AAIB Bulletin 1/2014 TO REPORT AN ACCIDENT OR INCIDENT PLEASE CALL OUR 24 HOUR REPORTING LINE 01252 512299 Air Accidents Investigation Branch Farnborough House AAIB Bulletin: 1/2014 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 System 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 and The Civil Aviation (Investigation of BHPA British Hang Gliding & Paragliding Association NDB Non-Directional radio Beacon CAA Civil Aviation Authority nm nautical mile(s) Air Accidents and Incidents) Regulations 1996. 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 PNF Pilot Not Flying 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 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) TGT Turbine Gas Temperature HP high pressure TODA Takeoff Distance Available 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 January 2014 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 2014 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: 1/2014 CONTENTS SPECIAL BULLETINS / INTERIM REPORTS S8/2013 Pilatus Britten-Norman BN2B-21 Islander G-CIAS 03-Nov-13 3 S9/2013 Eurocopter EC135 T2+ G-SPAO 29-Nov-13 7 AAIB FIELD INVESTIGATIONS COMMERCIAL AIR TRANSPORT FIXED WING North American Rockwell OV-10B Bronco G-BZGK 10-Jul-12 13 ROTORCRAFT Sikorsky S-76C G-XXEB 23-May-13 32 GENERAL AVIATION FIXED WING None ROTORCRAFT None SPORT AVIATION / BALLOONS None AAIB CORRESPONDENCE INVESTIGATIONS COMMERCIAL AIR TRANSPORT Beech A36TP Bonanza N7205T 30-Aug-13 37 Boeing 747-436 G-CIVA 09-Jun-13 39 GENERAL AVIATION Beagle Auster D5 Series 180 Husky G-ATMH 29-Sep-13 40 Cessna 182P Skylane G-EEZS 23-Aug-13 42 Luscombe 8A Silvaire G-BSNT 22-Jul-13 43 Pierre Robin DR400/100 Cadet G-FTIN 31-Aug-13 44 Piper PA-28-181 Cherokee Archer II G-OODW 10-Oct-13 45 Streak Shadow G-BVTD 10-Aug-13 48 Zenair CH 701SP G-IMME 08-Sep-13 49 © Crown copyright 2014 i AAIB Bulletin: 1/2014 CONTENTS Cont AAIB CORRESPONDENCE INVESTIGATIONS Cont SPORT AVIATION / BALLOONS Cyclone AX2000 G-MZER 09-Aug-13 50 Kolb Firefly G-CEPN 26-Jul-13 51 Mainair Blade 912 G-MZGI 20-Aug-13 52 MW5 Sorcerer G-MWSX 10-Aug-13 53 P & M Aviation QuikR G-CFXZ 15-Oct-13 54 Team Minimax 91 G-CEDW 24-Oct-13 55 MISCELLANEOUS ADDENDA and CORRECTIONS None List of recent aircraft accident reports issued by the AAIB 59 (ALL TIMES IN THIS BULLETIN ARE UTC) The AAIB Bulletin has changed format this month from two columns to one column. This is to enable easier online reading. © Crown copyright 2014 ii AAIB Bulletin: 1/2014 AAIB Special Bulletins / Interim Reports AAIB Special Bulletins and Interim Reports This section contains Special Bulletins and Interim Reports that have been published since the last AAIB monthly bulletin. © Crown copyright 2014 1 AAIB Bulletin: S8/2013 G-CIAS EW/C2013/11/01 ACCIDENT Aircraft Type and Registration: Pilatus Britten-Norman BN2B-21 Islander, G-CIAS No & Type of Engines: 2 Lycoming IO-540-K1B5 piston engines Year of Manufacture: 1982 (Serial no: 2162) Location: Near Devil’s Hole, approximately 2.5 nm north of Jersey Airport, Channel Islands Date & Time (UTC): 3 November 2013 at 1908 hrs Type of Flight: Private (Search and rescue) Persons on Board: Crew - 1 Passengers - 4 (Search crew) Injuries: Crew - None Passengers - None Nature of Damage: Significant damage to wing, left main landing gear and forward fuselage Commander’s Licence: Airline Transport Pilot’s Licence Commander’s Age: 65 years Commander’s Flying Experience: 25,200 hours (of which 60 were on type) Last 90 days - 101 hours Last 24 hours - 2 hours Information Source: AAIB Field Investigation The investigation The Air Accidents Investigation Branch was notified of the accident by Jersey Air Traffic Control at 1920 hrs on Sunday 3 November 2013 and an investigation was commenced under the provisions of the Civil Aviation (Investigation of Air Accidents and Incidents) (Jersey) Order 2000. This Special Bulletin is published to provide details of the initial facts surrounding the accident. The investigation is ongoing and a final report will be published in due course. Background The aircraft was operated by a charitable organisation staffed by volunteers whose purpose was to carry out search operations in and around the Channel Islands. It was equipped for its role with aviation and maritime communication equipment, search radar, and infra-red This Special Bulletin contains facts which have been determined up to the time of issue. It is published to inform the aviation industry and the public of the general circumstances of accidents and serious incidents and should be regarded as tentative and subject to alteration or correction if additional evidence becomes available. © Crown copyright 2013 3 AAIB Bulletin: S8/2013 G-CIAS EW/C2013/11/01 and video cameras, as well as smoke flares, lights and loudhailers, and an air-droppable dinghy. History of the flight At approximately 1820 hrs on 3 November 2013, the organisation was alerted to carry out a search for two fishermen who were in difficulties near Les Écréhous, a group of rocks north-east of Jersey. The pilot, accompanied by the search director, and three observers, gathered at the aircraft’s base at Guernsey Airport, and made preparations for flight. There was no moon and the Channel Islands were affected by poor weather, with strong southerly winds, low cloud, and poor visibility. The pilot reported encountering “strong turbulence” during the flight. The aircraft took off at 1847 hrs and, taking account of the cloud base and visibility, the pilot levelled the aircraft at approximately 700 ft amsl on track towards the search area. When the aircraft was approximately six miles north of Jersey Airport, the right engine rpm began to vary, repeatedly reducing and then increasing.