What happened
On 4 June 2006, a B737-800, registration EI-DCT, was conducting a scheduled passenger flight from London Stansted to Cork Airport. During the arrival phase, the pilot flying decided to deviate from the initial instrument approach briefing to request a visual approach to Runway 17.
While on the first attempt at this visual approach, the crew realized the aircraft was too high, as indicated by the Precision Approach Path Indicator (PAPI) showing four white lights. Instead of executing a standard missed approach, the pilot requested and was granted permission by Air Traffic Control to perform a right-hand orbit to reposition the aircraft. During this maneuvering, the aircraft descended significantly while in a landing configuration. The flight path took the aircraft over the Bishopstown residential area of Cork City at an altitude as low as 425 feet above ground level. During the subsequent final approach, the Enhanced Ground Proximity Warning System (EGPWS) issued two "Glide Slope" cautions. The aircraft eventually landed safely at 16:53 hrs with no injuries to the 128 passengers or 6 crew members.
The investigation
The AAIU investigation examined flight data recorder (DFDR) information, radar returns, and air traffic control communications. The investigation established that the aircraft's descent during the orbit led to a height of only 553 feet above sea level, which was notably low given the terrain. Radar data confirmed a steep glide slope of approximately 6 degrees on the initial approach. The investigation also reviewed the crew's adherence to Standard Operating Procedures (S/OPs) and Crew Resource Management (CRM) principles. Furthermore, the AAIU noted that at least sixteen residents in the Bishopstown area filed complaints regarding the low altitude and noise levels of the passing aircraft.
Findings
- The flight crew did not follow the operator's established SOPs during either approach to the runway.
- The pilot flying did not adhere to CRM principles, specifically regarding the integration of inputs from the monitoring pilot.
- The aircraft was flown at or below 500 feet AGL over a residential area while in a landing configuration during the base leg of the orbit.
- The pilot flying's failure to follow standard procedures and disregard for the monitoring pilot's concerns was the primary driver of the incident.