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B752, vicinity London Gatwick UK, 2008

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Summary
On 13 December 2008, a rushed daylight radar to ILS approach into London Gatwick was made by a Monarch Airlines Boeing 757-200 inbound on a short haul passenger flight. During the approach, flown by the aircraft commander, the speedbrakes had been extended prior to joining the FAT to help slow down, and both flight crew then forgot that the speed brakes were still extended and also did not realise that the commander had disconnected the Autothrottle whilst manually positioning the aircraft onto the ILS LLZ after a late selection of the LLZ mode on the FD had caused an initial fly-through. A speed loss and eventual stick shaker activation at about 1000 ft aal followed after which a go around, initially somewhat unstable until control was passed to the co pilot, was flown with the speed brakes still remaining unintentionally extended until the aircraft was approaching 3000ft aal after which the remainder of the flight was uneventful.
Event Details
When December 2008
Actual or Potential
Event Type
Human Factors, Loss of Control
Day/Night Day
Flight Conditions IMC
Flight Details
Aircraft BOEING 757-200
Operator Monarch Airlines
Domicile United Kingdom
Type of Flight Public Transport (Passenger)
Origin Innsbruck
Intended Destination London Gatwick Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Missed Approach
APR
Location - Airport
Airport vicinity London Gatwick Airport
General
Tag(s) Approach not stabilised
HF
Tag(s) Distraction,
Ineffective Monitoring,
Procedural non compliance,
Inappropriate crew response (automatics)
LOC
Tag(s) Flight Management Error,
Temporary Control Loss
Safety Net Mitigations
Stall Protection Effective
Outcome
Damage or injury Yes
Aircraft damage Minor
Injuries None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Injuries" property.
Fatalities None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Fatalities" property. ()
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 13 December 2008, a rushed daylight radar to ILS approach into London Gatwick was made by a Monarch Airlines Boeing 757-200 inbound on a short haul passenger flight. During the approach, flown by the aircraft commander, the speedbrakes had been extended prior to joining the FAT to help slow down, and both flight crew then forgot that the speed brakes were still extended and also did not realise that the commander had disconnected the Autothrottle whilst manually positioning the aircraft onto the ILS LLZ after a late selection of the LLZ mode on the FD had caused an initial fly-through. A speed loss and eventual stick shaker activation at about 1000 ft aal followed after which a go around, initially somewhat unstable until control was passed to the co pilot, was flown with the speed brakes still remaining unintentionally extended until the aircraft was approaching 3000ft aal after which the remainder of the flight was uneventful.

The Investigation

The UK AAIB carried out an Investigation into this Incident and their Report attributed the incident to the “rushed approach putting the crew under increasing pressure” which led to both a failure to follow relevant SOPs and to an lack of perception of the cues for the excess drag afforded by the relationship of aircraft attitude to the applied thrust both descending on the ILS GS and during the subsequent go around. However, it was also noted in the Report that “having allowed the aircraft to slow to a speed where stick shaker activation occurred on final approach, the situation was recovered by the commander making best use of the resources available to him by handing over control to the co-pilot, who retained his situational awareness”. No Safety Recommendations were made.


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