examples.

2.2.1

Improper receipt of information – failure in readback and hearback both between inter-ATC
units and ATC/pilots. This is one of the major sources of altitude violation. Both parties
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involved in the communication chain could be at fault. Pilots are required to readback
ATC altitude/level instructions, and it is the responsibility of the controller to ensure that a
correct readback is received (hearback).

Failure to readback by the receiving party or

failure for the issuing party to demand a correct readback or detect a mistake in the
hearback contributed to a large share of level busts.
2.2.2

Failure to seek confirmation when in doubt – restate the current cleared level whenever
there is the slightest doubt.

Request a further readback if it does not exactly satisfy you

especially if the other party has trouble understanding - treat readbacks with care, better
to be safe than sorry.
2.2.3

Use of multiple instructions –ATC should avoid giving too many figures, especially
similar ones within the same transmission.

Level and heading instructions can transposed;

do not allow any chance for confusing one set with the other.

The complexity of the

controller’s transmission has a direct effect on the pilot’s ability to register, readback and
execute the instruction.
2.2.4

The ‘Hear only what one expects to Hear’ syndrome – we are all set to hear what we
expect to hear. Controllers/pilots expectations contribute to a large number of
communication errors, when issuing a clearance that is different from that which the other
party normally expects - emphasize the difference and actively listen to the readback.

2.2.5

Failure to follow Standard Operating Procedures – this includes two possible scenarios:
a) failure to use standard
misinterpretation;

phraseologies

leading

to

a

misunderstanding

or

b) failure to act on an altitude/level clearance correctly, e.g. failure to input new clearance
into a Flight Management System due to distraction.
2.2.6

Improper or incorrect altimeter setting/MODE CONTROL PANEL (MCP)/FLIGHT
CONTROL UNIT (FCU) input – failure to comply with altimeter setting procedures,
incorrect value/setting inputs, wrong transition level recognition.

2.2.7

Flight crew failure to monitor climb/descent progress during change of vertical profile as a
result of system (e.g. Flight Management and Guidance System/Flight Control
Computer/auto-pilot system) anomalies or cockpit distractions.

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3.

Reporting

3.1

Airline operators and pilots should report level bust incidents using Civil Aviation
Department Occurrence Report Form - DCA 201, or through the airline’s own safety
reporting system.

3.2

ATC should report level bust incidents using Civil Aviation Department ATC Occurrence
Form – DCA 201.

3.3

The voluntary reporting of occasions when a level bust almost occurred is also encouraged
as a means to reinforce of a strong safety culture.

4.
4.1

Summary
There are many known cases of a level bust leading to ATC safety occurrences of varying
severity.

It is important that all parties adopt best practices and maintain a conscientious

attitude to provide the necessary safety net.

5.

Further Information

5.1

Comprehensive information on the prevention of level bust is available at the following
web-sites:
a) www.eurocontrol.int/safety/downloads/EurpeanPlanPreventionLevelBust.pdf
b) www.caa.co.uk/docs/33/CAP710.pdf

6.

AIC 02/05 is hereby superseded.

_______________________________________________________________________________
This Circular is issued for information, guidance and necessary action
By direction of the Director-General of Civil Aviation
Norman LO
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