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B738, vicinity Cork Ireland, 2006 (CFIT HF)

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Summary
On 4 June 2006, a Boeing 737-800 being operated by Ryanair on a passenger flight from London Stansted to Cork became too high to land off a day visual approach and requested a right hand orbit to reposition. This positioning was flown too close to terrain with TAWS alert triggered prior to a second approach to a successful landing.
Event Details
When June 2006
Event Type CFIT, HF
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BOEING 737-800
Operator Ryanair
Domicile Ireland
Type of Flight Public Transport (Passenger)
Origin Stansted
Intended Destination Cork Airport
Flight Phase Missed Approach
APR
Location - Airport
Airport vicinity Cork Airport
General
Tag(s) Approach not stabilised
Circling Approach
Event reporting non compliant
CFIT
Tag(s) Into terrain
Vertical navigation error
HF
Tag(s) Ineffective Monitoring
Manual Handling
Procedural non compliance
Safety Net Mitigations
TAWS Effective
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 4 June 2006, a Boeing 737-800 being operated by Ryanair on a passenger flight from London Stansted to Cork became too high to land off a day visual approach and requested a right hand orbit to reposition. This positioning was flown too close to terrain with TAWS alert triggered prior to a second approach to a successful landing.

Investigation

The Irish AAIU was not advised of this event at the time and did not find out about it until contacted by the Operator 9 days later at which point an Investigation was commenced. It was established that the aircraft commander, with good aircraft type experience, had been PF.

The break to the right off the first approach was found to have initially been made at at the prescribed minimum manoeuvring altitude of 1100 feet QNH (equivalent to 600 feet aal) but altitude was then gradually lost during this orbit. The lowest altitude recorded was 553 feet QNH (51 feet aal) although, because some of the terrain around the airport was considerably lower than the airport elevation, the actual minimum height above terrain recorded by the radio altimeter was 425 feet agl. When it became visually obvious to the flight crew that the aircraft was well below the appropriate vertical approach profile, a climb was initiated to a height from which a safe landing was ultimately effected.

The Investigation noted that:

“The two subject approaches raise questions for standard CRM Courses pursued by the wider aviation industry, in general. In particular, to what degree can the PNF assert himself or herself when the PF is not responding to or disregarding inputs from the right hand seat? The ‘experience gradient’ between the PF and the PNF in this instance was steep, but not unusual in day-to-day operations, and may have been a contributory factor in the PF’s attitude to the PNF. Regardless, the PNF did endeavor to comply with CRM principles as trained. His inputs had little effect. However, this is not to excuse the aberrant deviation from the Operator’s SOP’s, which require that the aircraft be fully stabilized in the landing profile by 500 ft agl on a visual approach, and adherence to CRM procedures by the PF.”

It was concluded that:

“this serious incident was precipitated by the PF not adhering to the Operators explicit SOP’s in the two approaches to (the runway in use) and also by not conforming to established CRM principles in relation to the PNF.”

The Final Report of the investigation was published on 30 January 2007 and may be seen in full at SKYbrary bookshelf: AAIU Synoptic Report No: 2007-002

No Safety Recommendations were made.

Further Reading

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