AAIB Bulletin 8/2018 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 8/2018 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 MDA Minimum Descent Altitude amsl above mean sea level METAR a timed aerodrome meteorological report AOM Aerodrome Operating Minima min minutes APU Auxiliary Power Unit mm millimetre(s) ASI airspeed indicator mph miles per hour ATC(C)(O) Air Traffic Control (Centre)( Officer) MTWA Maximum Total Weight Authorised ATIS Automatic Terminal Information Service N Newtons ATPL Airline Transport Pilot’s Licence NR Main rotor rotation speed (rotorcraft) BMAA British Microlight Aircraft Association N Gas generator rotation speed (rotorcraft) AAIB investigations are conducted in accordance with g BGA British Gliding Association N1 engine fan or LP compressor speed Annex 13 to the ICAO Convention on International Civil Aviation, BBAC British Balloon and Airship Club NDB Non-Directional radio Beacon EU Regulation No 996/2010 and The Civil Aviation (Investigation of BHPA British Hang Gliding & Paragliding Association nm nautical mile(s) CAA Civil Aviation Authority NOTAM Notice to Airmen Air Accidents and Incidents) Regulations 2018. CAVOK Ceiling And Visibility OK (for VFR flight) OAT Outside Air Temperature CAS calibrated airspeed OPC Operator Proficiency Check cc cubic centimetres PAPI Precision Approach Path Indicator The sole objective of the investigation of an accident or incident under these CG Centre of Gravity PF Pilot Flying Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PIC Pilot in Command CPL Commercial Pilot’s Licence PNF Pilot Not Flying purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true POH Pilot’s Operating Handbook CVR Cockpit Voice Recorder PPL Private Pilot’s Licence DME Distance Measuring Equipment psi pounds per square inch Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed QFE altimeter pressure setting to indicate height or blame or determine liability, since neither the investigation nor the reporting EASA European Aviation Safety Agency above aerodrome ECAM Electronic Centralised Aircraft Monitoring QNH altimeter pressure setting to indicate process has been undertaken for that purpose. 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 FDR Flight Data Recorder SB Service Bulletin FIR Flight Information Region SSR Secondary Surveillance Radar FL Flight Level TA Traffic Advisory ft feet TAF Terminal Aerodrome Forecast AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAS true airspeed http://www.aaib.gov.uk g acceleration due to Earth’s gravity TAWS Terrain Awareness and Warning System GPS Global Positioning System TCAS Traffic Collision Avoidance System GPWS Ground Proximity Warning System TGT Turbine Gas Temperature hrs hours (clock time as in 1200 hrs) TODA Takeoff Distance Available HP high pressure UAS Unmanned Aircraft System hPa hectopascal (equivalent unit to mb) UHF Ultra High Frequency 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 9 August 2018 Cover picture courtesy of Stephen R Lynn REF V Never Exceed airspeed (www.srlynnphotography.co.uk) kg kilogram(s) NE KCAS knots calibrated airspeed VASI Visual Approach Slope Indicator © Crown copyright 2018 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: 8/2018 CONTENTS SPECIAL BULLETINS / INTERIM REPORTS None SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS None AAIB FIELD INVESTIGATIONS COMMERCIAL AIR TRANSPORT FIXED WING None ROTORCRAFT None GENERAL AVIATION FIXED WING Piper PA-28RT-201 Cherokee Arrow IV G-BHAY 11-Sep-17 3 ROTORCRAFT None SPORT AVIATION / BALLOONS None AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT Sikorsky S-92A G-CHHF 29-Jan-18 23 GENERAL AVIATION Cessna 140 G-HALJ 05-Mar-18 27 Denney Kitfox Mk 3 G-KTTY 09-Jun-18 28 DH82A Tiger Moth G-AXBW 17-Apr-18 29 Europa G-RICS 20-Apr-18 31 Piper PA-18-150 Super Cub G-RWCA 07-Apr-18 32 Piper PA-24-250 Commanche N7832P 18-Feb-18 35 SPORT AVIATION / BALLOONS P&M Aviation PulsR G-FFFA 18-Apr-18 36 P&M Aviation Quik GT450 G-CEZX 02-Jun-18 38 © Crown copyright 2018 i All times are UTC AAIB Bulletin: 8/2018 CONTENTS Cont AAIB CORRESPONDENCE INVESTIGATIONS Cont SPORT AVIATION / BALLOONS Cont Pegasus Quik G-CEMZ 12-May-18 40 Quik GT450 G-TBLB 09-Apr-18 42 Skyranger J2.2(2) G-MARO 19-May-18 43 UNMANNED AIRCRAFT SYSTEMS None MISCELLANEOUS ADDENDA and CORRECTIONS Jetstream 4100 G-MAJC 16-Oct-17 47 List of recent aircraft accident reports issued by the AAIB (ALL TIMES IN THIS BULLETIN ARE UTC) © Crown copyright 2018 ii All times are UTC AAIB Bulletin: 8/2018 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 2018 1 All times are UTC AAIB Bulletin: 8/2018 G-BHAY EW/C2017/09/03 ACCIDENT Aircraft Type and Registration: Piper PA-28RT-201 Cherokee Arrow IV, G-BHAY No & Type of Engines: 1 Lycoming IO-360-C1C6 piston engine Year of Manufacture: 1979 (Serial no: 28R-7918213) Date & Time (UTC): 11 September 2017 at 0956 hrs Location: Wolferton, Norfolk Type of Flight: Private Persons on Board: Crew - 1 Passengers - 1 Injuries: Crew - 1 (Fatal) Passengers - 1 (Fatal) Nature of Damage: Engine front fuselage, wings and landing gear severely disrupted Commander’s Licence: Private Pilot’s Licence Commander’s Age: 58 years Commander’s Flying Experience: 1,129 hours (of which 406 were on type) Last 90 days - 15 hours Last 28 days - 10 hours Information Source: AAIB Field Investigation Synopsis The aircraft was en route from London Southend Airport to Newcastle International Airport. Over the Wash, the pilot reported that the aircraft’s engine was rough running and he turned towards the coast, during which time the engine failed. During the forced landing it is likely that the aircraft stalled and then struck a berm (the old sea wall) with a high rate of descent. The pilot and his passenger were fatally injured. Whilst it could not be positively determined why the aircraft stalled, the investigation revealed that the aircraft’s engine had not been maintained according to the manufacturer’s instructions whilst it was not used for long periods and parked outside. History of the flight Background information The aircraft had been based at Newcastle International Airport and the pilot flew it via France to Menorca, Spain, in July 2017. In September 2017, the pilot and passenger flew the aircraft back from Menorca, through France, bound for Newcastle. On 10 September they landed at London Southend Airport after the pilot decided to divert, due to inclement weather, en route to Newcastle and elected to stay overnight. © Crown copyright 2018 3 All times are UTC AAIB Bulletin: 8/2018 G-BHAY EW/C2017/09/03 Accident flight On 11 September 2017 the pilot planned to continue from Southend to Newcastle. Prior to departure the occupants were seen to take about an hour preparing the aircraft. The aircraft took off at 0908 hrs. At 0953 hrs, when the aircraft was over the Wash after crossing the Norfolk coast, the pilot transmitted a MAYDAY to the Distress and Diversion Cell (D&D) on 121.5 MHz, stating he had a “VERY ROUGH RUNNING ENGINE,” that the aircraft was at 3,300 ft amsl, descending, and he would turn south towards RAF Marham. A short time later he transmitted “THAT’S SMOKE NOW I THINK WE’VE GOT AN ELECTRICAL FIRE…”. About one minute later he transmitted “ENGINE HAS FAILED”. At this point the aircraft was at about 1,400 ft amsl and D&D informed the pilot the aircraft was 13.5 nm from RAF Marham, to which the pilot replied he would not make it.