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AAIB Bulletin: 8/2021

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AAIB Bulletin: 8/2021 AAIB Bulletin 8/2021 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 8/2021 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 Service 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 (as amended) and The Civil Aviation BHPA British Hang Gliding & Paragliding Association NDB Non-Directional radio Beacon CAA Civil Aviation Authority nm nautical mile(s) (Investigation of Air Accidents and Incidents) Regulations 2018. 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 PM Pilot Monitoring 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 Union 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) TODA Takeoff Distance Available HP high pressure UA Unmanned Aircraft hPa hectopascal (equivalent unit to mb) UAS Unmanned Aircraft System 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 August 2021 Cover picture courtesy of Stephen R Lynn LRPS REF V Never Exceed airspeed (www.srlynnphotography.co.uk) kg kilogram(s) NE KCAS knots calibrated airspeed VASI Visual Approach Slope Indicator © Crown copyright 2021 ISSN 0309-4278 KIAS knots indicated airspeed VFR Visual Flight Rules KTAS knots true airspeed VHF Very High Frequency Published by the Air Accidents Investigation Branch, Department for Transport km kilometre(s) VMC Visual Meteorological Conditions Printed in the UK on paper containing at least 75% recycled fibre kt knot(s) VOR VHF Omnidirectional radio Range AAIB Bulletin: 8/2021 CONTENTS SPECIAL BULLETINS / INTERIM REPORTS None SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS None AAIB FIELD INVESTIGATIONS COMMERCIAL AIR TRANSPORT FIXED WING None ROTORCRAFT Sikorsky S-92A G-LAWX 14-Oct-19 3 GENERAL AVIATION FIXED WING Cessna 185A Skywagon G-BLOS 7-Oct-20 68 ROTORCRAFT None SPORT AVIATION / BALLOONS None UNMANNED AIRCRAFT SYSTEMS None AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT AgustaWestland AW109SP G-TAAS 22-Apr-21 89 GENERAL AVIATION Druine D.31 Turbulent G-ARNZ 18-Oct-20 93 Piper PA-44-180 G-BGCO 12-Feb-21 96 SPORT AVIATION / BALLOONS None UNMANNED AIRCRAFT SYSTEMS None © Crown copyright 2021 i All times are UTC AAIB Bulletin: 8/2021 CONTENTS Cont RECORD-ONLY INVESTIGATIONS Record-Only Investigations reviewed: May / June 2021 101 MISCELLANEOUS ADDENDA and CORRECTIONS DJI Inspire 2 n/a 04-Apr-21 107 List of recent aircraft accident reports issued by the AAIB 109 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2021 ii All times are UTC AAIB Bulletin: 8/2021 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 2021 1 All times are UTC AAIB Bulletin: 8/2021 G-LAWX AAIB-26196 SERIOUS INCIDENT Aircraft Type and Registration: Sikorsky S-92A, G-LAWX No & Type of Engines: 2 General Electric CO CT7-8A turboshaft engines Year of Manufacture: 2004 (Serial no: 920007) Date & Time (UTC): 14 October 2019 at 1742 hrs Location: Near Shipston-on-Stour, Warwickshire Type of Flight: Private Persons on Board: Crew - 2 Passengers - 9 Injuries: Crew - None Passengers - None Nature of Damage: None reported Commander’s Licence: Airline Transport Pilot’s Licence (Helicopters) Commander’s Age: 54 years Commander’s Flying Experience: 6,200 hours (441 of which were on type) Last 90 days - 25 hours (25 hours on type) Last 28 days - 15 hours (15 hours on type) Information Source: AAIB Field Investigation Synopsis On an approach to a private landing site in conditions of reduced visibility shortly before night, the pilots became uncertain of their position and the helicopter descended to within 28 ft of rising terrain close to a house. During the subsequent emergency climb at low indicated airspeed, engine torque increased to 131% and the pitch attitude of the helicopter was unstable. The helicopter made another approach to the landing site and landed without damage or injury to the occupants. The investigation identified the following factors: ● Standard operating procedures for altitude alert setting, stabilised approach criteria and crew communication were either absent or not effective, ● a strong desire as a customer-facing director not to inconvenience the client, which was potentially in tension with his obligation as the commander to ensure a safe flight, ● uncertainty about the Rules of the Air when landing, and ● attitudes, behavioural traps and biases likely to have contributed to the occurrence. © Crown copyright 2021 3 All times are UTC AAIB Bulletin: 8/2021 G-LAWX AAIB-26196 The circumstances of this serious incident indicate the need for greater awareness of the hazards of operating in degraded visual conditions and highlight the potential safety benefits of Point-in-Space approaches at landing sites. The AAIB has made eight Safety Recommendations in these areas. History of the flight The pilots of the Sikorsky S-92A (S92) had been operating for several days from the landing site (LS) in the northern Cotswolds. They had flown the day before and reported that they were properly rested. On the day of the flight they arranged to meet nine passengers arriving in a fixed-wing aircraft at Birmingham Airport and fly them in the helicopter to the LS. Planning and positioning to Birmingham The pilots planned the flight and reviewed the weather, and the commander completed a risk assessment tool known as the Pre-flight Crew Briefing Aide Memoire. The forecast for Birmingham indicated a cloud base of 1,100 ft amsl, with visibility as low as 4,000 m for short periods. Sunset was at 1716 hrs. The helicopter departed the LS at 1550 hrs with the commander acting as PF in the right seat for the IFR flight from the LS to Birmingham. The pilots assessed the cloud base at the LS as 1,000 ft agl in 5 km visibility. Similar conditions were experienced on the approach to Birmingham, where the commander flew an ILS approach manually. After landing at 1610 hrs the pilots reviewed the weather, noting that the TAF at Birmingham was unchanged, and were advised that the fixed-wing aircraft was estimated to arrive at 1710 hrs.
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