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AAIB Bulletin: 11/2006 CONTENTS COMMERCIAL AIR TRANSPORT FIXED WING Avro 146-RJ100 G-CFAH 29-Mar-05 1 Boeing 737-76N G-STRH 07-Mar-06 9 Boeing 767-304 G-OBYJ 16-Feb-05 14 DHC-8-311 Dash 8 G-BRYW 07-Oct-05 18 Dornier 28 D2 Turbo Skyservant HA-ACO 24-Jun-06 26 ROTORCRAFT Agusta A109S Grand G-CGRI 07-Apr-06 28 GENERAL AVIATION FIXED WING ARV1 Super 2 G-BMWE 26-Aug-06 32 Casa 1-131E Series 2000 Jungermann G-JWJW 18-Jul-06 34 Cessna 152 G-BNXC 18-Dec-05 36 Aerotechnik EV-97 Eurostar G-GHEE } Cessna 152 G-BTIK 19-Jul-06 51 Cessna 182Q G-BWRR 11-Aug-06 52 DH82A Tiger Moth G-AHVU 08-Jul-06 54 DH82A Tiger Moth G-EMSY 15-Aug-06 55 Europa G-TAGR 21-Jul-06 56 GROB G115 G-BOPT 26-Jul-06 59 Grumman AA-1B G-BDLS 17-Nov-05 61 Jabiru UL-D G-JAAB 15-Aug-06 70 Mooney Aircraft Corporation M20J G-EKMW 16-Oct-04 71 Morane Saulnier Rallye 235E G-BWWG 28-Jun-06 94 Pierre Robin HR200/120B G-BYLH 27-Aug-06 95 Pierre Robin HR200/120B G-BXGW } Pierre Robin DR400/120A G-GBVX 29-Jul-06 97 Piper PA-28R-200-2 Cherokee Arrow II G-BCGS 19-Aug-06 99 Piper PA-32RT-300 G-RHHT 25-May-06 101 Piper PA-38-112 Tomahawk G-BYLE 22-Oct-05 103 Piper PA-38-112 Tomahawk G-LFSD 09-Sep-06 116 Pitts S-2A Special G-ODDS 01-Aug-06 118 Rans S6-ES G-BYOU 29-Jun-06 120 Reims Cessna F152 G-BTFC 27-Jul-06 121 Reims Cessna FR172K G-PJTM 25-Jun-06 123 Rockwell Commander 114 G-DDIG 19-Jul-06 126 Van’s RV-6A G-RVSA 15-Jul-06 128 Van’s RV-6A G-RVSH 25-Jun-06 130 ROTORCRAFT Robinson R22 Beta G-OHSL 08-Aug-06 131 Rotorway Executive G-BRGX 12-May-06 133 © Crown copyrght 2006 AAIB Bulletin: 11/2006 CONTENTS Continued SPORT AVIATION / BALLOONS EV-97 TeamEurostar UK G-IHOT 16-Jun-06 135 Gemini Flash 2 Alpha microlight G-MTJZ 11-Jul-06 137 Lindstrand LBL 210A hot air balloon G-BZDE 16-Apr-06 139 Lindstrand LBL 317A hot air balloon G-CDHN 09-Aug-05 146 Mainair Rapier microlight G-MZON 05-Jul-06 153 P & M Aviation Quik GT450 microlight G-GTSO 09-May-06 155 Pegasus Quantum 15-912 G-BYDM 02-Mar-06 157 Renegrade Spirit UK microlight G-TBMW 02-Jul-06 158 Shadow Series CD G-MYUS 22-Jul-06 159 Skyranger 912(2) G-CCKF 18-Jul-06 161 ADDENDUMS and CORRECTIONS Boeing 757-236 G-CPET 10-Mar-06 165 List of recent aircraft accident reports issued by the AAIB 166 (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyrght 2006 AAIB Bulletin: 11/2006 G-CFAH EW/C2005/03/06 INCIDENT Aircraft Type and Registration: Avro 46-RJ00, G-CFAH No & Type of Engines: 4 Lycomng LF507-H turbofan engnes Year of Manufacture: 200 Date & Time (UTC): 29 March 2005 at 89 hrs Location: London (Cty) Arport Type of Flight: Publc Transport (Passenger) Persons on Board: Crew - 5 Passengers - 04 Injuries: Crew - None Passengers - None Nature of Damage: Tal scrape protecton strp damaged Commander’s Licence: Arlne Transport Plot’s Lcence Commander’s Age: 34 years Commander’s Flying Experience: 5,725 hours (of whch 2,549 were on type) Last 90 days - 67 hours Last 28 days - 66 hours Information Source: AAIB Feld Investgaton Synopsis The first officer had stabilised the aircraft on an uneventful. Ths was the crew’s thrd sector of the day ILS approach, at nght, to Runway 0. At 400 ft the and was to be ther second landng that day at London commander sghted the runway lghts, took control (Cty) Arport. n accordance wth the Operator’s procedures and dsconnected the autoplot and autothrottle. Durng the The forecast weather was poor and the crew loaded landing flare the rate of descent appeared to be high and addtonal fuel. They brefed for a montored ILS the commander corrected ths by ncreasng the ptch approach to Runway 10, with the first officer (FO) as the atttude. The arcraft touched down at a body angle that pilot flying (PF); the briefing considered the actions to exceeded the safe lmt, causng the undersde of the rear be taken n the event of a go around at decson alttude. fuselage to contact the runway surface. The arcraft operator’s procedures requred that landngs by 146-RJ100s, at London (City), were to be flown by History of the flight the arcraft commander. He should take control of the The crew had rested for 4 hours and 20 mnutes before aircraft when he had acquired sufficient visual references reportng for duty. The arcraft departed Geneva at to land. 650 hrs and the transt to London (Cty) Arport was © Crown copyrght 2006 AAIB Bulletin: 11/2006 G-CFAH EW/C2005/03/06 The crew expected to land at a weght slghtly above but ths had been corrected mmedately and the speed 39 tonnes and used the assocated Vref of 122 kt; 5 kt accelerated through 22 kt. At about 60-70 ft RA the was then added to ths to gve an approach speed of commander notced that the rate of descent was hgh 27 kt. In accordance wth the manufacturer’s landng and at about 40-50 ft RA he commenced the landng profile, this should result in a predicted touchdown flare. The FO saw an IAS of 117 kt during the flare, speed of 115 kt eVref -7 kt. The centre of gravty was but wth a hgher than normal rate of descent and almost at a md poston. mmedately sensed the ‘ground-rush’. ATC radar vectored the arcraft onto an ntercept headng The touchdown was heaver than normal but the arcraft to establsh on the ILS localser for Runway 0. The was able to stop well wthn the avalable runway length. arcraft ntercepted the localser wth the autoplot and ATC consdered that a possble tal scrape had occurred autothrottle both engaged, the landng gear DOWN and and ntated a runway nspecton. An external nspecton the flaps set at 33º. As the aircraft intercepted the 5.5º of the arcraft revealed that the tal protecton strp had gldeslope, the arbrake was selected and the arcraft contacted the runway surface causng lght damage to commenced the descent. At 500 ft on the Rado Altmeter the protector plate; the flight crew were unaware that this (RA), the approach was confirmed as stable and at 400 ft damage had occurred. RA the commander saw the runway lghts through the Weather conditions ran, took control, and dsconnected the autoplot and autothrottle. The decson alttude for the approach was The synoptc stuaton at 800 hrs on the day of the 360 ft. ncdent, showed an area of low pressure, and ts assocated frontal systems, movng slowly east along the The speed remaned stable at 27 kt untl 200 ft RA when Englsh Channel. The weather n the area was lght ran the FO noted an ncreasng speed trend. The commander whch reduced the surface vsblty to 2,000 m, wth reduced thrust by approxmately % N: ths was n an overcast cloudbase of 400 ft and a mean sea level addton to the automatc 2% reducton, appled by the pressure of 011 hPa. engnes’ full authorty dgtal engne control system (FADEC), when the autothrottle had been dsconnected. The relevant TAF for London (Cty) Arport forecast the followng condtons between 600 hrs and 2200 hrs: Indications from the PAPIs confirmed that the aircraft was on the correct glde slope and, two to three seconds Surface wind from 070º at 10 kt, visibility 2,000 m after the automatc call of “00 ft” (RA), the commander in mist, cloud overcast at 500 ft, temporarily reduced thrust to acheve a touch down speed of 115 kt. lowering to 400 ft, with temporary rain between The FO, who had been monitoring the flight instruments, 1800 hrs and 2200 hrs. saw that the IAS had decreased at one pont to 20 kt, The METAR at London (Cty) Arport, ssued at 820, Footnote contaned the followng nformaton: Radar vectorng resulted n more fuel beng used and the arcraft eventually landed at a weight of 38.7 tonnes; the correct Vref for ths weght s 2 kt. However, the Vref of 22 kt calculated by the crew s used throughout the report. © Crown copyrght 2006 2 AAIB Bulletin: 11/2006 G-CFAH EW/C2005/03/06 Manufacture’s Flight Operations Bulletin Surface wind from 060º at 09 kt, visibility 2,000 m in light rain, overcast cloud at 400 ft, temperature In June 989 the manufacturer ssued a Flght Operatons 7ºC, dewpoint 7ºC and pressure 1,011 hPa. Bulletn coverng ‘the rsk of tal strkes’. The bulletn London (City) Airport related to the 46-300 but apples equally to the RJ00 variant and mainly covered the takeoff phase of flight. London Cty arport has a sngle, concrete runway, orentated 28/0, whch s ,508 m long and 30 m wde. The final paragraph of the bulletin addresses the landing The Landng Dstance Avalable (LDA) for Runway 0 phase of flight and states: s ,39 m and the threshold elevaton s 6 ft. The end of the touchdown zone is defined by two pairs of white, ‘With regard to the possibility of a tail strike hgh-ntensty lghts, ether sde of the runway centrelne occurring on landing, it is our opinion that this and postoned 360 m from the runway threshold.