AAIB Bulletin 3/2015
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AAIB Bulletin 3/2015 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 3/2015 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 March 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: 3/2015 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 Yak-52 G-YAKR 29-Mar-14 3 ROTORCRAFT None SPORT AVIATION / BALLOONS None AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT Airbus A320-232 G-TTOB 18-Dec-14 15 Boeing 737-8JP(WL) LN-DYS 23-Dec-14 17 GENERAL AVIATION DA 42 Twin Star G-CTCF 02-Dec14 19 Denney Kitfox Mk 2 G-KITY 19-Nov-14 21 Pietenpol Air Camper G-ECVB 23-Jul-14 23 Piper PA-28-161 Cherokee Warrior II G-BFYM 30-Dec-14 25 Piper PA-28-181 Cherokee Archer II G-TALE 01-Nov-14 26 SPORT AVIATION / BALLOONS Ikarus C42 FB100 G-FLYC 02-Jan-15 28 Pegasus Quik G-CBVN 30-Nov-14 30 Pegasus XL-Q G-MWOY ∫ ∫ 19-Nov14 31 P&M Aviation QUIK GT450 G-CEGJ Team Minimax G-MYRG 06-Dec-14 33 © Crown copyright 2015 i AAIB Bulletin: 3/2015 CONTENTS Cont MISCELLANEOUS ADDENDA and CORRECTIONS Reims Cessna F172P Skyhawk G-BITM 27-Sep-14 37 Sikorsky S-76C G-WIWI 03-May-12 38 List of recent aircraft accident reports issued by the AAIB 39 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2015 ii AAIB Bulletin: 3/2015 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: 3/2015 G-YAKR EW/C2014/03/04 ACCIDENT Aircraft Type and Registration: Yak-52, G-YAKR No & Type of Engines: 1 Ivchenko Vedeneyev M-14P piston engine Year of Manufacture: 1989 (Serial no: 899803) Date & Time (UTC): 29 March 2014 at 1453 hrs Location: Near Highwood, Chelmsford, Essex Type of Flight: Private Persons on Board: Crew - 1 Passengers - 1 Injuries: Crew - 1 (Fatal) Passengers - 1 (Fatal) Nature of Damage: Aircraft destroyed Commander’s Licence: Airline Transport Pilot’s Licence Commander’s Age: 50 Commander’s Flying Experience: in excess of 15,000 hours1 (of which approximately 40 hours2 were on type) Last 90 days - 1 hour Last 28 days - 1 hour Information Source: AAIB Field Investigation Synopsis The aircraft was carrying out a local flight when, five minutes into the flight, it was observed flying at low level. Having carried out a level turn, the aircraft climbed sharply and entered a stall or spin, from which it did not recover before striking the ground. Both occupants received fatal injuries and there was a fire. The reason the aircraft was flying at low level and the cause of the final manoeuvre could not be determined. History of the flight The pilot, who was one of three co-owners of the aircraft, arrived at North Weald mid-morning and prepared for a short local flight. He had not made an arrangement to take anyone with him, until he met someone at the airfield and offered him the opportunity to fly as a passenger. Following pre-flight preparations, some of which were witnessed by onlookers at the flying club, the aircraft’s engine was started and at 1439 hrs the pilot booked out by radio for a “TWENTY MINUTE LOCAL FLIGHT”. The aircraft taxied for departure from Runway 02 and took off Footnote 1 No up-to-date log books were available; the total hours stated is taken from the pilot’s medical declaration in October 2013. 2 Flight records for G-YAKR were audited but did not match records kept of movements at North Weald; time on type is derived from information on an insurance application in March 2013 adjusted to reflect some recent flying. © Crown copyright 2015 3 AAIB Bulletin: 3/2015 G-YAKR EW/C2014/03/04 at 1447 hrs. Following an apparently normal takeoff run, the aircraft lifted off and climbed before turning on course towards the east. The AFISO last saw the aircraft climbing away from the airfield, above 1,000 ft aal. In the pilot’s final communication to the AFISO, at 1448 hrs, he reported that he was “VACATING TO THE EAST”. No further transmissions from the pilot were heard. Primary radar returns show that the aircraft then flew a predominantly easterly track. Although the aircraft was fitted with a transponder which, according to the other co-owners, was serviceable, no secondary radar responses from the aircraft were recorded. Therefore, there was no height information. The aircraft’s track included a left and then right turn, which were co-incident with the position of a small airfield.