What happened
On 17 March 2006, a Boeing 757-2T7, registration G-MONE, was conducting a passenger flight from Luton to Gibraltar. During a surveillance radar approach to Runway 09, the flight crew lost visual contact with the runway strobe lights after passing the Visual Decision Point (VDP).
In response to the loss of visual references, the commander initiated a go-around procedure. During this maneuver, the aircraft deviated from the prescribed missed approach track. The aircraft entered a right turn that directed it toward high ground near the 'Rock' of Gibraltar. Air Traffic Control (ATC) intervened promptly, providing heading instructions to prevent a collision. The aircraft's lowest altitude over land was 2,100 ft, while the highest nearby terrain was 1,420 ft. Once the aircraft was clear of the terrain, the crew diverted to Malaga Airport.
The investigation
An investigation by the AAIB examined the flight path using Quick Access Recorder (QAR) data and reviewed radio communications. The investigation established that the commander had disconnected the autopilot and autothrottles to fly manually, which made it difficult to maintain visual contact with the runway while simultaneously managing flight parameters.
It was noted that the first officer had pre-set a new radio frequency during the turn, which may have caused both pilots to momentarily focus on cockpit instruments rather than the external environment. Additionally, the investigation reviewed the effectiveness of the airport's lighting and the accuracy of the radar returns during the approach.
Findings
- The crew failed to maintain continual visual contact with the runway strobe lights.
- The crew did not fully comply with the established missed approach procedures during the go-around.
- The commander applied manual thrust for the go-around but failed to select the 'Go-Around' switch on the thrust levers initially.
- The limited intensity and nature of the airport lighting at Gibraltar made visual acquisition difficult.
- The aircraft's track deviated toward high ground due to the crew's focus on reconfiguration and the lack of adherence to the missed approach heading.
Safety action
Following the incident, the aircraft operator updated its crew briefing for Gibraltar to include more detailed information regarding airport procedures. ATC procedures were also reviewed, with instructions issued to ensure controllers confirm visual contact with crews at the VDP. There was also a recommendation to evaluate the performance of primary radar for surveillance approaches.