x12 why would you consider Gibraltar to be dangerous – the apes?
Many airports have unique operating hazards; these are identified and appropriate precautions taken.
In this incident, the crew encountered a set of circumstances that resulted in the aircraft not following the required flight path. Unfortunately, the AAIB appears not to have fully explored the circumstances – the human factors.
The focus of the report is on the need to maintain visual contact. In this incident, the first officer appears to have been head down and perhaps the Captain also when selecting FD off. Using the Reason/Dekker approach to organizational errors; then company SOPs could have prohibited the extraneous tasks. The frequency change could be made at a later point, and the need to switch off the FD for a visual approach has to be examined. This is classic threat and error management – avoid the error provoking situations.
Another consideration is the possibility that both crew members suffered a turning illusion. The aircraft was in a low bank angle turn and as the GA was commenced, the crew did not detect the continuing turn (“the commander considered that he was maintaining a constant heading”). This view could be supported in that the GA thrust was applied where the aircraft was apparently tracking north of the centreline (077), but then stabilised tracking south of the centreline (135) before ATC intervention, all headings approximate. Thus the ‘hold track’ GA function would have been expected to fly the aircraft on a more northerly track than that achieved (assuming a 077 hdg or there about, at GA selection).
A positive aspect is that this incident demonstrates the value of selecting EGPWS Terrain display for all approaches. Although this was fortunately not used due to timely ATC intervention, it provided another ‘in depth’ defensive layer which made the next threat visible (“… as the aircraft turned, noted high ground depicted on the left side of his HSI display”).
We should remind ourselves that a better understanding of an incident depends on our ability to assess why the conditions encountered by the crew (initial GA hdg) appeared normal to them at that time.