AAIU report into incident with G-FLTM

The Air Accident Investigation Unit (AAIU) of the Department of Transport has issued it's report into a serious incident which occurred with Flightline MD-83 G-FLTM at Santry Cross in Dublin on August 16 2007 at 23.34 hrs.

On the day in question the aircraft was on it's third sector having positioned empty from Dublin to Belfast, flown Belfast - Lisbon and finally Lisbon - Dublin with 112 passengers and a crew of six. On the night of August 16 runway 10-28 at Dublin was closed for maintenance with Runway 34 being used for landing and takeoff. Although the crew were in possession of NOTAM paperwork which indicated the runway status, it was not until the crew listened to the Dublin ATIS on descent, that they were aware of the runway change, having assumed that R10-28 was the active. As a result, the aircraft was at Top of Descent later than required for a VOR-DME approach to R34.

The aircraft was cleared for a non precision approach to R34 but at 5nm from touchdown it veered left of track. This deviation was as the result of the crew misinterpreting the lighting on a 16 storey hotel building at Santry Cross as being the approach lights for R34. The aircraft continued to descend below the Minimum Descent Altitude (MDA) without visual identification of the landing runway.

Following hand over from Approach control to the Tower controller, the Approach controller noticed that the aircraft had deviated left. At the moment the aircraft descended below the MDA the Tower controller was distracted by a call from the ground maintenance crew working on R10-28, just as the aircraft commander called the Tower to query if the runway lighting was working ok. This radio transmission was made at the same time as the Approach Controller called the Tower on the intercom to warn of the aircraft's situation.

At an altitude of 580 ft AMSL and with the aircraft 200 ft above and 1,700 ft from the hotel, ATC instructed a go around, having identified the aircraft as being off track, and offered the crew a vectored approach to R16 where the aircraft landed safely without injury to crew or passengers.

In it's investigation the AAIU found that the incident had occurred for a number of reasons.

• The aircraft commander who was pilot not flying (PNF) had failed to ensure that company Standard Operating Procedures (SOPs) for non precision approaches was followed, allowing a visual approach from a height of 2,200ft.
• Extraneous lighting from Dublin city made it difficult to correctly identify the approach lighting to R34.
• The lighting on the sixteen storey hotel in Santry Cross resembled the red and white lighting of a simple approach lighting system.
• Poor communication between the pilots (Italian and Croatian) and poor Crew Resource Management assisted in allowing poor situational awareness develop.
• The final intervention by ATC although somewhat late was a primary factor in ensuring a safe outcome.

Three recommendations are made in the report -

• The aircraft operator to review it's CRM training. Flightline ceased ops in Decmber 2008. The administrators stated that they would not be taking any action in response to the recommendation
• The Irish Aviation Authority (IAA) should review it's procedures for Tower manning levels during night ops or when maintenance is taking place
• That when considering it's guidelines for obstacle lighting in the vicinity of an aerodrome the IAA should consider the possibility of the lighting being mistaken for runway lighting. The IAA accepts this recommendation.

Pictured at top, G-FLTM lines up on R24 at Shannon, exactly two weeks before the incident on August 2, 2007.

Posted 090421