Air Accident Investigation Unit (Belgium) CCN Rue du Progrès 80 Bte 5 1030 Brussels FINAL REPORT ON THE ACCIDENT TO THE DIAMOND DA-40 D REGISTERED D-EQCO IN THE NORTH SEA ON 22 AUGUST 2009. Ref. AAIU-2009-15 Issue date: 21 January 2010 Status: Final AAIU-2009-15/ Final./ D-EQCO Table of Content. Foreword 2 Synopsis 3 1. Factual information 4 1.1. Chronology of the events 4 1.2. Injuries to persons 7 1.3. Damage to aircraft 7 1.4. Other damage 10 1.5. Personnel information 10 1.6. Aircraft information 11 1.7. Meteorological information 20 1.8. Aids to Navigation 20 1.9. Communication 21 1.10. Airport information 23 1.11. Flight Recorders 24 1.12. Wreckage and Impact information 26 1.13. Medical and Pathological information 26 1.14. Fire 26 1.15. Survival Aspects 26 1.16. Test and Research 26 2. Analysis 27 3. Conclusions 37 4. Safety recommendations. 37 Appendix: FADEC data 39 21 January 2010 Page 1 of 50 AAIU-2009-15/ Final./ D-EQCO FOREWORD This report is a technical document that reflects the views of the investigation team on the circumstances that led to the accident, In accordance with Annex 13 of the Convention on International Civil Aviation, it is not the purpose of aircraft accident investigation to apportion blame or liability. The sole objective of the investigation and the Final Report is the determination of the causes, and define recommendations in order to prevent future accidents and incidents. In particular, Article 13 of the King’s Decree of 9 December 1998 stipulates that the safety recommendations made in this report do not constitute any suspicion of guilt or responsibility in the accident. Unless otherwise indicated, recommendations in this report are addressed to the Regulatory Authorities of the State having responsibility for the matters with which the recommendation is concerned. It is for those Authorities to decide what action is taken. The investigation was conducted by L. Blendeman, Chief Investigator. The report was submitted for review to: - The European Aviation Safety Agency; - The Austrian Air Accident Investigation Bureau – Unfalluntersuchungsstelle – Luftfahrt; - The German Federal Bureau of Aircraft Accident Investigation – Bundesstelle für Flugunfallenuntersuchung; The comments and remarks received included those from the manufacturers Diamond and Thielert. All comments were analyzed, and the text of this report was amended accordingly. NOTE: For the purpose of this report, time will be indicated in UTC, unless otherwise specified. 21 January 2010 Page 2 of 50 AAIU-2009-15/ Final./ D-EQCO Synopsis Date and hour of the accident Saturday 22 August 2009 at 10:44 UTC. Aircraft Type: DIAMOND DA-40 D. Registration: D-EQCO Accident Location: In the North Sea, 10 Nm off the Belgian Coast, N 051° 16,154’ - E 002° 26,923’. Aircraft Owner Q Company Type of flight Private Persons on board 1 Abstract. The pilot filed a flight plan for a navigation flight from EBKT. After having performed an engine run-up, the pilot decided to change his original plan, and fly to EBOS for refueling instead. The flight to EBOS was not direct, and the pilot brought the airplane above sea (VFR route EBKT – KOK - CARLA – BULAM – COSTA – EBOS). The pilot stated that in flight the engine was producing a disturbing noise, and while the engine was rotating normally, the propeller was losing power; as felt by the pilot and seen on the instruments. The pilot considered he could not safely reach land, and decided to put its airplane in the water. He landed the airplane in see next to the Oostdijk platform, and was rescued by a small vessel. 30 minutes later, he was picked up by a SAR helicopter. The pilot was not injured. The airplane sank. 21 January 2010 Page 3 of 50 AAIU-2009-15/ Final./ D-EQCO 1. Factual Information 1.1. Chronology of the events The home base of the aircraft was EBKT, Belgium. The airplane was hangared from end October 2008 until 18 April 2009 at EBKT. At that time, he was put outside on the grass apron until the 22 August 2009. During this period, the airplane flew only twice, in December 2008 and January 2009. The pilot came to EBKT on 22 August, with the intention to perform a flight. He had logged a flight plan for that purpose. The route was: EBKT – COSTA – KEGIT – BULAM – DIBLI – CARLA – MADUX – KOK – EBKT; a flight mostly above the sea. The airplane was towed to the apron, and the pilot requested the help of the fire brigade, in order to start the engine. An external battery was connected. After a discussing with the traffic controller, the pilot moved the airplane further away from a business jet. The pilot performed a preflight check, including the draining of the wing tanks and started the engine, reportedly with some difficulties. The pilot decided to fly to Ostend in order to refuel. He indicated he had enough fuel to reach Ostend. He further indicated that the left tank was full and the right tank was half full upon starting. The pilot confirmed on the radio to the tower of EBKT that he did not activate the original flight plan, and that he was going to Ostend instead. D-EQCO took off from EBKT at 09:54. D-EQCO contacted Ostend Approach at 10.02., in order to notify its intention. The flight route given was KOK, CARLA, BULAM, COSTA to end up in EBOS. D-EQCO was identified on the radar, and instructed to fly at an altitude of 2000ft. At 10:16, D-EQCO notified EBOS it was crossing the coast line out to the sea. At 10:30. D-EQCO is reaching CARLA and turns towards BULAM. The initial part of the route followed seems more towards DIBLI (that was originally intended in the non-activated flight plan), but the route soon reverted in the general direction of BULAM, although North of the intended route. At 10:36. D-EQCO starts to lose altitude. 21 January 2010 Page 4 of 50 AAIU-2009-15/ Final./ D-EQCO At 10:40:30. The pilot of D-EQCO contacts the Ostend Tower to notify that he experiences “funny noise in the engine” and therefore returns immediately to the coast line. The pilot later stated the noise was rather a “crunching” noise. The pilot had the impression that “the engine was OK, but there was no thrust developed”. At 10:40:57, D-EQCO is turning towards the shore. At 10:41:40 the pilot of D-EQCO notifies EBOS he has difficulties to maintain altitude. The pilot further stated that the engine was running at cruise power, but the propulsion was degraded resulting in a loss of thrust. Every attempt to recover thrust were unsuccessful. The pilot further stated he shut down the engine, and restarted, without problem. At 10:42, Ostend Approach contacted directly the Rescue Center in Koksijde. At 10:43:22. the pilot stated he was veering towards a vessel, and that he had the intention to land the plane on the sea. At 10:44:39. the radar plot of D-EQCO disappears from the screen. The pilot succeeded in landing the airplane on the sea in the vicinity of the Oostdijk sea platform. The contact with the sea surface was done with the rudder first. The airplane was nearly intact after landing, and the pilot climbed out, onto the wing, and was rescued by divers on a Zodiac rubber boat almost instantly. A Sea King helicopter took off from Koksijde Air Base at 10:53, and headed towards the Oostdijkplatform. The pilot was winched up in the helicopter at 11:12. The D-EQCO airplane was sinking at the position N051° 16.154 E002° 26.924. The location was marked with two buoys. 21 January 2010 Page 5 of 50 . The Flight of D-EQCO. AAIU-2009-15/ Final./ D-EQCO 1.2. Injuries to persons Injuries Pilot Passenger Others Total Fatal 0 0 0 0 Serious 0 0 0 0 Minor 0 0 0 0 None 1 0 0 1 Total 1 0 0 1 1.3. Damage to aircraft The airplane sank on the bottom of the sea, 15m deep, nearly intact and remained 3 weeks in the sea water. It rested on the landing gear, at first. In the water, due to the stream, the aircraft moved away from its original position, and went on its back, causing damages to the engine cowling, canopy and nose landing gear. Left Wing 21 January 2010 Page 7 of 50 AAIU-2009-15/ Final./ D-EQCO Vertical Stabilizer – rudder missing Main Landing gear wheel. 21 January 2010 Page 8 of 50 AAIU-2009-15/ Final./ D-EQCO The recovery of the airplane was done on Monday 14 September 2009 with the use of a sea-crane – the Walrus – and a team of divers on the SAR ship Brandaris. 21 January 2010 Page 9 of 50 AAIU-2009-15/ Final./ D-EQCO All 3 blades of the propeller were broken, indicating a rotation while hitting the sea surface. 1.4. Other damage The recovery was decided also in order to avoid pollution of the sea bed. 1.5. Personnel information Pilot . Sex: Male Age: 44 Nationality: Dutch Licence: Private Pilot Licence – issued by the Belgian CAA on 25 June 2008, transferred from a German LBA licence first issued on 24 June 2002. The licence is valid until 25 June 2013. Ratings: SEP (land) - valid until 31 May 2011. Medical: Class 2 issued on 11 April 2008, valid until 24 April 2010.