Pilot sick on QF flight

[gulfboy]

Situation well handeled!

http://www.smh.com.au/news/travel/qantas-pilot-collapses-in-cockpit/2007/11/29/1196037038648.html

[ThreadBaron]

Yet another confirmation that the systems work!


co-pilot ... forced to leave his seat - leaving the plane unmanned


Now that is the real story!

[Capn Bloggs]

He had to get out of his seat to get his red pen from his overnight bag. Red pens are required to be carried by all FOs in Australian Operations to put a line through the captain's name on the seniority list (CAR 315 (3)a refers) when he falls ill.

[Lowkoon]

Was it "pan fried" meal? Or visine in the tea? :)

[Doug E Style]

Maybe he'd eaten some sushi whilst in Japan and it hadn't been cooked properly.

[yowie]

MMMM Crewing with Cap'n Bloggs today, Check red pen, Check spare red pen, check spare spare red pen:p

[frangatang]

Aagh am alweez coming to theese chanel for daa comedy! menee thanksss

[sitigeltfel]

Check out post #17 here by Soggyblonde.

http://www.pprune.org/forums/showthread.php?p=3693838&mode=linear#post3693838

Was she CC on this flight?

[Pinkman]

Thread Baron, yes, that is how its supposed to work and we should celebrate that. But remember the really sad case where, on a 747 classic - about 1989 - where the f/o got food poisoning (I think the sector was BAH-LHR) and was made to rest 'out back'.

Although he returned to the flight deck, the PIC workload, tiredness, weather conditions (Cat 3 limits) , and an accompanying autoland failure/conflict meant that he failed to notice until very late in the approach that the autoland system had allowed the aircraft to drift off the centreline, whereupon he executed a go-around. In the G/A the aircraft missed the Heathrow Penta hotel (by about 12 feet reportedly).

The oldies will remember the very sad outcome where the PIC eventually committed suicide. Yes it worked, but Cairns isnt exactly as labour intensive as EGLL and we need to keep remembering lessons learned.

P

[747flyby]

We can always discuss what would be best to do. However I salute this First Officer for handling the situation the best he thought was possible.

We can also consider the scenario if the captain had food poisoning from hotel food or catering. The F/O might be becoming sick as well. With no access to the cockpit becaus the capt was blocking the door. I would say the F/O did excactly the right thing. However I was not there, I dont know.

Again I salute this First Officer for handling a difficult situation well.

[Dave Gittins]

I remember at the time a lot of condemnation of the authorities and "There but for the grace of God ... " comments.

RIP Glen Stewart.

Does anybody still have a copy of the "Pilot" article about the incident ? ... and more interestingly the painting that accompanied it ?.

[kingair9]

A few weeks ago a Eurowings CRJ Captain died in his seat on a TXL-DUS flight, FO landed the plane in Hannover HAJ probably despite not having a red pen. Unfortunately such things happen everywhere in the world....

[Flight Detent]

Just noticed....wonder where the pax sit on those longer flights, ...I understand from the report that the doctor was "called to the cabin", from where, I wonder.

Cheers...FD :D

[BoeingMEL]

Pinkman....many of us will never forget G-AWNO...

In my 28 years at the sharp end I never encountered such injustice and tragedy. Awful, just awful. May he forever RIP. Rgds, bm.:ugh:

[Will Hung]

15 years ago to the day. RIP

[Connetts]

I messed up a first attempt to comment on Pinkman and G-AWNO. It's the first attempt I've made to post and apologise for making a nuisance of myself. I gave and repeat a brief personal profile to explain my interest.

I am not a pilot but a retired legal academic with a research post in criminal justice and with an interest in your work - which it was the Lord's intention that I should do, just over fifty years ago, but was frustrated by a paternal decree which I still resent. Now and then I blow some pension and wander round for an hour or so in a Tomahawk with an instructor, but I cannot obtain even a PPL: the process was interrupted permanently by an aneurysm a few years back, though the surgeon insists his Teflon tubing is better than the aorta which was originally installed over 70 years ago.

G-AWNO (and its tragic aftermath) is a horrible case which upset me greatly. It is a case I have studied and published on. I am currently working on a further paper on the criminal liability of pilots, a topic which continues to bother me as there seems to be a lack of coherence in the jurisprudence. I would hope to be able to contribute to legal literature and prevent something like that ever happening again, but I am confused about some of the legal issues.

I have no problems about disclosing my identity off-list but I am uncertain about the protocol and feel somewhat intrusive watching your collective workspace thus at all.

I should be grateful if anyone could give me instances, anywhere in the world, of the conviction of a professional pilot under legislation which makes it an offence which might be broadly described as endangering an aircraft - any country in the world would be relevant. As the sort of model, I refer to the UK's ANO Arts 73 and 74. I would need publicly accessible bibliographic citation details (eg newspaper reports and law reports) so that it can be referred to in a refereed law journal, and it would inevitably make for a publicly-identifiable incident. I am a little reluctant to use the "personal communication" footnote as this could cause ethical problems of disclosure and anonymity.

It is remarkable how few such cases I have been able to locate. I have some statistics of UK prosecutions but these appear to be almost invariably of PPLs.

I hope that I am not out of order in making this enquiry.

[Connetts]

Reply to Dave Gittens:

I do. It's a bit dog-eared and was photocopied badly by some university library, and I am seeking a better myself. The full reference is
Wilkinson, Stephan: `The November Oscar Incident’, Pilot, February 1994, 32.

It is well-written, well-researched and detailed, and makes for unhappy reading.

[dkaarma]

co-pilot ... forced to leave his seat - leaving the plane unmanned

Otto was flying... (sorry, just watched Airplane/Flying High last weekend)

...I'll get my coat

[Taildragger67]

Connetts,

I put it to you that you may be asking slightly the wrong question (or that a related one also needs to be asked) - that is, are there countries which put criminal liability on pilots for endangering passengers, rather than aircraft?

I am not sure of this, not having read a report on the incident, but I seem to recall that the PIC of an aircraft which diverted into Kansai within the last few years, following a cargo hold smoke alarm, was very eager to stay airside. My recollection (from press reports) is that as the a/c landed, tower confirmed smoke (which may simply have been from the tyres contacting the runway), so the pilot initiated an evac, during the course of which a couple of passengers were slightly injured. The drum seemed to be that if he went landside, ie. lnaded' in Japan, he'd get knicked for setting in train the events by which some passengers were injured.

Turns out it was a false fire alarm and all was ok.

Maybe another PPRuNer can provide more details.

My point is, I suspect that, aside from well-trodden paths regarding liability for property damage (to the hull and non-human contents), the main source of criminal liability is for personal injury.

Good luck and my legal brain would love to hear of the outcome of your research.

[Rainboe]

Connetts- very intriguing post. The legislation in the UK seems to have been used on Rail employees and Ferry employees mainly. The G-AWNO incident is little known publicly because no damage or injuries were caused, but the ramifications went deep. It was inexplicable to us colleagues of the Captain exactly why the prosecution was brought in the first place, and what exactly it achieved. Indeed it alone caused a dreadfully serious fallout.

As far as aviation is concerned, the nearest that springs to mind was the Exeter Viscount fuel starvation of about 30 years back, but I do not believe that was a prosecution.

[Pinkman]

Connetts
Bizarrely, your query is to a small degree answered by an old post in pprune
( http://www.pprune.org/forums/showthread.php?t=67009&referrerid=9605 )
on this exact topic. Browsing the posters and PMing the ones with obvious aviation legal knowledge may bring you a few steps further on. Its telling that the above thread, started many years ago, is still being commented on in 2007. I thought M. Mouse's comment on that thread interesting.
Pinkman

[747flyby]

Im sorry about the ignorance.
Are you gentlemen talking about the approach in heathrow were they just missed a hotel on the go-around?

I have just heard briefly about it. What I heard from ex BA captains that they were all suffering from food poisoning and everything in this flight went wrong from the begining starting with delays.

I also remember the poor captain died shortly after this incident.

I dont want to comment since I dont know the details.

However from what I heard was that the crew did not get a fair treatment as a result of PR thing in BA.

I asked some of those BA guys where BALPA stood in this.
They said that BALPA did not defend this crew since they could not.
Reason I dont know.

Maybe some of you gentlemen would kindly shed some light on this incident for the rest of us.

In my company we once had an incident/accident and the company and the union backed the crew 100% even if the outcome could have been unfavorable for the crew.

Also if the crew or the captain was to blame it is still the duty of the union were the pilot pays his dues to defend him and do their best for the most favorable outcome for them with their employer.

[GrumpyOldFart]

Does anyone know why there seems to be no reference to the G-AWNO incident on the AAIB website? Politics? Commercial pressure?

[Pinkman]

Jerry

As far as I know it wasnt investigated by the AAIB. It became a criminal matter and it was the CAA that brought the prosecution. I cannot imagine it playing out the same way in todays' climate.

[Brian Abraham]

By grace of a fellow Ppruner I have a photo copy of the G-AWNO "Pilot" article. Anyone desiring same please PM with email address to send the attachments.

[747flyby]

Can you paste it on this forum for the rest of us to see.

[weasil]

co-pilot ... forced to leave his seat - leaving the plane unmanned
even my old man who has never been in aviation was amazed at the stupidity of the emphasis that was placed on this tidbit. He said all the local news channels near his house were going on about how the plane was not being flown by anyone! Even he is aware of the existence of an auto pilot...

:ugh:

[PBL]

Following Connetts's reference to G-AWNO and Brian's offer, I called up Pilot magazine at +44 1799 544 200, and was forwarded to a lady named Becky, who is their archivist and quite happy to photocopy and send the article to me for GBP 6.75.

PBL

[Connetts]

I'm replying to the post on 30 November from Taildragger, who appears to be a lawyer also.

The more I look at the law in SA and the UK -- which make a useful comparison -- the more confused I become. Remember that I'm like all academics: one starts one's career confident that one knows a little about everything, and one ends it 35 or so years later uneasily aware that one might possibly have learned a great deal about almost nothing and unsure whether one knows anything useful at all.

One of the things that has become clear is that the form the law takes varies greatly from country to country, and this includes the presence or absence of references to the state of mind (the mens rea) of the person accused. In South Africa, there is no reference at all in Civil Aviation Regulation 91.01.10 to any state of mind, but the Constitution's Bill of Rights has been interpreted to deal with that very effectively and wisely, and the regulation is thus terse, clear and I like it.

By comparison, the ANO (under which Capt. Stewart was prosecuted) formulates the law very differently in the UK, as I tried to explain in a paper I wrote some years ago. Reference is made to recklessness and negligence, but what the words mean I won't even begin to explain. I thought in 1996 that the UK law was a mess. The explanation why I think this is boring lawyers' law. As they say, those who claim to know the answer obviously don't understand the problem.

I have not looked at the law closely in other jurisdictions, but it is clear when one looks at the reported instances of prosecutions of airline pilots that there are huge differences which involve not only the definitions of the offences but the procedures by which they are dealt with.

When I'm a passenger I trust the guys in front because they're well-trained, and there's at least two of them who don't entirely trust each other and act accordingly.

[Idle Thrust]

Connetts:

Canada has now joined the club:

http://www.cbc.ca/canada/manitoba/story/2007/11/02/winnipeg-crash.html#skip300x250

I have the judgment in pdf format - will forward to any PM requests.

Negligent, yes, but criminally? I guess the lawyers can argue that.

[Brian Abraham]

The photo copy I have of the “Pilot” magazine article by Stephan Wilkinson on the “November Oscar Incident” is not of high quality (thanks PBL for the info) so I’ve taken the time to type it out and so post it for all. Will leave copyright issues to the Mods to determine and delete if they see fit.

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.

[Brian Abraham]

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, ‘Boy, 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.)
Stewart also balked, refused to speak with a BA Air Safety investigator and drove the 25 miles straight home to his small, 500 year old restored medieval house in the travel poster cliché Berkshire village of Wokingham. His wife, Samantha, a thinly, attractive, red haired, ex British Airways flight attendant, remembers that, “It was the same sort of morning as after any long trip. He was tired, but w3e talked about Mauritius, because we’d both been there together on vacation. An hour later, he said, ‘I’m off to bed, but you might get a call from BA, because there was a go around.’ It wasn’t anything I thought important.”
It was. “He got a call around eight that evening saying the crew had been suspended,” Samantha Stewart says.
Three days later, Glen Stewart wrote letters to both Brian Laversha and Tim Luffingham unstintingly praising their airmanship under difficult conditions and accepting full responsibility “as both captain and handling pilot” for the November Oscar incident. British Airways investigated the affair, and after a tortuous fourteen drafts that Stewart and his crew continued to claim were riddled with errors, finally issued a report castigating Stewart and chiding Luffingham and Laverska as well. Stewart was demoted to first officer, to fly out the rest of his career in the right seat, and his air transport pilot’s license was concurrently altered to copilot status by the CAA.
That was too much for a proud, stubborn Scotsman who began flying RAF aircraft at the age of 21, who had devoted virtually all of his adult life to British Airways, and who was being disciplined for – as he saw it, doing the best he could to get his passengers to their destination without unnecessary expense and awkwardness. On April 2, 1990, Glen Stewart resigned from BA, spent the next three days learning how to use a word processor, and set out to appeal the CAA’s license downgrading.
Others saw it differently, of course. Stewart was not a star aviator. Recently, he had been receiving grades of “average” on his every six month simulator check rides, and instructors had noted that he did not perform well under pressure. During his final flight he made a number of minor errors that were caught by Luffingham and Laverska – mis set switches, faulty cross checks, some awkward flying. He was slow moving and methodical in a trade where some decisions must be made expeditiously. Indeed, the prosecution at Isleworth would claim that he had been too slow moving and methodical in flying the necessary go around that November day.
There is a common assumption that the biggest airliners get the best pilots. It is not necessarily true, for there are no merit promotions in the cockpit. Pilots move up based on seniority – the length of time they’ve been with the company. The flight engineer on a weary 727 flying between Cleveland and Cincinnati might be an ex Blue Angel with golden hands, while the captain of the same line’s shiniest 747-400 Big Top en route to Bangkok might be an average Joe who started out in Cessnas and has managed to make it through thirty years without busting a regulation or bending the metal. That Stewart was flying one of British Airways’ bigger and more complex aircraft was a reflection of the airline axiom, “A captain is nothing but a copilot who’s been with the company longer.”
Yet why the Stewart case ever came to trial remains the subject of speculation. There is considerable feeling that British Airways was not sorry to see it happen – that the prickly Stewart was a loose cannon who could have made things awkward for an airline that is famously concerned about its public image. Some feel that Stewart could have revealed some debateable company procedures, such as the unfortunate all weather dispensation policy. For Stewart to be branded a criminal would effectively negate whatever his accusations might be.
Stewart himself felt he was hauled into court “because British Airways and its supervisor the CAA condoned, wished, hoped, prayed, pressurized me to keep quiet, but preferably dematerialize,” and that when he didn’t, they had no option but to publicly punish him.
Others suspect that empire building within the CAA legal branch should be considered – that this looked like a juicy case for an aspiring prosecutor to take public and demonstrate that even the flag carrier’s jumbo jet captains daren’t take on the Aviation Authority’s cops and lawyers casually.
“Glen was the first line pilot they could go after,” Samantha Stewart opines. “A management pilot landed a Concorde on fumes, and they never did a thing to him.”
Management pilots are those with company executive rank. Director of Flight Training, Concorde Chief Pilot and the like and indeed in 1987 one of them demonstrated airmanship that many argue was far more faulty than Glen Stewart’s. Despite the pleas of his flight engineer to divert, he pressed on and landed at Heathrow with so little fuel that the supersonic transport had its forward tanks topped off before the passengers could be disembarked, to stop it tipping backwards. Only when press accounts of the incident surfaced did British Airways quietly retire that captain, his license and pension – unlike Stewart’s, untouched.
Said one Hong Kong based L-1011 captain, British albeit not a BA pilot, “My personal opinion is that the fleet manager who authorized November Oscar’s approach with an unqualified crew should have been the one in court.” Six weeks after the incident, British Airways anounced that it was no longer granting all weather dispensations.
A senior British Airways captain quoted by a London newspaper at the time said, “The aircraft was certificated for three crew who are supposed to cross check each other’s movements. The other flight crew members are back flying again [In fact, Brian Laversha had also resigned from BA.] So why is it Captain Stewart is in the dock? Even if, at worst, it was a flying cock up, how can that be construed as criminal? There but for the grace of God go a lot of pilots. Are we to be prosecuted for every little slip up?”
But was it just “a little slip up?” My sympathies for Stewart were being surely tried, for the approach he’d flown was one that I was tempted to say I’d have discarded and reflown long before things got out of hand. Many professionals privately agreed that they’d have thrown it away as well, though Samantha Stewart characterized them as “a few clever Dicks who think they’re too smart for it ever to happen to them.”
Still, it was well known among Classic Fleet crews that the early 747’s Sperry autopilot required lots of gentling before it would lock onto an ILS. “If your strictly within speed and intercept parameters, it will capture the localizer. If not, it will never capture. It’ll bracket and get worse and worse,” says another BA Classic captain.
In retrospect, Stewart might have demanded of the controller a longer final approach, to allow the autopilot time to settle down. But at eight in the morning, with night flights from all over the world converging on Heathrow, the rules need to be flexible. Stewart was in fact placed five miles behind the traffic he was following rather than the legal minimum of six, and he was asked to fly a hasty approach beyond the autopilot’s capabilities. The controller who put November Oscar in this position, however, was not in the dock.
“They showed Glen the courtroom in advance, so he’d know what to expect,” Samantha Stewart recalls, “but he was horrified. He was a terribly moral gentleman and here was a dock where rapists stood. They at least during the trial let him sit with the BAI.PA people who had organized Stewart’s defence, but during the sentencing, he had to sit in the dock with a policeman. It was awful for him.”
The trial took eleven days of extremely complex, technical testimony, before a lay jury of nonpilots the average age of which was 26. And before a judge who, well into the trial, admitted that he still didn’t know where a 747 flight engineer sat. Some jurors napped, not surprisingly, for the testimony detailing the sequence of checklists, button pushing, instrument indications and warning lights that marked November Oscar’s progress down the Heathrow 27R ILS was a complex yet dry recitation. Stewart himself used homemade pocket notes of indicator light colours and switch sequencing during the approach to ensure that he’d got it right.
“It’s a very, very complicated procedure,” another British Airways 747 captain admits. “Flying that aircraft on automatic demands a workload that can actually be too much, especially if you don’t have a good copilot.”
Stewart, in defence of his actions during the company’s own inquiry, had doggedly raised issue after issue, some of which danced around the question of exactly what had gone wrong and why. Accused, for example, of failing to file immediately upon landing the necessary MOR – ‘mandatory occurrence report.’ Stewart argued that because he had at least initiated the go-around from decision height and had landed successfully out of the second approach, it didn’t constitute an ‘occurrence.’ Few agreed.
He argued that nowhere was it officially written that a proper go around required a pitch up in the airplane’s attitude of three degrees per second, which the airline claimed was the proper technique. (Stewart had applied back yoke that rotated November Oscar at a rate of less than one degree per second). Well, maybe not, but it is the way to get the job done.
At one point, Stewart created a transcription of every oral call-out, checklist response and radio transmission required by company and CAA regulations during the approach and demonstrated that simply reading the script aloud, nonstop, took seven minutes. The entire approach itself had consumed only four, thus demonstrating that the letter of the law required the impossible. It was an interesting point, but nobody cared.
Much was made by Stewart and his supporters of the fact that November Oscar was dispatched on its next leg, to Nairobi, before recalcitrant autopilot could be examined for possible faults. And that four crucial pages from the airplane’s maintenance log, which might have detailed repairs to that autopilot, are to this day missing. “There was a coverup,” Flight Engineer Laversha insists. “That was made obvious by the fact that they sent the airplane right out again, and nobody was given an opportunity to examine it.” But if the autopilot indeed was malfunctioning, isn’t it the crew’s job to detect that and compensate for it?”
Much of the trial revolved around arcane legal points and Stewart himself was never even called to testify on his own behalf. His BALPA lawyers apparently believed that he would only continue to raise issues not relevant to the manner in which the charges were worded. He at best would seem to be mitigating his actions, at worst could incriminate himself further.
When the verdicts were announced, Stewart’s many supporters in the courtroom cheered , for the first of the two found him not guilty of endangering people on the ground. “Even the ushers were on our side,” Sam Stewart recalls. The second verdict, however, branded him guilty of criminal negligence in endangering his passengers.
How he could be guilty of one and not the other baffled even a member of the prosecution team, who after the trail commented that the judgement was ‘bizarre.” It is said that when the jury told the judge they’d come to a decision on the first charge but hadn’t yet agreed on the second, he suggested with some impatience that they get their act together and wind the thing up, thus prodding the jury to perhaps made an overly hasty assessment.
Still, Judge George Bathurst-Norman did seem to hold a degree of sympathy for Stewart. He turned down the CAA’s demand that Stewart pay £45,000 in court costs and assessed only £1,500, and his refusal to levy a mandatory jail sentence reflected to observers the sense that Bathurst-Norman felt the case should never have come to trial.
Stewart appealed the decision. Lawyer Arthur Mitchell, an aviation specialist, raised a variety of subtle legal points, most notably the defence that the CAA had no legal right to itself bring a prosecution. “In fact, the CAA itself was fault,” Mitchell later said, “for permitting a situation to exist in which the BA Flight Operations Manual contained a provision that Glen would be expected to use, by which it could authorize Glen to make the approach without a qualified copilot. The approach was actually illegal at the fault of British Airways, yet they were not charged.
“Had that provision not existed, Glen would have diverted to Frankfurt with cozy fuel reserves, to await better weather at London. It would not have been a long wait and would have given an opportunity to refuel, resulting in less stress on the eventual approach to London.”
Stewart’s appeal was summarily rejected.
“The great problem is that aircraft accident and incident investigation has always concentrated on finding out what happened rather than why it happened,"”says David Beaty, a former BOAC pilot and today one of the world's leading authorities on human factors in aviation. “Glen got himself into an impossible position on that approach and took fifteen seconds too long to do something about it. That would be enough for the typical investigating body. In England, an investigation is actually an allocation of blame, and the cause of the mistake disappears in the process. The idea of taking something like this into a court of law is absolutely wrong. You will never get near the truth that way.
“A mistake was made,” Beaty admits, “but it was a collective mistake. Loads of other people made mistakes too, and that has not sufficiently been brought out.”
In the end, I rejoined the Stewart camp, embarrassed to admit to myself that I, too, would never have understood the pressures under which a modern day airline captain operates unless friends and acquaintances who do it every day made it obvious to me. That I too might in fact have continued with the approach, convinced that it would be more expedient to sort it out while descending than to get myself into a box that might cost me a reprimand. A lot of lip service is paid to the myth of command residing in the cockpit, to the fantasy of the captain of the ship as ultimate decision maker. Too often today, however, the commander must first consult with the accountant. (The sound you hear is the outrage of airline executives the world over insisting that nothing is ever allowed to compromise safety. True, in a perfect world.)
“As a small boy, Glen lived near RAF Leuchars at the end of the War, and he used to watch the Coastal Command B-24 Liberators take off and land. That inspired him to become a pilot,” David Beaty muses. “I was flying Liberators out of Leuchars at the end of the War, and it makes me sad to think that perhaps one of those airplanes he watched was mine.”
On December 1, 1992, three years and nine days after B747-136 G-AWNO set off car alarms in the Petra Hotel parking lot, William Glen Stewart left his small house in Wokingham without a word to his wife. He drove some nine hours to a beach ten miles from his birth place in Scotland, near RAF Leuchars.
Stewart attached a hose to the exhaust pipe, led it into the car through a nearly closed window and in moments had asphyxiated himself. He did not leave a letter or any explanation for his action.

[Eagle45]

I never heard of it before. After reading it, I can only say: very dramatic and sad story. As a heavy jets professional flight engineer I understood every step of it but the trial := - not fair at all.

[Gipsy Queen]

Thanks for taking the trouble, Brian. I have to admit the reading of the attachment to the PM you kindly sent me was causing all sorts of occular problems!:ouch:

[Ye Olde Pilot]

The important point about Glen Stewart is he should have decided to abort the flight and land or divert earlier. To try an approach with all the cards stacked against him was pushing it.

[Itswindyout]

We have all been there, and 20/20 hindsight is always a bonus when tea and biscuits are offered.

The same guys who insists that the company will FLY by the book, will be the first who insists that the approach he made was perfectly safe....whatever....

[outofsynch]

If you haven't already....
Have a look at AN903 9/6/95. A DH8 accident in New Zealand.

Police took out their own investigation, (in parallel to TAIC) and after almost 10yrs brought criminal proceedings against the Captain. It all got thrown out fairly quickly, but there was a long court case over police getting access to the CVR, which they got in the end. This resulted in almost all CVR's being deactivated in NZ for a few years, until futher protective legislation was enacted.

[Frank Furillo]

Many thanks for posting that Brian. My Fiancee's Aunt is Glens widow, she has pictures of Glen with her when she was a child and remembers him in the way that we remember our Uncle's and Aunty's.
I have been trying to find some information on this incident for some time. We both thank you very very much for posting this very objective and interesting article.
Frank

[skiesfull]

Glen was the Captain on 2 trips that I did not long before the "November Oscar" incident. He was an absolute gentleman and deserved the description of being 'a gentle giant'. In my view, he was appallingly treated by both Airline and CAA and as for the Judge, who tried to liken flying with driving, words fail me.
Later on, as a Captain, I flew 'NO' on a very interesting automatic approach, which weaved it's way down the ILS until I disconnected the automatics. My memory of that 747, is that it was downgraded to CAT 1 frequently.

[corsair]

A very unfortunate incident. As it happens I knew Tim Luffingham, he was one of my early instructors. A good guy. Lost touch with him long ago. Anyone know of his current wherabouts?

[Poof in Boots]

Your account of this incident is wonderful Brian and really should be published for a wider audience.

I remember this incident very well and I had flown with Capt Stewart a couple of times before. He was a lovely man, very pleasant and kind.

To be honest, some of the CRM issues here remind me of the Staines Trident crash. Things are no better nearly twenty years on from this near crash. I recently flew over India in Monsoon season on a 777, where the weather radar had completly failed 45 minutes after leaving SIN for LHR.

We should have gone back rather than risk putting the aircraft into a CB for so long. No advice from the airline was forthcoming, it was left to the Captain to make the decision whether to carry on or not. Once again the commercial impact of going back to SIN was no doubt in the minds of that Flight Crew, as that which persuaded Capt Stewart not to divert. Of course if we had of survived an encounter with a CB, it would have been tea and biscuits for them. It was a poor decision, but they got away with it.

Tim Luffingham is a Captain on the 747-400.

[M.Mouse]

We should have gone back rather than risk putting the aircraft into a CB for so long. No advice from the airline was forthcoming, it was left to the Captain to make the decision whether to carry on or not.

A now retired but very well respected BA training captain with whom I flew several times told me over a beer somewhere downroute of a total weather radar system failure just airborne out of Sydney, Australia bound for Bangkok. He elected to continue have assessed the options and risks as he saw them. A couple of hours out from Bangkok, in the dark, they inadvertantly flew into a Cb. There were injuries on board and in his words it was very frightening. He said he would never ever continue again without serviceable weather radar.

I have always remembered that conversation and to BA's credit, while they would perhaps not advise me of what to do should I ask in flight for example, I am 99.9% certain that if I did divert in such circumstances I would face no comeback.

I would also say that much has changed within BA since the November Oscar travesty. A cliché but I believe much has been learned since from that incident and others. Also it would appear that corporate responsibility and prosecution of executives in recent years might well have served to change matters too.

[flash8]

Brian

Many thanks. That must have taken many hours to type out. I thought at the time it was completely shameful how they hounded a decent man to the grave.

Those involved at the time and contributed to the outcome should be utterly ashamed of their role. Time does not heal, and some of us have long memories.

flash.

[equal]

wow, what an amazing article. :ooh:

[captaintunedog777]

Strange no one has asked. But why the hell did the FO get out of his seat??? The CSM came forward to help so why didn't the CSM bring some other FA's to help lift the Cap? Instaed the FO gets out of his seat!!!

[Keg]

If you're talking about the original incident in 2007, the door of the 767 opens inwards. If a crew member has fallen down beside it on the flight deck side of it the door is not going to open without the potential of serious injury to the already stricken crew member. Additional F/As on the wrong side of the door won't help. Once the door was clear the F/O jumped back in his seat.

[dragon man]

Thank you Brian i lost my copy of this many years ago and am pleased to have one again. This story is amongst other things why we have and need a strong union. Anyone who thinks management would back them read this. Its my belief that a good and very decent man was let down and appallingly treated by BA management. Do i think Qantas would be any different? NO. To younger pilots read this story, print it, and never forget it.

[nitpicker330]

God what a load of bollocks, this F/O did exactly what he should have done, I hope that my F/O wouldn't leave me lying beside the door in a heap!!

Why is this even a story?

[gobbledock]

nitpicker330, I agree.
Why is this even a story?
Big deal, pilot gets sick, whoopee doo and who gives a sh#t. It happens on ocaasion. Life goes on.

[teresa green]

Had a Flight Engineer take a fit on a red eye. (B727). About 0300, he complained of back pain earlier, but nothing to drastic. Myself and the F/O were present on the flight deck, and it would have to be said, it was quite spectacular. He lost complete control of his body functions, he fell sideways only kept in by his shoulderstrap, and he had no control of his limbs which were all over the place. I hit the button for the Cabin Manager, who thankfully was a trained nursing sister, she assessed him straight away, and he slowly came out of it, and had no memory of it what so ever, in fact just went back to his panel like nothing had happened. Needless to say the F/O and I just looked at him dumbfounded. Turned out he had a raging kidney infection, which pushed his blood pressure up thru roof, which in turn caused him to take a fit. I realised then what we take for granted (good health) is not always so, and enrolled myself in a first aid course, in the hope it would give me some insight to medical problems on the flight deck. Luckily for us many of the female flight attendants at TAA were trained nursing sisters, and were a great help in illness in both PAX and crew, (and the occasional death).