Technical report A-002/2020 ______________________________ Accident involving a DIAMOND DA20-A1 aircraft, registration EC-JLN, in front of El Altillo beach on the island of Gran Canaria (Las Palmas de Gran Canaria), on 19 January 2020 Please note that this report is not presented in its final layout and therefore it could include minor errors or need type corrections, but not related to its content. The final layout with its NIPO included (Identification Number for Official Publications) will substitute the present report when available. Notice This report is a technical document that reflects the point of view of the Civil Aviation Accident and Incident Investigation Commission regarding the circumstances of the accident object of the investigation, its probable causes and its consequences. In accordance with the provisions in Article 5.4.1 of Annex 13 of the International Civil Aviation Convention; and with Articles 5.5 of Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010; Article 15 of Law 21/2003 on Air Safety; and Articles 1, 4 and 21.2 of RD 389/1998, this investigation is exclusively of a technical nature, and its objective is the prevention of future aviation accidents and incidents by issuing, if necessary, safety recommendations to prevent their recurrence. The investigation is not intended to attribute any blame or liability, nor to prejudge any decisions that may be taken by the judicial authorities. Therefore, and according to the laws detailed above, the investigation was carried out using procedures not necessarily subject to the guarantees and rights by which evidence should be governed in a judicial process. Consequently, the use of this report for any purpose other than the prevention of future accidents may lead to erroneous conclusions or interpretations. ii CONTENTS Notice ........................................................................................................................... ii CONTENTS .................................................................................................................. iii ABBREVIATIONS ......................................................................................................... v Synopsis ....................................................................................................................... 7 1. FACTUAL INFORMATION .................................................................................... 9 1.1. History of the flight .......................................................................................... 9 1.3. Damage to the aircraft .................................................................................. 10 1.4. Other damage ............................................................................................... 10 1.5. Personnel information ................................................................................... 10 1.5.1. Pilot ....................................................................................................... 10 1.6. Aircraft information ........................................................................................ 11 1.6.1. General information ............................................................................... 11 1.6.2. Airworthiness and maintenance information .......................................... 11 1.6.3. The Rotax 912S engine lubrication system ............................................ 12 1.6.4. Aircraft Technical Log (TLB) .................................................................. 14 1.6.5. Flight manual. ........................................................................................ 15 Pre-flight inspection ........................................................................ 15 Emergency procedures ................................................................... 15 1.6.6. Weight and balance ............................................................................... 16 1.6.7. Rotax912S operating manual ................................................................ 16 1.7. Meteorological information ............................................................................ 18 1.8. Aids to navigation ......................................................................................... 19 1.9. Communications ........................................................................................... 19 1.10. Aerodrome information .............................................................................. 19 1.11. Flight recorders ......................................................................................... 21 1.11.1. Radar trace ........................................................................................ 21 1.12. Aircraft wreckage and impact information .................................................. 22 1.13. Medical and pathological information ........................................................ 22 1.14. Fire ............................................................................................................ 23 1.15. Survival aspects ........................................................................................ 23 1.16. Tests and research ................................................................................... 23 1.16.1. Aircraft inspection............................................................................... 23 1.16.2. Inspection of the life jacket ................................................................. 27 1.16.3. Pilot’s statement ................................................................................. 28 1.16.4. Passenger testimony .......................................................................... 29 1.17. Organisational and management information ............................................ 30 1.18. Additional information ................................................................................ 30 1.18.1. Similar incidents ................................................................................. 30 1.18.2. Tides .................................................................................................. 31 1.19. Useful or effective investigation techniques ............................................... 31 2. ANALYSIS .......................................................................................................... 32 2.1. Operational analysis ..................................................................................... 32 2.2. Analysis of the engine failure ........................................................................ 32 2.3. Analysis of the annotations in the TLB .......................................................... 34 2.4. The engine’s oil consumption ....................................................................... 36 iii 2.5. Analysis of the oil-level check procedure ...................................................... 36 2.6. Operation of the life jackets .......................................................................... 37 3. CONCLUSIONS .................................................................................................. 39 3.1. Findings ........................................................................................................ 39 3.2. Causes/contributing factors .......................................................................... 40 4. OPERATIONAL SAFETY RECOMMENDATIONS .............................................. 41 iv ABBREVIATIONS Grado(s), minuto(s) y segundo(s) Degree(s), minute(s) and ' " sexagesimal(es) second(s) C Grado(s) centígrado(s) Degree(s) Celsius F Grado(s) Fahrenheit Degree(s) Fahrenheit % AD GCLP Aeropuerto de Gran Canaria Gran Canaria Airport Agencia Estatal de Seguridad Spain’s National Aviation Safety AESA Aérea Agency AGL Sobre el nivel del terreno Above ground level AMSL Sobre el nivel medio del mar Above mean sea level Certificado de revisión de la Airworthiness review certificate ARC aeronavegabilidad Organización de formación Approved training organisation ATO aprobada Licencia de piloto de transporte Airline Transport Pilot License ATPL de línea aérea Condiciones de visibilidad de 10 Visibility, cloud and present km o más, ninguna nube por weather better than prescribed debajo de 5000 pies, ausencia de values or conditions CAVOK cumulonimbus y torrecúmulos y ningún fenómeno meteorológico significativo cm Centímetro(s) Centimetre(s) CPL Licencia de piloto comercial Commercial Pilot License CTR Zona de control Control zone FL Nivel de vuelo Flight level ft Instructor de vuelo Flight instructor Control de aproximación del Gran Canaria airport approach GCLP APP aeropuerto de Gran Canaria control h Hora(s) Hour(s) hp Caballo de potencia Horsepower hPa Hectopascal(es) Hectopascal(s) kg Kilogramo(s) Kilogramme(s) KIAS Velocidad indicada en nudos Knots indicated airspeed km Kilómetro(s) Kilometre(s) km/h Kilómetros por hora Kilometres per hour kt Nudo(s) Knot(s) kW Kilovatio(s) Kilowatt(s) L Litro(s) Litre(s) l/h Litros por hora Litres per hour LDG Aterrizaje Landing v m Metro(s) Metre(s) m2 Metro(s) cuadrado(s) Square metre(s) Informe meteorológico ordinario Aviation routine weather report (in METAR de aeródromo (en clave aeronautical meteorological code) meteorológica aeronáutica) min Minuto(s) Minute(s) mph Millas terrestres por hora Miles per hour Nº Número Number PPL Licencia de piloto privado Private Pilot License psi Libras por pulgada cúbica Pounds per square inch rpm Revoluciones por minuto Revolutions per