AAIB Bulletin 8/2017

AAIB Bulletin 8/2017 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 8/2017 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 10 August 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: 8/2017 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 Druine D.31 Turbulent G-ARNZ 14-Aug-16 3 ROTORCRAFT None SPORT AVIATION / BALLOONS None AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT Airbus A320-214 G-EZTK 20-Jan-17 11 Airbus A320-214 G-EZTM 26-Mar-17 14 DHC-6 Series 310 Twin Otter G-BVVK 07-Mar-17 16 GENERAL AVIATION Aerotechnik EV-97 Eurostar SI G-CHMW 07-May-17 21 Bell 206B Jet Ranger III G-BTHY 19-Feb-17 22 Denney Kitfox Mk 3 G-DJNH 14-Apr-17 26 DH82A Tiger Moth G-ANSM 04-Feb-17 27 Grumman AA-5 Traveller G-BBSA 22-May-17 28 Hughes 500 Model 369E G-MRRR 24-Mar-17 29 Isaacs Fury II G-BBVO 25-Mar-17 31 Jodel D112 G-BIAH 07-May-17 32 Jodel DR100A Ambassadeur G-BFBA 23-Jan-17 33 Piper PA-28-161 Cherokee Warrior II G-BNSZ 09-Apr-17 36 © Crown copyright 2017 i AAIB Bulletin: 8/2017 CONTENTS Cont AAIB CORRESPONDENCE INVESTIGATIONS Cont GENERAL AVIATION Cont Pitts S-2A Pitts Special G-SKNT 17-Mar-17 38 Socata TB9 Tampico G-JUFS 09-Apr-17 39 Zenair CH 701SP G-TORI 26-May-17 40 SPORT AVIATION / BALLOONS Denney Kitfox Mk 2 G-TWTW 25-Mar-17 41 Mainair Blade G-CCXR 09-Mar-17 44 Mercury G-MYUB 26-Mar-17 46 Rotorsport UK MTOsport G-RMTO 29-Apr-17 48 Savannah VG Jabiru(1) G-WHYS 13-Mar-17 49 MISCELLANEOUS ADDENDA and CORRECTIONS None List of recent aircraft accident reports issued by the AAIB 53 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2017 ii AAIB Bulletin: 8/2017 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: 8/2017 G-ARNZ EW/C2016/08/03 ACCIDENT Aircraft Type and Registration: Druine D.31 Turbulent, G-ARNZ No & Type of Engines: 1 Volkswagen 1600 piston engine Year of Manufacture: 1961 (Serial no: PFA 579) Date & Time (UTC): 14 August 2016 at 1430 hrs Location: In the intertidal zone, Herne Bay Beach, Kent Type of Flight: Private Persons on Board: Crew - 1 Passengers - None Injuries: Crew - 1 (Minor) Passengers - N/A Nature of Damage: Damage to the wing and from salt water immersion Commander’s Licence: Private Pilot’s Licence Commander’s Age: 71 years Commander’s Flying Experience: 922 hours (of which 360 were on type) Last 90 days - 8 hours Last 28 days - 2 hours Information Source: AAIB Field Investigation Synopsis During the ‘balloon bursting’ element of a flying display on the coast, the engine lost power and the pilot ditched the aircraft in shallow water. The aircraft flipped inverted and the pilot was trapped in the cockpit by his lifejacket, which had inflated automatically, and his proximity to the sea bed. Two members of the public righted the aircraft and helped the pilot out of the cockpit. The pilot had suffered a minor injury. CAA Safety Sense Leaflet 21d, ‘Ditching’, provides advice on the correct type of lifejacket to wear and guidance and information on ditching. The investigation revealed that a fragment of balloon had become lodged in the carburettor restricting the airflow into the engine. An approved modification has since been developed to fit a screen to the intake of the carburettor. History of the flight The aircraft was one of a team of three Turbulent aircraft participating in the 2016 Herne Bay Air Show. The aircraft had assembled at Maypole Farm, where the pilots briefed for their display and walked through the routine they planned to carry out. Consideration was given to the fact that, because the display was taking place just offshore, adjacent to a congested area, the option in the event of an engine failure would probably be to ditch the aircraft in the sea. © Crown copyright 2017 3 AAIB Bulletin: 8/2017 G-ARNZ EW/C2016/08/03 The display routine proceeded normally until the ‘balloon bursting’ segment, for which the aircraft adopted a race-track pattern aligned with the display line. A member of the Turbulent Team ground crew, who had been pre-positioned in a small boat, released a series of balloons so that the team aircraft could burst them by flying into collision with them.

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