Air Accident Investigation Unit Ireland
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Air Accident Investigation Unit Ireland ACCIDENT REPORT Irish Air Corps 265, PC-9(M) Cornamona, Connemara, Co. Galway 12 October 2009 IAC 265 Cornamona, Connemara, Co. Galway 12 October 2009 AAIU Formal Report No: 2011-016 State File No: IRL00909098 Published: 08/11/2011 Operator: Irish Air Corps (IAC) Manufacturer: Pilatus Aircraft Ltd Model: PC-9(M) Nationality: Ireland (Military) Registration: 265 Location: Crumlin East, Cornamona, Connemara, Co. Galway, Ireland N53°32.192’′, W009°30.436’′ Date/Time (UTC1): 12 Oct 2009 @ 16.57 hrs 2 1 UTC: Coordinated Universal Time. Times in this Report are in UTC (local time minus one hour) Air Accident Investigation Unit Report 16/2011 SYNOPSIS The military training flight departed its base at Casement Aerodrome, Baldonnel, Co. Dublin (EIME), on a Visual Flight Rules (VFR) cross-country, navigation-training exercise with Galway Airport (EICM) as the intended destination. Its crew consisted of an Instructor and a Cadet in training who was the handling pilot. The aircraft flew initially northwest and later southwest towards Maum, Co. Galway. As it approached high ground on the western shores of Lough Mask, the weather ahead was deteriorating. The aircraft, keeping in visual contact with the ground, crossed a ridge into a narrow and steep-sided valley. It then commenced a rapid series of steep turns and turned onto a northerly heading while pitching up and climbing into cloud. The aircraft then entered a progressively increasing pitch down attitude while rolling to the right. It impacted the northern slopes of the valley in a steep nose down, wings level attitude at high speed. Both crew members were fatally injured and the aircraft was destroyed. The Investigation determined that the probable cause of the accident was Controlled Flight Into Terrain (CFIT) attributable to Spatial Disorientation due to a Somatogravic Illusion following the loss of Situational Awareness2. NOTIFICATION Castlebar Fire Station, Co. Mayo initially notified the Air Accident Investigation Unit (AAIU) at 17.10 hrs of a possible aircraft accident. After confirmation, AAIU and Irish Air Corps (IAC) investigation teams were deployed and commenced the investigation at first light the following morning. Members of An Garda Síochána3 initially secured the accident site and were later assisted by personnel from the Irish Defence Forces. Whereas initially the IAC took the lead role in the Investigation, the Minister for Defence and the Minister for Transport agreed and directed, pursuant to Regulation 27 (1) of Statutory Instrument No. 205 of 1997, 3 Air Navigation (Notification and Investigation of Accidents and Incidents) Regulations, 1997, that these Regulations would be applied to the investigation of this accident and that therefore the AAIU would conduct the Investigation. Consequently, the Chief Inspector of Air Accidents, on 13 Oct 2009, appointed Paddy Judge as the Investigator-in-Charge (IIC) to carry out a Formal Investigation into this Accident. The Minister for Transport appointed three IAC Officers as Inspectors of Air Accidents to assist the IIC in the Investigation. The aircraft and engine manufacturers appointed Advisors who travelled to Ireland to assist the Investigation and an international Expert in Aviation Medicine was later appointed to advise the Investigation. The sole purpose of this Investigation is the prevention of aviation accidents and incidents. It is not the purpose of the Investigation to apportion blame or liability. 2 These factors are explained in detail in the Report. 3 An Garda Síochána: The national police service of Ireland. IAC 265 Cornamona, Connemara, Co. Galway 12 October 2009 INDEX 1. FACTUAL INFORMATION ......................................................................................................................8 1.1 History of the Flight ................................................................................................................................. 8 1.1.1 General ....................................................................................................................................... 8 1.1.2 Witnesses ................................................................................................................................... 9 1.1.2.1 Witnesses who saw F265 ........................................................................................ 9 1.1.2.2 Other Witnesses ................................................................................................... 10 1.1.3 Crew F261 (Search Aircraft) ...................................................................................................... 10 1.1.3.1 F261 Instructor ..................................................................................................... 11 1.1.3.2 F261 Cadet ........................................................................................................... 11 1.1.4 F266 Instructor .......................................................................................................................... 12 1.1.5 F266 Cadet ............................................................................................................................... 13 1.1.6 Instructor Off-Duty Activity ....................................................................................................... 13 1.2 Injuries to Persons ................................................................................................................................... 14 1.3 Damage to Aircraft ................................................................................................................................. 14 1.4 Other Damage ........................................................................................................................................ 14 1.5 Personnel Information ............................................................................................................................. 14 1.5.1 Instructor ................................................................................................................................... 14 1.5.2 Cadet ........................................................................................................................................ 16 1.6 Aircraft Information ................................................................................................................................. 17 1.6.1 General Description .................................................................................................................. 17 1.6.2 Leading Particulars .................................................................................................................... 17 1.6.3 Aircraft Maintenance ................................................................................................................. 18 1.6.4 Electronic Limiter Unit (ELU) ..................................................................................................... 18 4 1.7 Meteorological Information..................................................................................................................... 19 1.7.1 Weather Aftercast ..................................................................................................................... 19 1.7.2 Weather Reports by Airports .................................................................................................... 19 1.7.3 Weather Reports by Witnesses ................................................................................................. 20 1.8 Aids to Navigation .................................................................................................................................. 20 1.9 Communications ..................................................................................................................................... 20 1.9.1 PC-9(M) Radios ......................................................................................................................... 20 1.9.2 Flight Plan ................................................................................................................................. 20 1.9.3 Radar ......................................................................................................................................... 21 1.10 Aerodrome Information ........................................................................................................................ 21 1.11 Flight Recorders .................................................................................................................................... 21 1.11.1 General ................................................................................................................................... 21 1.11.2 Flight Data Recorder (FDR) ..................................................................................................... 21 1.11.3 Cockpit Voice Recorder (CVR) ............................................................................................... 24 1.11.4 CVR Other Recordings ............................................................................................................ 27 1.11.5 FDR Navigational Position Data ............................................................................................. 27 1.12 Wreckage and Impact Information ........................................................................................................ 28 1.12.1 Site Inspection .......................................................................................................................