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MINISTRY OF AVIATION


CIVIL AIRCRAFT ACCIDENT


Report on the Accident to
Lockheed 1049G (Super Constellation) EC-AMQ at London (Gatwick) Airport on 2nd September, 1963


LONDON: HER MAJESTY'S STATIONERY OFFICE
Price 2s. 6d. net

Accident Report No. EW/C/032

ACCIDENTS INVESTIGATION BRANCH

AIRCRAFT Lockheed 1049G (Super Constellation)
EC-AMQ
 
     
ENGINES Four Wright 972 TC 18 DA-3  
     
REGISTERED OWNER Lineas Aereas de Espana (Iberia Air Lines of Spain).  
     
OPERATOR Aviacion y Comeroio, S.A  
     
CREW Captain V. Marcos Clavero - uninjured  
  Co-pilot J. M. Medina Diez - uninjured  
  First Flight Engineer F. Tona Campos - uninjured  
  Second Flight Engineer I. Blasco Castro - uninjured  
  Steward J. Grande Sanchez - uninjured  
  Steward R. Jimenez Casiano - uninjured  
  Stewardess C. Sacristan Rosado - uninjured  
     
PASSENGERS 75 - uninjured  
     
PLACE OF ACCIDENT London (Gatwick) Airport.  
     
DATE AND TIME On 2nd September, 1963, at 0154 hrs.  
  All times in this report are G.M.T.  


1. NOTIFICATION
By telephone from London (Gatwick) airport air traffic control at 0935 hrs. on 2nd September, 1963. An investigation was commenced immediately.


2. BRIEF CIRCUMSTANCES
The aircraft was engaged on a charter flight from Barcelona to London (Gatwick) in connection with an inclusive tour arranged by a British travel agency. The flight was without incident until the aircraft commenced the approach procedure. Radar positioning for an ILS (instrument landing system) approach to runway 09 was provided by Gatwick approach control. When the aircraft was on base leg the captain reported that the aircraft's glide-path equipment was inoperative. The controller directed the aircraft on to final approach and later passed descent clearance. During the descent the aircraft brushed the trees on Russ Hill, about 220 feet above and 1.75 nautical miles from the runway threshold. The aircraft was slightly damaged but a safe landing was made.


3. THE AIRCRAFT
The aircraft was constructed in the United States of America. It was issued with a certificate of airworthiness by the Spanish Civil Aviation authorities on 27th August, 1957; this was renewed on 6th May, 1963, and was current until 5th November, 1963. The aircraft was maintained in accordance with a programme approved by the Spanish Civil Aviation authorities; it had completed 18,089 flying hours.
The weight and load distribution were within the prescribed limits.
Duplicated VHP radio navigation equipment was fitted for use with ILS and VOR but no glide-path receiver was attached to VHF navigation receiver No.2.

4. THE CREW
Captain V. Marcos Clavero aged 31, holds a current airline transport pilot's licence endorsed for Lockheed 1049G aircraft and an instrument rating. He also holds a licence to operate R/T. His total flying experience at the time of the accident amounted to 8,761 hours of which 1,064 hours had been obtained in command of Lockheed 1049G aircraft.
Captain Marcos Clavero had flown to Gatwick on five previous occasions.

Mr. J. M. Medina Diez aged 37 holds a current senior commercial pilot's licence endorsed for Lockheed 1049G aircraft and an instrument rating. He also holds a current flight radio operator's licence. At the time of the accident he had flown 618 hours as co-pilot in Lockheed 1049G aircraft. From February, 1954 until March, 1963, Mr. Medina Diez had been employed as a flight radio operator, in which capacity he accumulated 11,615 hours experience.

5. THE WEATHER
The following weather observation was recorded at 0217 hrs. on 2nd September 1963, by the Meteorological Office at Gatwick.

Wind 090° 5 knots
   
Visibility 4 nautical miles
   
Weather Nil
   
Cloud 6/8 at 600 feet
  8/8 at 700 feet
   
QNH 1004 millibars (29.65 inches of mercury)
   
QFE 997 millibars (29.44 inches of mercury)

The normal method of observation of visibility at Gatwick is to use the Gold visibility meter and the farthest visible standard light. The visibility given by this method is supplemented by estimation of the visibility in other directions on the airfield by the relative clarity of airfield lighting and the low level sky illumination visible on most nights. The meteorological observer on duty at the time of the accident has stated that he is in the habit of using the flashing beacon on Russ Hill to assist him in his estimation of visibility. While no records are available the observer thinks it most unlikely that the beacon would have been invisible to him when reporting a visibility of 4 nautical miles. The reported cloud was of layer type and its height was measured by means of the cloud searchlight near the centre of the aerodrome. The Meteorological Office have stated that it is conceivable that the combination of very high humidity, stable lower air and light drift of wind on to the flank of the ridge on which Russ Hill stands produced a local patch of cloud lower than that above the aerodrome.

6. THE APPROACH FACILITIES
The aerodrome elevation at Gatwick is 194 feet. Among the facilities available for runway 09 is ILS with its associated outer and middle markers. The glide-path has a 3 degree slope and at the outer marker, which is 4.25 nautical miles from the threshold of the runway, there is an NDB (non-directional beacon). The ILS procedures for Gatwick contained in the Air Pilot provide, among other things, that aircraft should not descend below a height of 490 feet above aerodrome level at the middle marker, located 0.8 nautical miles from threshold, during an approach with the glide-path inoperative. PAR (precision approach radar) which has a 3 degree glide-path is also available and can be brought into operation within about ten minutes if requested. PPI (plan position indicator) step-down approaches can also be provided by the Gatwick director.

The section of the Air Pilot concerned with runway 09 lists obstacle clearance limits in relation to landing aids as follows:-

ILS (localiser and glide-path) 180 feet
   
ILS (localiser only) 290 feet
   
PAR (azimuth and elevation) 180 feet
   
PAR (azimuth only) 400 feet
   
PPI (stepdown) 470 feet
   
NDB 590 feet

7. THE FLIGHT
The accident occurred at the termination of a flight arranged by a British travel agency with Aviaco (Aviacion y Comercio) to fly from Barcelona to London (Gatwick). Though the aircraft and the crew members belonged to Iberia the operator was Aviaco who adopted the Iberia operations manual for the purpose of this flight.
The aircraft took off from Barcelona at 2305 hrs. and reported its position above Lydd VOR at 0138 hrs. A minute later Gatwick approach control passed the following weather report:-

Wind 070 5 knots
   
Visibility 4 nautical miles
   
Weather Drizzle
   
Cloud 5/8 700 feet
  8/6 1,000 feet
   
QNH 1,004 millibars
   
QFE 997 millibars

The Gatwick controller then provided radar positioning directions for an ILS approach to runway 09. When the aircraft was on base leg flying at 2,000 feet the pilot asked Gatwick whether the glide-path transmitter of the ILS was working properly and on being given an affirmative reply he informed the controller that the glide-path equipment in the aircraft was inoperative.
After acknowledging this message, the controller cleared the aircraft to descend to 1,500 feet QFE 997 and advised the pilot when to turn on to the ILS localiser. The localiser was intercepted at a range of six miles after which the aircraft was cleared to descend to 1,000 feet and cleared to land. After the pilot reported over the outer marker the controller cleared the aircraft to descend to critical height. He also informed the pilot that the obstacle clearance limit was 470 feet and added that there were four and a half miles to go. The captain, who was flying on instruments from the left hand seat, has stated that he crossed the outer marker at a height of 1,400 feet and thereafter maintained a rate of descent of 800 feet per minute. As the aircraft crossed Russ Hill it brushed through the tops of trees; at this time the copilot, who had been instructed to keep a look-out for the aerodrome lights, saw a red light to his left which he could not distinguish as being either steady or flashing. The captain increased the engine power slightly and almost immediately afterwards the airfield lights became visible. No difficulty was experienced in controlling the aircraft and a successful landing was made without further incident. Hydraulic pressure was lost whilst taxying to the terminal and the aircraft was brought to a stop by means of the parking brake system. The aircraft was slightly damaged in its collision with the trees but nobody was injured.
Subsequently the captain explained that he believed the aircraft was being monitored on radar in both azimuth and elevation during the approach; he also said that he had selected a personal critical height of 400 feet.

8. EXAMINATION OF THE AIRCRAFT
The landing light, which was extended from the underside of the left wing at the time the aircraft touched the trees, was broken. About 6 inches of the tip of a blade of No. 3 propeller was broken off, and No. 3 engine nacelle was dented. Quantities of twigs and foliage were found in the engine cowling and attached to the right landing gear strut. A hydraulic line on the strut was broken and adjacent hydraulic lines were dented. Both pilots' altimeters were set at 29.64 inches (1003.7 millibars).
Examination of the radio equipment showed that there was no glide-path receiver attached to VHP navigation receiver No. 2 and that the glide-path receiver attached to VHP navigation receiver No.1 was defective.

9. INSPECTION OF RUSS HILL
Russ Hill is a tree covered ridge running north-south across the approach path to runway 09. A hazard beacon is positioned on a tower where the extended centre line of the runway crosses the ridge. The beacon is 227 feet above aerodrome level and 1.75 nautical miles from the threshold of runway 09. The trees adjacent to the beacon had their top branches broken off at a height lower than the top of the tower over an area about 150 feet long and 70 feet wide. Fragments of a propeller which matched the fractures at the tip of No.3 propeller and pieces of the left landing light were found in the vicinity of the beacon.

10. THE WEATHER MINIMA
In compliance with Article 25 of the Air Navigation Order, 1960, the operator of an aircraft being used for public transport and not registered in the United Kingdom is required to furnish the Minister of Aviation with such particulars as he may require relating to the weather conditions specified by the operator for landing at United Kingdom aerodromes. The particulars specified by Aviaco were those contained in the Iberia operations manual, details of which had been furnished to the Minister in a letter of 14th February 1963. The letter stated that the weather minima appropriate to runway 09 using ILS localiser and glide-path were 250 feet (critical height) and 1 mile (runway visual range); there was no reference to critical height in the event of the ILS glide-path being inoperative. In a letter dated 24th April 1963 however, it was stated on behalf of the company that "any operation undertaken by Iberia is always based on the instructions as per U.K. Air Pilot".
The captain stated that the company minima for this flight were a critical height of 250 feet and a runway visual range of 1 mile but since there was no glide-path available his 'personal' critical height was 400 feet.

11. OBSERVATIONS

11.1. In view of the availability of PAR at Gatwick, it would have been good airmanship on the part of Captain Marcos Clavero to have requested this facility when he became aware that his ILS glide-path receiver was unserviceable. Nevertheless a decision to continue the approach on the ILS localiser without glide-path information in the reported weather conditions was not one which in itself warrants criticism. It did, however, render it important to have regard to the heights associated with such a procedure if a safe operation was to be ensured.
Primary responsibility for initiating the use of PAR lay with the captain but in the absence of such a request the air traffic controller might reasonably, as a matter of prudence, have reminded him of its availability. In the event, the controller put into effect what might be considered an abbreviated form of PPI step down approach. This, as is shown by the extract from the Gatwick approach R/T recording (see Appendix), did not justify, though it might explain, the assumption by the captain that the progress of the approach was being monitored in elevation by radar. On the other hand, the OCL of 470 feet which was passed should have alerted him to the need for attention to his height.

11.2. The Iberia operations manual contained the weather minima to be used when the full facilities of the ILS were available. It did not specify the minima to be used when making an approach to land with the ILS localiser only, nor was guidance given on the amount by which the ILS minima should be raised in these circumstances.
The critical height of 400 feet selected by the captain was greater than the OCL of 290 feet with localiser only but, to ensure a safe approach when glide-path information is not available, regard must also be had to the procedure notified in the Air Pilot for this type of approach; this requires a minimum height of 490 feet above aerodrome level to be maintained at the middle marker. The operations manual made no reference to this.

11.3. The hazard beacon is 227 feet above aerodrome level and trees in its vicinity were cut off below beacon level while the aircraft was breaking cloud during the approach. Since the airfield lights did not become visible to the captain until subsequent to the brush with the trees, it appears that the approach was continued, without visual reference to the ground, well below the critical height of 400 feet which the captain had set himself, and also below the critical height of 250 feet laid down by the operator for a normal ILS approach.

11.4. Although it is considered there is no justification for the assumption by the captain that the approach was being monitored in elevation by radar, the circumstances of this incident illustrate the undesirability of a controller not adhering to standard procedures, particularly when the language spoken is not the pilot's mother-tongue. It may also be observed that the OCL passed was that of a standard PPI step-down. If the full procedure is not followed, the OCL may to some extent be invalidated. This had no bearing on the cause of this incident.

11.5. The possibility that there might have been confusion between QFE and QNH altimeter settings has been carefully considered. It is standard practice in Iberia for the altimeters to be set to QNH during landing. The captain should, therefore, have been in the habit of adding the aerodrome elevation to the critical height when determining the height at which an overshoot should be commenced. He should likewise have been in no doubt about interpretation of the OCL. From the evidence given by the pilots there is no reason to believe that there was any mistake between QFE and QNH values. Neither does it appear that inadequate attention was paid to the indications of the altimeter.


12. CONCLUSIONS

12.1. The aircraft documentation was in order except for the inadequacies of the operations manual concerning weather minima.

12.2. The pilots were properly licensed and sufficiently experienced to carry out the flight.

12.3. The glide-path receiver attached to VHF navigation receiver No.1 failed before the final approach was commenced. Otherwise there was no failure of the aircraft, its engines or equipment.

12.4. The cloud base and visibility in the vicinity of the hazard beacon on Russ Hill were probably lower than those reported for the aerodrome.

12.5. The operations manual did not specify weather minima for an approach to land using ILS without glide-path information nor provide any guidance on the amount by which the full ILS minima should be raised in these circumstances.

12.6. The captain did not maintain the notified minimum height for the middle marker; he also descended below his critical height without having visual reference to the ground.

13. OPINION
The aircraft struck tree tops when the captain descended below a safe approach path whilst making an ILS approach to land without use of the glide-path at night in low cloud conditions. Lack of information in the operations manual for such an approach was a contributory factor.

14. COMPLIANCE WITH REGULATIONS
In conducting this investigation the provisions of Regulation 7(5) of the Civil Aviation (Investigation of Accidents) Regulations, 1951, have been complied with, the following action having been taken.

Captain V. Marcos Clavero and Lineas Aereas de Espana were informed of the conclusions and the opinion set out in paragraphs 12 and 13 above, and offered an opportunity of exercising the rights conferred by the Regulation.

Captain V. Marcos Clavero and a representative of Lineas Aereas de Espana attended a meeting at the Ministry of Aviation on 15th September, 1964. Careful consideration was given to the representations they made but this necessitated no change in the opinion as to the cause of the accident.


J. D. ROSE

Inspector of Accidents
Accidents Investigation Branch, Ministry of Aviation.
September, 1964.

 

Appendix


RECORDING OF AERODROME APPROACH CONTROL COMMUNICATIONS AIRCRAFT AVIACO 1120 (EC-AMQ)

OPERATION OF RECORDER Continuous

TO FROM MESSAGE TIME (GMT) CALCULATED TIME REMARKS
    (ACH) 0138   Channel quiet
GATWICK DIRECTOR AVIACO 1120 GATWICK AVIACO ONE ONE TWO ZERO GOODMORNING      
AVIACO 1120 GATWICK DIRECTOR ONE ONE TWO ZERO GATWICK GOODMORNING GO AHEAD      
GATWICK DIRECTOR AVIACO 1120 ONE ONE TWO ZERO OVER LYDD AT THREE EIGHT LEVEL AT NINE ZERO C      
AVIACO 1120 GATWICK DIRECTOR ONE ONE TWO ZERO GATWICK DIRECTOR ROGER IDENTIFIED AT LYDD CLEAR TO DESCEND TO SIX ZERO AND LEVEL OFF AND ADVISE PASSING BATTLE      
GATWICK DIRECTOR AVIACO 1120 ROGER GIVE YOU A CALL PASSING BATTLE
     
    (ACI) 0139   Channel quiet
AVIACO 1120 GATWICK DIRECTOR ONE ONE TWO ZERO THE GATWICK WEATHER ZERO SEVEN ZERO AT FIVE KNOTS FOUR NAUTICAL MILES IN DRIZZLE FIVE OKTAS AT SEVEN HUNDRED FEET EIGHT OKTAS AT ONE THOUSAND FEET THE Q N H ONE ZERO ZERO FOUR THE Q F E NINE NINE SEVEN THIS IS RADAR TO I L 8 RUNWAY ZERO NINE      
GATWICK DIRECTOR AVIACO 1120 ONE ONE TWO ZERO ROGER      
    (ADZ) 0140   Channel quiet
AVIACO 1120 GATWICK DIRECTOR GATWICK DIRECTOR ONE ONE TWO ZERO PRESENT FLIGHT LEVEL      
GATWICK DIRECTOR AVIACO 1120 AVIACO 1120 ONE ONE TWO ZERO PASSING THROUGH EIGHT ZERO      
AVIACO 1120 GATWICK DIRECTOR ROGER CONTINUE RIGHT DOWN TO : THREE THOUSAND FEET ON Q N H ONE ZERO ZERO FOUR AND ADVISE ME PASSING SIX ZERO      
GATWICK DIRECTOR AVIACO 1120 ROGER WILL DO      
    (ADA) 0141   Channel quiet
GATWICK DIRECTOR AVIACO 1120 AVIACO ONE ONE TWO ZERO PASSING BATTLE LEAVING SEVEN ZERO      
AVIACO 1120 GATWICK DIRECTOR __GER*     * End of word
    (ADB) 0142   Channel quiet
    (ADC) 0143   Channel quiet
GATWICK DIRECTOR AVIACO 1120 AVIACO ONE ONE TWO ZERO
LEAVING SIX
     
AVIACO 1120 GATWICK DIRECTOR __GER*     * End of word
    (ADD) 0144   Channel quiet
AVIACO 1120 GATWICK DIRECTOR ONE ONE TWO ZERO MAKE YOUR HEADING TWO SEVEN ZERO AND CONTINUE DESCENT TO TWO THOUSAND FEET      
GATWICK DIRECTOR AVIACO 1120 ONE ONE TWO ZERO ROGER      
GATWICK DIRECTOR AVIACO 1120 ONE ONE TWO ZERO PASSING MAYFIELD      
AVIACO 1120 GATWICK DIRECTOR __KYOU      
    (ADE) 0145   Channel quiet
    (ADF) 0146   Channel quiet
    (ADG) 0147   Channel quiet
    (ADH) 0148   Channel quiet
    (ADI) 0149   Channel quiet
AVIACO 1120 GATWICK DIRECTOR ONE ONE TWO ZERO RIGHT NOW ONTO THREE SIX ZERO BASE LEG      
GATWICK DIRECTOR AVIACO 1120 (AEZ) AVIACO ONE ONE TWO ZERO TURNING RIGHT TO THREE SIX ZERO REACHING TWO THOUSAND 0150 0150.06s  
AVIACO 1120 GATWICK DIRECTOR ROGER      
GATWICK DIRECTOR AVIACO 1120 GATWICK AVIACO ONE ONE TWO ZERO WOULD YOU CONFIRM THAT THE GLIDEPATH IS WORKING WELL   0150.30s  
AVIACO 1120 GATWICK DIRECTOR YES IT'S OK      
GATWICK DIRECTOR AVIACO 1120 SORRY MY EQUIPMENT IT IS NOT WORKING ON THE GLIDEPATH   0150.38.5s  
AVIACO 1120 GATWICK DIRECTOR OK      
AVIACO 1120 GATWICK DIRECTOR ONE ONE TWO ZERO DOWN TO FIFTEEN HUNDRED FEET ON QFE NINE NINE SEVEN   0150.53.5s  
GATWICK DIRECTOR AVIACO 1120 ROGER PASSING THROUGH TWO THOUSAND (AEA) AT THIS TIME 0151    
AVIACO 1120 GATWICK DIRECTOR ROGER      
AVIACO 1120 GATWICK DIRECTOR ONE ONE TWO ZERO TURN RIGHT NOW ZERO NINE ZERO      
GATWICK DIRECTOR AVIACO 1120 ZERO NINE ZERO THANK YOU   0151.49s  
AVIACO 1120 GATWICK DIRECTOR COMING ONTO THE LOCALISER AT SIX MILES   0151.53s  
GATWICK DIRECTOR AVIACO 1120 ROGER (AEB) 0152    
AVIACO 1120 GATWICK DIRECTOR CONTINUE DESCENT NOW TO ONE THOUSAND FEET   0152.15s  
GATWICK DIRECTOR AVIACO 1120 ONE ONE TWO ZERO ROGER      
AVIACO 1120 GATWICK DIRECTOR QUITE CLEAR TO LAND   0152.24s  
GATWICK DIRECTOR AVIACO 1120 'KYOU      
GATWICK DIRECTOR AVIACO 1120 ONE ONE TWO ZERO ON THE OUTER MARKER   0152.35s  
AVIACO 1120 GATWICK DIRECTOR ROGER CLEARED TO CONTINUE DESCENT TO YOUR CRITICAL HEIGHT THE OBSTACLE CLEARANCE LIMIT FOUR SEVEN ZERO FEET YOU'VE GOT FOUR AND A HALF MILES TO GO   0152.46s  
GATWICK DIRECTOR AVIACO 1120 THANK YOU      
AVIACO 1120 GATWICK DIRECTOR ADVISE WHEN BELOW CLOUD AND FIELD IN SIGHT   0152.57.5s  
GATWICK DIRECTOR AVIACO 1120 (AEC) WILL DO 0153    
    (AED) 0154   Channel quiet
AVIACO 1120 GATWICK DIRECTOR ONE ONE TWO ZERO IF YOU LANDED 0K OVER TO TOWER ONE ONE EIGHT ONE   0154.26s  
GATWICK DIRECTOR AVIACO 1120 ONE ONE TWO ZERO ON THE GROUND CHANGE TO ER TOWER THANK YOU   0154.39.5s  
AVIACO 1120 GATWICK DIRECTOR ROGER OVER TO ONE ONE EIGHT ONE      
GATWICK DIRECTOR AVIACO 1120 'KYOU   0154.45s  
    (AEE) 0155   Channel quiet