Thank you for the link Whopity.
Interesting report...
The ANSP at Birmingham, in common with several other major UK airfields, had applied to the CAA to remove their signalling lamp approximately six to ten years before the incident. This application was supported by a study which showed that signal lamps had limited effectiveness at those airfields. The CAA acknowledged that they had given permission for the signal lamp to be removed but neither they nor the ANSP could locate a copy of the application, permission or the supporting study.
Overall, the report reads a lot less dramatic than the initial posts here which basically suggested that the pilot was some kind of a cowboy. Also, if the aircraft had indeed been impounded once on the ground (as had been reported here) that would seem a massive over-reaction. By who, I wonder?
The Tower controller had logged onto the briefing system after the Safety Notice had been issued but had not seen or acknowledged it. It was subsequently determined that the Safety Notice had been removed in error and thus was not available for the controller to view or acknowledge at that time.
After it became apparent that the controller had not read the Safety Notice, the AAIB asked the unit air traffic manager to interrogate the system and provide a list of staff who also had not electronically signed as having read or printed it. The system generated a list that included this controller but also included members of staff who were not licensed controllers and were therefore not expected to have read it. It also listed controllers who for various reasons were no longer at the unit.
Interesting pre-occupation by the AAIB with NDB approaches.
The pilot stated that he last flew an NDB approach four years before the incident and could not recall flying one in the TBM 850 even though he was reported to have accomplished two during his TBM course.
I can see they could not officially say anything else, but they really ought to know that practically every modern pilot flies NDB approaches using the GPS, either using an overlay or using the OBS mode. Thus, an NDB approach is no different from e.g. a VOR approach (which would be flown using the same method). The actual navaids are (or should be) tuned in, at least.
The lateral accuracy of the final approach suggests he did indeed use the GPS (**)
Apart from his frequency selection mistake, he did not commit any crime by landing without a landing clearance.
ICAO Doc 4444, the UK AIP and the specific instructions for Birmingham, in common with most other UK airfields, require a crew having lost communications on intermediate or final approach to continue visually or by means of an appropriate final approach aid. As the pilot of N850TV had lost communications, albeit through a frequency mis‑selection, this is the situation in which he found himself.
Following a loss of communications, ICAO Doc 4444 and the UK AIP require aircraft to continue visually and at least 17 multi-pilot public transport passenger flights have landed without clearance in the UK in the 12 months to March 2011. In those cases the runway was clear.
[my bold]
In summary it is likely that air traffic controllers assume that a loss of communications will probably result in a go-around while pilots are expecting that they will land if they are able.
The ATC assumption assumes the pilot detects the loss of comms, but that is obviously not always going to happen...
Another little gem:
The ATIS also significantly exceeds the recommended MATS (Part 1) length
(**) I have just looked up the ILS 15 for EGBB and wonder if the AAIB report page 2 (shown as page "54" in the PDF, curiously) has a mistake on it. The plate does not suggest the ILS or NDB is offset, but the AAIB diagram shows a ~ 5 degree offset. The Jepp plate shows both the ILS/NDB 15 and the runway 15 to be 148 degrees.