What happened
On March 20, 2017, a SAAB-3ER was operating a flight from EGPB to EGPA (Kirkwall). While executing the ILS approach for runway 27, air traffic control or monitoring noted that the aircraft was at a lower altitude than prescribed by the approach procedure. Specifically, at a distance of 11NM from the runway, the aircraft was flying at approximately 1,600ft, despite the crew reporting an altitude of 1,900ft.
Upon landing, data from the Flight Data Recorder (FDR) revealed that the barometric altimeter was indicating 960ft, even though the airport elevation is 58ft. This discrepancy indicates the crew was operating with an incorrect pressure setting.
The investigation
The PKBWL investigation focused on the discrepancy between the crew's reported altitude and the actual altitude recorded by the FDR. The investigation examined the cockpit procedures, specifically the execution of the approach checklist, and reviewed the crew's preparation for operating in the United Kingdom.
Findings
- The primary cause of the incident was crew error resulting from the failure to set the altimeter to the correct QNH pressure.
- The crew failed to properly monitor cockpit tasks due to an imprecise execution of the Approach checklist.
Safety action
Following the investigation, the following preventive measures were implemented:
- Flight crews were notified of the incident via an information bulletin distributed by email.
- The Operations Manager was instructed to ensure all crews assigned to UK operations are thoroughly prepared and conduct self-briefings regarding airport-specific procedures, in accordance with operational instructions.
- Crew scheduling was adjusted to ensure that at least one pilot on a flight has prior experience with operations conducted for Logan Air.
- Crews were provided with updated UK-specific regulatory publications, including the UK AIP (Enr 1), UK Flight Information Services (CAP 774), and the Radiotelephony Manual (CAP 413).