Flight Details
The flight crew reported for duty at Liverpool Airport at 0845 hrs. Their original task was to fly to Belfast City Airport, collect a transplant organ, and take it to Cambridge Airport. However, upon arrival at Belfast, the transfer was no longer required, and they were given a new task to fly to Belfast Aldergrove Airport to collect an organ for transport to Birmingham Airport. The aircraft departed Belfast Aldergrove at 1450 hrs with the co-pilot as the pilot flying. The flight was uneventful, and air traffic control provided a radar vector to intercept the ILS for a straight-in approach to Runway 15 at Birmingham.
Approach and Incident
The aircraft was on an autopilot track of 135°M, 13 nautical miles from the touchdown zone at a groundspeed of 254 kt, when it crossed the localiser centreline. It turned right onto a corrective track but passed through the localiser course again. Further corrections were made, and the aircraft passed through the localiser once more before becoming established at 5 nm. The co-pilot later reported that, because the autopilot was not capturing the localiser, he disconnected it and flew the approach manually.
At 10 nm, the radar controller broadcast a message advising of a fog bank on final approach and gave RVRs of 1,400 m at touchdown and in excess of 1,500 m at both the mid-point and stop end. The commander sighted the airfield during the approach, but the co-pilot did not. A handover to the tower frequency occurred at about 8 nm. At 6 nm, landing clearance was given and acknowledged. The tower controller then advised the aircraft of a fog bank over the airfield boundary and that the touchdown RVR was 1,400 m. The commander responded, “WE’VE GOT ONE END OF THE RUNWAY.”
The aircraft was correctly on the localiser and the glideslope at 4 nm. The decision altitude (DA) of 503 ft amsl (200 ft aal) was written on a bug card mounted centrally above the glare shield. Both pilots recalled that the standard operating procedure (SOP) calls of “500 above” and “100 above” DA were made by the commander. However, neither pilot could recall a call of “decision” or “go-around” being made.
Between 1.1 nm and 0.9 nm, and 400 ft to 300 ft aal, the aircraft turned slightly right onto a track of 152°M. This track was maintained until the aircraft struck the glideslope antenna to the right of the runway some 30 seconds later. The aircraft came to rest in an upright position on the grass with a fire on the left side. The co-pilot evacuated through the main cabin door on the left side of the fuselage and suffered flash burns as he passed through the fire. The commander was trapped in the cockpit for a time.
Probable Cause
The official probable cause stated that the co-pilot’s task of flying the approach became increasingly demanding as the aircraft descended, and it is probable that his attention was fully absorbed by this. This was confirmed by his erroneous perception that the aircraft was in instrument meteorological conditions (IMC) from below 2,000 ft amsl. The co-pilot reported that during the final stages of the approach, when he noticed he had lost the localiser indication, he asked the commander whether he should go around. The response he reported hearing—“no, go left”—was not what he had expected, and may correspond to the time from which no further control inputs were made. The commander could not recall having given any instructions to the co-pilot after the “100 feet above” call. It is likely that the crew commenced the approach expecting it to be completed visually. However, the weather conditions were unusual, and the aircraft entered IMC unexpectedly late in the approach. As an aircraft gets closer to a runway, the localiser and glideslope indications become increasingly sensitive, and small corrections have relatively large effects. The monitoring of this approach broke down in the latter stages, and the crucial “decision” call was missed, which led to the aircraft’s descent below minima.