AAIB Bulletin 1/2018
Total Page:16
File Type:pdf, Size:1020Kb
AAIB Bulletin 1/2018 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 1/2018 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 1996. 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 PNF Pilot Not Flying 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 January 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: 1/2018 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 None SPORT AVIATION / BALLOONS None AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT Airbus A319-111 G-EZAW 03-Jul-17 3 Britten-Norman Islander BN2B-26 VP-FBR 04-Sep-17 8 GENERAL AVIATION Cessna 152 G-BKAZ 14-Sep-17 10 Cessna 182T N60554 28-Aug-17 12 Diamond DA42 Twin Star G-OCCX 22-Aug-17 15 Mooney M20J G-OBAL 15-Sep-17 16 Nipper T.66 RA45 Series 3 G-AVKI 17-Oct-17 17 Piper PA-25-235 Pawnee G-BCBJ 28-Oct-17 18 Piper PA-28-140 Cherokee G-BCJM 28-Aug-17 19 Piper PA-28RT-201 N2136E 22-Jul-17 21 Piper PA-32R-301 Saratoga SP G-RIGH 28-Aug-17 22 Piper PA-32R-301T N414AG 23-Aug-17 23 Piper PA-34-200T Seneca II G-BPXX 13-Oct-17 27 Titan T-51 Mustang G-DHYS 31-May-17 29 Vans RV-6A G-CCVS 15-Aug-17 34 © Crown copyright 2018 i AAIB Bulletin: 1/2018 CONTENTS Cont AAIB CORRESPONDENCE INVESTIGATIONS Cont SPORT AVIATION / BALLOONS 3DR Solo (UAS) None 13-Jun-17 36 Ikarus C42 G-FLYM 29-May-17 39 Pegasus Quik GT450 G-CDUU 24-Sep-17 42 Skyranger 912S(1) G-ZADA 18-Jun-17 43 MISCELLANEOUS ADDENDA and CORRECTIONS Agusta AW139 G-CIPW 09-Jun-17 49 List of recent aircraft accident reports issued by the AAIB 50 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2018 ii AAIB Bulletin: 1/2018 AAIB Correspondence Reports These are reports on accidents and incidents which were not subject to a Field Investigation. They are wholly, or largely, based on information provided by the aircraft commander in an Aircraft Accident Report Form (AARF) and in some cases additional information from other sources. The accuracy of the information provided cannot be assured. © Crown copyright 2018 1 AAIB Bulletin: 1/2018 G-EZAW EW/G2017/07/26 SERIOUS INCIDENT Aircraft Type and Registration: Airbus A319-111, G-EZAW No & Type of Engines: 2 CFM 56-5B5/P turbofan engines Year of Manufacture: 2006 (Serial no: 2812) Date & Time (UTC): 3 July 2017 at 1931 hrs Location: Munich Airport, Germany Type of Flight: Commercial Air Transport (Passenger) Persons on Board: Crew - 6 Passengers - 149 Injuries: Crew - None Passengers - None Nature of Damage: Damage to the nose and right main landing gear Commander’s Licence: Airline Transport Pilot’s Licence Commander’s Age: 41 years Commander’s Flying Experience: 11,179 hours (of which 9,300 were on type) Last 90 days - 192 hours Last 28 days - 35 hours Information Source: Aircraft Accident Report Form submitted by the pilot and further enquiries by the AAIB Synopsis The aircraft was established on an ILS approach to Runway 26L at Munich Airport. When the aircraft was at about 1,500 ft aal, the commander’s Flight Management Guidance Computer (FMGC)1 failed. The crew were unable to alter the target approach speed, and the engines began to spool up un-commanded. The pilot flying disconnected the autopilot and autothrust and the rest of the approach was flown manually. Below 50 ft the pitch attitude of the aircraft was reduced slightly just before the aircraft was flared for landing, and it touched down heavily in a relatively flat attitude. The normal acceleration recorded at touchdown was 3.01 g, which is classified as a Severe Hard Landing. All three landing gear legs were replaced, although subsequent examination revealed that only the nose and right main gear were damaged. History of the flight The aircraft was performing a scheduled passenger service between Edinburgh and Munich Airports. The co-pilot was pilot flying (PF). The aircraft was established on an approach to Runway 26L at Munich when, at about 1,500 ft aal, FMGC1 froze. Both flight crew attempted to alter the target approach speed but were unable to do so through either the FMGC or the Flight Control Unit. At 1,288 ft aal, the engines began to spool up un-commanded by the crew, so the autopilot (AP) and autothrust (A/THR) were disconnected by the PF. The rest of the approach was flown manually with manual thrust. © Crown copyright 2018 3 AAIB Bulletin: 1/2018 G-EZAW G-EW/G2017/07/26 During the approach, a cabin pressure landing elevation fault was triggered, thought to be associated with the failure of FMGC1. As the aircraft approached the touchdown point, the PF selected a lower-than-normal pitch attitude and the aircraft touched down firmly. The crew taxied the aircraft to the stand as normal but a LOAD<15> report1 was printed automatically, indicating the aircraft had suffered a hard landing.