What happened
On 3 May 2015, a Beech 95-B55 Baron, registration G-RICK, was conducting a private flight from Inverness to Dundee for an annual inspection. The flight included the pilot and one passenger. While performing an ILS/DME approach to Runway 09 at Dundee Airport in instrument meteorological conditions (IMC), the aircraft failed to arrive at the airfield.
Despite the pilot reporting he was on final approach and four miles from the runway, the aircraft struck high ground approximately 6.7 nm west of the airport. The impact resulted in two fatalities and the total destruction of the aircraft. A Search and Rescue helicopter located the wreckage on a hillside following a search initiated by air traffic controllers.
The investigation
The AAIB investigation examined radar data, recovered GPS records, and the aircraft's wreckage. Analysis of the Garmin GPSMAP 696 receiver revealed that the aircraft's track was inconsistent with the published ILS/DME procedure. The flight path showed the aircraft was navigating using GPS-derived information from the 'DND' NDB rather than using the DME distance from the runway threshold.
Microscopic examination of the HSI source annunciator bulbs confirmed that the GPS source was active at the time of impact. The investigation also noted that the aircraft's autopilot was unserviceable, requiring manual flight. Furthermore, the aircraft was flying with an overdue annual inspection, as no application for a temporary Permit to Fly had been made.
Findings
- The accident was a case of Controlled Flight into Terrain (CFIT).
- The pilot likely mistook GPS distance from the 'DND' NDB for DME distance from the runway threshold, leading to a premature descent.
- The pilot's use of the GPS 'direct to' function likely contributed to a loss of situational awareness regarding his actual position relative to the runway.
- The pilot failed to switch the navigation source to the ILS via the CDI key, meaning the HSI continued to display GPS data.
- Adverse weather, including low cloud, rain, and turbulence, increased the risk of the accident.
- The lack of radar surveillance at Dundee Airport meant air traffic controllers were unable to detect the aircraft's deviation from the prescribed approach.
Safety action
Following the accident, Dundee Airport authorities implemented immediate measures, including updating the ATIS broadcast to remind pilots that the NDB and DME are not co-located. A safety survey was also commissioned to investigate long-term improvements, such as relocating the NDB, installing air traffic monitoring, and implementing RNAV approach procedures.