A Ryanair flight with 138 passengers and six crew on board almost crashed near Knock when it 'overshot' the runway and came way below the recommended flying level due to a series of errors, a report revealed today.
The brand new Boeing 737-800 plane flying a routine passenger flight from London Gatwick to Knock almost crashed at 6.20pm on March 23rd after confusion arose in the cockpit over the runway in use for landing.
The serious incident is officially classified in international aviation terms as "controlled flight into terrain only marginally avoided".
The crew were forced to recover the aircraft just 400 feet from the ground and 'go around' for another attempt to bring it down safely.
A warning signal alerting the crew that the plane was too close to the ground was set off. Effectively, the aircraft 'overshot' the runway, was approaching too quickly and came too close to the ground.
The events in the cockpit failed to conform to 'standard operating procedures', the AAIU said. The report also noted the captain and first officer were "so engrossed" in trying to reprogramme the aircraft that they both "lost their critical situational awareness" for a time.
Both the pilot and the first officer on the flight were experienced Ryanair pilots, with 11,700 flying hours clocked up between them. However, both had only recently converted to flying the newer Boeing 737-800 aircraft from the older 737-200 then being phased out.
However, uncertainty over changing weather conditions and the pilots' lack of familiarity with the particular approach to Knock impaired their decision-making process, the report found.
It emerged during an investigation by the Department of Transport's Air Accident Investigation Unit (AAIU) that crucial information about improvement works at the airport was not available to the pilots when they commenced their flight.
Ryanair also failed to provide the crew with a crucial supplement informing them of changes to the air routes at Knock, leading them to put the wrong flight information into the aircraft's computer.
In addition, the manual containing the information on all the approach routes, carried on all flights, was not up to date.
AAIU investigator Frank Russell, when asked by ireland.com if the report meant the flight had "almost crashed", said: "Yes".
However, he emphasised the strict official definition set down for such an incident by the International Civil Aviation Organization (ICAO) is "controlled flight into terrain only marginally avoided".
"That's as close as you get, but I don't personally think it was going to crash. When it broke cloud cover at around 400 feet, the pilots saw the ground and the runway and immediately took steps to avoid it. But the aircraft was not configured for landing, there was no undercarriage down and no flaps [activated].
"The point is how do you define 'close'. How close do you want to be?"
Mr Russell said the AAIU's main objective was to ensure such incidents, once investigated, never happen again.
He noted that all six safety recommendations made by the AAIU had been accepted. Four of the recommendations related to Ryanair, one to the Irish Aviation Authority and one to Jeppesen, the publisher of the pilots' information manual.
All were accepted, including a recommendation that the IAA facilitate special flight data operations meetings for Irish airlines, along similar lines to a forum in Britain.
Ryanair also accepted the safety recommendations made by the AAIU, including the recommendation that flight data from any such incident should be "immediately preserved" for any State investigation.
AAIU also said the operator should report such serious incidents without delay.
The budget carrier also told the AAIU it had scheduled a series of safety presentations for autumn of this year in order to "reinforce" the safety requirements.
In a single-line statement, Ryanair said it had "assisted and cooperated fully with this AAIU report and we have accepted and implemented all of the recommendations made".
The investigation also recommended that Jeppesen, the publisher of the onboard flight route manual, review its own procedures for providing updates to its charts.