A passenger plane with 118 people on board was involved in a serious incident when its pilot mistook the lights on a hotel near Dublin airport for the runway, a report revealed today.
The Department of Transport’s Air Accident Investigation Unit (AAIU) today published its final report into the incident on August 16th 2007, when the McDonnell Douglas MD-83 operated by Flightline was on a flight from Lisbon to Dublin.
It landed safely mainly due to the intervention of an air traffic controller who alerted the pilot at the last moment that his descending aircraft was not heading for the runway.
The aircraft was off course and flying to the left of where it should have been, heading towards lights on the 16-storey hotel at nearby Santry Cross.
It was about 1,700 feet from the building and 200 foot above it when it was directed to turn right and climb to a safe altitude before it landed without further incident.
The runway in use at Dublin airport at the time was not the regular runway, which was undergoing maintenance. The co-pilot, who was flying the plane at the time of the incident, had initially prepared for landing on the main runway.
During the investigation, the AAIU carried out a series of test approaches using an Irish Air Corps helicopter in both day and night conditions and they found “a somewhat unique problem” with the lighting on the hotel building at Santry Cross.
Although it was lit in accordance with international standards for such an obstacle near an airport, at night it “closely resembled, in general appearance" the approach lighting on runway 34, where the Flightline plane was due to land.
Accident investigator Leo Murray identified “poor communication and teamwork and a major degradation of situational awareness” on the part of the flight crew.
And he said the final intervention by air traffic control was the “primary factor in a safe outcome to this serious incident”.
In safety recommendations, the investigator said the operator, Flightline, should undertake a “comprehensive review” of the crew resource management (CRM) training provided to its flight crews. The crew failed to observe the airline's standard operating procedures on the approach to Dublin airport, the report said.
However, the operator went into administration in December last year and the administrators told the AAIU they would not be taking any action in response to the safety recommendation.
Mr Murray’s report also noted that an air traffic controller on duty in the tower in Dublin at the time of the incident was performing two roles. The sole air traffic controller on duty in the tower was dealing with a call from a maintenance crew at the time when the flight started to deviate significantly from its path.
Mr Murray said the deviation “may have been identified earlier had an additional [air traffic controller] been present in the tower to share the workload at the time”.
He recommended that the manning levels in the tower should be examined, in particular during night operations and during times of scheduled maintenance activity.
The Irish Aviation Authority, which has responsibility for air traffic control, accepted the safety recommendation.
The lights on the top of the hotel were changed from fixed red lights to flashing red in October 2007 after an initial report into the incident said they lighting could be mistaken for approach lights.
Mr Murray also said he was of the opinion that any assessment of new obstacles or other lighted projects, such as roads, being built close to an aerodrome, should include "a general risk analysis".
"This analysis should include an asessment of the visual impression that such objects may present to pilots, when lighted at night.”