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AAIB Bulletin 1/2017

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AAIB Bulletin 1/2017 AAIB Bulletin 1/2017 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 1/2017 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 mb millibar(s) amsl above mean sea level MDA Minimum Descent Altitude AOM Aerodrome Operating Minima METAR a timed aerodrome meteorological report APU Auxiliary Power Unit min minutes ASI airspeed indicator mm millimetre(s) ATC(C)(O) Air Traffic Control (Centre)( Officer) mph miles per hour ATIS Automatic Terminal Information System MTWA Maximum Total Weight Authorised ATPL Airline Transport Pilot’s Licence N Newtons BMAA British Microlight Aircraft Association N Main rotor rotation speed (rotorcraft) AAIB investigations are conducted in accordance with R BGA British Gliding Association N Gas generator rotation speed (rotorcraft) Annex 13 to the ICAO Convention on International Civil Aviation, g BBAC British Balloon and Airship Club N1 engine fan or LP compressor speed EU Regulation No 996/2010 and The Civil Aviation (Investigation of BHPA British Hang Gliding & Paragliding Association NDB Non-Directional radio Beacon CAA Civil Aviation Authority nm nautical mile(s) Air Accidents and Incidents) Regulations 1996. CAVOK Ceiling And Visibility OK (for VFR flight) NOTAM Notice to Airmen CAS calibrated airspeed OAT Outside Air Temperature cc cubic centimetres OPC Operator Proficiency Check The sole objective of the investigation of an accident or incident under these CG Centre of Gravity PAPI Precision Approach Path Indicator Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PF Pilot Flying CPL Commercial Pilot’s Licence PIC Pilot in Command purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true PNF Pilot Not Flying CVR Cockpit Voice Recorder POH Pilot’s Operating Handbook DME Distance Measuring Equipment PPL Private Pilot’s Licence Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed psi pounds per square inch or blame or determine liability, since neither the investigation nor the reporting EASA European Aviation Safety Agency QFE altimeter pressure setting to indicate height ECAM Electronic Centralised Aircraft Monitoring above aerodrome process has been undertaken for that purpose. EGPWS Enhanced GPWS QNH altimeter pressure setting to indicate EGT Exhaust Gas Temperature elevation amsl EICAS Engine Indication and Crew Alerting System RA Resolution Advisory EPR Engine Pressure Ratio RFFS Rescue and Fire Fighting Service ETA Estimated Time of Arrival rpm revolutions per minute ETD Estimated Time of Departure RTF radiotelephony FAA Federal Aviation Administration (USA) RVR Runway Visual Range FDR Flight Data Recorder SAR Search and Rescue FIR Flight Information Region SB Service Bulletin FL Flight Level SSR Secondary Surveillance Radar ft feet TA Traffic Advisory AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAF Terminal Aerodrome Forecast http://www.aaib.gov.uk g acceleration due to Earth’s gravity TAS true airspeed GPS Global Positioning System TAWS Terrain Awareness and Warning System GPWS Ground Proximity Warning System TCAS Traffic Collision Avoidance System hrs hours (clock time as in 1200 hrs) TGT Turbine Gas Temperature HP high pressure TODA Takeoff Distance Available 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 12 January 2017 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 2017 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: 1/2017 CONTENTS SPECIAL BULLETINS / INTERIM REPORTS None SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS None AAIB FIELD INVESTIGATIONS COMMERCIAL AIR TRANSPORT FIXED WING Airbus A319-111 G-EZFJ 14-Apr-16 3 Saab 2000 G-LGNR 06-Nov-15 14 ROTORCRAFT None GENERAL AVIATION FIXED WING Piper PA-28-161 Cherokee Warrior II G-CDER 06-Aug-16 23 ROTORCRAFT None SPORT AVIATION / BALLOONS Ikarus C42 FB80 Ikarus G-OJDS 09-Jun-16 35 Pegasus Quantum 15 G-MZCR 16-Jul-16 37 AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT Airbus A319-111 G-EZFP 09-May-16 45 Cessna 750 Citation X G-CEDK 12-Aug-16 48 GENERAL AVIATION Albatros DV.a ZK-TGY 15-Sep-16 49 Beech B55 Baron SE-EXW 29-Aug-16 50 DHC-1 Chipmunk 22 G-BXCP 22-Sep-16 51 Diamond DA42 Twin Star G-CTCB 28-Apr-16 52 Evans VP-1 Series 2 G-TGJH 27-Aug-16 55 Grob G115E Tutor G-BYVE 24-Aug-16 56 Klemm Kl35D HB-UBK 06-Jul-16 57 Piper PA-28-180 Cherokee G-AZDX 26-Aug-16 59 Pitts S-2A Special G-BTUL 07-May-16 61 Reims Cessna F182P Skylane G-DATG 10-Jul-16 62 © Crown copyright 2017 i AAIB Bulletin: 1/2017 CONTENTS Cont AAIB CORRESPONDENCE INVESTIGATIONS Cont GENERAL AVIATION Cont Robinson R44 Raven G-RFUN 05-Aug-16 67 Robinson R44 II G-SAIG ∫ ∫ 15-Jun-16 70 Spitfire IXT G-CCCA Socata TB9 G-BTWX 24-Mar-16 75 Tecnam P2002-JF Sierra G-TECI 15-Sep-16 82 SPORT AVIATION / BALLOONS Fournier RF5 G-AZPF 02-Oct-16 83 Ikarus C42 FB80 G-SARM 22-Jul-16 84 Mainair Blade 912 G-BYHS 21-Oct-16 86 Zenair CH 601UL Zodiac G-CBUR 22-Jul-16 87 MISCELLANEOUS ADDENDA and CORRECTIONS Piper PA-46-350P Malibu Mirage N186CB 14-Nov-15 91 Zenair CH 601XL Zodiac G-EXXL 19-Jun-16 93 List of recent aircraft accident reports issued by the AAIB 94 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2017 ii AAIB Bulletin: 1/2017 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 2017 1 AAIB Bulletin: 1/2017 G-EZFJ EW/C2016/04/01 SERIOUS INCIDENT Aircraft Type and Registration: Airbus A319-111, G-EZFJ No & Type of Engines: 2 CFM CFM56-5B5/3 turbofan engines Year of Manufacture: 2009 (Serial no: 4040) Date & Time (UTC): 14 April 2016 at 0847 hrs Location: Malaga Airport, Spain Type of Flight: Commercial Air Transport (Passenger) Persons on Board: Crew - 6 Passengers - 157 Injuries: Crew - None Passengers - None Nature of Damage: None Commander’s Licence: Airline Transport Pilot’s Licence Commander’s Age: 57 years Commander’s Flying Experience: 21,000 hours (of which 4,000 were on type) Last 90 days - 200 hours Last 28 days - 78 hours Information Source: AAIB Field Investigation Synopsis While calculating takeoff performance data, the flight crew elected to use the Multiple Runway Computation (MRC) function on their Electronic Flight Bag (EFB). Due to a software anomaly in the EFB, runway information for Runway 31 was displayed alongside takeoff performance data for Runway 13. The flight crew did not notice this during cross-checking and subsequently took off from Runway 31 using takeoff performance figures for Runway 13. The manufacturer (of both the aircraft and the EFB), operator and flight crew were unaware of this anomaly at the time of the serious incident. The operator has since disabled this function in the EFB and the manufacturer has communicated this anomaly to all affected operators of this version of the EFB. History of the flight The aircraft was on scheduled flight from Malaga Airport, Spain to Liverpool International Airport. The flight crew consisted of the commander who was a Line Training Captain and a co-pilot who was under training. At the time, Runway 31 was in use and the wind was from 300° varying between 270° and 340° at 5 kt. The commander was the Pilot Flying (PF) and the co-pilot the Pilot Monitoring (PM) for the sector. While calculating the takeoff performance figures using the Electronic Flight Bag (EFB), the co-pilot asked the commander if he could use the Multiple Runway Computation © Crown copyright 2017 3 AAIB Bulletin: 1/2017 G-EZFJ EW/C2016/04/01 (MRC) function in case the departure runway changed to Runway 13. Although it is not part of the line training syllabus, and as it was a training flight, the commander felt it would be beneficial for the co-pilot to look at this function.
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