Edit Accident: D328, Manchester UK, 2006 (CFIT HF)

Accident Form

When:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Event Type:	AGC AI AW BS CFIT CS FIRE GND HF LB LOC LOS RE RI WAKE WX
Day/Night:	None Not Recorded Day Night
Flight Conditions:	None Not Recorded VMC IMC On Ground - Low Visibility On Ground - Normal Visibility
One sentence description:	On 18 January 2006, a Dornier 328 on descent into Manchester UK, avoided CFIT only by response to EGPWS following failure to capture the ILS Glideslope and a high rate of descent in IMC.
Validation Code:

Add Aircraft Involved

Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

Add Location en-route

Origin: Destination:

Add Location Airport

Airport: In Vicinity of airport:

Airport: In Vicinity of airport:

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Coordinates: Location: ICAO Region: AFIAPACCARSAMEURMIDNAMNAT ICAO Territory: AGANAYBGBIBKCCTDADBDFDGDIDNDRDTDXEBEDEEEFEGEHEIEKELENEPESEVEYFAFBFCFDFEFGFHFIFJFKFLFMFNFOFPFQFSFTFVFWFXFYFZGAGBGCGEGFGGGLGMGOGQGSGUGVHAHBHCHDHEHFHHHKHLHRHSHTHUKLALBLCLDLELFLGLHLILJLKLLLMLOLPLQLRLSLTLULWLXLYLZMBMDMGMHMKMMMNMPMRMSMTMUMWMYMZNCNFNGNINLNSNTNVNWNZOAOBOEOIOJOKOLOMOOOPOROSOTOYPAPGPHPJPKPLPMPOPPPTPWRCRJRKRORPSASBSCSESFSGSKSLSMSOSPSUSVSYTATBTDTFTGTITJTKTLTNTQTRTTTUTVTXUAUBUDUEUGUHUIUKULUMUNURUSUTUUUWVAVBVCVDVEVGVHVIVLVMVNVOVQVRVTVVVYWAWBWIWMWPWRWSYYPZZKZM

Add General Tags

Tags: ATC Training Flight Crew Training Military use of civil airport Civil use of military airport Approach not stabilised Aircraft-aircraft collision Aircraft-aircraft near miss Extra flight crew (no training) Safety pilot present Non Precision Approach Circling Approach Event reporting non compliant Inadequate Airworthiness Procedures Inadequate Aircraft Operator Procedures Inadequate ATC Procedures Airspace Design Airport Layout Ineffective Regulatory Oversight Root Cause Not Determined Military Fast Jet Formation Foreign Military Aircraft Approach to Wrong Airport Inadequate Airport Procedures

Tags: ATC Training Flight Crew Training Military use of civil airport Civil use of military airport Approach not stabilised Aircraft-aircraft collision Aircraft-aircraft near miss Extra flight crew (no training) Safety pilot present Non Precision Approach Circling Approach Event reporting non compliant Inadequate Airworthiness Procedures Inadequate Aircraft Operator Procedures Inadequate ATC Procedures Airspace Design Airport Layout Ineffective Regulatory Oversight Root Cause Not Determined Military Fast Jet Formation Foreign Military Aircraft Approach to Wrong Airport Inadequate Airport Procedures

Add AGC Tags

Tags: Call Sign Confusion Loss of Comms Incorrect Readback missed Phraseology Language Clarity Low Fuel Status CPDLC Flight Crew Oxygen Mask Use Take off without clearance Landing without clearance Military Formation Clearance Military/Civil Coordination Provision of Aircraft Performance Data ATC Clearance Cancelled

Add AI Tags

Tags: CA Incursion DA Incursion PA Incursion TSA Incursion GPS VFR Navigation ATC Complicit Aircraft not in contact with Airspace ATC

Add BS Tags

Tags: Large Birds Flocking Birds Significant Airframe Damage Flight Crew Injury Engine damage Coastal Location Migration Engine Ingestion Prior verbal warning

Add CFIT Tags

Tags: Into water Into terrain Into obstruction No Visual Reference Lateral Navigation Error Vertical navigation error Pressure altimeter setting error VFR flight plan IFR flight plan

Tags: Into water Into terrain Into obstruction No Visual Reference Lateral Navigation Error Vertical navigation error Pressure altimeter setting error VFR flight plan IFR flight plan

Add FIRE Tags

Tags: Post Crash Fire Non-Fire Fumes Dangerous Goods Fire-Cabin Baggage origin Fire-Cargo origin Fire-Electrical origin Fire-Fuel origin Fire-Power Plant origin Fire-Underfloor origin Fire-Galley Fire-Wing De-Ice fluid contamination Electrical fumes - No fire Landing Gear Overheat

Add HF Tags

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Add GND Tags

Tags: Taxiway collision On gate collision Aircraft / Aircraft conflict Aircraft / Person conflict Aircraft / Vehicle conflict Aircraft / Object or Structure conflict ATC clearance error Ground de/anti icing Jet Blast / Prop wash Surface Friction Towed aircraft involved Aircraft Push Back Incorrect Parking Position Airbridge Positioning Both objects moving Wingtip clearance Centreline obscured Accepted ATC clearance not followed Surface Lighting control Hold Loading Passenger Loading Cargo Loading Fuel Loading Dangerous Goods Engine Ground Running Engine Powered Systems Test No Flight Crew on Board

Add LB Tags

Tags: Accepted ATC Clearance not followed SID bust Clearance readback error undetected TCAS RA response Manual flight Pressure altimeter setting error

Add LOC Tags

Tags: Airframe Structural Failure Significant Systems or Systems Control Failure Degraded flight instrument display Uncommanded AP disconnect AP Status Awareness Non-normal FBW flight control status Loss of Engine Power Crew Incapacitation Flight Management Error Flight Control Error Environmental Factors Bird or Animal Strike Aircraft Loading Malicious Interference Temporary Control Loss Extreme Bank Extreme Pitch Last Minute Collision Avoidance Hard landing Take off Trim Setting Incorrect Thrust Computed Unintended transitory terrain contact Collision Damage Incorrect Aircraft Configuration Aerodynamic Stall

Add LOS Tags

Tags: TCAS RA Mis Flown Accepted ATC Clearance not followed See and Avoid Ineffective Required Separation not maintained Released to Own Separation Level Bust Lateral Navigation Error ATC Error Near Miss Lateral Offset in use Mid-Air Collision Uncommanded AP disconnect Military Aircraft involved Apparent de-selection of transponder Transponder non selection

Add RI Tags

Tags: ATC error Accepted ATC Clearance not followed Incursion pre Take off Incursion after Landing Runway Crossing Intersecting Runways Intersecting extended centrelines Towed aircraft involved Near Miss Ground Collision Phraseology Intentional Premature Rotation Vehicle Incursion

Add RE Tags

Tags: Overrun on Take Off Overrun on Landing Directional Control Undershoot on Landing Wrong Runway Excessive Airspeed RTO decision after V1 High Speed RTO (V above 80 but not above V1) Unable to rotate at VR Frozen Deposits Collision Avoidance Action Parallel Approach Operations Excess Water Depth Late Touchdown Significant Tailwind Component Significant Crosswind Component Thrust Reversers not fitted Landing Performance Assessment Off side of Runway Misalignment on runway Taxiway Take Off/Landing Runway Length Temporarily Reduced Intentional Premature Rotation Incorrect Aircraft Configuration Reduced Thrust Take Off

Add WAKE Tags

Tags: ICAO Standard Wake Separation prevailed ICAO Standard Wake Separation not met Accepted ATC clearance not followed Own separation In trail event Cross track event Pilot over compensation Intersection take off Intersecting extended centrelines Intersecting runways

Add WX Tags

Tags: In Flight Airframe Icing In Flight Icing - Piston Engine In Flight Icing - Turbine Engine CAT encounter En route In-cloud air turbulence Hail damage Volcanic Ash Effects Sand/Dust limited IFV Fog In Cloud on Visual Clearance Precipitation-limited IFV Strong Surface Winds Mountain Waves Lightning Damage Low Level Windshear

Add EPR Tags

Tags: Emergency Descent Emergency Evacuation Airport Emergency Medical Response MAYDAY declaration PAN declaration “Emergency” declaration Slide Malfunction RFFS Procedures Evacuation difficulties in Water Delay in Declaration of Emergency

Add CS Tags

Tags: Disruptive Pax Turbulence Injury - Cabin Crew Turbulence Injury - Pax with Seat Belts on Turbulence Injury - Pax with Seat Belts off Cabin Stowage - Pax Items Toilet compartment fire Cabin furnishings fire Evacuation slides deployed Pax oxygen mask drop Unauthorised PED use IFE fire Flight deck comms difficulty Cabin air contamination Malicious interference Hand held extinguisher used Evacuation on Cabin Crew initiative Flight Crew Evacuation Command Cabin Crew Incapacitation Cabin Crew Medical Fitness Passenger Illness Faulty or misused PED

Add AW Tags

System(s): Airframe Air Conditioning and Pressurisation Autoflight Communications Electrical Power Equipment / Furnishings Fire Protection Flight Controls Fuel Hydraulic Power Ice and Rain Protection Indicating / Recording Systems Landing Gear Landing Lights Navigation Oxygen Airborne Auxiliary Power (APU) Propellers Rotors Engine - General Engine Fuel and Control Bleed Air Other Emergency Evacuation Contributor(s): Maintenance Error (valid guidance available) Maintenance Error (invalid guidance available) Inadequate Maintenance Schedule Inadequate Maintenance Inspection Inadequate QRH Drills OEM Design fault Damage Tolerance Contributing ADD Component Fault in service Component Fault after installation Pilot verbal-only defect communication Corrosion/Disbonding/Fatigue Cross Connection Engine Compressor Washing

Add Safety Net Mitigation

Malfunction of Relevant Safety Net: None Yes No GPWS: None Effective Partially effective Available but ineffective TAWS: None Effective Partially effective Available but ineffective TAWS with RAAS: None Effective Partially effective Available but ineffective TCAS: None Effective Partially effective Available but ineffective STCA: None Effective Partially effective Available but ineffective MSAW: None Effective Partially effective Available but ineffective APM: None Effective Partially effective Available but ineffective APW: None Effective Partially effective Available but ineffective Mode 'S' EHS: None Effective Partially effective Available but ineffective Wind Shear Escape Guidance: None Effective Partially effective Available but ineffective Stall Protection: None Effective Partially effective Available but ineffective A-SMGCS: None Effective Partially effective Available but ineffective EMAS: None Effective Partially effective Available but ineffective TOCWS: None Effective Partially effective Available but ineffective

Malfunction of Relevant Safety Net: None Yes No GPWS: None Effective Partially effective Available but ineffective TAWS: None Effective Partially effective Available but ineffective TAWS with RAAS: None Effective Partially effective Available but ineffective TCAS: None Effective Partially effective Available but ineffective STCA: None Effective Partially effective Available but ineffective MSAW: None Effective Partially effective Available but ineffective APM: None Effective Partially effective Available but ineffective APW: None Effective Partially effective Available but ineffective Mode 'S' EHS: None Effective Partially effective Available but ineffective Wind Shear Escape Guidance: None Effective Partially effective Available but ineffective Stall Protection: None Effective Partially effective Available but ineffective A-SMGCS: None Effective Partially effective Available but ineffective EMAS: None Effective Partially effective Available but ineffective TOCWS: None Effective Partially effective Available but ineffective

Add Causal Factor Group(s)

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Add Safety Recommendations

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Accident Report text:

==Description== On 18 January 2006, a Dornier 328 being operated by Austrian-registered airline Euromanx on a scheduled passenger flight from Isle of Man to Manchester avoided [[CFIT]] during the approach at destination only by response to [[EGPWS]] following failure to capture the [[ILS]] Glideslope and a high rate of descent below it in [[IMC]]. ==Synopsis== The following is an extract taken from the Summary from the [[Aircraft Accident Investigation Branch (UK) (AAIB)|UK AAIB]] Report: '''"The aircraft failed to capture the glideslope during an ILS approach in IMC conditions to Runway 24R at Manchester Airport. The operating crew did not monitor the flight path of the aircraft and were only alerted that they had descended (with a high vertical speed) dangerously close to the ground some 5.5 nm from touchdown, by a “GLIDESLOPE” aural alert triggered by the EGPWS. The commander disconnected the autopilot and performed a go-around. ATC provided radar vectors to re-position the aircraft for another ILS approach, following which the aircraft landed without further incident."''' The report concluded: '''"The crew were nearing the end of an uneventful flight in a serviceable aircraft. Due to a failure to operate the aircraft in accordance with SOPs, the safety of the aircraft was seriously compromised. A possible Controlled Flight into Terrain (CFIT) accident was only avoided by the crew taking appropriate action upon being alerted by the EGPWS."''' ==Related Articles== *[[CFIT]] ==Further Reading== * For more information, see [http://www.skybrary.aero/bookshelf/books/430.pdf the AAIB report] *[[Accident and Serious Incident Reports: CFIT]] contains details of other accidents and incidents which resulted in, or might have resulted in, a CFIT [[category:Accident and Serious Incident Reports]]

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