blind pew, the saddest tale you can imagine, the story as told by Stephan Wilkinson in "Pilot" magazine.
On November 21, 1989, a British Airways 747 came within quite literally a stone’s throw of the ground at London Heathrow Airport in thick fog before reversing its descent on an unsuccessful instrument approach. The huge aeroplane was far enough to the right of the runway centreline that when Capt. William Glen Stewart discontinued the approach, he was actually outside the airport fence, paralleling a highway crowded with morning commuter traffic and only five feet higher than a nearby airport hotel the roof of which is exactly seventy feet above the ground. As the 747 thundered past the Penta Hotel, half in the mist and half out, car alarms all over the parking lot began to chirp and wail, their sensors set off by the four enormous turbofans spooling up.Stewart, 53, the 15,000 hour British Airways captain in command of 747 G-AWNO ‘November Oscar’, as the aeroplane has been referred to ever since – routinely landed out of the second approach through the same fog. Phones at British Airways’ head quarters were ringing even before he had parked at the gate, and that would be Stewart’s last landing., for he never flew again. He lost his job, and more.
That much is known.
Beyond that bare outline, however, lie two diverging accounts of not only what caused the incident but where the blame for the botched approach lay and how that blame should be apportioned. It is a landmark case in aviation history, for William Glen Stewart was njot simply censured or cashiered – the normal airline response even to accidents that injure and kill, neither of which the November Oscar incident did. Instead he was judged to be a criminal.
In the past, criminal proceedings have been brought against pilots who flew while drunk, showed off by flying under bridges or committed other acts of intentional stupidity.. We don’t yet know all that went on in the former Soviet Union, and there are tales of a captain on an African airline being summarily executed for damaging his 727 while attempting to land it in the grass alongside a runway - under company orders to spare wear on the tires. In 1990, two Korean Air Line DC-10 pilots were jailed by the Libyans after killing 72 passengers when they landed short at Tripoli.
But in the Western world, only one other crew had suffered any such indignity. In 1979, a Swissair DC-8 crew was jailed in Greece after landing long and skidding off the end of a wet runway at Athens. Fourteen passengers were killed, and many pilots fault not the crew but the airport management. Athens is a relatively primitive international airport, and its runways were slick with tire touchdown rubber deposits too infrequently scraped away by maintenance crews.
One November Oscar scenario is that Glen Stewart was fighting a recalcitrant, archaic, flawed autopilot with the minimal help of a crew that was not only inexperienced but sick, while doing his best to get the airline’s passengers to their destination as economically as possible. That he gave it his best shot and if anything should be commended for uncomplainingly playing the cards he was dealt.
The other account, however, holds that Stewart flew an inept instrument approach that legally he should never have attempted. That he came within an ace of creating an enormous holocaust involving not only his 255 passengers but motorists and Penta Hotel occupants. That any sensible pilot would have ‘thrown away’ the approach at an altitude of at least 1,000 feet above the ground, to try again or perhaps even divert to nearby Manchester, where the weather was better. That he made inexcusable errors of judgement, bungled the missed approach itself and revealed frightening gaps in airmanship.
On May 8, 1991, a jury at Her Majesty’s Crown Court in Isleworth hesitantly agreed. In a split verdict, ten to two – they found William Glen Stewart criminally guilty of negligently endangering his aircraft and passengers. He was sentenced to a fine of £2,000 or 45 days in jail. It was the first time in the history of British aviation that an airline pilot was found to be a criminal – was, in fact, even charged with being a criminal, as a result of the routine pursuit of his duties to what he believed to be the best of his abilities.
When I first heard of Glen Stewart and his sad fate, it seemed another bitter example of the indignities that airline pilots occasionally suffer at the hands of journalists, lawyers and nonpilots who understand nothing of the techniques and demands of the profession. Stewart had already been convicted in the press, in breathless accounts of how he’d mistaken a nearby highway for the runway and had actually been trying “to crash land” upon it, of how he’d “misread his instruments,” of how he’d “been flying too fast,” as though he were some kind of aerial speeder, of how he’d come so close to the hotel that he’d set off fire sprinklers. The press particularly liked the sprinklers.
My sympathies, however, were aligned with those of a friend, a former flight instructor of mine, today a USAir 767 captain, to whom I described the affair. “What was the guy found guilty of?” Tom asked in amazement.
“Endangering his passengers,” I said.
“I do that every day I fly,” he laughed, “That’s aviation.”
As I delved deeper into the November Oscar incident, I’d learn that things weren’t so simple.
How did this happen? Why did it happen? Though British Airways, the CAA, the British Airline Pilots Association and Glen Stewart’s copilot that day have either refused or ignored our repeated requests for interviews, we’ve talked to a number of both British and American widebody pilots familiar with the November Oscar incident, as well as safety experts and other participants in the affair. Perhaps this brief account of a complex affair that consumed thousands of pages of investigation and testimony will allow you to decide where the ultimate blame lies.
Stewart’s problems began at a Chinese restaurant on Mauritius, in the Indian Ocean. There, he and his entire flight and cabin crew, plus Flight Engineer Brian Laversha’s wife, Carol, dined during a lay over before flying on to Bahrain, bound from Brisbane for London. Bahrain – Heathrow would be the long last leg of the trip.
By the time the crew reached Bahrain several days later, many were doubled over by gastroenteritis. Stewart was unaffected, but his copilot, 29 year old Timothy Luffingham, and Flight Engineer Laversha were poleaxed by the bug. Carol Laversha suffered worst of all, and a Mauritian doctor had prescribed both a pallative and a painkiller for her, telling Brian that he too should take them in the same dosages if his own symptoms worsened.
The doctor was not on the standard list of British Airways approved flight surgeons, but the approved doctor was too far away to minister to the crew. He suggested the substitute physician, knowing that the new man had been vetted by British Airways and was soon to be added to the approved list. The examining doctor seemed unconcerned by the possibility of crewmembers dosing themselves or the fact the pilots were scheduled to fly in two days. British Airways would later accuse the crew of not following approved medical procedures.
“I could get pretty angry at a lot of the characters in this affair, after my years at Eastern Airlines,” says a pilot who today flies cargo widebodies for the New York Air National Guard. “Nobody ever consciously sits down and says, ‘Lets make it impossible for the crew to get to the right doctor, so that we later can claim company deniability when they go to the wrong one,’ but that’s what in effect happens.
“This was apparently a doctor who didn’t even understand the effects of self medication in a pressurized aircraft on the performance of a complex task, and right there is a microcosm of everything that pressured the crew to get the job done. That doctor’s vested interest is in sending flight crews out to fly. Certainly if he ever expects to work for BA again he isn’t going to ground crews right and left. The company wants you to fly.”
For Stewart, it turned out to be a difficult flight. Unanticipated headwinds cut into November Oscar’s fuel reserve. Copilot Luffingham was floored again by his stomach bug and had to leave the cockpit for several hours after taking some of Carol Laversha’s painkilling pills. The crew considered landing at Tehran but deemed it politically too chancy.
Stewart flew for over five hours, much of it in the dark, with only a fifteen minute respite. The crew also became dehydrated, and Laversha would later testify to the airline’s incident review board that he felt it happened because he had chastised a flight attendant for entering the cockpit without permission, and she retaliated by ignoring them.
Over Frankfurt, the crew got word that the weather at Heathrow had turned to excrement: it would probably have to be a category III landing, meaning the fog was so low that an enormously precise autopilot controlled approach and landing would have to be performed in near zero-zero conditions.
First Officer Tim Luffingham was not legal to participate in a cat III or even a cat II instrument approach, though Stewart and Laversha were. Like most pilots, Stewart had never made an actual cat III approach to minimums in his entire airline career, although he was a highly experienced instrument pilot: approximately half his airline flight hours were done as a British European Airways short haul pilot, amid what is generally agreed to be the some of the worst winter flying weather in the world.
But Luffingham, new with BA hadn’t even undergone the mandatory simulator training. His limitations were still category I – normal ILS approaches to ceilings that were no less than 200 feet, in visibility of half a mile or better, which is typically the worst a pilot will ever see. Few international airports, in fact, even have the electronics to permit cat II or III approaches.
With 255 dozing passengers dreaming they’d soon be breakfasting in London, there had to be a way around such an embarrassing hitch. There was. Stewart radioed British Airways’ Frankfurt office and asked them to telephone Heathrow and get a dispensation – an oral rule waiving to permit Luffingham to help out on this one approach in order to get November Oscar home. British Airways routinely gave such dispensations, though nothing in CAA regulations permits it, and they did it again this time.
Nobody on the ground bothered to ask Stewart how his crew was feeling and whether they were up to the job. Nor did Stewart volunteer the information that the very pilot for whom he was requesting a dispensation might at the moment be puking in the toilet.
Luffingham would also testify that nobody asked him if he wanted a dispensation – he was back in the first class cabin trying to control his diarrhea – but admitted that even if Stewart had consulted him, Luffingham would have been hard pressed to refuse. He later wrote, “I accepted, with BA’s intersts at heart, the dispensation to operate to category III autoland conditions. I personally would not mind if we had diverted. [But] what would BA have said to the captain if he had diverted without asking for a dispensation? What would they have said to me if I had not accepted it?”
In fact here is the core of the professional pilot’s constant conflict. Into one ear, the company lectures, “Never break regulations. Never take a chance. Never ignore written procedures. Never compromise safety.” Yet into the other it whispers, “Don’t cost us time. Don’t waste our money. Get your passengers to their destination rather than finding reasons why you can’t.”
Approaching London, November Oscar was told to hold at Lambourne, 24 miles northeast of Heathrow. Luffingham, by this time back in the right seat, was annoyed that Stewart insisted on hand flying the enormous Boeing round and round the racetrack pattern. Luffingham felt the autopilot could have done a smoother job, but Stewart had never trusted the old 747’s Sperry SPZ-1 dual autopilot system: he preferred to do it himself when maneuvering.
The 747 was designed way back in the 1960s, remember, and November Oscar was a 747-136, one of the earliest series made: even British Airways refers to its older 747s as ‘the Classic Fleet.’ And the autopilot was an adaption of an even earlier design, in the words of British air safety expert David Beaty, “never designed for that aircraft. It was bolted on, and had to be nursed carefully.”
Laversha, for his part, didn’t like the looks of the fuel totalizers. “While we were in the hold I told him, ‘Come on, Glen, we’ve got two minutes of [holding] fuel left, let’s buzz off to Manchester,” Laversha recalls. “But he was a very determined man.” Stewart did request the weather for both Manchester and London-Gatwick. The crew discussed the options, for Manchester’s weather was above category I limits. Stewart was on the verge of changing their destination to Manchester when Heathrow called and cleared November Oscar for an approach. The weather had improved slightly, to category II limits, but there was one further complication, the runway was now 27 Right rather than 09 Left, for the wind had changed.
“That was a very strange morning,” another captain would tell me later. “I landed not long ahead of Glen Stewart on the opposite runway, before they switched. We ran through a thick bank of fog on short final and in fact landed below limits. The runway actually disappeared in the flare. My feeling is that it might have been this very bank of fog that moved a couple of miles east and caused poor Glen’s problem.”
That captain’s admission that he did something every pilot is drilled never to do – break the ceiling and visibility limits on an instrument approach – is not irrelevant, for it illustrates that airline pilots frequently make judgement calls that are superficially illegal but ultimately the best course. Do you “hold what you’ve got” and land when you’re already committed but run into rogue fog, or do you attempt one of aviation’s more difficult maneuvers – a blind go around from a few dozen feet above the runway? Most professional pilots would vote for the former.
The approach itself was a hurried affair, complicated by a host of factors. Any one or two might have been inconsequential, but taken as a full ration of sudden additions to the crew’s workload, they turned a routine approach into a flying worm can.
The last minute runway switch required a reshuffling of charts, procedures and mental pictures.
A ten knot tailwind at altitude meant November Oscar would be steaming down the localizer at a better clip than ordinarily.
The approach controller turned Stewart onto the localizer ten miles from the runway rather than the customary twelve or more, making the approach even more hurried. He also did it at an altitude that required the autopilot to simultaneously intercept the glideslope for vertical guidance to the runway and the localizer (for side to side centering), quite possibly overloading its microcircuits.
Halfway down the localizer the control tower radioed to November Oscar that a group of high intensity approach lights apparently were inoperative, occasioning Laversha to take a hasty look through a checklist to see how that affected their planned procedures.
The tower controller witheld clearance for November Oscar to land until the very last moment – in fact it was actually delivered later than regulations permitted for there was an Air France jet still rolling down the runway, groping for its turnoff and almost certainly deflecting the localizer beam.
What truly tightened the noose, however, was that November Oscar’s autopilots were living up to Glen Stewart’s foulest suspicions. Were they in fact locked onto the localizer? Yes….no…..come on….maybe…..damn! “What’s this bloody autopilot doing now?” Laversha and Luffingham recalled Stewart saying at one point during the descent. “I don’t believe it, just look at it.”
In order to make a legal category II approach, November Oscar’s autopilots had to function perfectly, capturing both the glideslope and the localizer. Properly programmed and prepared, the dual autopilots would sense the approaching radio beams, calculate wind drift, speed, interception angle and other variables, electronically check that they agreed with each other. Then, after perhaps one slight feint, they’d nail the ILS and track it to the ground.
What they were doing on November 21, 1989, however, was ‘hemstitching’ – trundling back and forth through the localizer beam like a clumsy bloodhound not quite able to catch the scent. Laversha was worried about Stewart, tired, irritable after all that time in the saddle, trying to handle the monitoring of autopilot status lights and nav instruments largely solo. Copilot Luffingham had become little more than an observer. "I was not qualified to make this approach and could not make any suggestions as to what was wrong," he would later testify. Luffingham had decided the best course was to stay out of the way.
Stewart was illegal, and had been ever since he’d passed the ‘thousand foot gate,’ the point in his approach where he’d descended through an altitude 1,000 feet above the ground. Though there are tricky rationalizations that can be argued endlessly, both airline procedures and CAA regulations seem to specify that a category II or III approach must be discontinued at that point unless all the required equipment, most notably the autopilots, is functioning perfectly and tracking the ILS.
Many highly competent professional pilots have said of November Oscar, “I’d have thrown away the approach, gone to my alternate or tried again. No question about it.”
But other professionals interviewed – some of them BA pilots – say, “Look, he was concerned about fuel. He had a first officer who was no help. He knew a diversion to Manchester would cost the airline a minimum of £20,000. He realized he’d be sitting in the chief pilot’s office trying to explain how he got himself into a position that required a missed approach in the first place. He figured the autopilots would settle down. And I’ll bet he was convinced he’d break out at cat I limits and could take over and hand fly it the rest of the way. I can understand why he carried on.”
It might have worked – and if it had, nobody would ever have heatd of November Oscar,and Glen Stewart would still be a British Airways captain. But at 125 feet above the ground on the radio altimeter, the runway wasn’t in sight, and Stewart made the mistake that turned a routine go around into newspaper headlines.
Always conscious of his passengers’ welfare and comfort he was the sole BA captain who’d bothered to learn enough Japanese to make cabin announcements in that language when he was on the Tokyo route. Stewart had already told the crew that if a go around was needed, it would be done gently rather than in the kind of full power flurry that has everybody back aft white knuckling their armrests.
And it was a leisurely go. Far too leisurely, and November Oscar sank another fifty feet. Stewart and Laversha also caught a glimpse of the approach lights out the left window, and it’s not hard to imagine that Stewart briefly considered sliding over and saving the approach. Said one US jumbo jet instructor pilot familiar with the November Oscar incident, “This is a pilot who was critically low on fuel, which probably was one reason why he waited a second before going around. At decision height on a category II approach, you look to see the slightest glow of approach lights, you wait one potato, see if anything comes into sight.
“At some point, you also become complacent on a familiar approach, you’re so used to it. A thousand time before, he’d watched that same autopilot do strange things on the same approach to the same airport, and he’d break out at 200 or 500 feet and make a play for the runway. And on the crew bus everybody says, ‘Bot, that autopilot screwed up again today.’”
Stewart’s second approach, though the landing elicited applause in the cabin, was not a happy affair. Luffingham noticed that his captain’s hands were shaking as November Oscar climbed out and then was radar vectored back for another try. Stewart was also “cursing under his breath,” as Laversha later put it. The copilot even gently suggested that he fly the second approach, but Stewart waved him away. Stewart then announced that this would be “a no limits attempt at 27R,” shorthand for, “Tires on concrete this time no matter how low we have to go.” It is a procedure not authorized in any manual or rulebook, but it is one that many a rational pilot will employ when fuel is critical.
On the way back to the crew room after shutdown, Stewart’s mind was probably racing, wondering what the consequences of his missed approach would be. When he found in his company letter box a note requesting that the crew see the chief pilot, he told Brian Laversha to collect his wife and go home, that Stewart would say they’d already left. (Carol Laversha had ridden through the entire incident in the cockpit of November Oscar, having been invited by Stewart to sit in the jump seat.)