Description

On 2 September 2019, a Boeing 777-300ER (9V-SWD) being operated by Singapore Airlines on a scheduled international passenger flight from Shanghai Pudong to Singapore Changi failed to climb as expected when the autopilot was engaged soon after takeoff in night VMC and a series of EGPWS ‘DON’T SINK’ cautions were followed by a ‘PULL UP’ activation. The autopilot was disconnected and climb restarted but when it was re-engaged, the aircraft again began to descend and it was only then realised that the FMS had been mis-programmed. Once corrective action was taken, the remainder of the flight was without further event. 

Investigation

An Investigation was commenced by the Singapore Transport Safety Investigation Bureau (TSIB) and was based on QAR data provided by the aircraft operator and interviews with the flight crew. Relevant CVR data were overwritten.
The 55 year-old Captain, who was acting as PF for the flight, had a total of 18,369 hours flying experience including 11,085 hours on type and the 29 year-old First Officer had a total of 1,744 hours flying experience, all of it on type.

What Happened

It was established that the pre-flight preparation had been somewhat more involved than normal (discussed below). It was also learned during the subsequent Investigation that whilst the Captain intended to engage the AP soon after the takeoff “because he was mindful of the need to convert altitude clearances given in metres to feet and of the potential weather to the east of the airport”, the First Officer did not recall this plan being communicated to him.