Crisis in a Ryanair cockpit
The inside story of the Ryanair flight that nearly went down
A Ryanair flight to Rome last year (2005) came close to crashing after a crisis in the cockpit, an internal Ryanair report has revealed. The last-minute actions of a relatively inexperienced co-pilot averted a potential crash.
The plane was approaching Rome's Fiumicino airport in a thunderstorm, when the captain, who was flying the aircraft just days after burying one of his children, suffered something like a temporary breakdown.
The autopilot had been turned off, the plane was being buffeted by the storm and the pilots weren't certain where exactly they were in relation to the runway.
A number of automatic warnings sounded in the cockpit, indicating that the plane was banking and descending too fast, and would crash if averting action was not taken.
The first officer, a junior pilot, started prompting the captain to see if he was in control. As the plane neared the ground, and realising the situation was dangerous, the co-pilot intervened: by increasing the power suddenly, he pulled the plane out of the approach and up into a climb to a safe altitude.
A senior pilot who has seen the report said, "this is as close to a crash, without it actually happening, as you can have". Another senior pilot described it as a "near accident", though he was aware of incidents where aircraft came closer to crashing without actually doing so.
Ryanair have disputed that the aircraft nearly crashed. According to the company's internal investigation report, the intervention of the co-pilot "prevented a potential CFIT (controlled flight into terrain) accident".
A CFIT is one of the most common types of aircraft accident, and occurs when an aircraft with no technical problems and in the control of its crew flies unexpectedly into an obstacle, such as the ground, or a mountain, or the sea.
Ryanair said to claim that the aircraft "nearly crashed" would be "untrue". According to the international Flight Safety Foundation's director of technical programmes, Jim Burin, a CFIT is "absolutely" a crash. CFIT accidents are normally fatal, he said, and are the number one cause of fatalities in commercial aviation.
The aircraft ultimately landed safely at another airport, outside Rome, and Ryanair subsequently conducted an internal investigation. The company said the resulting report was "copied to the regulatory authorities in the IAA [Irish Aviation Authority]" and "circulated to Ryanair's pilots".
The Irish Aviation Authority (IAA) said they had not received a copy of the report. "However, now that it has been brought to our attention, we will request a copy of same from the airline", the IAA said.
A Ryanair pilot we spoke to said a "sanitised" version of the report, without full detail of the incident, was posted on the company's internal network, but that the report itself had not been circulated.
Ryanair have also disputed that the captain suffered some kind of breakdown. The internal report found he was experiencing "task overload" and suffered "incapacitation", and that he had recently suffered a major personal trauma.
How the crisis developed
The crisis happened on board a Ryanair flight from Dusseldorf Niederrhein in Germany, originally scheduled to land at Rome's Ciampino airport. The draft report of the Ryanair investigation which we obtained, which is dated 9 December 2005, does not provide a date or flight number for the incident. A source said the incident occurred during 2005.
There was a two man crew flying the plane, a Boeing 737-800. The captain was the "pilot flying" (PF) and his co-pilot, the first officer, was the "pilot non flying" (PNF).
The first officer was relatively inexperienced, 24-years-old, with 475 flying hours in total and 300 hours "on type", or flying in this particular type of aircraft. The captain was very much his senior, aged 37 with 7,400 flying hours.
Nearing Ciampino airport, they encountered severe summer storm conditions, with thunderstorms (towering cumulus clouds) and turbulence.
After two attempts to line up a runway at Ciampino, they were diverted to Rome's Fiumicino airport.
While nearing Fiumicino, the captain disengaged the autopilot, apparently in order to handle "low level turbulence". The report is implicitly critical of this decision, as it increased the workload of the cockpit crew when they were already near their limits. The co-pilot then switched off a flight guidance instrument, the flight directors, as he considered that they were incorrect and distracting – the report finds that this added to the "disorientation" in the cockpit.
The captain then lowered the aircraft's undercarriage in a bid to stabilise the aircraft. At this point, the captain "was experiencing considerable difficulty controlling the aircraft altitude and airspeed", the report says.
Now flying with autopilot off, in turbulence, the crew were unable to follow the instructions from Rome Air Traffic Control and missed the first runway approach "heading" (or direction) set by Air Traffic Control.
Air Traffic Control then issued a second runway approach "heading". When the crew realised they had missed this also, they turned sharply to the right in an attempt to salvage the approach, causing the aircraft to bank (or tilt) steeply. (At some point in the approach, the aircraft's "bank angle warning" sounded several times, indicating that the aircraft was tilting at more than 35 degrees, though the report does not identify precisely when this happened.)
The crew then established visual contact with the ground and continued descending. But, under pressure, they had failed to follow the normal procedures for approach and landing. They had not carried out the normal approach checks, and had not entered details for Fiumicino airport into their flight management computer, and so had no illustration of the runway on the navigational display in the cockpit.
The crucial moments
As they descended on the approach to Fiumicino, the first officer became aware of some problem with the captain, and "repeatedly prompted" him "to ensure he was not suffering from some form of partial incapacitation", says the report.
During the final stages of the approach, the plane was in a precarious situation. It was badly off target for the runway, and was flying too low to make a safe landing.
According to the report, it was at "an unsafe altitude... without either being configured for, or in a position from which a safe landing could be conducted".
The captain had lowered the undercarriage to help stabilise the aircraft and had turned off the autopilot to enable him handle the turbulence during the approach and landing, but then - as the report finds - the captain suddenly suffered "a mild form of incapacitation".
(Ryanair have disputed that the aircraft was "dangerously unstable", saying this was "untrue".)
The co-pilot realised the aircraft "was now in a potentially unsafe situation". He took action: he increased the power suddenly, causing the plane to tilt up and into a climb, away from the ground. In the technical language of the report, he initiated a "missed approach" by pulling back on the control column and advancing the thrust levers.
The co-pilot saved the day: the report finds "the actions of the co-pilot in initiating the missed approach prevented a potential CFIT accident".
CFIT is an acronym for "controlled flight into terrain". Ryanair said that to say the aircraft "nearly crashed" and that "the co-pilot saved the flight from a possible crash" was "untrue".
According to the definition of a CFIT by the Flight Safety Foundation (at www.flightsafety.org), an independent, international air safety organisation, a CFIT occurs "when an airworthy aircraft under the control of the flight crew is flown unintentionally into terrain, obstacles or water, usually with no prior awareness by the crew".
Jim Burin of Flight Safety International said that, in a CFIT accident, "usually there are no survivors". There were four CFIT accidents on commercial jets in 2005, he said, in one of which there were a handful of survivors; in the other three, there were no survivors.
However, it would be technically possible for a CFIT to occur without fatalities.
The Ryanair aircraft was fitted with an "enhanced ground proximity warning system" (EGPWS), an alarm system designed to alert the crew if the plane is too close to the ground. This sounded its "sink rate" warning, indicating the plane was descending too fast. In normal conditions, Jim Burin said, a sink rate warning would indicate that the crew had 30 to 40 seconds before hitting the terrain, unless avoiding action was taken.
After aborting the approach at Fiumicino, the aircraft climbed to a safe altitude and the crew advised air traffic control that they wished to divert. They then headed for Pescara airport, outside Rome, where they subsequently touched down without incident.
to the pilot
According to the report, "the captain had very recently suffered a major personal traumatic event in his private life". A source has told us that a child of the pilot had died and been buried a couple of days before the incident.
The report finds that the captain had not told Ryanair about this. "For personal reasons he had failed to disclose this event to Ryanair, and had decided to return to work a short period following the event", it says.
The report finds that the captain "suffered task overload" during the approach to the second airport they approached, Fiumicino, and "subsequently suffered a mild form of incapacitation". According to experts we have spoken to, "task overload" is equivalent to being "stressed out", or "unable to assimilate any further information". The report does not clarify what the nature of the captain's incapacitation was.
The Ryanair report is an internal document, headed "Base Investigation draft report", marked "confidential", and dated 9 December 2005.
According to Ryanair, it is company policy "to investigate all such episodes, and, (where we feel there are lessons to be learned) bring our reported findings to the attention of both the IAA and all of our pilots rather than cover them up or keep them secret. This openness promotes awareness and enhances safety".
Ryanair said the report was also "copied to the regulatory authorities in the IAA [Irish Aviation Authority]. The IAA was brief on the content of this report and of the incident, and had nothing to add to the findings and recommendations, before this report was circulated to Ryanair's pilots".
The IAA said they had not received a copy of the report. "However, now that it has been brought to our attention, we will request a copy of same from the airline", the IAA said.
According to one Ryanair pilot, a "sanitised" version of the report, without full detail of the incident, was posted on the company's secure internal network for pilots, but the report itself had not been circulated to all pilots.
Ryanair said our article "contains a number of instances where sensational and inaccurate language has been used to describe in lay terms, an incident which was fully investigated by Ryanair and subsequently reported to all our pilots in order to heighten their awareness of such issues as part of our ongoing pilot education and safety culture".
Ryanair's statement concluded: "as this is an internal safety report for dissemination only among Ryanair pilots we will not be commenting further on it other than to correct the above factual errors in your article". The company declined to respond in detail to a list of questions with which we provided them.
In a previous serious incident with similar features, in July 2004, a Ryanair captain on his last day of work with the company approached a landing at Sweden's Skavsta airport at too steep an angle and at a dangerous speed, with autopilot off. The Irish Air Accident Investigation Unit (AAIU) conducted an investigation, and the captain told the AAIU that his mistake in approaching the landing "was directly attributable to physiological and psychological fatigue". The captain was having marital difficulties at the time, and his wife and children had recently returned to their home country, Australia, without him. The captain was not sleeping or eating properly, and had decided to resign from Ryanair because of the separation and stress. He told the investigation he "should have called ill for the flight, but at the time I didn't want to let down the company and on the day you always think you will be fine".
His co-pilot realised during the approach that they were approaching the runway too fast and too steeply, and tried to warn the captain, but was ignored. The captain also ignored the aircraft's "ground proximity warning system" alarm. In the event, the captain managed to land the aircraft safely, and after a 25-minute turnaround at Skavsta, the captain safely flew the return leg to Stansted.
In its report on the investigation, the AAIU recommended that Ryanair develop a Crew Resource Management (CRM) training module, "emphasising the insidious nature of stress as it affects the performance of a pilot's flying capabilities".
According to the AAIU report, Ryanair started this process immediately after the incident. We asked Ryanair what measures had been taken to implement this recommendation. The company did not respond to this question.
There was a further investigation by the AAIU into an incident on a Ryanair flight in November 2004. A Ryanair flight from Reus in Spain had an in-flight emergency shortly after take off and had to land at Biarritz in France. The crew had not activated the cabin air pressure controller.
The AAIU found that the crew had not conducted the appropriate briefing prior to departure and the "after take-off checklist" had not been completed. The report said the aircraft had taken off "after a 26 minute turnaround, which included some pressure from the ground handling agent to expedite the departure". The AAIU commented:
"The modern day commercial aviation concept of repetitive short-sector flights with rapid turnarounds, coupled with the commercial pressures associated with ground handling at high activity airports, makes for a continued high-pressure environment for the flight crews."
Postscript: As Village was going to print, we were informed by the IAA that they had received a copy of the internal investigation report from Ryanair since our initial inquiry to the IAA.
Notified by us of the report's existence, they had sought a copy from Ryanair and been provided with one. The IAA said Ryanair had previously provided them with a "brief, initial report" of the incident shortly after it occurred.p