reducing "Crew-caused"
approach and landing

Pilot-in-charge Monitored Approach

2006 B738 CFTT Knock Ireland

Brief account : 

The aircraft was on a flight from London Gatwick Airport to Ireland West Airport. The crew lacked familiarity with the automated flight control system of the aircraft, and became engrossed in trying to enter data into the system. A change in landing runway increased the crews’ workload and resulted in the aircraft being high and fast on the glideslope.

During the approach the aircraft was incorrectly configured, including the non deployment of flaps, landing gear, and speed brakes. When the aircraft broke clear of cloud at about 410 ft, the pilot-in-command disengaged the autopilot and commenced a go-around. At the same time the Enhanced Ground Proximity Warning System sounded. The occurrence was a ‘Serious Incident’ as defined in ICAO Annex 13; in particular, a ‘controlled flight into terrain only marginally avoided’.

A safe landing followed after 25 minutes further holding.

Crew-related factors : 

Both pilots were B737 experienced, but not familiar with the advanced features of the -800. The sequence of events probably started with the Operator's error when "the first and critical opportunity was lost to the pilots to input the most up-to-date information in the FMC."   Their departure briefing information had not been updated to reflect the non-availability of several instrument procedures, which probably disrupted any attempted briefing near the start of descent.

The cloudbase was marginal for landing using the into-wind runway and the wind on or above tailwind limits for the available precision approach, necessitating a break-off and visual circuit.  

Having to use the ILS with a strong tailwind instead of the originally planned routing shortened the approach and the crew had difficulty setting the temporary fix in the FMS.  The resulting approach was high and fast approach (410 ft  and 265 kt groundspeed at the threshold).  The high workload meant that both crew members lost all situation awareness and monitoring broke down completely.  The go-around was accompanied by an EGPWS alert. 

The report notes that "When they finally broke clear of cloud at about 400 ft over [the airport] the spatial reality finally dawned on both pilots as the PF disengaged the Autopilot and executed a non procedural Go Around, as he recalled ……“I went to manual on the way to the [holding beacon] ….I returned to basics handling”.   

In this event, the Captain's flying workload was high due to unfamiliarity with the EFIS, and added to the tactical ones caused by the fact that the information on which their planning had been based was invalid, and the weather marginal. 

The First Officer was entirely involved in assisting the Captain resolve the immediate problems, and neither pilot could see that the overall situation was in fact wrong. "The Captain and First Officer were so engrossed in trying to reprogramme the FMC that they both lost their critical situational awareness for a time." 

If the crew had been using PicMA then the undoubtedly Captain's workload would have been significantly reduced. He would have been better placed to make a strategic decision to delay the approach as necessary while resolving the issues of which runway to use, talking directly with ATC, as well as maintaining better overall situational awareness. 

The report noted that despite the extensive CRM training the crew had been given: "In this event, by continuing to concentrate on loading the required data in the FMC and ignoring the fundamental requirement for the PF to fly the aircraft and the PNF to perform those duties, normal CRM was compromised to a serious degree". 

It is not known whether they were in place at the time of this incident, but 18 months later the operator's policies would have required a "monitored Approach" procedure in circumstances of visibility 3000m and/or cloudbase below 1000ft for the non-precision approaches, or visibility/RVR at or below 1000m and ceiling 300ft  for ILS approaches.  

In this event the reported weather would not have required a Monitored Approach because of visibility for either approach, but at "broken 800ft" may have required one for a non-precision approach. Making the procedure an "ad-on"  for specific conditions, rather than the default, does not provide adequate protection against threats.        

Knock Ireland
Expected weather: 
Pilot in charge: 
Early transition: 
Go-around : 
At or above DH/A
Minor or none
PicMA potential: 
Vert Guidance: 
Both Head Up: 
Fully prepared: 
Actual Weather: 
Low Cloud
Autopilot :