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Air Accidents Investigation Branch Department for Transport Report On AIRCRAFT ACCIDENT REPORT 6/2008 Air Accidents Investigation Branch Department for Transport Report on the serious incident to Hawker Siddeley HS 748 Series 2A, registration G-BVOV at Guernsey Airport, Channel Islands on 8 March 2006 This investigation was carried out in accordance with The Civil Aviation (Investigation of Air Accidents and Incidents) (Guernsey) Order 1998 © Crown Copyright 2008 Published with the permission of the Department for Transport (Air Accidents Investigation Branch). This report contains facts which have been determined up to the time of publication. This information is published to inform the aviation industry and the public of the general circumstances of accidents and serious incidents. Extracts can be published without specific permission providing that the source is duly acknowledged. Published 21 August 2008 Printed in the United Kingdom for the Air Accidents Investigation Branch ii RECENT FORMAL AIRCRAFT ACCIDENT AND INCIDENT REPORTS ISSUED BY THE AIR ACCIDENTS INVESTIGATION BRANCH THE FOLLOWING REPORTS ARE AVAILABLE ON THE INTERNET AT http://www.aaib.gov.uk 4/2007 Airbus A340-642, G-VATL September 2007 en-route from Hong Kong to London Heathrow on 8 February 2005. 5/2007 Airbus A321-231, G-MEDG December 2007 during an approach to Khartoum Airport, Sudan on 11 March 2005. 6/2007 Airbus A320-211, JY-JAR December 2007 at Leeds Bradford Airport on 18 May 2005. 7/2007 Airbus A310-304, F-OJHI December 2007 on approach to Birmingham International Airport on 23 February 2006. 1/2008 Bombardier CL600-2B16 Challenger 604, VP-BJM January 2008 8 nm west of Midhurst VOR, West Sussex on 11 November 2005. 2/2008 Airbus A319-131, G-EUOB January 2008 during the climb after departure from London Heathrow Airport on 22 October 2005. 3/2008 British Aerospace Jetstream 3202, G-BUVC February 2008 at Wick Aerodrome, Caithness, Scotland on 3 October 2006. 4/2008 Airbus A240-214, G-BXKD February 2008 at Runway 09, Bristol Airport on 15 November 2006. 5/2008 Boeing 737-300, OO-TND April 2008 at Nottingham East Midlands Airport on 15 June 2006. iii Department for Transport Air Accidents Investigation Branch Farnborough House Berkshire Copse Road Aldershot Hampshire GU11 2HH June 2008 Mr Geoffrey Rowland The Bailiff of Guernsey Dear Sir I have the honour to submit the report by Mr R D G Carter, an Inspector of Air Accidents, on the circumstances of the serious incident to Hawker Siddeley HS 748 Series 2A, registration G-BVOV, at Guernsey Airport, Channel Islands on 8 March 2006. Yours sincerely David King Chief Inspector of Air Accidents iv Department for Transport Air Accidents Investigation Branch Farnborough House Berkshire Copse Road Aldershot Hampshire GU11 2HH June 2008 The Right Honourable Ruth Kelly Secretary of State for Transport Dear Secretary of State I have the honour to submit the report by Mr R D G Carter, an Inspector of Air Accidents, on the circumstances of the serious incident to Hawker Siddeley HS 748 Series 2A, registration G-BVOV, at Guernsey Airport, Channel Islands on 8 March 2006. Yours sincerely David King Chief Inspector of Air Accidents v Contents Synopsis ............................................................................................................................ 1 1 Factual Information .............................................................................................. 3 1.1 History of the flight ....................................................................................... 3 1.2 Injuries to persons .......................................................................................... 8 1.3 Damage to aircraft .......................................................................................... 8 1.4 Other damage ................................................................................................. 8 1.5 Personnel information ................................................................................... 9 1.5.1 Commander ...................................................................................... 9 1.5.2 First Officer ...................................................................................... 9 1.6 Aircraft information ..................................................................................... 10 1.6.1 General information ....................................................................... 10 1.6.2 Aircraft weight and centre of gravity ............................................. 11 1.6.3 Performance ................................................................................... 12 1.6.4 Brake system .................................................................................. 12 1.6.5 Other systems that provide additional braking ............................. 13 1.6.6 Enhanced Ground Proximity Warning System (EGPWS) ............. 14 1.6.7 Aquaplaning information .............................................................. 14 1.6.8 Maintenance information ............................................................... 14 1.7 Meteorological information ......................................................................... 15 1.7.1 Aerodrome .................................................................................... 15 1.7.2 Winds ............................................................................................. 15 1.8 Aids to navigation ........................................................................................ 16 1.8.1 Instrument Landing System (ILS) ................................................. 16 1.9 Communications .......................................................................................... 16 1.10 Aerodrome information ................................................................................ 16 1.10.1 Runway physical characteristics .................................................... 16 1.10.2 Lighting .......................................................................................... 16 1.10.3 Runway friction tests ..................................................................... 17 1.10.4 Runway inspection ......................................................................... 18 1.11 Flight Recorders .......................................................................................... 19 1.11.1 Available recordings ...................................................................... 19 1.11.2 Recorded data ................................................................................ 19 1.12 Incident site information .............................................................................. 20 vi 1.13 Medical and pathological information ......................................................... 21 1.14 Fire ............................................................................................................... 21 1.15 Survival aspects............................................................................................ 21 1.16 Tests and research ........................................................................................ 21 1.16.1 Maxaret tests .................................................................................. 21 1.17 Organisational and management information .............................................. 22 1.17.1 Regulatory oversight and previous investigations ......................... 22 1.18 Additional information ................................................................................. 26 1.18.1 Flight crew procedures ................................................................... 26 1.18.2 Landing procedures ........................................................................ 27 1.18.3 Aquaplaning ................................................................................... 29 1.18.4 ICAO guidance material ................................................................ 30 2 Analysis ................................................................................................................. 31 2.1 General ......................................................................................................... 31 2.2 Condition of the runway .............................................................................. 31 2.3 Condition of the aircraft ............................................................................... 32 2.3.1 Flight data recorders ...................................................................... 32 2.4 Crew procedures .......................................................................................... 33 2.5 Crew Resource Management ....................................................................... 34 2.6 Regulatory oversight .................................................................................... 34 3 Conclusions .......................................................................................................... 37 (a) Findings ....................................................................................................... 37 (b) Causal factors ............................................................................................... 39 (c) Contributory factors ..................................................................................... 39 4 Safety Recommendation ..................................................................................... 40 vii GLOSSARY OF ABBREVIATIONS USED IN THIS REPORT AAIB Air Accidents Investigation Branch RFFS Rescue and Fire Fighting Service aal above airfield level RVR runway visual range agl above
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