AAIB Bulletin 2/2015 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 2/2015 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 DFDR Digital Flight Data Recorder PPL Private Pilot’s Licence Accordingly, it is inappropriate that AAIB reports should be used to assign fault DME Distance Measuring Equipment psi pounds per square inch or blame or determine liability, since neither the investigation nor the reporting EAS equivalent airspeed QFE altimeter pressure setting to indicate height EASA European Aviation Safety Agency above aerodrome process has been undertaken for that purpose. ECAM Electronic Centralised Aircraft Monitoring QNH altimeter pressure setting to indicate 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 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 12 February 2015 Cover picture courtesy of Richard Ross REF kg kilogram(s) VNE Never Exceed airspeed © Crown copyright 2015 ISSN 0309-4278 KCAS knots calibrated airspeed VASI Visual Approach Slope Indicator KIAS knots indicated airspeed VFR Visual Flight Rules Published by the Air Accidents Investigation Branch, Department for Transport KTAS knots true airspeed VHF Very High Frequency Printed in the UK on paper containing at least 75% recycled fibre km kilometre(s) VMC Visual Meteorological Conditions kt knot(s) VOR VHF Omnidirectional radio Range AAIB Bulletin: 2/2015 CONTENTS SPECIAL BULLETINS / INTERIM REPORTS None SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS None AAIB FIELD INVESTIGATIONS COMMERCIAL AIR TRANSPORT FIXED WING Gulfstream 550 HZ-A6 10-Dec-13 3 ROTORCRAFT None GENERAL AVIATION FIXED WING Denney Kitfox G-TOMZ ∫ ∫ 23-Sep-14 17 Cessna F177RG G-AZTW ROTORCRAFT None SPORT AVIATION / BALLOONS None AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT Beechcraft 300 Super King Air SE-KOL 13-Nov-14 35 GENERAL AVIATION Cessna 152 G-GFID 13-Nov-14 36 Cessna 172M Skyhawk G-BIHI 18-Sep-14 37 Cirrus SR20 G-VGAG 12-Nov-14 39 DHC-1 Chipmunk 22 G-BXHF 12-Jul-14 40 Piper PA-28-140 Cherokee G-COLH 30-Oct-14 41 Reims Cessna F172P Skyhawk G-BITM 27-Sep-14 44 Robin DR400/180 Regent G-ETIV 02-Sep-14 46 SPORT AVIATION / BALLOONS None © Crown copyright 2015 i AAIB Bulletin: 2/2015 CONTENTS Cont MISCELLANEOUS ADDENDA and CORRECTIONS Airbus A330-243 G-OMYT 24-Jun-13 49 Short SC7 Skyvan 3 G-BEOL 03-May-13 50 Sikorsky S-76C G-WIWI 03-May-12 51 List of recent aircraft accident reports issued by the AAIB 52 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2015 ii AAIB Bulletin: 2/2015 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 2015 1 AAIB Bulletin: 2/2015 HZ-A6 EW/C2013/12/01 SERIOUS INCIDENT Aircraft Type and Registration: Gulfstream 550, HZ-A6 No & Type of Engines: 2 Rolls-Royce BR710C4-11 turbofan engines Year of Manufacture: 2004 Date & Time (UTC): 10 December 2013 at 0325 hrs Location: Stansted Airport, Essex Type of Flight: Commercial Air Transport Persons on Board: Crew - 4 Passengers - 3 Injuries: Crew - None Passengers - None Nature of Damage: Underside of left wing and left landing gear door Commander’s Licence: Airline Transport Pilot’s Licence Commander’s Age: 53 Commander’s Flying Experience: 8,685 hours (of which 1,311 were on type) Last 90 days - 70 hours Last 28 days - 0 hours Information Source: AAIB Field Investigation Synopsis The aircraft was carrying out a charter flight from Riyadh in Saudi Arabia to London Stansted Airport. It was radar vectored for a CAT I, ILS DME approach to Runway 22 at Stansted with the autopilot (AP) and autothrust (AT) engaged. Conditions at the time were below the CAT I approach minima. With the aircraft fully established on the approach, the AP and AT were disengaged at 1,600 ft aal and the aircraft was hand flown by the commander for the remainder of the approach and landing. The localiser was maintained, but the aircraft flew above the glidepath before descending through it. For reasons that could not be established, go-around mode was selected, which would have inhibited the EGPWS glideslope warnings. In the final stages of the approach the aircraft was well below the glideslope, causing it to strike the Runway 22 ILS localiser monitor aerial and the Runway 04 localiser aerial array, before touching down short of the Runway 22 threshold. The accident occurred as a result of the pilot continuing to land from a destabilised approach, rather than performing a go-around. History of the flight The flight crew reported for duty at 1730 hrs and carried out the normal flight planning, which included reviewing the weather. The TAF for Stansted covering the aircraft’s ETA gave a 40% probability of fog between 0300 hrs and 1000 hrs, with a surface visibility of 500 m and cloud overcast at 100 ft. The weather at Manchester Airport, the selected alternate, was forecast to be 10 km visibility with cloud FEW at 3,500 ft for the same period. © Crown copyright 2015 3 AAIB Bulletin: 2/2015 HZ-A6 EW/C2013/12/01 The commander was the pilot flying (PF) and the co-pilot was the pilot monitoring (PM). There was one deferred defect, concerning the commander’s audio control panel which had the mask/boom selector button stuck in the mask position, but with the hand-held microphone available to the commander, this defect was accepted. The aircraft departed at 2001 hrs and, following an uneventful flight, commenced a descent for a CAT I1 approach into Stansted. The Stansted ATIS was recorded as: Information Bravo, Runway 22 at time 0220 hrs, wind 160º at 04 kt, Runway 22, Runway Visual Range (RVR) 250 m in fog with broken cloud at 100 ft, temperature 2ºC with a dew point 1ºC and a QNH of 1030 hPa.