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Air Accidents Investigation Branch Department for Transport Report On AIRCRAFT ACCIDENT REPORT 3/2010 Air Accidents Investigation Branch Department for Transport Report on the accident to Cessna Citation 500 registration VP-BGE 2nm NNE of Biggin Hill Airport 30 March 2008 This investigation was carried out in accordance with The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996 The sole objective of the investigation of an accident or incident under these Regulations shall be the prevention of accidents and incidents. It shall not be the purpose of such an investigation to apportion blame or liability. © Crown Copyright 2010 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 may be published without specific permission providing that the source is duly acknowledged. Published 21 May 2010 Printed in the United Kingdom for the Air Accidents Investigation Branch ii Department for Transport Air Accidents Investigation Branch Farnborough House Berkshire Copse Road Aldershot Hampshire GU11 2HH April 2010 The Right Honourable Lord Adonis Secretary of State for Transport Dear Secretary of State I have the honour to submit the report by Mr K Conradi, an Inspector of Air Accidents, on the circumstances of the accident to Cessna Citation 500, registration VP-BGE, 2 nm NNE of Biggin Hill Airport on 30 March 2010. Yours sincerely David King Chief Inspector of Air Accidents © Crown Copyright 2010 iii Air Accident Report: 3/2010 VP-BGE EW/C2008/03/03 Contents Synopsis ............................................................................................................................ 1 1 Factual Information .............................................................................................. 3 1.1 History of the flight ........................................................................................ 3 1.2 Injuries to persons .......................................................................................... 5 1.3 Damage to the aircraft .................................................................................... 5 1.4 Other damage ................................................................................................. 5 1.5 Personnel information .................................................................................... 5 1.5.1 Pilot A ............................................................................................. 6 1.5.2 Pilot B .............................................................................................. 7 1.6 Aircraft Information ....................................................................................... 8 1.6.1 VP-BGE information ....................................................................... 8 1.6.2 General information ......................................................................... 8 1.6.3 Instruments ....................................................................................... 8 1.6.4 Engines ............................................................................................. 9 1.6.4.1 Engine control ............................................................... 9 1.6.5 Fuel system .................................................................................... 13 1.6.6 Electrical system ............................................................................ 15 1.6.7 Hydraulic system ........................................................................... 15 1.6.8 Pressurisation and air conditioning ................................................ 16 1.6.9 Baggage and passenger doors ........................................................ 16 1.6.10 Control surfaces ............................................................................. 16 1.6.11 Maintenance information .............................................................. 17 1.7 Meteorological information ......................................................................... 17 1.8 Aids to navigation ........................................................................................ 18 1.9 Communications .......................................................................................... 18 1.9.1 Radio communications .................................................................. 18 1.9.1.1 Transmission recording ............................................... 18 1.9.2 Radar .............................................................................................. 18 1.10 Aerodrome information ................................................................................ 22 1.11 Flight recorders ............................................................................................ 22 1.11.1 Flight Data Recorder/Cockpit Voice Recorder ............................. 22 1.12 Wreckage and impact information ............................................................... 22 1.12.1 Accident site and wreckage examination ....................................... 22 1.12.2 Airfield examination ...................................................................... 23 © Crown Copyright 2010 v Contents Air Accident Report: 3/2010 VP-BGE EW/C2008/03/03 1.12.3 Wreckage examination ................................................................... 23 1.12.3.1 General ........................................................................ 23 1.12.3.2 Doors and access panels .............................................. 24 1.12.3.3 Flight controls ............................................................. 24 1.12.3.4 Engine controls ........................................................... 25 1.12.3.5 Landing gear ............................................................... 27 1.12.3.6 Electrical system ......................................................... 27 1.12.3.7 Hydraulics ................................................................... 28 1.12.3.8 Pneumatics and air conditioning ................................. 28 1.12.3.9 Instrumentation ........................................................... 29 1.12.3.10 Fuel system ................................................................. 30 1.12.3.11 Powerplants ................................................................. 30 1.13 Medical and pathological information ......................................................... 36 1.14 Fire ............................................................................................................... 36 1.15 Survival aspects............................................................................................ 37 1.16 Tests and research ........................................................................................ 38 1.16.1 Cessna Citation I Model 500 (Cessna 500) data gathering and familiarization flight ................................................................ 38 1.16.1.1 Radio transmission recording ..................................... 38 1.16.1.2 Low-level fly-past ....................................................... 38 1.16.1.3 Single engine climb performance and shutdown and relight procedures ........................................................ 39 1.16.1.4 Circuits ........................................................................ 39 1.16.2 Aircraft performance calculations ................................................. 39 1.16.2.1 Direct thrust calculation .............................................. 39 1.16.2.2 Computer based simulation ......................................... 41 1.16.2.3 Accident flight thrust predictions ................................ 42 1.16.3 Aircraft ground tests ...................................................................... 42 1.16.5 Engine test cell .............................................................................. 44 1.16.6 Fuel system tests ............................................................................ 44 1.16.7 Citation full motion simulator ....................................................... 44 1.17 Organisational and management information .............................................. 45 1.18 Additional information ................................................................................. 47 1.18.1 Refuelling history .......................................................................... 47 1.18.2 Registration details ........................................................................ 47 1.18.3 Aircraft vibration ........................................................................... 47 1.18.4 Aircraft checklists .......................................................................... 47 © Crown Copyright 2010 vi Contents Air Accident Report: 3/2010 VP-BGE EW/C2008/03/03 2 Analysis ................................................................................................................. 48 2.1 Engineering .................................................................................................. 48 2.1.1 Impact analysis .............................................................................. 48 2.1.2 Vibration sources ........................................................................... 48 2.1.2.1 Airframe ...................................................................... 48 2.1.2.2 Aircraft systems .......................................................... 49 2.1.3 Fuel and
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