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AAIB Bulletin 10/2018

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AAIB Bulletin 10/2018 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 10/2018 Berkshire Copse Road Aldershot GLOSSARY OF ABBREVIATIONS Hants GU11 2HH aal above airfield level lb pound(s) ACAS Airborne Collision Avoidance System LP low pressure Tel: 01252 510300 ACARS Automatic Communications And Reporting System LAA Light Aircraft Association ADF Automatic Direction Finding equipment LDA Landing Distance Available Fax: 01252 376999 AFIS(O) Aerodrome Flight Information Service (Officer) LPC Licence Proficiency Check Press enquiries: 0207 944 3118/4292 agl above ground level m metre(s) http://www.aaib.gov.uk AIC Aeronautical Information Circular MDA Minimum Descent Altitude amsl above mean sea level METAR a timed aerodrome meteorological report AOM Aerodrome Operating Minima min minutes APU Auxiliary Power Unit mm millimetre(s) ASI airspeed indicator mph miles per hour ATC(C)(O) Air Traffic Control (Centre)( Officer) MTWA Maximum Total Weight Authorised ATIS Automatic Terminal Information Service N Newtons ATPL Airline Transport Pilot’s Licence NR Main rotor rotation speed (rotorcraft) BMAA British Microlight Aircraft Association N Gas generator rotation speed (rotorcraft) AAIB investigations are conducted in accordance with g BGA British Gliding Association N1 engine fan or LP compressor speed Annex 13 to the ICAO Convention on International Civil Aviation, BBAC British Balloon and Airship Club NDB Non-Directional radio Beacon EU Regulation No 996/2010 and The Civil Aviation (Investigation of BHPA British Hang Gliding & Paragliding Association nm nautical mile(s) CAA Civil Aviation Authority NOTAM Notice to Airmen Air Accidents and Incidents) Regulations 2018. CAVOK Ceiling And Visibility OK (for VFR flight) OAT Outside Air Temperature CAS calibrated airspeed OPC Operator Proficiency Check cc cubic centimetres PAPI Precision Approach Path Indicator The sole objective of the investigation of an accident or incident under these CG Centre of Gravity PF Pilot Flying Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PIC Pilot in Command CPL Commercial Pilot’s Licence PM Pilot Monitoring purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true POH Pilot’s Operating Handbook CVR Cockpit Voice Recorder PPL Private Pilot’s Licence DME Distance Measuring Equipment psi pounds per square inch Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed QFE altimeter pressure setting to indicate height or blame or determine liability, since neither the investigation nor the reporting EASA European Aviation Safety Agency above aerodrome ECAM Electronic Centralised Aircraft Monitoring QNH altimeter pressure setting to indicate process has been undertaken for that purpose. EGPWS Enhanced GPWS elevation amsl EGT Exhaust Gas Temperature RA Resolution Advisory EICAS Engine Indication and Crew Alerting System RFFS Rescue and Fire Fighting Service EPR Engine Pressure Ratio rpm revolutions per minute ETA Estimated Time of Arrival RTF radiotelephony ETD Estimated Time of Departure RVR Runway Visual Range FAA Federal Aviation Administration (USA) SAR Search and Rescue FDR Flight Data Recorder SB Service Bulletin FIR Flight Information Region SSR Secondary Surveillance Radar FL Flight Level TA Traffic Advisory ft feet TAF Terminal Aerodrome Forecast AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAS true airspeed http://www.aaib.gov.uk g acceleration due to Earth’s gravity TAWS Terrain Awareness and Warning System GPS Global Positioning System TCAS Traffic Collision Avoidance System GPWS Ground Proximity Warning System TGT Turbine Gas Temperature hrs hours (clock time as in 1200 hrs) TODA Takeoff Distance Available HP high pressure UAS Unmanned Aircraft System hPa hectopascal (equivalent unit to mb) UHF Ultra High Frequency IAS indicated airspeed USG US gallons IFR Instrument Flight Rules UTC Co-ordinated Universal Time (GMT) This bulletin contains facts which have been determined up to the time of compilation. ILS Instrument Landing System V Volt(s) IMC Instrument Meteorological Conditions V Takeoff decision speed Extracts may be published without specific permission providing that the source is duly acknowledged, the material is 1 IP Intermediate Pressure V Takeoff safety speed reproduced accurately and it is not used in a derogatory manner or in a misleading context. 2 IR Instrument Rating VR Rotation speed ISA International Standard Atmosphere V Reference airspeed (approach) Published 11 October 2018 Cover picture courtesy of Stephen R Lynn REF V Never Exceed airspeed (www.srlynnphotography.co.uk) kg kilogram(s) NE KCAS knots calibrated airspeed VASI Visual Approach Slope Indicator © Crown copyright 2018 ISSN 0309-4278 KIAS knots indicated airspeed VFR Visual Flight Rules KTAS knots true airspeed VHF Very High Frequency Published by the Air Accidents Investigation Branch, Department for Transport km kilometre(s) VMC Visual Meteorological Conditions Printed in the UK on paper containing at least 75% recycled fibre kt knot(s) VOR VHF Omnidirectional radio Range AAIB Bulletin: 10/2018 CONTENTS SPECIAL BULLETINS / INTERIM REPORTS None SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS None AAIB FIELD INVESTIGATIONS COMMERCIAL AIR TRANSPORT FIXED WING None ROTORCRAFT None GENERAL AVIATION FIXED WING None ROTORCRAFT AS350 B3e Ecureuil G-MATH 05-May-17 3 SPORT AVIATION / BALLOONS None AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT None GENERAL AVIATION Auster 6A Tugmaster G-APRO 19-Jul-18 33 Beech A36 Bonanza G-CDJV 26-Jun-18 34 CEA DR221B Dauphin G-RRCU 03-Jun-18 35 Cessna F172H Skyhawk G-AWUX 19-Apr-18 36 Dyn’Aero MCR01 G-CWMT 10-Mar-18 39 Groppo Trail G-CIGR 14-Jul-18 40 Pierre Robin R2100A G-BICS 06-May-18 44 Piper PA-18-150 Super Cub G-XCUB 06-Jun-18 52 Piper PA-28-181 Cherokee Archer II G-JJAN 20-May-18 54 Piper PA-38-112 Tomahawk G-BMVL 12-May-18 55 Piper PA-38-112 Tomahawk G-RVRR 15-May-18 58 Rans S6S-116 Super Six Coyote II G-XALZ 25-Jun-18 60 © Crown copyright 2018 i All times are UTC AAIB Bulletin: 10/2018 CONTENTS Cont AAIB CORRESPONDENCE INVESTIGATIONS Cont GENERAL AVIATION Cont Robinson R44 Raven G-CTFL ∫ ∫ 05-May-18 61 Robinson R44 Raven G-HYND Vans RV-8 G-JBTR 23-Jun-18 67 Yakovlev YAK C11 G-OYAK 21-Jun-18 69 SPORT AVIATION / BALLOONS Escapade 912(2) G-ECKB 02-Jul-18 72 EV-97 Teameurostar UK G-CEDX 17-May-18 74 Ikarus C42 FB80 G-HEVR 12-Jun-18 75 Quik GT450 G-CGSO 06-Jul-18 76 Rotorsport UK MTO Sport G-CIHH 30-Jun-18 78 Thruster T600N G-MZNX 05-Aug-18 80 UNMANNED AIRCRAFT SYSTEMS DJI Matrice 210 n/a 20-Dec-17 83 MISCELLANEOUS ADDENDA and CORRECTIONS Boeing 747-8R7F LX-VCF 30-Mar-17 85 List of recent aircraft accident reports issued by the AAIB 87 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2018 ii All times are UTC AAIB Bulletin: 10/2018 AAIB Field Investigation Reports A Field Investigation is an independent investigation in which AAIB investigators collect, record and analyse evidence. The process may include, attending the scene of the accident or serious incident; interviewing witnesses; reviewing documents, procedures and practices; examining aircraft wreckage or components; and analysing recorded data. The investigation, which can take a number of months to complete, will conclude with a published report. © Crown copyright 2018 1 All times are UTC AAIB Bulletin: 10/2018 G-MATH EW/C2017/05/01 ACCIDENT Aircraft Type and Registration: AS350 B3e Ecureuil, G-MATH No & Type of Engines: 1 Turbomeca Arriel 2D turboshaft engine Year of Manufacture: 2016 (Serial no: 8274) Date & Time (UTC): 5 May 2017 at 0830 hrs Location: Wycombe Air Park, Buckinghamshire Type of Flight: Training Persons on Board: Crew - 2 Passengers - 1 Injuries: Crew - 1 (Fatal) Passengers - 1 (Serious) 1 (Serious) Nature of Damage: Extensive Commander’s Licence: Commercial Pilot’s Licence (Helicopters) Commander’s Age: 45 years Commander’s Flying Experience: 5,747 hours (of which 579 were on type) Last 90 days - 53 hours Last 28 days - 17 hours Information Source: AAIB Field Investigation Synopsis The accident occurred whilst the helicopter was engaged in hydraulic failure training. An instructor was in the left seat of the helicopter, a pilot under training in the right seat and another pilot under training, who was a passenger on this flight, was seated in the rear. The right-seat pilot was performing a hydraulics-off approach, to finish in a run-on landing. The instructor became dissatisfied with the approach parameters and took control in the latter stages, performing a hydraulics-off go-around into a left-hand circuit, before lining up the helicopter on final approach for the pilot to make a second attempt. Once again, the instructor took control late in the approach and performed another go-around. On this occasion, the left turn onto the downwind was flown with a higher angle of bank (AOB). The instructor was unable to control the roll attitude and the helicopter rolled left, beyond 90° AOB, descended rapidly and struck the ground, coming to rest on its left side. All three occupants were seriously injured. The right-seat pilot died some weeks later from injuries sustained in the accident. No technical issues were identified and a definitive reason why the instructor was unable to roll the helicopter back to a level attitude could not be determined. © Crown copyright 2018 3 All times are UTC AAIB Bulletin: 10/2018 G-MATH EW/C2017/05/01 The investigation concluded that clearer instructions in the AS350 flight manual for hydraulics-off flight would help prevent similar accidents in future. In response to this accident, the helicopter manufacturer has taken safety actions including: amending the AS350 flight manual to limit the AOB to 30° during hydraulics-off flight and the inclusion of warnings not to conduct low speed manoeuvres with hydraulics off due to the danger of loss of control.
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