G-AGKN – accident report

ROUTE

The crew had left Cairo for El Adem, Libya at 08:00hrs on the 13th, landing at 11:10hrs. Departed after 30 minutes, landing at Luqa at 15:50hrs. It departed Malta on the 14th at 04:30hrs and was scheduled to land at Marigranne, southern France, at 09:25hrs, departing for the UK at 10:10hrs.

There were no problems into Malta, and a check of the aircraft as regards airframe, engines and radio equipment found everything in good working order.

Departure on the 14th was at 04:35hrs. Five minutes later, the captain reported passing through 7,5000 ft in clear weather on a true tack on 314 degrees. At 05:30hrs, the crew reported being between Sicily and Pantalleria, whilst at 06:42, they were in a position 100 kms from Sardinia. At 07:30hrs, the crew changed frequencies to AIX Area Control (This probably would have been AIX-en-Provence).

Wind speed

The wind forecast at Malta was given variously as varying between 260 and 300 degrees.

In reality the wind, at approx. 18-20 knots, was mostly SW up to Sardinia, SE over Sardinia and again SW up to about 200kms from the French coast. This explains why the aircraft’s arrival time was placed earlier than originally planned. Furthermore, instead of the forecast wind being from ¾ ahead, the crew encountered, without realising it, a beam wind, which caused the aircraft to drift eastwards.

Additionally, a fog bank covered the whole of the coast from Sete to St. Raphael, from sea level up to 2,500 ft in height, and a few kilometers wide.

Navigation - Conjectures

The navigator, described as being very confident, based his navigation on the information received from Malta. At 07:30hrs he must have realised the error/s when he found himself ahead of the time table in the flight plan. For this reason, he sent two revised ETA’s (Estimated Time of Arrival), the first giving an arrival at 09:00, instead of 09:25, and later, at 08:04hrs stating they would be landing at 08:48hrs.

Without consulting radio navigational equipment, the crew transmitted their position at 08:30hrs, placing them 45 kms South of Toulon.

(The above conjecture was borne out by the crew of a DC-3 that left 90 minutes after G-AGKN, and ended up 5 kms to the east of Toulon.)

As the aircraft had still not landed at Marigranne by 09:00hrs, an alarm was issued by the Area Control, and at 11:45 hrs reported came in from fishermen who had heard an aircraft strike Cap SICIE at about 08:30hrs.

The aircraft, subsequently identified as G-AGKN, was almost completely destroyed by the impact and the resulting fires. All six persons on board were killed by the impact. (A wrist watch found amongst the debris showed it had stopped at 08:38:5hrs.)

The pilot.

The captain, acting on the navigators’ calculation, must have believed he was off the coast between Toulon and Marseilles, ten minutes away from the airport. He must have made the decision to make a low approach, descending through what he though was a cloud bank, to emerge in clear weather over the airport.

Conclusions.

The aircraft, crew and company were in order as regards regulations in force at the time.

The aircraft was fully serviceable on leaving Malta, and no problems were reported during the flight.

The flight to France passed without incident, in favourable weather conditions.

The weather report from Malta was inaccurate as far as wind direction was concerned. This error was partly corrected by the navigator, who subsequently updated their arrival time at Marigranne.

There was an error of reckoning on the part of the navigator. Overall, the crew failed to verify their position using the navigational equipment on board the aircraft. *

The pilot started his descent below the level of the highest point in the surrounding area, outside a marked axis suitable for descent through cloud, and without verifying the position by a fix on the VHF or by a radio-compass bearing.

This led to the aircraft blindly flying into the obscured cliff face, resulting in the aircraft’s destruction and loss of life.

Cause/s of incident.

Error of navigation, insufficient attention to detail on the part of the crew, aggravated by rash behaviour on the part of the pilot.

Recommendations.

Navigation had to always be carried out with the greatest of care, whatever the weather encountered. Dead reckonings especially, must constantly be checked by bearings or positions obtained from ground stations.

It is dangerous to leave the safety altitude when not in visual flight, and without applying the standard procedure prescribed for approaching an aerodrome.

* There is a similarity to an accident that occurred with a Short Hythe flying-boat, G-AGHW, in the Isle of Wight on 19.11.47. As with the crew of G-AGKN, the pilot had all the radio and navigational aids on board the aircraft, but chose to ignore them. A note stated: “Two accidents of this type should not occur to aircraft of the same corporation within eight months of each other, in fact such elementary accidents should never occur to Corporation aircraft.”