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Aa2018-6 Aircraft Accident Investigation Report

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Aa2018-6 Aircraft Accident Investigation Report AA2018-6 AIRCRAFT ACCIDENT INVESTIGATION REPORT PRIVATELY OWNED J A 3 9 8 9 August 30, 2018 The objective of the investigation conducted by the Japan Transport Safety Board in accordance with the Act for Establishment of the Japan Transport Safety Board and with Annex 13 to the Convention on International Civil Aviation is to determine the causes of an accident and damage incidental to such an accident, thereby preventing future accidents and reducing damage. It is not the purpose of the investigation to apportion blame or liability. Kazuhiro Nakahashi Chairman Japan Transport Safety Board Note: This report is a translation of the Japanese original investigation report. The text in Japanese shall prevail in the interpretation of the report. AIRCRAFT ACCIDENT INVESTIGATION REPORT CRASH INTO THE VICINITY OF THE MOUNTAINTOP NEW CENTRAL AIRSERVICE CO., LTD. CESSNA 172P, JA3989 ASHIKURAJI, TATEYAMA TOWN, NAKANIIKAWA DISTRICT, TOYAMA PREFECTURE, JAPAN AT AROUND 14:50 JST, JUNE 3, 2017 August 10, 2018 Adopted by the Japan Transport Safety Board Chairman Kazuhiro Nakahashi Member Toru Miyashita Member Toshiyuki Ishikawa Member Yuichi Marui Member Keiji Tanaka Member Miwa Nakanishi SYNOPSIS <Summary of the Accident> On Saturday, June 3, 2017, a Cessna 172P, registered JA3989, operated by New Central Airservice Co.,Ltd., took off from Toyama Airport, while flying to Matsumoto Airport, at around 14:50 Japan Standard Time (JST: UTC+9 hours, unless otherwise stated all times are indicated in JST), it crashed into the vicinity of the top of Mt. Shishi-dake (elevation about 2,700 m) in the Tateyama Mountain Range. There were four people on board the Aircraft consisting of a PIC, a pilot and two passengers and all of them were fatally injured. The aircraft was destroyed but there was no outbreak of fire. <Probable Cause> It is probable that as the Aircraft got into clouds during VFR flight over the mountain region, it became difficult for the PIC and the Pilot to grasp its own position and surroundings by confirming visually the terrain, then, the Aircraft approached the vicinity of the mountaintop and crashed into it. It is somewhat likely that the Aircraft approached the vicinity of the mountaintop and crashed into it due to loss of visual contacts making the crash unavoidable, or due to failure to maintain minimum safe altitude caused by the Aircraft icing or stalled condition, or due to encountering a severe turbulence. However, it could not be determined, since the PIC and all members on board were fatally injured. Concerning the fact that the Aircraft came to fly into clouds, it is probable that the PIC and the Pilot had not confirmed thoroughly the weather forecast for the mountainous region before departure and they delayed in making a decision to turn back during flight. <Recommendations> Recommendations for the Minister of Land, Infrastructure, Transport and Tourism In this accident, it is probable that as the Aircraft got into clouds during VFR flight over the mountain region, it became difficult for the Aircraft to grasp its own position and the surroundings by confirming visually the terrain, then, the Aircraft approached the vicinity of the mountaintop and crashed into it. It is somewhat likely that the Aircraft approached the vicinity of the mountaintop and crashed into it due to loss of visual contacts making the crash unavoidable, or due to failure to maintain minimum safe altitude caused by the Aircraft icing or stalled condition, or due to encountering a severe turbulence. Concerning the fact that the Aircraft came to fly into clouds, it is probable that the PIC and the Pilot had not confirmed thoroughly the weather forecast for the mountainous region before departure and they delayed in making a decision to turn back during flight. In view of the result of this accident investigation, the Japan Transport Safety Board recommends pursuant to the provision of Article 26 of the Act for Establishment of the Japan Transport Safety Board that the Minister of Land, Infrastructure, Transport and Tourism should take the following measures in order to prevent the aircraft accidents and reduce damage from those when they occur. (1) Make it known to pilots that the icing conditions are extremely hazardous for the aircraft not certificated for flight in icing conditions and those aircraft should definitely avoid flying in icing conditions. (2) Encourage pilots for small airplanes to fasten their seat belts and shoulder harnesses and instruct them to ask their passengers to fasten their seat belts. (3) Provide small aircraft users with the information on the appropriate installation and operation of the ELTs. (4) Request relevant organizations to ensure that each search and rescue (SAR) aircraft during SAR operation shall be able to precisely listen on the distress frequencies. The main abbreviations used in this report are as follows: ADF: Automatic Direction Finder AIP: Aeronautical Information Publication ARSR: Air Route Surveillance Radar ELT: Emergency Locator Transmitter GPS: Global Positioning System IAS: Indicated Airspeed ICAO: International Civil Aviation Organization IMC: Instrument Meteorological Conditions LWC: Liquid Water Content PIC: Pilot In Command POH: Pilot’s Operating Handbook RCC: Rescue Coordination Center TAS: True Airspeed VFR: Visual Flight Rules VMC: Visual Meteorological Conditions Unit Conversion List: 1 kt: 1.852 km/h (0.5144 m/s) 1 nm: 1,852 m 1 ft: 0.3048 m 1 in: 25.40 mm 1 lb: 0.4536 kg TABLE OF CONTENTS 1 PROCESS AND PROGRESS OF THE INVESTIGATION............................................................. 1 1.1 Summary of the Accident .............................................................................................................. 1 1.2 Outline of the Accident Investigation ........................................................................................... 1 1.2.1 Investigation Organization .................................................................................................... 1 1.2.2 Representatives of the Relevant State .................................................................................. 1 1.2.3 Implementation of the Investigation .................................................................................... 1 1.2.4 Comments from the Parties Relevant to the Cause of the Accident ................................... 1 1.2.5 Comments from the Relevant State ...................................................................................... 2 2 FACTUAL INFORMATION .............................................................................................................. 2 2.1 History of the Flight ...................................................................................................................... 2 2.1.1 History of the Flight and Situation after the Accident ........................................................ 2 2.1.2 Statements of Relevant Persons ............................................................................................ 4 2.2 Injuries to Peoples ......................................................................................................................... 6 2.3 Damage to the Aircraft .................................................................................................................. 6 2.3.1 Extent of Damage ................................................................................................................... 6 2.3.2 Damage to the Aircraft Components ..................................................................................... 6 2.4 Personnel Information ................................................................................................................... 7 2.5 Aircraft Information ...................................................................................................................... 7 2.5.1 Aircraft .................................................................................................................................... 7 2.5.2 Engine ...................................................................................................................................... 8 2.5.3 Weight and Balance ................................................................................................................ 8 2.5.4 Fuel and Lubricating Oil ........................................................................................................ 8 2.6 Meteorological Information ........................................................................................................... 8 2.6.1 Meteorological Conditions at Airports .................................................................................. 8 2.6.2 Meteorological Conditions along the Flight Route ............................................................... 9 2.7 Information on Accident Site and the Aircraft .......................................................................... 16 2.7.1 Situation of Accident Site ..................................................................................................... 16 2.7.2 Situation of the Aircraft ....................................................................................................... 17 2.7.3 Detailed Situation of Damage.............................................................................................. 18 2.8 Medical Information .................................................................................................................... 20 2.9 Information on Communication
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