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| Date: | Tuesday 23 November 1993 |
| Time: | 09:54 |
| Type: |  McDonnell Douglas DC-9-15RC |
| Owner/operator: | Baltic International Airlines |
| Registration: | YL-BAA |
| MSN: | 47016/173 |
| Fatalities: | Fatalities: 0 / Occupants: |
| Other fatalities: | 0 |
| Aircraft damage: | None |
| Category: | Incident |
| Location: | London-Gatwick Airport (LGW/EGKK) -
 United Kingdom
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | Riga International Airport (RIX/EVRA) |
| London-Gatwick Airport (LGW/EGKK) | |
| Investigating agency: | AAIB |
| Confidence Rating: |  Accident investigation report completed and information captured |
The aircraft was operating on a scheduled service from Riga, Latvia, to London Gatwick. The crew comprised of a Latvian commander and first officer who, although well experienced, were new to type and undergoing the early stages of line training. They occupied the left and right-hand seats respectively and a UK CAA licensed training captain, contracted from a UK airline, occupied the centrally positioned observer's seat.
The Latvian crew, both ex-Aeroflot commanders, had considerable experience on the TU 134, TU 154 and Yak 40 aircraft. They had recently completed a conversion course on the DC-9 in the USA followed by two days of base training and briefings in Riga, Latvia. Their line training had commenced nine days earlier on 14 November 1993.
The departure, cruise and descent phases were flown by the Latvian commander and were assessed by the training captain to be of a good standard. Prior to arrival at Gatwick the Latvian commander briefed the first officer that they would be carrying out an autopilot coupled approach to Category 1 limits on Runway 26L with the autopilot remaining engaged down to their Decision Altitude (DA) of 395 feet amsl (200 feet agl). In addition the training captain reminded the crew that for autopilot coupled approaches it was standard practice for the pilot flying (PF), when approaching DA, to look out of the aircraft for visual cues and for the pilot not flying (PNF) to monitor the flight instruments throughout the approach and advise the PF of any deviations from the localizer or glide-path.
The weather at Gatwick was poor. The Gatwick ATIS for 0945 hrs was: 'SURFACE WIND 035°/02KT, VISIBILITY 550 METRES IN SUPERCOOLED FOG, CLOUD OVERCAST BELOW 100 FEET, AIR TEMPERATURE -2°C, DEWPOINT -3°C, QNH 1020MB, RUNWAY 26L, FURTHER INFORMATION; ATC LOW VISIBILITY PROCEDURES IN OPERATION...'
At 0935 hrs the aircraft made contact with Gatwick Approach and was instructed to maintain FL090 and take up the hold at EASTWOOD. At 0939 hrs the training captain asked Gatwick ATC to confirm the Runway Visual Range (RVR). Gatwick Approach replied "TOUCHDOWN ONE THOUSAND METRES MID POINT EIGHT ZERO ZERO METRES STOP-END EIGHT ZERO ZERO METRES IS THAT ACCEPTABLE?" The training captain replied in the affirmative and confirmed that the minimum RVR required was 550 metres. By 0946 hrs the aircraft was in contact with Gatwick Radar and at 0950 hrs the crew reported that the aircraft was established on the ILS for Runway 26L.
ILS glide-slope capture was normal and remained accurate throughout the approach. At 5 nm from touchdown the aircraft deviated from the localiser by ¼ of a dot but quickly regained the centreline.
At 4 nm the 'BOW TIE ANNUNCIATOR' illuminated indicating a failure of the first officer's glide slope receiver. The single channel autopilot and commander's flight instruments, however, continued to operate normally. From this point onwards the first officer became distracted by the failure. He tried continuously to cancel the annunciator system and as a result ceased to monitor the approach and omitted the standard altimeter calls. The calls for "500 FEET ABOVE SERVO" and "100 FEET ABOVE SERVO" were made instead by the training captain. At approximately 500 feet agl the autopilot suddenly rolled the aircraft to the left, applying about 20° of bank. The aircraft deviated to the left of the localizer giving rise to full 'fly right' instrument indications. The training captain called "Go around!" but the pilots, both of whom were now looking out of the aircraft for visual cues, did not respond.
The training captain initiated the go-around, from the observers seat, by calling "I have control going around". He leaned forward, disconnected the autopilot, applied full power and rotated the aircraft to a pitch attitude of 15º. Simultaneously the first officer, now realizing the situation, reacted incorrectly by selecting the flaps to the 0° position. The training captain, however, quickly re-selected them to the correct 20° position. During the go-around maneuver the training captain reported that he observed the Minimum Descent Altitude (MDA) warning light illuminate briefly and this led him to believe that the aircraft did not descend much below 200 feet agl (395 feet amsl).
After establishing the climb, the training captain handed control back to the PF. The aircraft was levelled at 3,000 feet whereupon the training captain exchanged seats with the PF. Now occupying the left-hand seat he carried out a further manually flown ILS approach, landing the aircraft without incident.
Accident investigation:
 |
|
Sources:
https://assets.publishing.service.gov.uk/media/5422eae0ed915d1374000039/DC-9-15__YL-BAA_04-94.pdf
https://www.jetphotos.com/photo/11208500 (Photo)
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 28-Mar-2025 08:12 | Justanormalperson | Added |
| 28-Mar-2025 08:13 | ASN | Updated [Narrative, Accident report, ] |
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