Air Accident

Investigation Unit
Ireland
SYNOPTIC REPORT

SERIOUS INCIDENT

ATR 72-201, EI-REH

Approach to Kerry Airport
19 December 2011
 ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

Foreword

This safety investigation is exclusively of a technical nature and the Final Report reflects
the determination of the AAIU regarding the circumstances of this occurrence and its
probable causes.

In accordance with the provisions of Annex 131 to the Convention on International Civil
Aviation, Regulation (EU) No 996/20102 and Statutory Instrument No. 460 of 20093,
safety investigations are in no case concerned with apportioning blame or liability. They
are independent of, separate from and without prejudice to any judicial or administrative
proceedings to apportion blame or liability. The sole objective of this safety investigation
and Final Report is the prevention of accidents and incidents.

Accordingly, it is inappropriate that AAIU Reports should be used to assign fault or blame
or determine liability, since neither the safety investigation nor the reporting process has
been undertaken for that purpose.

Extracts from this Report may be published providing that the source is acknowledged,
the material is accurately reproduced and that it is not used in a derogatory or misleading
1 context.

1
Annex 13: International Civil Aviation Organization (ICAO), Annex 13, Aircraft Accident and Incident
Investigation.
2
Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the
investigation and prevention of accidents and incidents in civil aviation.
3
Statutory Instrument (SI) No. 460 of 2009: Air Navigation (Notification and Investigation of Accidents, Serious
Incidents and Incidents) Regulations 2009.

Air Accident Investigation Unit Report 2014 - 006

 AAIU Report No: 2014 - 006
State File No: IRL00911112
Report Format: Synoptic Report
Published: 12 June 2014

In accordance with Annex 13 to the Convention on International Civil Aviation,

Regulation (EU) No 996/2010 and the provisions of SI 460 of 2009, the Chief Inspector of
Air Accidents on 19 December 2011, appointed Mr Paddy Judge as the Investigator-in-
Charge to carry out an Investigation into this Serious Incident and prepare a Report.

Aircraft Type and Registration: AVIONS DE TRANSPORT REGIONAL - ATR 72-201,

EI-REH

No. and Type of Engines: 2 x Pratt & Whitney 124 B

Aircraft Serial Number: 260

Year of Manufacture: 1990

Date and Time (UTC)4: 19 December 2011 @ 11.49 hrs

2
Location: Approach to Runway 26 at Kerry Airport (EIKY)

Type of Operation: Commercial Air Transport/Scheduled /Passenger

Persons on Board: Crew - 4 Passengers - 13

Injuries: Crew - Nil Passengers - Nil

Nature of Damage: None

Commander’s Licence: Airline Transport Pilot’s Licence (ATPL) issued by

the Irish Aviation Authority (IAA)

Commander’s Details: Male, aged 44 years

Commander’s Flying 6,998 hours, of which 4,816 were on type

Experience:

Notification Source: Shannon ATC

Information Source: AAIU Report Form submitted by the Commander

AAIU Field Investigation

4
UTC: Coordinated Universal Time, equivalent to local time on the date of the occurrence.
 ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

SYNOPSIS

While the aircraft was conducting an Instrument Landing System (ILS) approach to Runway
(RWY) 26 at EIKY with the autopilot engaged, difficulty was experienced in following the
glideslope and the aircraft descended below the glide path. As the aircraft passed over a
ridge on the approach the Enhanced Ground Proximity Warning System5 (EGPWS) activated
and a go-around was initiated. Following this, a non-precision approach was flown which
resulted in a successful landing. During that approach similar problems with the glideslope
were experienced.

Subsequent examination by the Operator found that the unstable reception of the ILS
glideslope signal was caused by a missing reflective strip from the inside of the aircraft’s
radome which had been recently repaired.

1. FACTUAL INFORMATION

1.1 History of the Flight

The aircraft, an ATR 72, departed Dublin Airport (EIDW) on the morning of 19 December
2011 at 11.06 hrs with EIKY as its destination. The Flight Crew comprised a training captain
(Commander) and a Captain, who was being line checked by the Commander. After
departure from EIDW the aircraft climbed to its cruising altitude of Flight Level (FL) 180 and
later descended towards EIKY for an ILS approach to RWY 26.
3
The Flight Crew reported that the aircraft had problems maintaining the glide path following
interception of the ILS with the autopilot engaged and that it later pitched down with a high
rate of descent. The EGPWS activated and a go-around was conducted. A second approach
was then commenced with similar glide path problems. The approach was continued as a
non-precision approach and the aircraft landed at 12.06 hrs without further incident.

1.2 Pilot Interviews

1.2.1 Commander

The Commander stated that he was the Pilot Flying (PF), though flying from the right hand
seat at the time of the occurrence. The other pilot on the aircraft (hereinafter referred to as
the Captain) was returning to line flying after a short break and Operator procedures
required retraining over eight sectors. The first four sectors were training flights and the
next four were line checks. The four training sectors had already been completed, three on
the previous day and one that morning with the Captain acting as PF.

5
EGPWS: Enhanced Ground Proximity Warning System provides flight crew with a representation of the terrain near the
aircraft by comparing the current position, derived from a Global Positioning System (GPS), with a terrain database for that
location. The system also issues cautions if the aircraft is closing with terrain and warnings, if the terrain is seen to be a
threat to the safety of the aircraft.

Air Accident Investigation Unit Report 2014 - 006

For the next four line check sectors the Captain was required to act as PF on two sectors and
as Pilot Monitoring (PM)6 on the other two. During the occurrence flight the Captain was
acting as PM from the left hand seat.

The PF stated that they departed EIDW on a Standard Instrument Departure (SID) and
shortly afterwards were cleared by ATC directly to INRAD7. Although their ATC flight plan
was filed for FL160 they received approval to climb to FL180 in the interests of fuel
efficiency. The autopilot was engaged throughout. They requested and were cleared by ATC
Shannon to descend towards EIKY, their intention being a steady 3° descent profile to the
airport. They were handed over to Kerry Tower about 5 nautical miles (NM) before INRAD.
He believed that they were then cleared to descend to 4,000 ft altitude and to call when
established on the localiser. The PF armed the Approach mode and believed that they were
descending with a rate of descent of about 1,200 ft/min at that time. His recollection was
that when they were at about 4,500 ft altitude at a speed of about 210 kts they entered the
LOC* mode, indicating that the aircraft’s automatic flight control system (AFCS 8) had entered
localiser capture mode. They became established on the localiser at about 15 NM from EIKY,
just below the glideslope on a normal descent profile. Shortly afterwards the AFCS entered
GS* mode, indicating that it had entered glideslope capture.

He commented that the glideslope appeared to be a little unstable, though he expected it to

stabilise closer to the airport, but the aircraft was tracking the localiser properly. Having
captured the glideslope, the aircraft initially went above it and then descended back through
the glideslope slightly. It then chased the glideslope, he believed possibly twice, and both
pilots commented on the poor performance of the autopilot in capturing the glideslope. He 4
recalled that at the time the PM remarked that the aircraft was close to one dot high on the
glideslope, but that they were still in glideslope capture mode and the aircraft was now
regaining the slope. The PF stated that again the aircraft did not stabilise on the glideslope,
whose display was moving more than would usually be expected. He then noticed the
aircraft pitching down to a vertical speed of about 2,000 ft/min and commented to the PM
on the high rate of descent, wondering if they had encountered a tailwind on the approach
but still expecting the aircraft to correct for this. At that time he believed that they were
approximately 9 NM (DME9) from EIKY. He recalled that shortly afterwards the EGPWS
‘CAUTION TERRAIN’ activated followed by the warning ‘TERRAIN AHEAD’. He stated that by
then he had already disconnected the autopilot and called “Go-around” from, he believed,
about 2,000 ft and 7 NM.

The full missed approach procedure was then flown with a climb to 3,000 ft and the aircraft
was positioned for another ILS approach. They decided to conduct this second approach
using a full ILS procedure and that if the glideslope should act the same way, they would
revert to a non-precision localiser/DME approach with standard height checks against
distance and they briefed accordingly.

6
PM: Pilot Monitoring is also known as Pilot Not Flying (PNF).
7
INRAD: A waypoint at 14 nm on the ILS approach to RWY 26 at EIKY.
8
AFCS: The ATR automatic flight control system consists of the flight director and autopilot systems.
9
DME: Distance Measuring Equipment.
 ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

He stated that the second approach was commenced with the aircraft configured as per
normal procedures and the aircraft became established on the localiser. Although the
glideslope was captured from below, the aircraft went through it and then pitched down
with an excessive rate of descent. As the glideslope was 'twitching' it soon became apparent
that the autopilot was not going to maintain it and that the aircraft was “chasing the
glideslope”. The PF stated that they discontinued the ILS approach and continued with a
localiser/DME approach as briefed. They became visual at about 700 ft and landed.

He had flown into EIKY many times previously and was quite familiar with the airport. He
stated that he was not expecting the aircraft to react the way it did. Since the AFCS was in
GS* mode he expected the system to sort itself out and was surprised that the end result
was an EGPWS activation.

1.2.2 Captain

The Captain informed the Investigation that at the time of the occurrence he was acting as
PM from the left hand seat. They had flown from EIKY to EIDW, to the Isle of Man, back to
EIDW and then to EIKY where the occurrence happened. He recalled that during the ILS
approach to RWY 26 the aircraft became established on the localiser at approximately 14
NM. It subsequently entered GS* mode normally. At approximately 9 NM both pilots
observed the aircraft struggling to maintain the glideslope. The aircraft became high with
respect to the glideslope and he observed to the PF that it was getting close to one dot
deflection. He then noticed the aircraft pitching down with a resulting high descent rate in
5 excess of 2,000 ft/min. Quickly thereafter an EGPWS ‘CAUTION TERRAIN’ followed. He
glanced at the glideslope which indicated that they were still high. He thought that the
caution was due to the high descent rate. They then got a “PULL UP" Terrain Warning. He
said that by that stage the PF had disconnected the autopilot and had already pitched the
aircraft up to +5°. The PF called a go-around which was then completed.

Shortly afterwards, EIKY Tower requested the reason for the go-around and he advised that
this was due to a glideslope issue that resulted in an EGPWS alert and a mandatory go-
around. He stated that on the second approach the glideslope again behaved erratically,
giving incorrect indications, and that they reverted to a non-precision localiser/DME
approach from which they landed.

The Minimum Safe Altitudes (MSAs) for EIKY were briefed in advance of the approach. He
said that the charts they used did not show spot heights (Appendix A). He had not cross-
checked the aircraft’s altitude versus DME distances and believed that during the approach
he was focussed on the aberrant glideslope and the descent rate and had not noticed the
reduced height over the ground.

He observed that during their earlier approach into EIDW they had received a CAT II invalid
warning but had not considered that significant at the time. On their later return from EIKY
to EIDW an ILS approach was flown without any glideslope issues. They were met by
technical staff on arrival at EIDW who checked the aircraft’s ILS system and informed them
that it was serviceable.

Air Accident Investigation Unit Report 2014 - 006

1.3 A ir Traffic Control (ATC)

While en-route the aircraft had been in contact with Shannon ATC which transferred it to
EIKY Tower frequency as it approached EIKY. Whereas Shannon ATC uses radar to control air
traffic, EIKY Tower operates a procedural control service which requires aircraft to make
mandatory reports to ATC providing information on their position and altitude.

The EIKY Tower recording showed that, on initial contact, EIKY Tower cleared the aircraft to
descend to 3,500 ft and to establish on the RWY 26 ILS. At 11.47:04 hrs the aircraft advised
EIKY Tower that it was established on the RWY 26 ILS localiser at 14 NM DME. ATC cleared
it to descend to 3,000 ft and for an ILS approach to RWY 26, requesting that it report at 4
NM. At 11.48:41 hrs the aircraft advised that it was going around.

At 11.48:46 hrs the Shannon ATC radar controller observed the aircraft on radar at 2,000 ft
altitude and 9 NM from EIKY when the Minimum Safe Altitude Warning (MSAW) system
activated. He contacted EIKY Tower by telephone to advise that the aircraft was too low.

At 11.49:08 hrs the aircraft, in a response to an ATC query, advised that they had an issue
with the glide path and that they had received a terrain warning which required a mandatory
go-around in IMC10 conditions. ATC then cleared EI-REH to return overhead the field and
carry out a procedural approach as published.

The ATC radar recording showed that the aircraft reached a minimum altitude of 2,000 ft
during the occurrence at 11.49 hrs, following which it climbed. 6

1.4 Flight Data Recorder (FDR)

FDR data was downloaded and examined. It did not record aircraft position information.
The downloaded data showed that the minimum altitude recorded during the occurrence
was 1,955 ft. Six seconds beforehand, the aircraft had begun to pitch up, eventually
reaching a pitch angle of +4.2° following which it climbed to 3,000 ft. During the pitch up,
the FDR recorded a full scale deflection of the ILS glideslope from fly up to fly down.

1.5 Enhanced Ground Proximity Warning System

EGPWS integrates positional information from GPS11 with three dimensional terrain data,
looking ahead of and beneath the aircraft to identify and warn of potential collisions with
terrain. It also logs historical data for a period about the event in the non-volatile flash
memory. The 30 seconds of EGPWS data for this event was recovered and showed that
during the occurrence the glideslope signal was irregular.

The data showed that the EGPWS issued an advisory Terrain Caution at position N52.23664°,
W009.25161° followed two seconds later by a Terrain Warning at position N52.23616°,
W009.25441°.

10
IMC: Instrument Meteorological Conditions at the time of the event were meteorological conditions where
the aircraft was in cloud and/or not in visual contact with the ground and/or with horizontal visibility less than
5,000 metres (ICAO Annex 2).
11
GPS: Global Positioning System.
 ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

The Terrain Caution activated as the aircraft was descending through an altitude of 2,246 ft,
at a Radio Altimeter (RADALT) height of 959 ft above the ground and at a distance of 10.02
NM from the threshold of RWY 26. At that time the rate of descent was 2,400 ft/min. The
Terrain Warning occurred at an altitude of 2,100 ft when the Glideslope Deviation was
showing a valid signal but which incorrectly showed that the aircraft was between 1 and 1.25
dots high.

Graphic No. 1 shows the altitude of the aircraft (dotted line) versus the height of the local
terrain for the period the EGPWS recorded.

Graphic No. 1: Altitude versus Distance to threshold of RWY 26

The minimum RADALT height recorded by the EGPWS was 651 ft shortly after the aircraft
became level at 9.39 NM from the threshold of RWY 26.

During the second approach the EGPWS also recorded a Mode 5 glideslope alert at 5 NM
from the threshold of RWY 26. This showed that the glideslope, which at the time was
reading 0.4 dot fly up, went to 3.3 dots fly up in 2 seconds and then became invalid.

1.6 Instrument Landing System (ILS) EIKY RWY 26

Glide Path monitors provide a warning in the EIKY Tower and shut down the glide path
system if any of the following conditions persist:

 A shift in the Glide Path angle of greater than minus 0.075°.

 A significant reduction in the output power.
 A change in the width of the Glide Path sector (displacement sensitivity).
 A reduction of DDM12 to less than 0.175 below the Glide Path sector.

12
DDM: Difference in the Depth of Modulation.

Air Accident Investigation Unit Report 2014 - 006

 Following the occurrence the ILS glideslope records for RWY 26 at EIKY were examined and
no abnormalities were found. The duty ATCO at EIKY confirmed that the ILS was monitoring
as “Normal” at the time of the incident and no issues were reported by other aircraft using
ILS 26 that day at EIKY, including the aircraft immediately ahead of and behind EI-REH.

The Aeronautical Information Publications (AIP) Ireland contains EIKY AD 2.24-7, the
Instrument Approach Chart for EIKY (Appendix B). This shows ground spot heights on the
approach, the highest being 1,679 ft, slightly west of VENUX.

1.7 EI-REH Maintenance

The aircraft was certified for flight and no prior operational or technical issues were reported
to the Investigation. A functional test (JIC 34-36-00 FUT10000) of the ILS system was carried
out later on the day of the occurrence in accordance with the Aircraft Maintenance Manual
(AMM). This found that the ILS system was operating correctly and the aircraft was released
to service with a request that a simulated CAT II13 approach be carried out. This was
completed successfully the following day, the 20 December 2011. Further investigation into
the erratic glideslope called for an on-going series of functional tests, replacement of
electronic units and wiring checks (Work Order 1038833, dated 23 December 2011). This
also included a requirement to “….check radome reflective strip for any obvious defects”.

On the 29 December 2011 pilots reported ‘Glideslope Fluctuations Up/Down One Dot, seems
to be happening on Box 1 and Box 2’. Both No 1 and 2 VOR14/ILS receivers were replaced
and the aircraft was again released to service. 8

During further troubleshooting early on the 30 December 2011, the glideslope antenna was
removed, tested and found serviceable and a functional test on the Radio Altimeter was also
found satisfactory.

After a flight later that day the radome was removed. The technical report states ‘…..the
radome currently fitted is found to be without metallic strip for ILS beam concentration,
which as per ATR communication email is a likely cause for glideslope problem’.

The metallic strip, a ‘Glideslope Antenna Deflector’, Part Number (P/N) S53975000-204, is
shown installed on a serviceable radome in Photo No. 1. It is used to concentrate the
glideslope beam towards the glideslope antenna. The strip is 335 mm long by 12.5 mm wide
and is attached to the radome by adhesive. The ILS on the aircraft is considered
unserviceable if the strip is missing.

13
CAT II: Category II ILS. A precision instrument approach and landing operation.
14
VOR: VHF Omni-Directional Radio Range.
 ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

Photo No. 1: Interior of Radome with metallic strip installed.

A different radome was then fitted and the aircraft was returned to service. Following a
9
functional test of the CAT II ILS the following day, the aircraft was cleared for CAT II
operations and no further ILS glideslope problems were reported.

1.8 Radome Records

A review of the aircraft’s records showed that the radome (P/N S539750000800) was last
removed from the aircraft during a base maintenance check at an approved facility in
Guernsey. The base maintenance check was completed on the 26 November 2011 when the
“Final Certificate of Release to Service following Base Maintenance” was issued. During the
check the radome bonding was found to be ‘out of limits’. In accordance with SRM15 51-21-
29 the radome was then stripped, sanded and repainted and subsequently refitted. The
facility’s technician who repaired the radome could not confirm if the Glideslope Antenna
Deflector was attached to the radome before or after it was repaired.

The ATR AMM JIC 53-91-21 RAI 10000, Radome Removal and Installation, step 3 states:

003 GENERAL VISUAL INSPECTION:

1. Verify Correct Installation of the Glideslope Antenna Deflector & Check for
General Condition.

15
SRM: Structural Repair Manual.

Air Accident Investigation Unit Report 2014 - 006

 No evidence was found that this check had been carried out. The Operator subsequently
inspected its fleet and found that each of its other ATR aircraft had the Glideslope Antenna
Deflector installed.

The maintenance facility also issued a Quality Alert to ensure that its technicians were aware
that it is possible that the Glideslope Antenna Deflector, which has a self-adhesive backing,
may become detached during overhaul and that it is the responsibility of the certifying
engineer to ensure the serviceability of the component subsequent to maintenance.

1.9 Meteorological Information

The weather conditions at that time, as reported by EIKY, were wind 290°/08 kts, visibility 10
km+, cloud broken at 500 ft, QNH 1013 hPa.

1.10 Aircraft Information

EI-REH is an ATR 72 which is a twin-engine turboprop short-haul regional airliner built by the
French-Italian aircraft manufacturer ATR. It seats up to 78 passengers in a single aisle
configuration and is operated by a two pilot crew. The Operator has used various ATR 42/72
variants over the past 10 years.

At the time of the occurrence the aircraft’s weight was 16,150 kg, the Maximum Landing
Weight being 21,350 kg. It was in trim at 23.9% MAC16, the limits for its weight being 18.3%
– 31.2%. 10

1.11 Personnel Information

1.11.1 Commander

Personal Details: Male, aged 44 years

Licence: IAA ATPL - Valid
Last Periodic Check: 25 September 2011
Medical Certificate: 30 August 2011

Flying Experience

Total All Types: 6,998 hours

Total on Type: 4,816 hours
Total on Type P1: 2,981 hours
Last 90 Days: 156 hours
Last 28 Days: 52 hours
Last 24 Hrs: 8 hours

16
MAC: Mean Aerodynamic Chord.
 ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

Duty Time

Duty Time up to Occurrence 5 hours

Rest Period Prior to Duty 10 hours 41 minutes

1.11.2 Captain

Personal Details: Male, aged 37 years

Licence: UK CAA ATPL - Valid
Last Periodic Check: 30 November 2011
Medical Certificate: 12 April 2011

Flying Experience

Total All Types: 3,344 hours

Total on Type: 3,144 hours
Total on Type P1: 908 hours
Last 90 Days: 146 hours
Last 28 Days: 26 hours
Last 24 Hrs: 2 hours

Duty Time
11
Duty Time up to Occurrence: 5 hours
Rest Period Prior to Duty: 10 hours 41 minutes

1.12 Previous Serious Incident at EIKY

EIKY Tower does not have a radar display and thus uses procedural control to ensure the
safe control of aircraft within its area. Consequently, aircraft are required to advise the ATC
controller by VHF radio of their position so that traffic can be coordinated.

An AAIU investigation (AAIU Synoptic Report No: 2010-012) into a serious incident at EIKY in
2009 found that there was a serious loss of navigational and situational awareness while an
aircraft was attempting to return to EIKY following a windshield fracture encountered shortly
after take-off. A contributory factor was that the situational awareness of the controller in
Kerry Tower was compromised by the lack of direct radar information.

Accordingly, that Investigation issued a Safety Recommendation that:

The licensee of Kerry Airport, in conjunction with the Irish Aviation Authority, should review
the provision of radar information to support the air traffic control service provided by Kerry
ATS unit (IRLD2010016).

Air Accident Investigation Unit Report 2014 - 006

 The IAA informed the Investigation that EIKY had purchased a system, the installation of
which commenced in December 2013. It was estimated that the hardware installation
(displays, lines etc.) and training for ATC personnel at EIKY would be completed in early
2014. It was planned that the Air Traffic Monitor would be commissioned into operational
service by the end of May 2014, subject to the regulatory acceptance of the associated
safety case.

1.13 Operator Procedures

Regarding the aircraft’s flight crew composition, the Operator informed the Investigation
that it was not its practice to roster two captains to fly together. The only situation where
that arose was when the right hand seat occupant was a Training Captain, ordinary line
captains are not right seat qualified.

Having examined the factual information the Investigation advised the Operator that there
may have been an issue regarding MSA awareness among the Operator’s pilots. Following a
review of procedures the Operator issued a Flight Crew Instruction (FCI 14/07) to pilots
amending the procedures in its Operations Manual Part B, Section 2.3.5, Altitude Checks.
This FCI was approved by the IAA on the 19 May 2014 and implemented new mandatory
callouts when passing through the MSA, whether climbing or descending.

2. ANALYSIS

2.1 General 12

The licences and medical certificates of the Flight Crew were valid. They were appropriately
qualified and at the time a line check was being conducted in accordance with the
Operator’s procedures. The aircraft’s documentation stated that it was airworthy and that it
did not have any relevant defects. The approach was conducted in IMC conditions during
which unstable glideslope reception resulted in a descent by the aircraft below the correct
glide path to such an extent that the EGPWS warning system activated. The incorrect
glideslope indication was due to a missing Glideslope Antenna Deflector which led to the
aircraft descending below the glide path and the MSA. Operationally, this descent should
have been noticed by the Flight Crew before the EGPWS safety net activated. Furthermore,
the local Tower Controller, who was controlling the traffic, was unable to see or monitor that
descent, although his ATC colleague at a distance in Shannon could view it on radar.

2.2 Glideslope

A functional test of the aircraft’s ILS following this occurrence was satisfactory and no defect
was found. Nevertheless, following a subsequent report of erratic glideslope,
troubleshooting of the ILS system was conducted in accordance with the Manufacturer’s
guidance. This eventually found that the Glideslope Antenna Deflector, which should have
been attached to the inside of the radome, was missing. This aluminium foil strip
concentrates the ILS glideslope signal and, when missing, the signal received by the ILS
receiver via its antenna is attenuated (weakened). In other weather conditions and at some
airports the glideslope signal was evidently strong enough to allow CAT II approaches to be
successfully flown under the control of the AFCS with the autopilot engaged.
 ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

This was not the situation at EIKY during this approach where the glideslope signal would
have been further attenuated by the 9 NM distance at which the event occurred.

It was not possible to determine where or when the metallic strip detached from the
radome. However, it appears likely that this may have happened during repair when the
radome was stripped, sanded, repainted and refitted to the aircraft without a check for the
presence of the Glideslope Antenna Deflector. As there was no evidence of ILS problems on
the aircraft prior to maintenance on the radome, the Investigation considers this the most
likely scenario.

Following discovery that the Glideslope Antenna Deflector was missing, a subsequent check
by the Operator found that the Glideslope Antenna Deflector was present on all other
radomes in its ATR fleet.

The Investigation is satisfied that this appears to be a one-off event and that the procedures
put in place by the maintenance facility, following determination of the cause of the ILS
glideslope attenuation, should be sufficient to prevent the future release of a radome from
maintenance without a serviceable Glideslope Antenna Deflector. Consequently, no Safety
Recommendation is considered necessary in this regard.

2.3 Operational Issues

During the approach the autopilot was used and, although the ILS glideslope was erratic, the
13 aircraft had commenced capture. Having done so the Flight Crew reported and EGPWS data
shows that the aircraft chased an unstable glideslope. Although the PF stated that he
expected the aircraft to stabilise on the glideslope, this did not happen as the AFCS chased
the glideslope and eventually the aircraft pitched down in accordance with the unstable
signal received.

The Flight Crew stated that the briefing for the approach included safety heights as depicted
in the chart they used. The chart in Appendix A (an extract from which is shown in Figure
No. 1 below) shows grey areas which are the minimum altitudes that should be maintained
until the appropriate DME distance is reached.

Figure No. 1: Extract from the Approach Chart in Appendix A.

The ILS approach procedure requires that VENUX, at 8.9 NM from the threshold of the
runway, should be crossed at an altitude of 3,000 ft and a descent then commenced.
Outside VENUX the safety altitude is 2,200 ft due to a ridge across the approach path.

Air Accident Investigation Unit Report 2014 - 006

The data shows that at a position approximately 1.1 NM before VENUX the aircraft
descended through 2,246 ft and had reached a descent rate of 2,400 ft/min at which point
the EGPWS activated.

In general, the ILS has proved over the years to be a very reliable guidance system which
pilots can trust. Having successfully captured the localiser and glideslope, flight crew can
reasonably expect that it will lead them safely towards the runway. This provides a certain
amount of comfort to air transport pilots as almost all of their flights conclude with flying an
ILS approach. In addition, modern aircraft design and technology generally provide warnings
to the pilot if either the ILS ground installation or the aircraft equipment is defective.
Consequently, an erratic ILS is an unusual event and pilots can be lulled into a certain
amount of complacency due to its normal reliable performance particularly when no
warnings are shown, as in this case.

Good situational awareness requires that the pilot should have an on-going accurate three-
dimensional overview of what the aircraft is doing, where it is and where it is going,
particularly regarding the horizontal and vertical flight path of an approach in IMC
conditions. Attention should not become focussed on one particular issue (which is known
as “attention tunnelling”) to the detriment of overall situational awareness, specifically the
spatial environment. As the MSA depicted on the chart at VENUX was 3,000 ft the aircraft
should not have descended below that until past VENUX.

It appears that the Flight Crew became distracted by the aberrant glideslope reception and
its effect on autopilot performance to the detriment of monitoring the aircraft’s position and 14
flight path. Moreover, the vertical flight path was not cross-checked by comparing altitude
with the distance to the runway, as shown by the DME.

An additional factor that should be considered is the crew resource management associated
with the non-normal flight crew composition, since the flight was a line check. Both pilots
were captains and, whereas the Captain in the left hand seat was acting commander, the
formal command rested with the training captain (the Commander) flying from what would
normally be the co-pilot’s or first officer’s position. In general it is recognised that an
appropriate cross cockpit experience and authority gradient leads to better crew co-
ordination. In part this is because the authority and leadership position is clearly defined
and recognised. Consequently, normal practice is to roster captains with less experienced
co-pilots in the right hand seat.

Due to the requirements of a line check the Captain was the acting commander whereas the
authority resided in the Commander, who was assessing the Captain. It is possible that
when the PF became pre-occupied with the performance of the autopilot and the glideslope,
the arousal levels of the PM were insufficient to generate concern regarding terrain
clearance.

As both pilots involved were quite experienced the Investigation considered that there may
have been an issue regarding MSA awareness among the Operator’s pilots and advised the
Operator accordingly. Following this the Operator issued an FCI to its pilots implementing
new procedural callouts when passing the MSA. In view of the action taken, the Investigation
considers that a Safety Recommendation is not necessary in this regard.
 ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

2.4 ATC Operational Issues

EIKY Tower does not have a radar display and accordingly uses procedural control to manage
its local air traffic. During procedural control flight crews are required to provide accurate
position and altitude reports to ATC which in turn is relying on pilots to provide this
information. Other than the position reports provided by the aircraft, the Tower Controller
had no direct knowledge of the exact position and altitude of the aircraft. Having cleared
the aircraft for approach, the Controller relied on the aircraft to monitor its own terrain
clearance. Although there is a radar display at Shannon, which has a terrain clearance
warning system, this requires that the Shannon controller calls the EIKY Tower controller by
phone to advise him that the MSAW has activated. In this case that call was made shortly
after the aircraft’s own EGPWS warning had activated and the aircraft had commenced a go-
around. Nevertheless, should the aircraft involved not be equipped with EGPWS vital
seconds may be lost during an occurrence.

In addition, as ATC is responsible for the utilisation of its airspace, the lack of a radar display
is an impediment to the efficient control of air traffic. In addition, the provision of a radar
display would provide an additional safety barrier by assisting controllers in identifying
situations in a timely manner. A previous Safety Recommendation was issued by the AAIU in
2010 concerning the provision of radar information to support the air traffic control service
in EIKY Tower. The Investigation has been informed that a radar display has been installed
and that it is in the process of being commissioned. Therefore, the Investigation considers
that a Safety Recommendation is not required regarding this matter.
15
3. CONCLUSIONS

(a) Findings

1. The Flight Crew were properly licensed with valid medicals.

2. The aircraft conducted two approaches at EIKY where IMC conditions prevailed.

3. The aircraft encountered unstable glideslope reception during its first ILS approach
to RWY 26 at EIKY.

4. When the glideslope incorrectly indicated that the aircraft was high the autopilot
pitched the aircraft down, reaching a descent rate of 2,400 ft/minute.

5. An EGPWS Terrain Caution activated followed immediately by a Terrain Warning

and a go-around was conducted.

6. A second ILS approach was commenced but due to the unstable glideslope
reception it was continued as a non-precision approach and a safe landing was
made.

Air Accident Investigation Unit Report 2014 - 006

 7. The minimum altitude recorded during the first approach was 1,922 ft at 9.39 NM
from the RWY 26 threshold, the height over the ground being 651 ft.

8. The unstable glideslope reception was caused by a missing Glideslope Antenna

Deflector from the aircraft’s radome.

9. The Glideslope Antenna Deflector probably detached during the recent repair of the
radome.

10. No check was made that the Glideslope Antenna Deflector was installed following
repair of the radome.

11. The Flight Crew focussed on the apparent poor performance of the autopilot and
did not adequately monitor the altitude of the aircraft vis-à-vis the distance to
landing.

12. EIKY Tower was unaware of the low approach as it had no radar display.

(b) Probable Cause

The absence of a Glideslope Antenna Deflector resulted in unstable glideslope

signal reception which led to the autopilot descending the aircraft below the glide
path in IMC.
16
(c) Contributory Cause(s)

1. Ineffective monitoring and lack of situational awareness by the Flight Crew.

2. Inability of the EIKY ATC to monitor the aircraft due to lack of a radar display.

4. SAFETY RECOMMENDATIONS

This Investigation does not sustain any Safety Recommendations.

- END -
ATR 72-201, EI-REH Kerry Airport 19 December 2011
FINAL REPORT

Appendix A

Figure 7: Navtech Approach Chart, EIKY ILS RWY 26.

In accordance with Annex 13 to the Convention on International Civil Aviation, Regulation (EU) No.
996/2010, and Statutory Instrument No. 460 of 2009, Air Navigation (Notification and Investigation of
Accidents, Serious Incidents and Incidents) Regulation, 2009, the sole purpose of this investigation is to
prevent aviation accidents and serious incidents. It is not the purpose of any such investigation and the
associated investigation report to apportion blame or liability.

A safety recommendation shall in no case create a presumption of blame or liability for an

occurrence.

Produced by the Air Accident Investigation Unit

AAIU Reports are available on the Unit website at www.aaiu.ie

Air Accident Investigation Unit,

Department of Transport Tourism and Sport,
2nd Floor, Leeson Lane,
Dublin 2, Ireland.
Telephone: +353 1 604 1293 (24x7): or
+353 1 241 1777
Fax: +353 1 604 1514
Email: [email protected]
Web: www.aaiu.ie