On 11 February 2022 an Airbus A320 making a visual approach to Guadeloupe at night was advised by ATC of a descent below the minimum safe altitude after continuing the approach after visual reference was temporarily lost. A repeat of this warning by ATC prompted crew recognition that the aircraft was not on the required approach track or profile and a go around was initiated from 460 feet agl. The decision to attempt a visual approach in unsuitable circumstances and a delay in recognising the need for a go-around were found to have been symptomatic of poor tactical decision making.

On 25 October 2022, a Boeing 777-300ER encountered deteriorating weather conditions after initiating a delayed arrival diversion from Singapore Changi to nearby Batam where four approaches were flown and a ‘MAYDAY Fuel’ declared before a landing was achieved. By this time, the fuel remaining was “significantly below final reserve” although the actual figure was not published in the Investigation Report. It was concluded that the delay in commencing the diversion and the inappropriate attempt to perform an autoland on RWY04 at Batam airport by the flight crew contributed to the potentially hazardous circumstances.

On 6 December 2019, a Boeing 737-800 below Decision Altitude on an ILS approach at Paris Orly was unexpectedly instructed to go-around in day VMC without explanation. The go around was mishandled and the aircraft began to descend after initially climbing which triggered EGPWS Warnings and controller alerting before recovery was achieved. It was suspected that surprise at the go-around and the early climbing turn required may have initiated the crew’s mismanagement of automated flight path control with further surprise leading to failure to revert to manual control when they no longer understood the automated system responses to their inputs.

On 18 October 2019, a Boeing 787-9 descending to 4,500 feet to join the ILS for runway 25R at Hong Kong at 15 nm from touchdown failed to establish on the localiser. The autopilot was disconnected and the aircraft manually positioned onto the localiser from the north, establishing at 12 nm with terrain proximity not sufficient to activate the EGPWS. It was found that the deviation was attributable to an anomaly in the aircraft type Autopilot Flight Director System, and a corresponding Alert Service Bulletin was issued by Boeing to replace the faulty system component.

On 22 November 2021, a Fokker F100 crew discovered as they neared their destination, Paraburdo, that the forecast weather was so inaccurate that instead of the anticipated benign conditions, a much lower cloud base prevailed. A delay in recognising the implications of initially unsuccessful approaches and difficulty in obtaining updated weather for diversion options resulted in a fourth approach being intentionally continued significantly below minima, albeit successfully. Relevant aircraft operator procedures were identified as inadequate.

On 22 April 2019, a Eurocopter-Kawasaki BK-117C-1 helicopter was being positioned for an aeromedical evacuation the following day when it was unintentionally flown into the sea at night. The three crew members were able to evacuate from the partially submerged aircraft before it sank. The accident was attributed to the single pilot’s loss of situational awareness due to loss of visual depth perception when using night vision goggles. The relevant aircraft operator procedures and the applicable regulatory requirements were both found be inadequate relative to the operational risk which the flight involved.

On 20 October 2021, the flight crew of a Bombardier CRJ1000 making a LNAV/VNAV approach at Nantes using Baro-VNAV minima read back an incorrect QNH which was not noticed by the controller. The crew then flew the approach approximately 530 feet below the procedure vertical profile which led to the MSAW system being activated and advised to the flight. The crew response was delayed until the controller had twice repeated the correct QNH after which the error was recognised and the vertical profile corrected. The investigation noted that neither the operator’s procedures nor aircraft instruments allowed straightforward crew detection of their error.

On 23 January 2020, a Bombardier CRJ700 making a HUD-supported manual Cat 3a ILS approach to Lyon Saint-Exupéry in freezing fog conditions deviated from the required flight path localiser and reached a minimum of 265 feet agl before a go around was initiated without initially being flown in accordance with standard procedures. The Captain involved was relatively new to type and had not previously flown such an approach in actual low visibility conditions. The Investigation was not able to determine exactly what contributed to the approach and initial go around being misflown but identified a number of possible contributors.

On 1 November 2021, a deHavilland DHC6-300 crew en-route to Fort Simpson realised that they had insufficient fuel on board to reach their intended destination and therefore decided to attempt a diversion to the nearest available airport at Fort Providence. As fuel available dwindled, one engine was shut down but after an inadvertent fuel tank selection, the initially intended diversion was no longer possible and a forced landing in a bog was successfully accomplished. The Training Captain involved had developed a habit of performing checklists silently and from memory after gaining all his professional pilot experience at the same operator.

On 4 March 2019, an Embraer 145 attempting to land off an ILS approach at Presque Isle in procedure-minima weather conditions flew an unsuccessful first approach and a second in similar conditions which ended in a crash landing abeam the intended landing runway substantially damaging the aircraft. The accident was attributed to the crew decision to continue below the applicable minima without acquiring the required visual reference and noted that the ILS localiser had not been aligned with the runway extended centreline and that a recent crew report of this fault had not been promptly passed to the same Operator.

On 1 January 2020, an Airbus A350-900 made an unstabilised night ILS approach to Frankfurt in good visual conditions, descending prematurely and coming within 668 feet of terrain when 6nm from the intended landing runway before climbing to position for another approach. A loss of situational awareness was attributed to a combination of waypoint input errors, inappropriate autoflight management and communication and cooperation deficiencies amongst the operating and augmenting flight crew on the flight deck.

On 10 September 2017, the First Officer of a Gulfstream G550 making an offset non-precision approach to Paris Le Bourget failed to make a correct visual transition and after both crew were initially slow to recognise the error, an unsuccessful attempt at a low-level corrective realignment followed. This had not been completed when the auto throttle set the thrust to idle at 50 feet whilst a turn was being made over the runway ahead of the displaced threshold and one wing was in collision with runway edge lighting. The landing attempt was rejected and the Captain took over the go-around.

On 24 February 2016 a DHC6 (9N-AHH) on a VFR flight to Jomsom which had continued towards destination after encountering adverse weather impacted remote rocky terrain at an altitude of almost 11,000 feet approximately 15 minutes after takeoff after intentionally and repeatedly entering cloud in order to reach the destination. The aircraft was destroyed and all on board were killed. The Investigation attributed this to the crew’s repeated decision to fly in cloud and their deviation from the intended route after losing situational awareness. Spatial disorientation followed and they then failed to respond to repeated EGPWS cautions and warnings.

On 2 May 2015, a Boeing 777-200 deviating very significantly north of its normal route from Malabo to Douala at night because of convective weather had just turned towards Douala very close to 13,202 feet high Mount Cameroon whilst descending through 5000 feet, when an EGPWS TERRAIN AHEAD alert and ‘PULL UP’ warning prompted an 8,000 foot climb which passed within 2,100 feet of terrain when close to and still below the summit. The Investigation attributed the dangerous event primarily to the augmented crew’s absence of situational awareness and the operator’s failure to risk-assess the route involved.

On 23 May 2022, an Airbus A320 came within six feet of the ground without crew awareness during a go around from a RNP BaroVNAV approach after failing to obtain visual reference. The descent below minimum altitude followed use of an incorrect QNH passed by ATC but not identified as such. The lack of an EGPWS warning was due to the non-current EGPWS version for which upgrading had not been mandated. It was concluded that the regulatory intention in Europe to transition from ILS to RNP approaches had not led to any recognition of the potential impact on operational safety.