What happened
On 29 August 2022, a Vans RV-7, registration G-RVDB, was conducting a private flight at Ronaldsway Airport, Isle of Man. While orbiting over the sea, the pilot was focused on reassuring a passenger who was experiencing unease. During this period, the pilot was given a choice between using Runway 08 or Runway 03.
After being instructed to orbit to accommodate a commercial ATR 76 aircraft, the pilot transitioned to a final approach. The pilot reported being on final for Runway 08; however, the aircraft actually approached and landed on Runway 03. The landing roll ended near the intersection of the two runways. The Air Traffic Controller (ATCO) did not visually observe the aircraft during its final approach, as they were focused on ground activities and hindered by significant sun glare through the tower windows.
The investigation
The investigation examined the pilot's actions and the air traffic services unit's (ATSU) performance. It was established that the pilot experienced confirmation bias, misreading the runway designation '03' as '08' while preoccupied with passenger management and landing techniques. The lack of fixed ground references during the sea orbit further complicated the pilot's orientation.
At the control tower, the investigation found that glare from the morning sun and the reflective surface of sunblinds made visual monitoring difficult. While the Air Traffic Services Assistant (ATSA) noticed the aircraft's alignment appeared incorrect on the radar monitor, this observation was not acted upon by the ATCO. Furthermore, the ATCO had ceased monitoring the aircraft's final approach to check on ground operations.
Findings
- The pilot misidentified Runway 03 as Runway 08 due to confirmation bias and distraction.
- The pilot's attention was divided between flying the aircraft and managing an uneasy passenger.
- The ATCO failed to monitor the aircraft during its final approach.
- Environmental factors, specifically sun glare and the position of sunblinds, impeded the ATCO's ability to visually acquire the aircraft.
- The ATSA identified a potential alignment issue but did not communicate it effectively to the ATCO.