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Old 16th Jan 2016, 09:17
  #54 (permalink)  
Weathergirly
 
Join Date: Apr 2013
Location: Scotland
Age: 34
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I think the AAIB have overlooked an important point. There is not even a mention of it in the report and I believe this type of accident will happen again if nothing is done. They talk about the Bowtie and error capture but yet they missed a fundamental latent error designed into the approach plate. We do not need to move NDB's or more regulation regarding GPS training, we need the Airports / designers of Airfield plates to ensure that the information is clear and unambiguous. I feel very sorry for the Pilot and passenger, families and loved ones because this could of happened to anyone of us. What I am talking about is how the distance between the DND NDB and the base turn is depicted. It shows a turn commencing at D8. Now is that from the NDB or the IDDE? I beleive the Pilot misinterpreted the plate and flew the 8 miles from the NDB. After very close examination in my front room drinking hot chocolate it becomes clear. Why not put the aid ident next to the dme range like they did years ago? A simple solution. The flight was 30 mins, it was IMC and no Automatics, Airfield plates need to be straightforward and in my opinion this one is not. Many other Airfields are very similar and when the holes in the cheese line up Aircraft bite. Hard.
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