The crew of a British holiday jet which broke in three on landing at a Spanish airport were not provided with detailed information about the intensity of a storm in the area, an official accident report said today. There were also "misunderstandings" which meant it was 70 minutes before passengers on the Britannia Airways Boeing 757 who were stranded in the dark were safely transported to the terminal building at Gerona airport. Torrential rain and the extinguishing of runway lights hindered the landing of the plane, carrying 236 passengers, which had flown in from Cardiff airport on the night of September 14, 1999. The plane bounced on the runway during its initial attempt to land and then approached in an excessive nose-down position for its second attempt, the report from Spain's official air accident investigation commission said. It said the probable cause of the accident was the destabilisation of the approach at a height below 250ft - meaningthat the plane was not level enough, not at the right speed and not at the right rate of descent to make a good landing. Contributory causes were the effect of shock or mental incapacitation on the plane's 57-year-old captain at the failure of the runway lights which could have inhibited him from making a decision to abort the landing and go round again. After landing the captain was knocked out when his head hit the flight deck windshield. The aircraft came to rest in a field outside the airport boundary with the fuselage broken in two places. None of the passengers was badly hurt and all were able to be evacuated from the plane. The report said it took 18 minutes to locate the plane and passengers and there was a further delaying getting to the passengers. The transfer to the terminal building was completed approximately one hour 10 minutes after the accident. The report said that a Gerona air traffic controller had given the crew a report on weather at the airport, including the location of storms to the south-west, but without specifying their movement. After the landing, the control tower controller selected the emergency alarm but it failed to sound in some areas of the airport. The report went on: "Misunderstandings occurred in respect of the aircraft's suspected final position, the runway direction in which it had landed and whether it was communicating on another radio frequency." The report made a number of recommendations to ensure that this particular set of circumstances was not repeated. Passengers have been involved in legal action against Thomson Holidays - the tour operator involved. Some cases have been settled and some are pending. Some passengers saw an advance copy of the Spanish report last week and expressed their continuing anger. Michael Pritchard, of Treharris, south Wales, who was on the plane with his wife and 13-year-old son, said he was "disgusted" that it has taken Spanish authorities five years to complete their investigation. Mr Pritchard, who suffered a knee injury in the crash, added: "We will never get over it completely. I remember certain things about the crash as if it were yesterday." Catherine Allaway, 35, of Blackwood, south Wales, was on the plane with her daughter Kirsty, then aged eight and can no longer fly without medication. She said: "The report told me what happened but we still don't know why. We have waited almost five years and then you think you are going to get all the answers." Kevin Hatton, Britannia Airways managing director, said today: "We appreciate that it was a very traumatic experience for all involved and that the publication of the report may highlight memories of the time. "We have been working closely with the UK Air Accidents Investigation Branch during the past five years and as a learning  organisation I give my full assurance that we will examine the report very carefully. Britannia will work with all relevant parties to ensure that any appropriate recommendations are actioned." Terence Bowden, 60, and his wife Marion, 55, of Bettws, Newport, south Wales, were among those hurt in the accident. Mr Bowden suffered head injuries and is now laid low with the debilitating Addison's disease. Mrs Bowden, who suffered whiplash and was cut and bruised, said today: "We are very disappointed that it has taken five years for this report to come out. "Britannia Airways have thrown every obstacle in our way as we battle to get compensation. We are not seeking very large sums, but still Britannia will not give in. "I hope this report and its conclusions will strengthen our case for compensation."

from this link

What I find slightly disturbing about the report are the references to fatigue and tiredness which are mentioned briefly but ignored in the conclusions. I know what I feel like on a third consecutive night duty. Add marginal, severe weather for a non-precision approach and I certainly wouldn't have envied this crew and what they had to deal with.

Section 2.3.1 specifically raises the points that whilst the crew did not think tiredness or fatigue were factors in the accident, considering that this was their third consecutive night flight, an analysis of their schedules carried out by DERA concluded that cumulative fatigue did not appear to be an issue but short term fatigue was a 'possibility' even though the recovery periods 'appeared' to be adequate. Even more interesting, I thought, was the reference to the previous two nights duty (Cardiff to Tenerife and Cardiff to Bodrum {and back}) exceeded the NASA and European Scientists 'recommended' 10 hour limit for duties starting or finishing between 0200 and 0600 local time.

In other areas of industry, studies have shown that the accident rate for shift workers increases on consecutive working nights. Also, scientific studies show that the change to being active in daytime rather than night, especially as you grow older, leads to difficulties in adapting to time changes as a result of the shortening of circadian rhythms. In the case of the commander, the report states specifically that "he was within the risk spectrum and on his third consecutive night of duty and it is therefore probable that he had suffered an accumulative loss of sleep."

And that's it from the report with regard to fatigue and tiredness. Does anyone else sense that there is some conflict between DERA concluding that the duties were not fatiguing and the two reports referenced to, one by NASA AMES Research (Principles and guidelines for duty and rest scheduling in commercial aviation) and one by Aviation Space and Environmental Medicine (Age, circadian rhythms and sleep loss in flight crew)? Considering that DERA had a hand in recommending the rostering practices as some sort of 'balance' between managements & beancounters desire to get their pound of flesh from pilots and the pilots desire to work as much as possible during daylight rather than through the night, their conclusion that 'recovery periods' appeared to be 'adequate' seems rather feeble.

I have read the report cover to cover, and I will start by saying it was a miracle there were no deaths or people crippled as a result of this accident. They were all very lucky that night. The muddy field/run-off area and the rain certainly was a fire suppressant – lucky.

I am sympathetic to the flight-deck crew at the sods-law sequence of events that culminated in the sad and dreadful accident. Those aviators left in the wake must learn from this accident.

Whilst 3 night flights might be legal, they play hell with your mental capacity even when the adrenalin is flowing and the “suits” and paperwork speak of more than minimum rest was taken.
On paper it looks good but hand on heart everyone, they are draining, even if you sleep well after the first two night flights.

Danny makes a good and valid point at the previous two night-flights these guys flew; a TCI (10.50 FDP) and that Turkey slog, 11 hrs FDP. Then this third launch into a very dirty night with CB’s where you don’t want them.

I mentioned luck, what was not lucky was the Commander’s choice of Ramp Fuel.
Taking such an small amount of extra fuel was not wise in my opinion, given the destination and ALL the alternates were forecast to suffer from thunderstorms.

There is the first lesson in commercial aviation – to hell with management pressures to take “minimum fuel” when you know the bets are against you.

I read about the fuel league tables – tear them up guys/managers. Penny pinching at the sharp end is completely futile. I think at the back of the Commander’s mind that night was that undeniable nagging doubt, “I have too little fuel to play with” – hence the mind changes about diverting. Taking, “an extra 15 minutes of holding fuel to allow for possible delays” does not cover it.

I have operated into GERONA many the time, and knowing there is no ATIS at least 120 ‘out’ and prior TOD one pilot talked to Gerona and got their “latest”. It would appear the “latest” weather was procured only about 50 miles from the overhead: “When within radio range of Girona at 21.14 hrs the crew requested the latest weather”. Eight minutes later they were O/H the VOR.

Another hellish bit of luck (airmanship) was the crew failing to notice the airbrakes were left “out” for 14 minutes ( 21.18 hrs until 21.32 hrs). It shows you the difficult and demanding task that was on their hands that night, and the lack of spare mental capacity available between them.
What did not help either was the Commander losing his VOR “plate” for R/W 02 (21.24) after he exercised his prerogative and became PF. A CRM question again? On passing, it is not clear to me if he managed to have his own “plate” for the ILS on 20 – perhaps I have missed that somewhere?

A CRM question might be, why did he not hand back control to the F/O who had already briefed for an ILS on 20 and still had his “plates” available? The task sharing throughout the whole unfortunate affair fell very heavily on the Commander.

Taking a small amount extra over and above the “minimum fuel” might look good in an office to some desk-bound manager, but on a rotten wet night, flying into thunder storms (destination and all ALTS) is not a very good idea.

I don’t think the Gerona Air Traffic Controller was very helpful to this crew either. Taking 20 seconds to pass the Barcelona weather is poor service in my experience, and the further lapse (see 21.36:52 exchange).
The female ATCO on duty had only been doing the job for 3 months; and it sounds/reads as if she was acting alone in the tower that night as the report mentions no other ATC Officer and indeed no Supervisor. I say that because I recall the time (years ago) on a night flying into a major Spanish airport that the same voice came up on APPR/TWR/GND and on questioning if he was actually covering all ‘positions’ I was told “Affirmative”. My ASR was never answered! Much like the Electric Power Company never answered the questions about power outages at Gerona that night (that was a damnable disgrace).
It may well be that Gerona had ATC assistant/s available, but they did not have immediately to hand the latest wx’s one might expect on such a foul night. Perhaps that is why the female ATC Officer was on the phone so much, and the crew's request for weather to the North was never fulfilled.

With the greatest respect, it must be said the mental capacity of the Commander must have been reaching saturation point during the GA and then straight into a runway switch for the ILS on the other end, as his calls for Flap Up and then Flap One were only 8 seconds apart (21.38:14 and 22). Perhaps the low fuel state and the “insufficient fuel” FMC message got home. I can really feel for him.

I’m not familiar with the B757 “Landing Check List” but it crosses my mind reading the landing check-list after the OM is a bit late (OM at 21.44:20 – 43) and the intimation the Landing Check List was read at 21.44:56.
When one considers the weather, all the checks should be done and dusted nice and early to concentrate on the execution of a precision approach in crap wx.

I am also surprised that the A/T could not handle the speed sufficiently well in the relatively smoother conditions on the ILS such that the F/O called, “bug minus 10” after the OM and then again, “bug minus 5” and then the Power Levers were advanced – it is unclear from the report if that was by physical intervention by the Commander or the A/T system itself, as the report mentions the A/P and A/T being disconnected 4 seconds after that minus 5 speed call (21.46:58) and some 26 seconds after the Commander called, “Lights in sight” (21.46:32).

The situation got very desperate indeed some 12 seconds later when at 120’ AGL “near full nose down elevator” was applied. The sods law of those lights failing (?) and the loss of spatial awareness by the Commander shows how rapidly it can turn to absolute .

The Commander stating he, “did not see approach lighting or PAPI lights” calls into question whether these lights were actually turned on for him after the 02 approach !
The F/O did not see the Approach Lights or the PAPI’s either.
The inexperienced ATC Officer acting alone said she was, “absolutely sure” the lights were on.
I would contend, two pilots with 18,194 hours between them would not miss seeing a full set of Approach Lights (CL5B) on a black, miserable, rainy night.

The Commander said, “Lights in sight” at 21.46:32, some 26 seconds before he disconnected the A/P and A/T.
Sorry Gerona ATC, but it’s two against one, and you offer no other evidence those lights were on and serviceable.

There are many lessons to be learned; from the ramp fuel decision, to the low fuel state in severe weather, the minimum ATC support and handling (not to mention the late “rescue” services), CRM, and the body/mental stress of operating three long night flights in succession. A hellish combination of misfortunes, hopefully never to be repeated.

We are all smart ar**s after the event.
One major item was the fuel carried. I do think the mental capacity would have been opened up if that huge worry was not with the Commander, and would have given him far more time and options up his sleeve. The pressures placed upon him were too many for my liking. I am very sorry it ended the way it did, but very relieved nobody was killed.

On Danny’s question: Does anyone else sense that there is some conflict between DERA concluding that the duties were not fatiguing and the two reports referenced to, one by NASA AMES Research (Principles and guidelines for duty and rest scheduling in commercial aviation) and one by Aviation Space and Environmental Medicine (Age, circadian rhythms and sleep loss in flight crew)?

There is conflict there. Even though 1993 might not be that long ago, things have changed.
http://human-factors.arc.nasa.gov/z...y-age.circ.html

http://human-factors.arc.nasa.gov/z...nd.g.intro.html