Captain Roger Attenborough, 54, slumped unconscious as he prepared to land a Britannia Airways Boeing 757, carrying 220 passengers, at Malaga airport in southern Spain.
His co-pilot managed to land the aircraft safely, but Capt Attenborough was declared dead after he was taken to hospital.
An Air Accident Investigation Branch into the incident on 28 January found:
8 A nurse could not be strapped into the spare seats in the cockpit to attend to the captain.
8 Having declared an emergency, the co-pilot could not land first time because the approach he was given triggered a ground proximity system alert.
8 A waiting paramedic could not board for two or three minutes as the steps had not arrived.
The report said the co-pilot had initially summoned assistance after he noticed the captain was struggling for breath.
A flight attendant arrived to find the captain apparently unconscious. Neither the flight attendant nor the nurse could tell if he had a very faint pulse or none at all. Two flight attendants and the nurse gave the captain heart massage when the plane landed and the paramedic administered adrenaline.
The report said the captain "died during or shortly after the flight". It added that the Spanish authorities had carried out a post-mortem examination and a full medical report was awaited.