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AAIB Bulletin: 10/2009 CONTENTS COMMERCIAL AIR TRANSPORT FIXED WING Airbus A320-232 G-EUUU 27-Mar-09 1 Airbus A320-233 HA-LPJ 12-Mar-09 3 Boeing 737-33A G-CELD 21-Feb-09 7 Boeing 767-324 G-OOBL 09-May-08 12 Jetstream 4102 G-MAJV 09-Apr-08 15 ROTORCRAFT None GENERAL AVIATION FIXED WING Beech 36 N7205T 01-Jul-09 27 Boeing ST 75 Stearman SE-BOG 26-Jul-09 29 Cessna 150D G-ASMW 14-Jul-09 30 Cessna 152 G-BRNE 13-Jun-09 32 DHC-1 Chipmunk 22A G-BWUV 20-Feb-09 33 Europa XS Europa G-CCUL 24-May-09 34 Piper PA-28-140 Cherokee G-AWPS 02-Jan-09 36 Piper PA-28-161 Cherokee Warrior II G-BPDT 27-Mar-09 46 Piper PA-28R-201 Cherokee Arrow III G-HERB 09-Jun-09 48 Piper PA-32RT-300 Cherokee Lance II G-RHHT 14-Jul-09 51 Piper PA-46 -310P Malibu N9122N 19-Apr-09 52 Pitts S-1 Pitts Special G-BXAU 15-Mar-09 54 Yak-52 G-OCBT 01-May-09 56 ROTORCRAFT Gazelle HT.Mk 3 G-CBXT (XW898) 01-Nov-08 58 Robinson R22 Beta G-TTHC 14-Feb-09 69 Robinson R44 Clipper II G-CLPR 28-May-09 79 SPORT AVIATION / BALLOONS Aerosport Ltd Ikarus C42 G-CEAN 16-Jul-09 82 Flight Design CTSW G-KFLY 02-Jul-09 83 Pegasus Quik G-CDAX 31-May-09 85 Pegasus Quik G-MAXS 05-Jun-09 86 Tecnam P92-EM Echo G-DWPF 01-Jun-09 88 Summary of: Aircraft Accident Report No: 5 /2009 90 Report on the serious incident to BAe 146-200, EI-CZO at London City Airport on 20 February 2007 List of recent aircraft accident reports issued by the AAIB 94 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2009 i AAIB Bulletin: 10/2009 G-EUUU EW/G2009/03/20 SERIOUS INCIDENT Aircraft Type and Registration: Airbus A320-232, G-EUUU No & Type of Engines: 2 International Aero Engine V2527-A5 turbofan engines Year of Manufacture: 2008 Date & Time (UTC): 27 March 2009 at 1520 hrs Location: Oslo, Norway Type of Flight: Commercial Air Transport (Passenger) Persons on Board: Crew - 6 Passengers - 147 Injuries: Crew - None Passengers - None Nature of Damage: None Commander’s Licence: Airline Transport Pilot’s Licence Commander’s Age: 42 years Commander’s Flying Experience: 9,000 hours (of which 600 were on type) Last 90 days - 175 hours Last 28 days - 27 hours Information Source: Aircraft Accident Report Form submitted by the pilot and further investigation by the AAIB Synopsis The aircraft was on final approach to land and was and briefed for an autoland and were using full flap experiencing airframe icing. At about 1,700 ft, airframe (know as configuration full) and autothrust with an buffet was felt which the crew thought was pre-stall approach speed of 138 kt. The aircraft was vectored buffet. The crew increased the aircraft’s approach speed extensively during which ice was noticed on the icing and the buffet reduced. It disappeared completely at probe. Both wing and engine anti-icing systems were 500 ft and the aircraft landed without further incident. selected to ON in response. It was probable that the buffet was due to ice accretion on the top surface of the wings and was not pre-stall While descending through about 1,700 ft on the buffet. final approach, airframe buffet was felt which the crew assessed to be the “early stages of stall buffet”. History of the flight They considered going around but thought that might The aircraft was on approach to Runway 01 at make the situation worse in the prevailing weather Oslo but there were delays due to snow clearance conditions. The approach speed was increased in operations on the runway. The crew had planned stages to 145 kt and, although the buffet continued, it © Crown copyright 2009 1 AAIB Bulletin: 10/2009 G-EUUU EW/G2009/03/20 became “lighter in intensity”. The buffet disappeared Wing anti-icing completely at 500 ft and the aircraft landed without In flight, selecting the wing anti-ice system to ON opens further incident. a valve in each wing so that hot air from the pneumatic After the flight, the captain inspected the wings and system heats the three outboard slats of each wing. There saw “evidence of snow and ice in patches on the top is no direct heating of the rest of the wing surfaces. surface and leading edges”. However, in his opinion, Guidance from the manufacturer on flying in icing the contamination would not have caused the aircraft to conditions stall even though the buffet had felt like the early stages of stall buffet. The Flight Crew Operating Manual (FCOM) Part 3 has a section on ice protection. It states: Weather conditions The weather at Oslo was a surface wind of 050°/11 kt, ‘If there is evidence of significant ice accretion, visibility of 2,000 m, broken cloud at 800 ft and a and to take account of ice formation on temperature of -3° C. The runway headwind component non‑heated structure, the minimum speed should be, in configuration full, V + 5 kt.’ was about 8 kt. LS Calculation of approach speed (V ) Recorded data APP Data was available from the aircraft flight data recorder. For an approach using autothrust, the Flight Management During the incident, the aircraft was in configuration full and Guidance Computer (FMGC) computes VAPP as VLS 1 plus the higher of 5 kt or one third of the headwind and the landing gear was down. VLS was 128 kt and 2 component on landing. The crew can modify the figure VαProt varied between 117 and 119 kt. The approach speed selected by the crew was 138 kt but this was increased in the FMGS (Flight Management Guidance System) to progressively to 145 kt as the buffet was detected. take account of conditions on the day. In addition, the crew may manually select the speed to be flown by the Analysis of the data by the manufacturer autothrust system. The manufacturer analysed the flight data recorder information and stated that it: The wind conditions reported at Oslo meant that the FMGS would have calculated the approach speed as VLS ‘seemed to reflect the buffet, probably due to the (128 kt) plus 5 kt giving a VAPP of 133 kt. presence of ice on the top of the wings. There Analysis was buffet but the alpha reached (up to +7°) was too far from the alpha stall to lead to stall VAPP, at 133 kt, effectively included the 5 kt increment buffet.’ recommended in the FCOM for flight with ice formation Footnote on non-heated parts of the aircraft. The crew’s manual 1 selection of an approach speed of 138 kt, prior to the onset VLS is the lowest selectable speed and is computed by the Flight Augmentation Computers (FACs) based on aerodynamic data. 2 of buffet, gave an additional margin above VAPP. During VαProt is a speed corresponding to an angle of attack at which the flight control system switches to a low speed protection mode. the buffet, the aircraft speed was further increased from © Crown copyright 2009 2 AAIB Bulletin: 10/2009 G-EUUU EW/G2009/03/20 138 to 145 kt during which time VαProt remained below It is probable that the buffet experienced was due to ice 120 kt and the angle of attack remained below 7°. At no accretion on the top surface of the wings, as suggested time did the low speed protection features of the aircraft by the manufacturer, and was not pre-stall buffet. become active. © Crown copyright 2009 3 AAIB Bulletin: 10/2009 HA-LPJ EW/G2009/03/06 ACCIDENT Aircraft Type and Registration: Airbus A320 -233, HA-LPJ No & Type of Engines: 2 IAE V2500-A1 turbofan engines Year of Manufacture: 2007 Date & Time (UTC): 12 March 2009 at 0902 hrs Location: Stand 40, London Luton Airport Type of Flight: Commercial Air Transport (Passenger) Persons on Board: Crew - 6 Passengers - 136 Injuries: Crew - None Passengers - None Nature of Damage: Nosewheel and damage to engine cowling Commander’s Licence: Airline Transport Pilot’s Licence Commander’s Age: 35 years Commander’s Flying Experience: 5,447 hours (of which 2,952 were on type) Last 90 days - 198 hours Last 28 days - 64 hours Information Source: Aircraft Accident Report Form submitted by the pilot and further enquiries by the AAIB Synopsis While the aircraft was being pulled forward by the tug aircraft’s nose gear that connects the towbar head to after a misaligned pushback, both the towbar’s shear the towbar. pins failed and the aircraft became detached from the tug. The aircraft continued to roll forwards and collided Approximately eight months before this incident, the with the tug causing damage to both. Neither ground towbar had two bricks attached to one side to help level crew was injured. the undercarriage when it was raised. After this incident it was discovered that the level imbalance was because Background information one of the undercarriage’s tyres was pneumatic and one The towbar in this incident had a wheeled undercarriage was solid. The valve in the hydraulic pump, which holds to support it while being moved un-laden. The up the undercarriage, was also found to be leaking. undercarriage was adjusted hydraulically through the range of heights necessary to facilitate connecting Stand 40 at London Luton Airport has a descending to, and towing, aircraft.