Computer-Related Incidents with Commercial Aircraft

Beech 300, CFIT, Blumberg near Donaueschingen, Germany, October 2000

24 October 2000

Synopsis The contract flight crew were testing navigation signal strength and accuracy for certifying a new instrument approach at the Donaueschingen airport. The weather was cloudy. The proofing procedure required the aircraft to land at the airport at the end of testing, but a visual flight rules approach and landing was impractical because of the weather. The captain decided to try to fly the approach, even though it was not yet certified and therefore not legally available. Because he had no approach plate, he tried to fly it from memory. His memory was not accurate, and the aircraft impacted a hillside, killing the pilot, copilot and the navigation test engineer.

This incident is not directly computer-related. I include it here because it is an astounding and particularly vivid example of what is called "continued flight into adverse conditions" resulting in a CFIT accident. Such accidents happen to all too many general aviation aircraft every year. But this pilot was a professional, working on contract to the German aviation authorities. Of all people, he should have been most aware of the risks.

The Final Report is only available in German, as is a Why-Because Graph of the accident.