Ryanair and chart specialist Jeppesen have accepted a series of safety recommendations after a lack of up-to-date aeronautical information and poor crew management led a Boeing 737-800 to carry out a highly-unstable, high-speed approach to Knock Ireland West airport.
Investigators state the serious incident, which occurred on 23 March this year, amounted to a marginally-avoided controlled flight into terrain. The aircraft descended to just 400ft (130m), without its landing-gear or flaps deployed, before aborting the approach.
Ireland’s Air Accident Investigation Unit (AAIU) says neither Ryanair nor Jeppesen provided the crew with crucial information on amended navigation procedures at Knock, but adds that the pilots also failed to deal appropriately with the subsequent confusion.
Airport improvement work at Knock meant certain approach paths were unavailable. But the pilots, uninformed of the restrictions, programmed an invalid approach to Knock runway 09 into the 737’s flight-management computer.
The lack of current information also meant the pilots were unaware of a temporary waypoint, designated ELPEN, to the east of Knock to which traffic was being directed prior to landing. This resulted in both pilots becoming “engrossed” with programming the flight-management computer with the additional waypoint, says the AAIU.
Their relative unfamiliarity with the 737-800’s sophisticated avionics, compared with the older 737-200, further confused the crew – and this led to their losing situational awareness at a critical time.
“By continuing to concentrate on loading the required data into the flight-management computer and ignoring the fundamental requirement for the ‘pilot flying’ to fly the aircraft and the ‘pilot not flying’ to perform those duties, normal crew resource management was compromised to a serious degree,” states the investigation agency.
It adds: “What ensued in the cockpit in the latter part of the cruise and descent phase to [Knock Airport] did not conform in any way with [Ryanair’s] standard operating procedures or crew resource management requirements.”
With the programmed approach pattern to runway 09 unavailable, air traffic control instructed the crew instead to make an initial approach to runway 27, for a circling arrival to 09. But this unexpected change required a much earlier descent, and the crew put the aircraft into a high-speed dive in a bid to capture the required vertical profile.
No descent or approach briefing was carried out and the aircraft was incorrectly configured in several aspects: its landing-gear, flaps and speed-brakes were not deployed and, despite the rapid descent, it remained too high on the glideslope.
As the 737 continued to descend, it dropped below the minimum circling approach height of 1,300ft. Its ground-proximity warning system sounded and the aircraft, just 410ft above terrain and still travelling at 265kt (490km/h), aborted the approach and executed a go-around – one which itself contravened the airline’s operating procedures.
After completing the go-around the aircraft, operating as flight FR1293 from London Gatwick, touched down without further incident. None of the 138 passengers and six crew members was injured.
The AAIU says the pilots had not been given vital information on the airport work and navigation changes, which were contained in a supplement to Ireland’s Aeronautical Information Publication.
Although this supplement had been sent from the Irish Aviation Authority’s aeronautical information service, Ryanair failed to provide it to pilots on the day. Jeppesen had also been copied the supplement but had not issued chart NOTAMs detailing the effects on navigation procedures.
Ryanair has accepted four AAIU recommendations to ensure pertinent information is available to crews, pilots perform comprehensive landing briefings, and that serious incidents are reported promptly.
Jeppesen has also accepted a recommendation to review its procedures in order that timely chart NOTAMs are issued. It says: “Written change was made to procedures documentation to ensure that announced temporary changes with unknown or approximate effective dates are reviewed for appropriate NOTAM or charting action.”
Source: FlightGlobal.com
