Incident Overview
On 29 August 2022 at 0753 UTC, a Vans RV-7 (registration G-RVDB) experienced a serious incident at Ronaldsway Airport, Isle of Man, when it landed on Runway 03 instead of the active Runway 08. The aircraft, a single-engine piston powered by a Superior XP-IO-360-B1HC2 engine, was on a private flight with one pilot and one passenger on board. No injuries were reported and the aircraft sustained no damage.
Sequence of Events
The flight was cleared to enter the control zone under VFR and was advised to expect a right-hand downwind landing on Runway 08. The pilot was transferred to the tower frequency approximately 3.5 nm southeast of the airport at 2,800 ft. The ATCO reported a surface wind from 080° at 9 kt and offered a choice of Runway 08 or 03. The pilot requested Runway 08 and was instructed to report ready for right base.
As the aircraft turned, its position was consistent with both a downwind for Runway 08 and a right base for Runway 03. The pilot reported ready for right base and was instructed to orbit left to accommodate an ATR 76 on a commercial flight joining final for Runway 08 at 8 nm. The pilot could not see the ATR and was advised when it landed. After leaving the orbit, the pilot aligned with what he perceived as the correct runway, called "final zero eight", and was cleared to land. However, he inadvertently approached and landed on Runway 03. The aircraft stopped its landing roll near the intersection of the two runways. Confusion over taxi instructions, issued as though the aircraft had landed on Runway 08, led the pilot to re-orient using his chart.
Contributing Factors
The pilot reported focusing attention on reassuring an uneasy passenger while orbiting over the sea, which made orientation difficult due to the absence of fixed ground references. He noticed a crosswind on final but did not check the compass. He believed he experienced confirmation bias, misreading the runway designation numbers "03" as "08" while thinking about landing technique.
Air traffic services reported a quiet morning. Glare from the morning sun and sea, exacerbated by sunblind reflections, made visual acquisition difficult from the control tower. The ATCO did not visually acquire the aircraft on final because he was checking the ATR's parking stand. The ATSA noticed the aircraft was not aligning correctly but his input was not acknowledged by the ATCO.
Safety Actions
The Air Traffic Services Unit initiated several safety actions: issuing a reminder to monitor all stages of final approach, implementing team resource management (TRM) training as a matter of urgency, and researching alternative sunblinds to address visibility issues. The Isle of Man's Head of air traffic services confirmed the first action was completed and the intent to undertake the others.
Human Performance Considerations
The AAIB report references guidance on situation awareness, sterile cockpit procedures, and vigilance. It notes that distractions can disrupt task focus and emphasizes the importance of recovering situation awareness before commencing an approach. The report also discusses the role of teamwork in detecting misperceptions and the need for controllers to maintain visual observation of aircraft on approach.