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MD83, vicinity Dublin Airport, Ireland, 2007

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Summary
On 16 August 2007, during a non-precision approach to RWY34 at Dublin airport, the flight crew of a MD83 misidentified the lights of a 16-storey hotel at Santry Cross as those of the runway approach lighting system. The aircraft deviated to the left of the approach course and descended below the Minimum Descent Altitude (MDA) without proper visual recognition of the runway in use. A go-around was initiated as soon as ATC corrective clearance was issued.
Event Details
When August 2007
Actual or Potential
Event Type
Controlled Flight Into Terrain (CFIT), Human Factors
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft MCDONNELL DOUGLAS MD-83
Operator Not Recorded
Type of Flight Public Transport (Passenger)
Origin Lisbon Portela Airport
Intended Destination Dublin Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Descent
ENR / APR
Location - Airport
Airport vicinity Dublin Airport
General
Tag(s) Non Precision Approach,
Event reporting non compliant
CFIT
Tag(s) Into terrain,
Lateral Navigation Error,
Vertical navigation error
HF
Tag(s) Spatial Disorientation,
Distraction,
Ineffective Monitoring
Outcome
Damage or injury No
Aircraft damage None"None" is not in the list (Minor, Major, Hull loss) of allowed values for the "Aircraft damage" property.
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) Aircraft Operation,
Air Traffic Management
Investigation Type
Type Independent

Description

On 16 August 2007, a MCDONNELL DOUGLAS MD-83 departed Lisbon with the Co-pilot as Pilot Flying (PF) on a scheduled passenger flight FLT344E to Dublin, Ireland. The flight progressed without incident until commencing its approach to Dublin Airport. The approach was made at night; the weather and visibility were good. As scheduled maintenance on the main runway (RWY 10-28) was under way, RWY 34 was in use for landing. The flight was cleared by Air Traffic Control (ATC) to carry out a non-precision approach to RWY 34. During the approach, at approximately 5 nm9,260 m
9.26 km
30,380.577 ft
from touchdown, the aircraft began to deviate left of the approach course. This deviation was due to the Flight Crew mis-identifying the lights of a 16-storey hotel at Santry Cross as those of the runway approach lighting system on RWY 34 (See: Figure 1). The aircraft descended below the Minimum Descent Altitude (MDA) without proper visual recognition of the runway in use, and descended to an altitude of 580 ft176.784 m
above mean sea level (AMSL) before ATC issuing instruction for right turn and climb. At the point the go-around commenced, the aircraft was approximately 1,700 ft518.16 m
from the building and 200 ft60.96 m
above it. The aircraft subsequently landed without further incident after vectoring for Instrument Landing System (ILS) approach for RWY 16.

Approach-RWY-34-Dublin
Figure 1. View of the RWY 34 approach at 5.5 NM to touchdown, with the Hotel building at Santry Cross indicated on the left of the photograph.Source: AAIU Report 2009-010

The Investigation

The investigation of the Serious Incident came to the following probable cause:

The decision of the Flight Crew, to continue an approach using visual cues alone, having mis-identified the lights of a building with the approach lights of the landing runway.

Along with the latter, several contributing factors are mentioned. Some of them are the visual resemblance of the building in night conditions with the approach lights, non-adherence to Company SOPs, poor Crew Resource Management (Crew Resource Management), etc.

The recommendations comprise comprehensive review of the CRM training of the operator and airport control tower manning level examination by IAA. Furthermore, the IAA, when considering the type and positioning of warning lights specified for an obstacle in the vicinity of an aerodrome, should take account of the potential for confusion by pilots of such lights with visual navigation aids at the aerodrome.

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