UK investigators have heavily criticised poor crew communication, slack reporting procedures and failure to respond quickly to a ground-proximity warning after a British Airways CitiExpress regional turboprop came close to striking terrain during an approach earlier this year.

Failure to report the incident immediately, large discrepancies between the accounts of the crew – a highly experienced captain and an inexperienced co-pilot – and the absence of corroborating flight-recorder information have left investigators unable to piece together a definitive version of events.

The co-pilot of the Bombardier Q300, operated by BA’s regional division CitiExpress, was attempting a visual approach to Ronaldsway Airport on the Isle of Man off north-west England when it descended far below the required glidepath.

At one point the aircraft was travelling at a height of just 650ft (200m) but flying towards a 573ft cliff, just 1.3nm (2.4km) ahead, on which the airport’s navigation beacon is sited. Even though two urgent ground-proximity warnings sounded, a go-around was not initiated until 20s after the first alert and 8s after the second.

The captain took control of the aircraft to conduct the go-around and the Q300, with 24 passengers and crew, subsequently landed without incident.

While a ground-proximity event should normally be reported within 96hr, the co-pilot only reported the incident 11 days later, and the captain only submitted a report after an investigators’ request – although he explained the delay as being due to illness and leave. This delay, however, meant that cockpit-voice and flight-data recorder information was overwritten and lost before it could be analysed.

In its report into the 24 March event the Air Accidents Investigation Branch says there were “significant differences” between the two pilots’ versions of events:

  • The co-pilot claimed no briefing – either for a visual or other type of approach – took place, while the captain said the co-pilot gave a good briefing.
  • The captain claimed that he asked whether the co-pilot wanted to fly a visual approach – to which the co-pilot responded that he would – while the co-pilot claimed that he only passed an informative call that he had visual contact, and that the captain requested a visual approach from air traffic control.
  • The co-pilot claimed the captain retuned the navigation receivers to the Isle of Man navigation beacon frequency; the captain claimed no retuning took place.
  • The co-pilot claimed the captain lowered the landing gear and selected landing flap. The captain claimed he did not, adding that the aircraft was in clean configuration while making its final turn to the airport, and that the co-pilot lowered the gear on request after a ground-proximity warning system alert.
  • The co-pilot claimed he surrendered control of the aircraft, without verbal confirmation from either crew member, after losing visual contact with the airport. The captain claimed that, although he considered the co-pilot was flying a poor approach, he took control only after the ground-proximity warning sounded – adding that there was verbal confirmation from both crew members.

Despite these differences the AAIB says that the aircraft clearly descended at an inappropriate point, that corrective action was delayed, and that the crew did not respond correctly to the ground-proximity warning.

Data from the ground-proximity warning system appeared to support the co-pilot’s recollection of the aircraft’s configuration – it was flying with its gear lowered and its flaps set for landing before the initial proximity warning – but the AAIB says that both crew members seem to have suffered loss of situational awareness.

This was partly due to uncertainty over visual contact with the airport and, in the co-pilot’s case, the potentially confusing fact that Ronaldsway’s navigation beacon is not located at the airport itself but situated about 4.6nm from the runway.

In its report the AAIB says the circumstances of the event, and its subsequent reporting, point to “shortcomings” in crew resource management which allowed a dangerous situation to develop: “Had the basic principles of good crew resource management been followed, it would be hard to imagine how a situation could have arisen whereby the co-pilot became so disoriented that he commenced an inappropriate descent without intervention or comment from the commander.”

But it criticises the captain for not heeding the ground-proximity warning immediately: “Regardless of the events leading to the [ground-proximity] warning, when it did finally trigger, the commander did not take the actions that would be expected – namely a positive climb away at maximum power.”

British Airways CitiExpress has accepted the findings of the report. While the aircraft’s 60-year-old captain retired following the incident, a spokeswoman for the carrier insists this decision was “completely unconnected” to the event.

She adds that the airline has provided additional training to the co-pilot and “acted responsibly” on other findings from the investigation.

Source: Flight International

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