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Engine Failure During Initial Climb, Stall and Spin, Collision with Ground, in Training

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Engine Failure During Initial Climb, Stall and Spin, Collision with Ground, in Training INVESTIGATION REPORT www.bea.aero (1 )One of the Accident to the PS-28 Cruiser investigators from the Swiss registered HB-WXA Transportation Safety Investigation Board on 5 July 2017 (STSB) was onboard (1) the aeroplane as at Colombier (Switzerland) instructor. In order to safeguard the impartiality of the Time 14:13(2) investigation, STSB chose to delegate Operator GVM Lausanne it to the BEA. Type of flight Training (2)Except where Persons onboard Student pilot and instructor otherwise indicated, times in this report Student pilot and instructor fatally injured, aeroplane Consequences and damage are in local time. destroyed This is a courtesy translation by the BEA of the Final Report on the Safety Investigation published in March 2020. As accurate as the translation may be, the original text in French is the work of reference. Engine failure during initial climb, stall and spin, collision with ground, in training 1 - HISTORY OF THE FLIGHT The student pilot, accompanied by an instructor, departed from Lausanne-La Blécherette airport (Switzerland) bound for Neuchâtel aerodrome (Switzerland). On arriving at the aerodrome, he carried out three aerodrome traffic patterns before making a complete landing shortly before 14:00. After passing by the runway office, the student pilot and instructor got back into the plane. At 14:12, they took off from runway 05 for the return flight. During the initial climb, the aeroplane turned left, then the turn became steeper. The aeroplane entered a nose-down spin and crashed into a small wood bordering Neuchâtel lake, at around 600 m from the threshold of runway 23 of the aerodrome. The BEA investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities. 1/12 BEA2017-0409.en/June 2020 Figure 1: Accident flight path 2 - ADDITIONAL INFORMATION 2.1 Instructor information The instructor, aged 34, had held a professional pilot licence since 8 June 2011 and the instructor rating since 12 May 2016. The day of the accident, he had logged 4,481 flight hours on aeroplanes, of which 103 hours as instructor. 2.2 Student pilot information The student pilot, aged 40, who was following practical training for the private pilot licence (PPL) had logged a flight time of 26 hours 45 minutes and 138 landings. All the flight hours had been carried out on the aeroplane involved in the accident. The student pilot carried out his first solo flight on 21 June 2017. The BEA investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities. 2/12 BEA2017-0409.en/June 2020 2.3 Aircraft information 2.3.1 General The PS-28 Cruiser was built by Czech Sport Aircraft. This aeroplane is classed in the LSA (Light Sport Aircraft) category and holds a restricted certificate of airworthiness. (3)European Aviation This CS-LSA type certificate, issued by EASA(3), specifies that the aeroplane can be equipped Safety Agency. with a certified engine or an uncertified engine. When it is equipped with an uncertified engine, the latter is certified as if forming part of the aeroplane. The aeroplane and engine are then certified as a whole. In this particular case, it is the aircraft manufacturer who provides the maintenance programme concerning the engine. The manufacturer generally takes the maintenance programme provided by the engine manufacturer. The aeroplane had been bought new by GVM Lausanne in April 2013. The PS-28 Cruiser registered HB-WXA was equipped with an uncertified Bombardier Rotax 912 ULS 2 4-cylinder (4)Cf. para. 2.7.3. engine(4). On the crew taking charge of the aeroplane, it had logged 1,493 operating hours and 4,997 landings. Various engine related problems had been reported and treated since April 2015. In particular, engine vibrations and power losses, notably during take-off, had been reported. 2.3.2 Climb speed and stall speed The flight manual indicates a best angle of climb speed of 55 kt and a best rate of climb speed of 62 kt. The flight manual also specifies the following stall speeds at maximum weight (600 kg): flaps retracted: 37 kt; 1st flap detent position (12°): 35 kt; flaps fully extended (30°): 31 kt. 2.3.3 Aircraft manufacturer’s procedure in event of engine failure The engine failure after take-off procedure described in the aeroplane flight manual is the following: (5)Knots-Indicated “1. Airspeed - maintain 60 KIAS(5) Air Speed 2. Flaps - as necessary 3. Fuel selector - OFF 4. Ignition switch - OFF 5. MASTER GEN - OFF 6. MASTER BAT - OFF - before landing 7. Land straight ahead, turning only to avoid obstacles. Note Altitude loss during 180° turn is approximately 400 ft.” The BEA investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities. 3/12 BEA2017-0409.en/June 2020 2.4 Meteorological information The meteorological conditions were anticyclonic, the wind was calm, visibility above 10 km with no clouds. The temperature was 28 °C. 2.5 Aerodrome Information Neuchâtel aerodrome (LSGN) bordering the lake of the same name, is situated 7.5 km southwest of Neuchâtel, at an altitude of 435 m (1,427 ft). It has a 700 x 20 m paved runway 05/23 which is bordered by a 550 x 30 m grass runway. There is no air traffic control service at the aerodrome. The pilots transmit A/A messages on the frequency allocated to the aerodrome. Figure 2: Neuchâtel aerodrome (LSGN) visual approach chart The BEA investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities. 4/12 BEA2017-0409.en/June 2020 2.6 Witness statements The different witnesses reported having heard engine misfires before the engine noise stopped. The witnesses then heard a cracking noise but no-one saw the plane. 2.7 Technical Examinations 2.7.1 Examination of wreckage The examination of the wreckage of the PS-28 did not find any malfunction likely to explain the loss of control of the aeroplane. The flaps were set to 12°, in the take-off position. (6)Electronic Flight 2.7.2 Read-out of parameters recorded in EFIS(6) and video from Neuchâtel Instrument System aerodrome webcam which displays instruments in The accident flight data was retrieved from the two EFIS equipping the instrument panel the cockpit of the aeroplane. The read-out of this data revealed a loss of engine power during the initial climb. This significant loss of power occurred at low height and suddenly: the engine rpm dropped from 5,100 rpm, the nominal rating used for take-off according to the flight manual, to 3,150 rpm, in less than ten seconds. The sampling of the “engine rating” parameter meant that it was not possible to precisely determine the time of the power decrease but the (7) The points examination of the altitude and speed parameters situated this failure at around point(7), correspond to Figure 1 and Figure at a point when the altitude was increasing while the speed was decreasing from 61 kt 3 of the report. to 54 kt. The aeroplane then started a left turn while continuing to climb (point), the pitch being kept above 5°. The left bank increased steadily while the pitch and vertical speed decreased quickly. The airspeed reached a minimum of 34 kt (point) and then the altitude started to quickly decrease. The aeroplane entered a nose-down spin before colliding with the ground. This spin is confirmed by the video recorded by the aerodrome surveillance camera. The BEA investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities. 5/12 BEA2017-0409.en/June 2020 (8)Positive values correspond to a right bank. (8) Figure 3: Accident flight data 2.7.3 Examination of powerplant 2.7.3.1 Carburetors The engine is equipped with two Bing 64 carburetors. The carburetors are located on each side of the upper part of the engine, each one supplying its two neighbouring cylinders. Although the engine was damaged, they were in good condition. The figure below shows cross-section views of this carburetor. Source: manufacturer maintenance manual Figure 4: carburetor cross-section The BEA investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities. 6/12 BEA2017-0409.en/June 2020 On this carburetor, the throttle valve is controlled in the cockpit. The fuel is metered by the movement of a carburetor piston equipped with a jet needle which slides in the needle jet. The higher the needle, the greater the quantity of fuel injected. The needle is equipped with a circlip associated with an O-ring. The circlip prevents the needle from coming out of the carburetor piston under gravity. At the top, the needle is held by a fixation screw (in orange on Figures No 4 and 5) screwed into the carburetor piston. This fixation screw is machined to accommodate the circlip, O-ring and needle. This type of assembly allows the circlip to remain integral with the needle. The end of the needle has several slots. These slots are used to assemble the circlip in various positions. The manufacturer specifies, for each engine, the nominal position of the circlip in order to adjust the fuel flow rate. The needle of the right carburetor was found separated from the circlip, wedged in the main jet. It was bent following a buckling phenomenon. The circlip and O-ring were found whole in the carburetor piston.
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