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ASN Wikibase Occurrence # 229885
Last updated: 11 October 2019
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Date:17-OCT-2018
Time:14:29
Type:Silhouette image of generic E145 model; specific model in this crash may look slightly different
Embraer EMB-145EP
Owner/operator:bmi Regional
Registration: G-RJXF
C/n / msn: 145280
Fatalities:Fatalities: 0 / Occupants: 21
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:South of Norrköping/Kungsängen Airport -   Sweden
Phase: Approach
Nature:International Scheduled Passenger
Departure airport:München-Franz Josef Strauss Airport (MUC/EDDM)
Destination airport:Norrköping-Kungsängen Airport (NRK/ESSP)
Investigating agency: SHK Sweden
Narrative:
The serious incident occurred during approach to Norrköping/Kungsängen Airport during a scheduled passenger flight from Munich. The aircraft, an Embraer EMB-145, had the call sign Midland 753G. During the approach, the weather conditions were good with a visibility of more than ten kilometres. The crew performed self-positioning for an ILS approach. At the time, there was an ultralight aircraft (ATEC 122 Zephyr SE-VKA) in uncontrolled airspace below Midland's cleared route.
During the self-positioning and about seven nautical miles south of the outer marker beacon "ON", Midland suddenly initiated a left turn towards the west outside the control zone and descended below controlled airspace, approaching the ultra-light aircraft. As Midland descended and approached the aircraft, a near collision incident occurred.
The aircraft passed 200 feet above the ultralight at a lateral distance of 0.85 NM (1570 m).

The autopilot was engaged as the aircraft positioned for the ILS approach. When Midland was outside the coverage area of the ILS, the
aircraft picked up a false signal, turned and descended.
The air traffic controller did not have time to correct Midland's incorrect navigation, as it was not quite clear how the approach should be performed. The initial turn was interpreted as Midland having visual contact with the airport and making a correction towards the airport. When Midland then continued the turn and descended, disturbances arose in the form of communication and surprise reactions, and this was probably the reason why a correction of the flight did not occur. According to the ATC provider’s operations manual, self-positioning for the ILS approach that Midland received should be terminated by radar vectors, which would have minimized the risk of picking up false lateral signals.
The incident was caused by the fact that planning and follow-up of the approach were not carried out in an appropriate manner.
A contributing factor has been lack of knowledge of false ILS signals.

Sources:

SHK

See also: 22 Nov. 2013 - Dutch Safety Board issues alert on unexpected autopilot behaviour on ILS approaches

Accident investigation:
cover
  
Investigating agency: SHK Sweden
Status: Investigation completed
Duration: 11 months
Download report: Final report


Images:

Photo of G-RJXF courtesy AirHistory.net


Newcastle - International (EGNT / NCL)
24 June 2010; (c) Malcolm Clarke


Figure: SHK

Revision history:

Date/timeContributorUpdates
11-Oct-2019 16:59 harro Added
11-Oct-2019 18:00 harro Updated [Source]

Corrections or additions? ... Edit this accident description