The incident was notified to the Air Accidents investigation Branch (AAIB) on 14 March 2005. By that time the aircraft had returned to the UK where the aircraft’s Flight Recorders were interrogated. The AAIB investigation team comprised:
Mr J J Barnett (Investigator-in-Charge)
Mr N C Dann (Operations)
Mr P Wivell (Flight Recorders)
The aircraft was attempting to land at Khartoum by night in conditions initially reported as blowing sand but which were in fact consistent with a forecast dust storm. Runway 36 was in use but the ILS on this runway was out of service. The commander assessed the weather conditions passed to him by ATC and believed that he was permitted, under his company’s operations policy, to carry out a Managed Non-Precision Approach (MNPA) to Runway 36. This type of approach requires the autopilot to follow an approach path defined by parameters stored in the aircraft’s commercially supplied Flight Management and Guidance System (FMGC) navigation database.
On the pilot’s approach chart, which was also commercially supplied but from a different supplier, the final descent point was depicted at 5 nm from the threshold of Runway 36 whereas the FMGC’s navigational database had been correctly updated with a recent change to this position published by the Sudanese CAA which placed it at 4.4 nm from the threshold. The discrepancy amounted to a difference in descent point of 0.6 nm from the Khartoum VOR/DME beacon, the primary navigation aid for the non-precision approach.
The pilots commenced the approach with the autopilot engaged in managed modes (ie the approach profile being determined by the FMGC instead of pilot selections). The aircraft began its final descent 0.6 nm later than the pilots were expecting. Believing the aircraft was high on the approach, the handling pilot changed the autopilot mode in order to select an increased rate of descent. The approach became unstable and the aircraft descended through 1,000 ft agl at an abnormally high rate. The aircraft then passed through its Minimum Descent Altitude (equivalent to a height of 390 ft agl) with neither pilot having established the required visual references for landing. Instead each pilot believed, mistakenly, that the other pilot was in visual contact with the runway approach lights.
When the confusion between the two pilots became apparent, the aircraft had descended to approximately 180 ft agl and the handling pilot commenced a go-around. Between 3.4 and 5.1 seconds later, with the aircraft at a radio altitude of approximately 125 ft agl, in a position approximately 1.5 nm short of the runway, the Enhanced Ground Proximity Warning System (EGPWS) “TERRAIN AHEAD, PULL UP ” audio warning was triggered. The correct emergency pull-up procedure was not followed in full, partly because the handling pilot had already initiated a go-around. The minimum recorded terrain clearance achieved during the recovery manoeuvre was 121 ft.
One further non-precision approach to Runway 36 was attempted using selected autopilot modes. The crew were attempting a third approach when they received visibility information from ATC that was below the minimum required for the approach. The aircraft then diverted to Port Sudan where it landed without further incident.
The following causal factors were identified:
The pilots were unaware of a significant discrepancy between the approach parameters on the approach chart and those within the navigation database because they had not compared the two data sets before commencing the approach.
Confusion regarding the correct approach profile and inappropriate autopilot selections led to an unstable approach.
The unstable approach was continued below Minimum Descent Altitude without the landing pilot having the required visual references in sight.
The UK CAA’s guidance and the regulatory requirements for approval to conduct MNPA were fragmented and ill-defined.
The operator’s planning and implementation of MNPA (Managed Non-Precision Approaches) procedures included incomplete operational and written procedures and inconsistent training standards.
The ability of the installed EGPWS to provide sufficient warning of inappropriate terrain closure during the late stages of the approach was constrained by the lack of a direct data feed from the GPS navigation equipment.
Following this serious incident, significant safety action was taken by the operator and the UK CAA. The AAIB made four safety recommendations.
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5-2007 G-MEDG.pdf (5,102.52 kb)