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Report on the Serious Incident to Saab 2000, G-LGNO Approximately 7

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Report on the Serious Incident to Saab 2000, G-LGNO Approximately 7 AIRCRAFT ACCIDENT REPORT 2/2016 AAir AccidentsA InvestigationIB Branch Report on the serious incident to Saab 2000, G-LGNO Approximately 7 nm east of Sumburgh Airport, Shetland 15 December 2014 Unless otherwise indicated, recommendations in this report are addressed to the appropriate regulatory authorities having responsibility for the matters with which the recommendation is concerned. It is for those authorities to decide what action is taken. In the United Kingdom the responsible authority is the Civil Aviation Authority, CAA House, 45-49 Kingsway, London WC2B 6TE or the European Aviation Safety Agency, Postfach 10 12 53, D-50452 Koeln, Germany. AIRCRAFT ACCIDENT REPORT 2/2016 Air Accidents Investigation Branch Report on the serious incident to Saab 2000, G-LGNO Approximately 7 nm east of Sumburgh Airport, Shetland 15 December 2014 This investigation has been conducted in accordance with Annex 13 to the ICAO Convention on International Civil Aviation, EU Regulation No 996/2010 and 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 is the prevention of future accidents and incidents. It is not the purpose of such an investigation to apportion blame or liability. Accordingly, it is inappropriate that AAIB reports should be used to assign fault or blame or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. © Crown Copyright 2016 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, the material is reproduced accurately and it is not used in a derogatory manner or in a misleading context. Published 6 September 2016 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 August 2016 The Right Honourable Chris Grayling Secretary of State for Transport Dear Secretary of State I have the honour to submit the report on the circumstances of the serious incident to Saab 2000, registration G-LGNO, approximately 7 nm east of Sumburgh Airport, Shetland on 15 December 2014. Yours sincerely Keith Conradi Chief Inspector of Air Accidents © Crown Copyright 2016 iii Intentionally left blank Air Accident Report: 2/2016 G-LGNO EW/C2014/12/01 Contents Summary .......................................................................................................................... 1 1 Factual Information ................................................................................................ 3 1.1 History of the flight .......................................................................................... 3 1.1.1 Flight crew recollection of the event .................................................. 6 1.2 Injuries to persons ........................................................................................... 6 1.3 Damage to the aircraft .................................................................................... 7 1.4 Other damage ................................................................................................. 7 1.5 Personnel Information ..................................................................................... 7 1.5.1 Commander ...................................................................................... 7 1.5.2 Co-pilot .............................................................................................. 7 1.5.3 Flight crew information ...................................................................... 8 1.6 Aircraft Information .......................................................................................... 9 1.6.1 General information .......................................................................... 9 1.6.2 Flight envelope .................................................................................. 9 1.6.3 Flight control system ....................................................................... 10 1.6.4 Autopilot system ...............................................................................11 1.6.5 Air Data Computer system .............................................................. 14 1.6.6 Maintenance history ........................................................................ 14 1.6.7 Autopilot system requirements for initial Saab 2000 certification .... 15 1.6.7.1 Current requirements.................................................... 15 1.6.7.2 EASA and FAA interpretation on whether the Saab 2000 would meet the current 25.1329(l) requirements ......... 19 1.6.7.3 Design rationale for the Saab 2000 autopilot system during flight crew override ............................................ 19 1.6.8 Aircraft examination ........................................................................ 20 1.7 Meteorological information ............................................................................ 21 1.7.1 Conditions in flight ........................................................................... 21 1.7.2 Handbook of Aviation Meteorology ................................................. 21 1.7.3 Triggered lightning .......................................................................... 21 1.7.4 Saab 2000 and Saab 340 response to lightning strikes .................. 22 1.7.5 Instructions and information provided to flight crew concerning lightning strikes ............................................................................... 22 1.8 Aids to navigation .......................................................................................... 22 1.9 Communications ........................................................................................... 22 1.10 Aerodrome information ................................................................................. 22 1.11 Flight recorders ............................................................................................. 23 1.11.1 Cockpit voice recorder .................................................................... 23 1.11.2 Flight data recorder ......................................................................... 23 © Crown Copyright 2016 v Contents Air Accident Report: 2/2016 G-LGNO EW/C2014/12/01 1.12 Wreckage and impact information ................................................................ 27 1.13 Medical and pathological information ............................................................ 27 1.14 Fire ................................................................................................................ 27 1.15 Survival aspects ............................................................................................ 27 1.16 Test and research ......................................................................................... 28 1.16.1 Flight mechanics modelling ............................................................. 28 1.16.2 Crew override effects on autopilot systems on other commercial aircraft types ................................................................................... 31 1.16.3 Previous occurrences involving flight crew override of the autopilot ..35 1.16.3.1 Accident to Airbus A300, registration B-1816, on approach to Nagoya Airport, Japan on 26 April 1994 ... 35 1.16.3.2 Serious incident to Fokker F28 Mark 0100 (Fokker 100), registration G-BYDN, on approach to Paris Charles de Gaulle Airport, France on 3 November 2000 ................. 36 1.16.3.3 Serious incident to Cessna 550 Citation II, registration G-JBIZ, on approach to Edinburgh Airport, UK on 14 March 2008.............................................................. 37 1.16.4 Previous serious incident involving a significant out-of-trim condition .. 38 1.16.5 FAA survey of aircraft without autopilot disengagement during flight crew override ........................................................................... 38 1.17 Organisational and management information ............................................... 39 1.18 Additional information ................................................................................... 39 1.18.1 Human performance ....................................................................... 39 1.18.1.1 Identification of flight control malfunctions .................... 39 2 Analysis ................................................................................................................ 41 2.1 Aircraft examination ...................................................................................... 41 2.2 Aircraft response during the incident ............................................................ 41 2.3 Operation of the aircraft ............................................................................... 42 2.4 Analysis of the Saab 2000 autopilot system ................................................. 44 2.5 Analysis of autopilot system certification requirements ................................ 47 3 Conclusions .......................................................................................................... 51 4 Safety Recommendations and safety action ..................................................... 53 4.1 Safety Recommendations ............................................................................
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