Serious incident Piper PA-28-151 G-BOTI,
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ASN Wikibase Occurrence # 316506
 
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Date:Saturday 22 October 2022
Time:13:30 UTC
Type:Silhouette image of generic P28A model; specific model in this crash may look slightly different    
Piper PA-28-151
Owner/operator:Falcon Flying Services Ltd
Registration: G-BOTI
MSN: 28-7515251
Year of manufacture:1975
Engine model:Lycoming O-320-D3G
Fatalities:Fatalities: 0 / Occupants: 2
Aircraft damage: None
Category:Serious incident
Location:9 nm final approach into Exeter Airport, Exeter, Devon -   United Kingdom
Phase: Approach
Nature:Private
Departure airport:
Destination airport:Exeter Airport (EXT/EGTE)
Investigating agency: AAIB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
On the final approach to Exeter Airport, the pilot lost situation awareness with respect to his position relative to the runway and ILS (instrument landing system) descent point. The aircraft began its descent early and descended to 400 ft from terrain before ATC instructed the pilot to climb. It is possible there was a malfunction of the glideslope deviation indicator on the course deviation indicator (CDI), but the pilot’s awareness would have been improved by referencing the distance measuring equipment (DME) to confirm his position relative to the descent point.

The approach controller noticed the early descent three minutes after the aircraft departed the cleared level and instructed the pilot to climb. The subsequent approach was flown using the localiser and without vertical guidance to a successful landing. The CDI had been reported as unserviceable prior to scheduled maintenance, which had been completed on the day of the flight, although no fault was found with the glideslope indicator.

The investigation found that the approach controller did not use the correct phraseology – this would have made the approach clearance conditional on the pilot confirming his distance from the runway threshold using DME. The pilot would in any case have improved his situation awareness and probably prevented this serious incident by checking the DME range at the descent point. A DME check is an important part of procedures such as this, because it provides an independent means of confirming that it is safe to descend.

Accident investigation:
cover
  
Investigating agency: AAIB
Report number: AAIB-28761
Status: Investigation completed
Duration: 8 months
Download report: Final report

Sources:

1. AAIB Final Report: https://assets.publishing.service.gov.uk/media/649aee18b4d6ef0012038f9e/Piper_PA-28-151__Modified__G-BOTI_08-23.pdf
2. https://www.planelogger.com/Aircraft/Registration/G-BOTI/804574
3. https://en.wikipedia.org/wiki/Alfington

Media:

G-BOTI G-BOTI G-BOTI Piper PA-28 151 Cherokee Warrior at Exeter 17/07/2023

Revision history:

Date/timeContributorUpdates
06-Jul-2023 10:16 harro Added
11-Aug-2023 06:12 Dr. John Smith Updated
26-Feb-2024 08:51 Dr. John Smith Updated [Embed code]

Corrections or additions? ... Edit this accident description

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