reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

Top-of-descent

At 2222 Sommeton Centre cleared XXX99 to descend to FL290.  R/T quality was poor. The First Officer read back “FL290” but the Captain selected FL250 in the altitude select. The voice recorder contains the following conversation:

Capt: OK, FL250 set

F/O: Uh…. I think that was 290.

Capt: No, I’m sure it was 250 - that’s where they usually hand us over.

F/O: OK - they could use a decent mike down there.

F/O: Umm… you know I’m sure he said two NINE zero….. I’d like to just check it.

Capt: OK…if you want to.  

Sommeton confirmed FL 290.

Capt: Thanks for picking that up, I was sure he said twenty-five.

About a minute later the Captain remarked “looks like a nice night down there - I think that’s Capital City over there” (about thirty miles ahead).  

At 2226 XXX99 was handed off to Sommeton Approach, which cleared it to FL160, and added “traffic is northbound, domestic departure off runway 17”.

A change of plan.

At this point the Captain remarked: “the domestic terminal is up at the north end of the field, about as far as you can get from our terminal. ……  he must have taken a tailwind.”  About twenty seconds later he asked the F/O “find out what the wind is.” Approach responded “wind is 010 at 4 knots, do you want runway 17?”    The F/O replied “standby.”  The Captain then said, “hmmm.... if we take 17 we’ll save about eight or nine minutes plus we won’t have to taxi the full length back. We’ve got about fifty miles….. tell him we’ll take 17”.  The F/O duly confirmed that XXX99 was requesting a straight-in on Runway 17.

At 2229 the Captain said “have you got the 17 plate?” but the F/O’s response was interrupted by a radio call from Sommeton Approach, who asked XXX99 its DME from STN. The F/O replied “DME 30”. Approach then cleared XXX99 to turn left and join the 17 ILS, cleared to JOYNR at 4000 feet. The Captain then said “OK, we’re a bit high now, so I’ll get it all off so we get in the groove again as soon as we can”, extended full speed-brakes, and turned onto a heading of 120.

F/O: That’s 110.7, “ISS”, I’ve identified the 17 ILS  for you. 

Capt. Thanks… I guess that’s Ridgeville up ahead.  Should hit the ILS soon - I’ll make it 140 (degrees heading).

Shortly afterwards, the Captain retracted the speed-brakes and called for ten flaps.

The first snag.

F/O: Speed checked, ten flaps selected…… by the way you need to go to raw data not map.

Capt. Oh yes. OK. Thanks.

A central warning system alert tone sounded.

F/O: Uh oh what’s that….... it’s “Flap Motor”.

Capt: OK I’ll hold this speed, you do the “Flap Motor” checklist.

F/O: um….. it says “do not use standby motor….. use 27 flap on selector…. use Vapp 32 plus 25 kts……check landing distance”. Just a minute……”

Capt: OK….

A question of data.

F/O: I make it it’s too short - this chart’s a bit confusing but I……..

Capt:. No I’m sure it’s not too short, have another look…

Capt: S*** it’s gone through the localizer.

The Autopilot disconnect alert  sounded.

Capt: I’ve taken it out - I can see Ridgeville. Maintaining 4000.

Manual flying, workload increasing.

The Captain then made several turns to re-establish on the ILS centerline.

F/O: OK I think you’re OK for landing distance - do you want to check it?

Capt: No, we need to get down. Do you have a glideslope your side?

F/O: uh no……. your final speed’s gonna be 170..  Are you sure about the... it looks.......

Approach: XXX99 you are cleared for the approach 17.

XXX99: Roger

No vertical guidance.

Capt.: OK we’re on the ILS, select flap 18, I’m reducing to 190… where’s that Glideslope? We can go down to 2200 at Ridgeville….  7 on the DME like we said.. (Speed-brakes then stowed)…. Give me the landing checklist when you can….. are you sure that speed’s right, sounds a bit high.

F/O: hang on…   oh no it’s based on the 32 flap setting not the 27 we were planning on. But you only select to 27.

Capt: yeah its confusing.  I still don’t have a glide-slope - what height should we be at on that DME?

F/O: uh…. Let’s see……. I think it’s 2200, we’re at 6.

Capt. OK we’re in the groove then, ask him where’s that glideslope.

Approach confirmed glideslope is off due to power problem, and changed XXX99 to tower.

Capt: call me the DME heights.

Radio altimeter voice was heard at this point: “One thousand”

F/O: this doesn’t seem right somehow.

Confirmation bias?

Capt. Did you call the tower? - I can see the ground

F/O: OK, DME 4, should be 1600 - you’re about 80 high.

Tower was contacted and landing clearance obtained, wind 010 at 3 knots.

F/O: landing check is complete, should be 900 feet.

Finally, doubt. 

Capt: funny I don’t have the runway

F/O: I don’t think we should….

Capt: something ain’t right - we’ll go around.  Go-round, flap 18. 

Thrust levers were fully advanced and the aircraft rotated but the aircraft hit a group of houses on the top of a ridge at 740 ft. m.s.l.

There were no survivors among the 179 passengers and crew, and 46 casualties on the ground.