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AAIB Bulletin: 12/2007 CONTENTS SPECIAL BULLETINS None COMMERCIAL AIR TRANSPORT FIXED WING Airbus A300 B4 TC-MND 13-Apr-07 1 Airbus A321-231 G-OZBN 28-Aug-07 7 Lockheed T-33 Silver Star Mk 3 G-TBRD 06-Sep-06 8 ROTORCRAFT Agusta A109A G-DNHI 09-Oct-06 17 GENERAL AVIATION FIXED WING Cessna 152 G-BNKS 12-Sep-07 29 Cessna 172S Skyhawk G-GFMT 20-Aug-07 30 Cessna 210 Centurian N761JU 07-Aug-07 32 Cessna A150L Aerobat G-BOYU 15-Sep-07 34 Denney Kitfox Mk2 Kitfox G-KAWA 08-Sep-07 36 DHC-1 Chipmunk 22A G-AORW 22-Sep-07 38 DHC-2 Mk.III Turbo-Beaver OY-JRR 11-Mar-07 39 Pierre Robin DR400/180 Regent G-FCSP 11-Aug-07 52 Piper PA-25-235 Pawnee G-BLDG 03-Sep-07 54 Piper PA-28-140 Cherokee G-AVGD 16-Sep-07 56 Piper PA-28-140 Cherokee G-BBBK 03-Feb-07 58 Piper PA-28-181 Cherokee Archer II G-BVOA 31-Jul-07 71 Reims Cessna F152 G-BLZH 04-Sep-07 73 Reims Cessna F152Q Skylane G-BHIB 30-Sep-07 75 Rockwell Commander 112TC G-ERIC 11-Jul-07 76 Taylor Monoplane G-BFDZ 23-Jun-07 78 Yak-50 G-IIYK 04-Sep-07 79 Zenair CH701SP G-CCSK 02-Aug-07 81 ROTORCRAFT RAF 2000 GTX-SE G-HOWL 31-Mar-07 83 Robinson R22 Beta G-UNYT 13-Jan-07 85 Schweizer 300 G-JAMA 07-Sep-07 88 SPORT AVIATION / BALLOONS Escapade Jabiru (3) G-PADE 09-Sep-07 90 Mainair Blade G-MZMB 14-Apr-07 92 Pegasus Photon G-MTAL 05-Sep-07 95 © Crown copyrght 2007 AAIB Bulletin: 12/2007 CONTENTS (Continued) SPORT AVIATION / BALLOONS (Continued) Pegasus Quantum 15-912 G-TUSA 31-Jul-07 96 Skyranger 912S(1) G-CDIU 29-Sep-07 97 Tipsy Nipper T.66 Series 2 G-ARBP 01-Aug-07 98 Team Minimax G-MYAT 16-Jun-07 100 ADDENDA and CORRECTIONS None Summary of: Aircraft Accident Report No: 5/2007 102 Report on the incident to Airbus A321-231, G-MEDG during an approach to Khartoum Airport, Sudan on 11 March 2005 List of recent aircraft accident reports issued by the AAIB 107 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyrght 2007 AAIB Bulletin: 12/2007 TC-MND EW/G2007/04/15 INCIDENT Aircraft Type and Registration: Arbus A300 B4, TC-MND No & Type of Engines: 2 CF6-50C2 turbofan engnes Year of Manufacture: 982 Date & Time (UTC): 3 Aprl 2007 at 234 hrs Location: Manchester Arport Type of Flight: Commercal Ar Transport (Cargo) Persons on Board: Crew - 3 Passengers - None Injuries: Crew - None Passengers – N/A Nature of Damage: None Commander’s Licence: Arlne Transport Plot’s Lcence Commander’s Age: 54 years Commander’s Flying Experience: 7,640 hours (of whch 7,800 were on type) Last 90 days - 72 hours Last 28 days - 43 hours Information Source: Arcraft Accdent Report Form submtted by the plot Synopsis During its final approach to Runway 24L at Manchester, the final descent to the Minimum Descent Altitude the arcraft descended below the mnmum alttudes (MDA) 2 of 660 ft. specified in the VOR/DME procedure for that runway. The Tower controller observed on radar that the arcraft History of the flight was 1 nm right of the published approach track. He The arcraft was cleared to descend n accordance advsed the plots of ths and asked them to report when with the Manchester (MCT) VOR/DME approach visual with the lights of Runway 24L. At 5 nm from the procedure for Runway 24L at Manchester Airport. touchdown threshold, the Tower controller notced that The co-plot contacted the Tower frequency at a the arcraft appeared low on the approach and when ths range of approxmately 0 nm from touchdown and was confirmed by the Approach controller, instructed the the Tower controller confirmed that the aircraft was aircraft to go around. The aircraft stopped descending cleared for this approach. The commander calculated and shortly afterwards reported that the runway was n the Visual Descent Point and at 6 nm commenced sight. The Tower controller considered the aircraft now Footnote Footnote The pont at whch a nomnal 3° glde path to the touchdown pont 2 The MDA s the alttude n a non-precson approach below whch coincides with the published MDA. descent may not be made without the required visual reference. © Crown copyrght 2007 AAIB Bulletin: 12/2007 TC-MND EW/G2007/04/15 to be at a sutable alttude and lned up wth the correct arcraft reached the MDA of 660 ft. The recommended runway and asked the crew f they were able to contnue vertical profile, given in the form of altitude versus visually. The commander replied that they were and the dstance from the MCT (and also, from the touchdown aircraft landed without further incident. threshold) was shown n a table on the same page as the chart. Meteorological information Recorded information The weather reported at 2250 hrs was a wnd of 2 kt wth variable direction and a visibility of 4,800 m in haze. Due to a delay in notification of this incident the AAIB The temperature was 10ºC and the QNH was 1022 mb. was unable to recover nformaton from the cockpt voice recorder or the flight data recorder. Aerodrome information Manchester Arport has two parallel runways wth Radar recordngs ndcated the poston and alttude of a south-westerly algnment whch at the tme of the the aircraft as it approached Runway 24L. As it turned it incident were designated 24L and 24R. A VOR/DME crossed the final approach track and established a track procedure was published for both runways. The final parallel to the north of it. The table below shows the approach track for the Runway 24R procedure was aircraft altitude relative to the profile recommended on offset 5º to the south of the runway headng, such that the approach chart at intervals of one mile. an arcraft followng the publshed track would be south Distance to Recommended Aircraft of the approach track to Runway 24L. The runway MCT VOR / nm Altitude / ft Altitude / ft centrelines are 0.21 nm apart and the threshold of the 6 2,400 ,800 left hand runway is 1.02 nm beyond the threshold of the 5 2,080 ,300 right hand runway in the landing direction. 4 ,770 800 Approach procedure 3 ,450 800 The VOR/DME approach procedure for Runway 24L 2 ,30 800 was publshed n the UK Aeronautcal Informaton 820 800 Package (AIP) and is shown in Figure 1. The pilots of TC-MND used a commercally avalable approach chart Ths nformaton ndcates that the arcraft descended whch contaned nformaton equvalent to that shown n below the mnmum procedure alttude of 2,400 ft before the UK AIP. passng the FAF and below 2,080 ft before passng the associated SDF at 5 nm. As the aircraft passed within Accordng to the publshed procedure the arcraft was 5 nm of the threshold ts track began to converge wth requred to mantan an alttude of 2,400 ft untl passng the published approach track. the Final Approach Fix (FAF) 6 nm from the MCT. When establshed on the publshed approach track the Recordngs of the Manchester Approach and Tower mnmum alttude untl passng the Step Down Fx at frequences ndcated that the plots had receved and 5 nm from the MCT was 2,080 ft. Thereafter there read back instructions correctly. were no further publshed alttude restrctons untl the © Crown copyrght 2007 2 AAIB Bulletin: 12/2007 TC-MND EW/G2007/04/15 UK AIP (19 Jan 06) AD 2-EGCC-8-15 180° EGCC MANCHESTER 35 CAT A,B,C,D 35 VOR/DME RWY 24L 270° 090° AD ELEV THR ELEV TRANSITION ALT VAR MCT 113.55/I-MC 111.55 257FT 227FT 5000 4°W 24 31 360° ARRIVAL ATIS APPROACH/RADAR TOWER GROUND MSA 25NM ARP 128.175 135.000, 118.575, 121.350 118.625, 119.400 121.850, 125.375 002 20W 002 10W 002 00W 2490 10NM 550 1775 5330N BAE 325 R319/1.7 bae 542610 504 MCT D7 (I-MC D7.7) 634 235° 2077 774 472 798 391 540 431 CAT C,D MCT D6 (I-MC D6.7) 945 434 1348 CAT A,B 594 MCT D5 (I-MC D5.7) 1750 R068 ,B MCT D8 IAF I-MC D8.7 CAT A ( ) 2087 D 285 R073 654 MCT mct113.55 390 CAT C,D MAXIMUM IAS 185KT 1867 I-MC 111.55D MAPt 550 imc 850 5320N 1150 1 MIN 235° 235° 055° POL 112.1 WFD 380 POL R166 405 wfd 134 ° LHA 3000 633 1450 MCT R11 D 1028 2 Procedure not available without DME MCT or I-MC 378 1249 1834 1571 AMLET MCT D16 560 POL D30 DAYNE 1810 MCT R134 D11 TNT 115.7D D314/2.9 R314 D17 314° 850 550 WHIwhi368.5 5310N 1125 D304/3.5 IAF (Hold if required in VOR MCT hold) VOR DME MCT I-MC MAPt ( ) MCT DME 0.7 (THR RWY 24L)/ CAT C,D I-MC DME ZERO 3000 R073 D6.7 I-MC CAT A,B D8.7 Climb straight ahead to 3500 continue as055 directed. R068 2400(2173) ° RCF: From VOR MCT DME 10 at 3500, (if below 2080(1853) 3500 continue climb in left to 3500), turn left onto I-MC track 069°M continuing climb to FL60 to join the 235° SDF D7.7 DAYNE hold.