21 November 1989 BA 747 Penta Hotel LHR

[interestedparty]

Can someone kindly indicate the source of a resume of the details in this case.
Many thanks
interestedparty

[Unwell_Raptor]

http://aviation-safety.net/database/record.php?id=19891121-1

[apaddyinuk]

My goodness. Heard all about this in training but of course they dont tell you the full nitty gritty that the captain killed himself. Very sad.
And please no pathetic comments about just how much sadder it could have been!

[Captain Airclues]

The aircraft was operating from Bahrain to Heathrow. The F/O was incapacitated with severe diarrhoea. An autoland was attempted as LHR was operating LVP's. On the latter stages of the approach the aircraft became unstabe on the localiser and the ILS Deviation lights illuminated. The procedure at the time was to monitor the aircraft and to go-around if they were still on at 200ft which the captain did. Unfortunately the automatic go-around maintains the ground track that the aircraft is flying when the switches are pressed. This track took the aircraft towards the Penta Hotel.
As a result of this incident the rules on the 747-100/200 were changed to make a manual go-around mandatory if the ILS Deviation lights illuminated at any stage on the approach.

Airclues

[MAN777]

How on earth was the captain convicted of any offence in these circumstances, no crew assistance, faulty avionics, poor weather, why was this poor man not recognised for saving lives rather than procecuted for endangering lives.

Shame on you British Airways, CAA and the legal system.

[apaddyinuk]

How on earth was the captain convicted of any offence in these circumstances, no crew assistance, faulty avionics, poor weather, why was this poor man not recognised for saving lives rather than procecuted for endangering lives.
Shame on you British Airways, CAA and the legal system.

Man777, I am guessing that there is a whole lot more to it then that which neither of the above posts explain in any detail. Pilot error is not an easy judgement for any authority to make without full evidence. Still a sad story all the same.

[The Nr Fairy]

From memory, Glen Stewart was convicted in a court, having been prosecuted by the CAA.

He was found guilty by a jury. I seem to remember thinking that the technical issues hadn't been presented properly to make the jurors capable of understanding quite how complex was the web of decisions had been taken that night, both in terms of the company's approach to (again, from memory) putting GS in a position where he had to fly with an incapacitated FO, and in terms of why the go-around got so close to the hotel.

[blue up]

Very distant memory, here. Was "the wife of a now-prominent politician" a part of the prosecution?

[Doors to Automatic]

Very distant memory, here. Was "the wife of a now-prominent politician" a part of the prosecution?

Would that be the same wife that now sticks up for terrorists and paedophiles (and makes a fortune in the process)?

[Captain Airclues]

MAN777

Could you please explain why you say "Shame on you British Airways"? BA gave Captain Stewart nothing but support, even offering to employ him in the RHS when the CAA withdrew his ATPL. The CAA, who had initially decided against prosecution, changed their mind when he decided to appeal against the ATPL revocation.
There is no doubt that the trial was a miscarriage of justice. However, proving that now would be too late to help Captain Stewart.

Airclues

[boogie-nicey]

Honourable man trying to do the best thing that he could under the circumstances.

[Golf Charlie Charlie]

I don't know if it's available on-line, but there was a very detailed lengthy article on this whole sorry affair in Pilot magazine in 1994, not sure what month - my copy is boxed up somewhere.....

[treadigraph]

The article that appeared in Pilot was by Stephan Wilkinson and I think had also appeared in an American magazine. Sorry, my copy is also buried somewhere, but I will see if I can unearth it.

NR Fairy, you are right - if I remember correctly, one of the issues raised in the article above was that cases such as this (and not just aviation) should not be held before a lay jury who may find the technicalities incomprehensible.

[CaptainFillosan]

I really feel sad that this subject has come up again. It was indeed a sorry affair. Captain Stewart was, as someone said an honourable man, and one who would have been distraught at being found guilty by a jury who could not have had more than just a little understanding of an ILS approach let alone flying an aeroplane with the FO incapacitated, or of the complexities of flying at all.

It is hard to think that justice was the winner that day.

That he felt so miserable and desolated to take his own life is tragic, and a very bad reflection of the justice system.

[forget]

The outcome of this was a tragedy. What, in fact, did Glen Stewart do ‘wrong’ to get the aircraft into the position it was and, secondly, what convinced the jury he was ‘guilty’.

I seem to remember that forecast weather at LHR was below minimums for the FO’s qualifications, sick or not, and that a ‘dispensation’ was sent to the inbound aircraft to allow it to make the approach/landing. Is this right?

What part did BALPA/BA play in the man’s defence?

[wint3rmute]

Tragic indeed, I remember a groundschool teacher regaling this sad sequence of events in a lesson on ILS & related errors.

The CAA, who had initially decided against prosecution, changed their mind when he decided to appeal against the ATPL revocation.


This is the bit I really don't understand - is it true? Why would they change their mind? Really makes me think the CAA deserve their reputation.

[sox6]

http://www.airandspacemagazine.com/ASM/Mag/Index/1994/FM/Contents.html was the US article (link to index only).

The next big CAA prosecution was for the 737 that ran out of oil I believe and that according to evidence in Parliament: "The CAA had just performed a check of the Quality Assurance department at British Midland, and though finding it wanting, had approved it because it believed the issues were being addressed."

[Flying Lawyer]

sox6

There's not necessarily any link between the British Midland B737 incident you mention and evidence (if what you say is correct) that "the CAA had just performed a check of the Quality Assurance department at British Midland, and though finding it wanting, had approved it because it believed the issues were being addressed."
Nor even, IMHO, if an audit of an organisation finds nothing needing to be addressed, which happens extremely rarely - if ever, in a large organisation.

However good a system in place, human beings still breach procedures/make mistakes. Human error is a fact of life. We take steps to minimise such mistakes, and put check systems in place in an attempt to detect any errors, but it is impossible to entirely prevent them because human beings make mistakes/fail to follow procedures.


Professional rules prevent me from saying anything about the specific incident because I advised British Midland at the time, but I can say that, although the consequences could have been disastrous (they weren't), the error which led to the B737 losing its oil (and consequently engines) was a human error which could IMHO have happened in any organisation.



Tudor Owen