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ASN Wikibase Occurrence # 147059
Last updated: 20 October 2020
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Date:07-FEB-1993
Time:10:39
Type:Silhouette image of generic B742 model; specific model in this crash may look slightly different
Boeing 747-243B
Owner/operator:Continental Air Lines
Registration: N33021
C/n / msn: 20520/190
Fatalities:Fatalities: 0 / Occupants: 241
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:London-Gatwick Airport (LGW/EGKK), Horley, Surrey -   United Kingdom
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Houston-Intercontinental Airport, Texas (IAH/KIAH)
Destination airport:London-Gatwick Airport (LGW/EGKK)
Investigating agency: AAIB
Narrative:
On the first approach to runway 26L at Gatwick, with the automatic flight control system (AFCS) engaged in the LAND mode, the aircraft flew through the localiser at 9.5 nautical miles from touchdown and established on an inbound track about 3,000 feet to the right of the centre line. The aircraft was still not established on the centre line at 3 nautical miles from touchdown and a missed approach was initiated.

On the second approach the aircraft again flew through the localizer and established on an inbound track about 2,500 feet to the right of the centre line, at 7.75 nautical miles from touchdown. At 1.75 nautical miles from touchdown and 1,500 feet to the right of the centre line, the commander saw the approach lights, then the runway, to his left.

He banked the aircraft left towards the touchdown point, however, he considered it imprudent to carry out the manoeuvres required to achieve a landing and a missed approach was initiated; power was applied at about 500 feet amsl. The lowest recorded altitude the aircraft reached was 432 feet amsl, at 0.5 nautical miles from touchdown; it was displaced about 900 feet to the right of the centre line. The published elevation of the highest point on the south terminal building was 316 ft; this point was about 500 feet to the right of the aircraft's track.

The commander elected to carry out a third approach under manual control; this approach was uneventful and Continental 04 landed at 10:51.

CAUSAL FACTORS:
(i) Failure of the AFCS to capture and establish the aircraft on the localiser.
(ii) Failure of the aircraft crew to appreciate that the navigational information being presented to them on the flight deck was correct.
(iii) Failure of the commander to appreciate the extent of the aircraft's displacement from the centreline, on the second approach, and to take prompt and effective action to regain the correct approach path.
(iv) Failure of the No 2 radar director to appreciate the extent of the aircraft's displacement from the centreline which caused him to pass misleading information to the aircraft commander.
(v) The commander's acceptance of the azimuth guidance given by the radar director and the ILS glidepath information as adequate reference to continue the approach beyond the final approach point.

Sources:

1. Flight International 24.2-2.3.93 (p.8)
2. Flight International 31.8-6.9.94 (p. 18)
3. AAIB Aircraft Incident Report 4/94: https://assets.digital.cabinet-office.gov.uk/media/5422f18740f0b613460003bf/Summary_AAR_4-1994_Boeing_747-243__N33021_10-94.pdf
4. https://assets.digital.cabinet-office.gov.uk/media/5422ec14ed915d13740000df/4-1994_N33021.pdf

Accident investigation:
cover
  
Investigating agency: AAIB
Status: Investigation completed
Duration:
Download report: Final report

Media:

Boeing 747-243B N33021 Continental Micronesia Boeing 747-243B (N33021 20520 190) (3975821460)

Images:

Photo of N33021 courtesy AirHistory.net


London - Heathrow (EGLL / LHR)
21 September 1993; (c) Lewis Grant

Revision history:

Date/timeContributorUpdates
26-Jul-2012 07:20 harro Added
11-May-2016 20:35 Dr.John Smith Updated [Location, Departure airport, Destination airport, Source, Embed code, Narrative]

Corrections or additions? ... Edit this accident description