Originally Posted by paulross
It does seem that ATC became aware that there was a problem and acted at the time. From page 4 of the report:"At 11:42:27 the LOC N controller switched ON the approach lights. Following the MSAW and the omission of switching ON the approach lights, the LOC N was replaced by his LOC-N assistant and a new LOC-N assistant took over."
Fully accepted. It is the nature of such reports that some information that is available to investigators may not be included. It would be interesting to know how long after the first event that the original LOC N was replaced and why - simply omitting to switch the lights on seems unlikely to be a suitable justification. But if the significance of the QNH was recognised as a potential contributing factor, I would expect the correct value to be stressed somewhere before the second approach was commenced and, as someone else pointed out, there was likely a period of level flight during which the discrepancy between assigned level and mode C could have been checked - and back in my day, in an incident with which I was involved that bears some similarity, it most certainly was! There are many other 'ground-based' questions which could be investigated, and I hope that they will form part of the final report