What happened
On 31 March 2005, an Embraer E120 Brazilia, registration F-GFEO, was conducting a passenger shuttle flight from Manchester to Ronaldsway Airport, Isle of Man. The flight crew, which included a chief training captain and a new first officer undergoing line training, was on approach to Runway 08.
During the approach, the crew mistakenly selected the Isle of Man VOR frequency instead of the correct ILS frequency. The commander, aware of the error, chose not to correct it, intending to use the mistake as a teaching moment for the inexperienced first officer. Consequently, the crew used the incorrect DME distance for their descent profile.
As the aircraft descended, it reached approximately 475 ft above sea level, roughly 5 nm from the runway. At this altitude, the aircraft was only about 1 nm away from rising terrain. The flight data recorder showed that the aircraft had descended far below the protected airspace. The commander eventually initiated a climb to 1,600 ft to re-establish the correct approach path before completing the landing without further incident. There were no fatalities and no injuries among the three crew members and seven passengers.
The investigation
The AAIB investigation utilized data from the flight data recorder, which successfully captured the descent and subsequent climb. The cockpit voice recorder was unavailable as it had not been electrically isolated following a previous landing, allowing the data to be overwritten.
Investigators examined the crew's decision-making and the navigation setup. They noted that the commander's decision to maintain the incorrect frequency was a deliberate deviation from standard operating procedures. The investigation also looked into the radar monitoring by Air Traffic Control, noting that the controller observed the aircraft's altitude drop unexpectedly on radar.
Findings
- The crew was using the Isle of Man VOR frequency instead of the ILS frequency.
- The commander deliberately failed to correct the navigation error to use it as a training point for the first officer.
- The use of the incorrect DME reference caused the aircraft to initiate its descent approximately 5 nm early.
- The aircraft descended to 475 ft, which was approximately half the altitude required to clear the terrain ahead.
- The commander's decision to knowingly deviate from established procedures on a scheduled passenger flight was highly inappropriate and undermined safety margins.