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B741, British Airways, London Heathrow UK, 1989 (Legal Process - Flight Crew)

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Article Information
Category: Human Error
in Aviation
and Legal Process
Human Error in Aviation and Legal Process
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The Event

Date: 21 November 1989

Location: London Heathrow Airport

Summary: After an ad hoc Company dispensation to operate to lower minima than the crew were routinely authorised for, the crew of a British Airways Boeing 747-100 flew an ILS approach contrary to the applicable procedures and regulations. Despite not being properly established on the ILS LLZ in IMC, the approach was not discontinued until the aircraft was at 125 feet agl. The go around was then initiated in a manner, and from an aircraft position, which led the aircraft to descend to 75 ft agl abeam the intended landing runway and come within 12 feet (3.65m) of a hotel below. The subsequent approach was completed without further event, and there was no damage to the aircraft or injury to any person. The aircraft commander was the handling pilot. In the normal course of events, this incident would have been investigated independently as a Serious Incident by the UK AAIB. However, this did not happen because their team of Inspectors were already involved in two major fatal accident investigations.

The Non Judicial Investigations

Carried out by British Airways as Operator and the UK Civil Aviation Authority as Regulator

The Findings:

  • British Airways - unacceptable conduct by the aircraft commander in commencing and continuing the approach, in delaying the go around, and in not commencing the go around in the prescribed manner. The First Officer and Flight Engineer were also found not to have performed in accordance with their training and with company procedures.
  • UK Civil Aviation Authority - grounds for criminal prosecution of aircraft commander and a determination that he no longer had sufficient competence to retain the full privileges of his ATPL.

Action by the Entity Involved: Demotion of aircraft commander from Captain to First Officer and formal admonishment of the other two flight crew

Action by the Regulator: Initiated, under delegated powers, a criminal prosecution of the aircraft commander having already endorsed their licence to prohibit operation as pilot-in-command of any multi-crew commercial aircraft.


The Criminal Prosecution

Persons Prosecuted: The aircraft commander

The Court: Isleworth Crown Court (near Heathrow)

The system : A Judge and a Jury of 12 persons

The Charge(s):

  1. Negligently endangering persons and property on the ground
  2. Negligently endangering an aircraft and its occupants

The Plea(s): Not Guilty to both charges

Prosecutors Sentencing Request: Imprisonment and costs of GBP 45,000

The Verdict: Was given on 8 May 1991:

  • Charge 1 - Not Guilty
  • Charge 2 - Guilty (majority verdict 10:2)

The Sentence(s): A Fine of GBP 2000 or 45 days in jail Costs of GBP 1500

Appeal Lodged: Yes, lost

Related Facts

  • The aircraft commander resigned from British Airways on 2 April 1990.
  • He appealed unsuccessfully against the endorsement to his pilots licence.
  • He committed suicide on 1 December 1992.
  • This case is understood to have been the first UK criminal prosecution of a professional pilot as a result of their actions whilst in command of an aircraft being used for the purposes of commercial air transport. There has since been no comparable prosecution in the UK.

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