Safety Mat­ters

Safety Mat­ters and Safety Briefs are based on the AAIB Bul­letin, UK Air­prox Board re­ports and ad­di­tional ma­te­rial from the US Na­tional Trans­porta­tion Safety Board

Pilot - - CONTENTS -

Two fatal ac­ci­dents; de­cid­ing whether to go around again

Poor weather, fatal out­come

Air­craft Type: Rock­well Com­man­der 114B Date & Time: 3 De­cem­ber 2015 Com­man­der’s Fly­ing Ex­pe­ri­ence: PPL, in ex­cess of 200 hours, at least 100 on type (the pi­lot’s log books were not re­cov­ered) Last 90 days: Un­known Last 28 days: Un­known The air­craft took off from Isle of Man (Ron­aldsway) at 0836 on a pri­vate VFR flight to Black­pool. The Black­pool TAF pre­dicted the low­est vis­i­bil­ity around the air­craft’s time of ar­rival would be 1,400m in heavy rain, with bro­ken cloud 300ft above the aero­drome. At 0851 the pi­lot es­tab­lished con­tact with the Black­pool Ap­proach con­troller, who was pro­vid­ing a pro­ce­dural ser­vice — Black­pool does not have radar. The sub­se­quent R/T ex­change went thus (Ba=black­pool Ap­proach, C114=com­man­der 114):

BA: “I’ll give you the full weather be­cause it’s not very nice. Sur­face wind in­di­cat­ing zero niner zero de­grees at four knots, vis­i­bil­ity two thou­sand me­tres in slight rain and mist, cloud few at two hun­dred feet, scat­tered at one thou­sand six hun­dred feet, bro­ken at three thou­sand six hun­dred feet, tem­per­a­ture plus eight.” C114: “Er, can I fly this… can I land in this?” BA: “That’s en­tirely up to you and your li­cence re­stric­tions.”

C114: “Of course it’s up to me… Er, I can al­ways di­vert back to the Isle of Man if it’s not suit­able. Which run­way is in use please?” BA: “Run­way one zero in use.” C114: “Run­way one zero. Er, if I can land, can I take it on a long fi­nal?”

BA: “You can make a straight-in ap­proach for run­way one zero.”

The air­craft tracked to­wards Black­pool, through a heli­copter traf­fic zone around oil and gas rigs in More­cambe Bay, and ex­ited the zone at 0858 at an al­ti­tude of 800ft and a ground­speed of around 115kt. It reached, and then tracked, the ex­tended cen­tre­line of Rwy 10. At ap­prox­i­mately 12nm from the aero­drome the air­craft de­scended to 700ft. At 0902 the pi­lot re­ported at ‘ap­prox­i­mately ten miles’, and was in­structed to re­port when he had the run­way in sight. At 0904 he en­quired again about the weather and was given ‘Cur­rent cloud­base is few at one thou­sand one hun­dred, but (in­dis­tinct word) is few lower at about two hun­dred,’ which he ac­knowl­edged.

When the Com­man­der was 7nm from the aero­drome it de­scended to 500ft, and then at about 5nm to 400ft. Ground­speed re­duced pro­gres­sively to less than 60kt, and its track turned north-east­erly at around 4nm, be­fore turn­ing again to­wards the run­way cen­tre­line, now at 300ft. The fi­nal R/T ex­change took place at 0907:

BA: “(Call­sign) re­port visual with the aero­drome, the lights are on max­i­mum.”

C114: “Er, wilco… I haven’t, haven’t got it in sight yet.”

The Com­man­der’s low­est ground­speed shown on radar was 48kt, and the fi­nal radar re­turn recorded at 0907 showed it at 200ft, de­scend­ing, at 57kt. The R/T record­ing in­cluded two very brief sounds, one at 0908 and one at 0909, which could have been mo­men­tary trans­mis­sions from the air­craft. In the back­ground of the first was a high-pitched tone, pos­si­bly the stall warner. At 0910 the con­troller asked the pi­lot to re­port his range from Black­pool, but re­ceived no re­ply, so he ini­ti­ated search and res­cue ac­tion. Sev­eral he­li­copters took part, and their pilots re­marked upon the low cloud, poor vis­i­bil­ity, and ‘fish­bowl’ ef­fect they en­coun­tered over the sea in the search area. One, who was a mil­i­tary fixed- and ro­tary-wing pi­lot, com­mented that it ‘was not a day to be out over the sea at low level… there was a sig­nif­i­cant op­por­tu­nity for [the pi­lot] to have been dis­ori­en­tated.’

An SAR op­er­a­tion by the Mar­itime & Coast­guard Agency (MCA) spot­ted a fuel or

light oil slick in the vicin­ity of the last known radar po­si­tion of the air­craft, and sev­eral very small pieces of wreck­age were also found. No other items were re­cov­ered un­til the fol­low­ing morn­ing when a mem­ber of the pub­lic found a small shoul­der bag con­tain­ing var­i­ous items in­clud­ing an in­stru­ment fly­ing text­book which linked it to the pi­lot. MCA staff later re­cov­ered a set of plas­tic air­craft wheel chocks.

Sev­eral hours af­ter the ac­ci­dent, con­di­tions de­te­ri­o­rated into a pro­longed pe­riod of very se­vere weather which pre­vented a fur­ther un­der­wa­ter search for wreck­age un­til eleven days later, when a po­lice mar­itime unit found an air­craft on the seabed. The very poor sub-sea vis­i­bil­ity pre­cluded pos­i­tive iden­ti­fi­ca­tion or ex­am­i­na­tion, but the lo­ca­tion, de­scrip­tion and colour scheme strongly sug­gested it was the Com­man­der, ly­ing in­verted in one piece, with the fin and cabin area buried in soft sand, and land­ing gear ex­tended.

A pri­vately-funded sal­vage op­er­a­tion con­ducted al­most three months af­ter the ac­ci­dent could not be com­pleted be­cause the air­craft had be­come full of com­pacted sand and was firmly lodged within the sea bed, but it did re­cover the en­gine, pro­pel­ler and part of the left wing, which were ex­am­ined by the AAIB. The en­gine showed signs of im­pact with the sea and had been dam­aged by the sal­vage op­er­a­tion. All three pro­pel­ler blades were bent and twisted and the spin­ner had been flat­tened. The dis­tor­tion of the pro­pel­ler blades in­di­cated that the en­gine had been pro­duc­ing power when it came into con­tact with the sea. The flat­ten­ing of the spin­ner sug­gested a steep an­gle of im­pact, but there was not enough ev­i­dence to de­ter­mine whether the air­craft was up­right or in­verted.

The AAIB re­port concludes: ‘[Whilst] a tech­ni­cal fault or an ex­ter­nal in­flu­ence, such as a bird-strike, can­not be en­tirely dis­counted… the me­te­o­ro­log­i­cal con­di­tions were cor­rectly fore­cast, and al­though it was not pos­si­ble to es­tab­lish what fore­cast in­for­ma­tion the pi­lot had gath­ered, his con­ver­sa­tion with [an­other Ron­aldsway pi­lot] in­di­cated that he was aware of the pos­si­bil­ity of in­clement weather. Al­though he was not in­ex­pe­ri­enced, he held a PPL with­out any in­stru­ment fly­ing qual­i­fi­ca­tion, which would have made a flight in the pre­vail­ing con­di­tions chal­leng­ing… The pi­lot’s en­quiry to the Black­pool Ap­proach con­troller, “Er, Can I fly this… can I land in this?” sug­gests that he was du­bi­ous about car­ry­ing on, and his re­mark that re­turn­ing to Ron­aldsway was an op­tion sug­gests that he con­sid­ered do­ing so. A prompt re­ver­sal of his course, back to­wards the bet­ter weather at Ron­aldsway, might have pre­vented the ac­ci­dent.’

Un­ex­plained mi­cro­light fa­tal­ity

Air­craft Type: Dragon Chaser Date & Time: 31 Oc­to­ber 2015 Com­man­der’s Fly­ing Ex­pe­ri­ence: NPPL, 242 hours, 2 on type Last 90 days: 17 hours Last 28 days: 4 hours The pi­lot reg­u­larly flew flexwing mi­cro­lights solo, and three-axis types un­der in­struc­tion. He had flown the flexwing Dragon Chaser on two pre­vi­ous oc­ca­sions. The air­craft took off from Sy­well Aero­drome in be­nign weather con­di­tions with light winds, good vis­i­bil­ity and no low cloud.

Noth­ing fur­ther is known un­til sev­eral wit­nesses saw the air­craft in flight close to the ac­ci­dent site. Though none had a lengthy un­in­ter­rupted view, their com­bined ac­counts pro­vided an im­pres­sion of the fi­nal min­utes of the flight. One saw the air­craft fly­ing ‘lower than air­craft usu­ally do’, make a sharp left turn onto a south-west­erly head­ing, and de­scend ‘quite steeply’ be­fore it passed out of her view. A sec­ond re­ported that he first saw the air­craft in level flight at about 100ft agl be­fore it gained a lit­tle height and then be­gan to de­scend, turn­ing to the left onto a more southerly track. The de­scent was at a con­stant an­gle for a pe­riod un­til, ‘at about the height of a house’, its de­scent steep­ened and the air­craft struck the ground hard. He re­called hear­ing noth­ing un­til the im­pact with the ground, which he heard quite clearly, which led him to be­lieve that the en­gine ei­ther had not been run­ning or had been run­ning qui­etly.

The at­ten­tion of a third wit­ness was first drawn by the sound of the air­craft, which be­came qui­eter, prob­a­bly abruptly, and the air­craft was de­scend­ing quite steeply be­fore it dis­ap­peared from sight be­hind a tree, af­ter which she heard a ‘crunch’. A fourth saw the air­craft ‘com­ing down quite steeply’ be­fore it hit the ground. It ap­peared to be un­der con­trol and he thought the pi­lot might have been at­tempt­ing to land. A fifth heard the ‘loud-ish noise’ of the air­craft and saw it ‘very low’ close to the ac­ci­dent site. He said that the en­gine ‘feath­ered’ as if the throt­tle had been closed and the air­craft then dropped, with the front wheel of the trike dig­ging into the ground, af­ter which the air­craft som­er­saulted and then came to rest. Two of the wit­nesses ran to the crashed air­craft and at­tempted to give first aid but the pi­lot had been fa­tally in­jured.

A post-mortem ex­am­i­na­tion of the pi­lot re­vealed that he had died from chest in­juries. No ev­i­dence of any med­i­cal condition likely to be in­ca­pac­i­tat­ing was found, and tox­i­co­log­i­cal test­ing re­vealed noth­ing re­mark­able.

The air­craft crashed in a large field some 400m long and 100m wide, com­ing to rest at the top of a gen­tly slop­ing knoll. There were sev­eral ground marks con­sis­tent with the nose­wheel strik­ing the ground heav­ily, af­ter which the air­craft ap­peared to have per­formed a som­er­sault, mak­ing two holes in the ground, first with the apex of the wing and then with the top of the mast, be­fore it came to rest in an up­right po­si­tion.

The air­craft was in­spected and no ev­i­dence of a pre-ex­ist­ing struc­tural fail­ure or con­trol prob­lem was found. The wreck­age was taken to AAIB head­quar­ters in Farn­bor­ough for a more de­tailed

ex­am­i­na­tion dur­ing which the bat­tens were re­moved from the wing and checked against the man­u­fac­turer’s full-scale draw­ing. Noth­ing sig­nif­i­cant was found. The en­gine was stripped by the UK dis­trib­u­tor, which found no ev­i­dence of any me­chan­i­cal fail­ure or ab­nor­mal run­ning of en­gine or gear­box. It was con­cluded that the en­gine was prob­a­bly pro­duc­ing sig­nif­i­cant power on im­pact, be­cause both pro­pel­ler blades had bro­ken.

The AAIB re­port concludes: ‘There was no ev­i­dence of the progress of the flight from take­off un­til wit­nesses saw the air­craft close to the crash site. From the wit­nesses’ rec­ol­lec­tions, the air­craft ap­peared to be un­der con­trol and un­der power be­fore, from a low height, it en­tered a de­scent which steep­ened and ended with im­pact with the ground. The ac­counts of en­gine noise draw­ing at­ten­tion to the air­craft sug­gest that the en­gine was run­ning at least un­til a change in tone was heard; the air­craft was al­ready at a low height when this oc­curred. The rea­son for this low height could not be de­ter­mined; it may have been a con­se­quence of a prob­lem with the air­craft, or in­ten­tional on the part of the pi­lot, or be­cause of some other fac­tor.

De­scrip­tions of the en­gine note chang­ing or ceas­ing sug­gest the en­gine power may have re­duced, ei­ther in re­sponse to pi­lot in­put or as a con­se­quence of an en­gine prob­lem. The com­bi­na­tion of dew point and tem­per­a­ture in­di­cate that con­di­tions were on the bor­der be­tween those in which se­ri­ous ic­ing of the car­bu­ret­tor might oc­cur at any power and moder­ate ic­ing at cruise power. Se­ri­ous ic­ing might oc­cur at de­scent power, but car­bu­ret­tor ic­ing leaves no ev­i­dence and thus no con­clu­sion could be reached in this re­gard.

‘The field in which the air­craft crashed was suit­able for a land­ing, ei­ther pre­planned or forced. Be­cause the landowner’s per­mis­sion had not been sought, an in­ten­tional land­ing seems un­likely. In ei­ther event, any land­ing could have been chal­leng­ing be­cause the ap­proach would have been al­most di­rectly into a low, set­ting, sun, and on the knoll be­fore a slightly-down-slop­ing sur­face. Al­though the post-mortem ex­am­i­na­tion did not iden­tify any ev­i­dence of in­ca­pac­i­ta­tion in flight, this pos­si­bil­ity could not be ruled out.’

Un­ex­plained power loss

Air­craft Type: Piper Saratoga II TC Date & Time: 12 April 2016 at 1300 Com­man­der’s Fly­ing Ex­pe­ri­ence: CPL, 4,061 hours, 35 on type Last 90 days: 78 hours Last 28 days: 31 hours The air­craft was re­turn­ing to Daedalus Air­field [formerly Lee-on-so­lent] from where the pi­lot had de­parted ear­lier. Af­ter lev­el­ling at 1,800ft amsl, he se­lected cruise power and turned off the elec­tric fuel pump. Shortly after­wards, the en­gine be­gan to run roughly, so he turned the pump back on and changed tanks, but these ac­tions had no ef­fect, nor did lean­ing the mix­ture then re­turn­ing it to full rich.

As he was now half­way to his des­ti­na­tion, the pi­lot de­cided to con­tinue the flight, and joined down­wind for Daedalus’s Rwy 23. No PAN call was trans­mit­ted, but when down­wind the pi­lot saw a glider and tug air­craft op­er­at­ing on the air­field and made a ra­dio call to an­nounce his po­si­tion. In re­sponse he was in­formed that the launch would be ex­pe­dited but, on fi­nal at 300ft agl, the glider had yet to be­gin its take­off roll, and the Saratoga’s pi­lot ap­plied power to go-around. How­ever, the en­gine did not re­spond and the air­craft was forced to land in a grass field short of the run­way.

The air­craft sus­tained sub­stan­tial dam­age. A to­tal of fifty US gal­lons of fuel was found on board the air­craft and test­ing showed no water or other con­tam­i­nants. The en­gine and an­cil­lar­ies were re­moved and sent for over­haul, but, de­spite ex­ten­sive ex­am­i­na­tion, no fault was iden­ti­fied.

Lat­est Air­prox re­ports

The Air­prox Board reviewed twenty in­ci­dents in July 2016, of which nine were as­sessed as risk bear­ing, Cat­e­gories A or B, five of which in­volved drones. The re­main­ing four in­volved a Cessna 152 fly­ing through the Chat­teris DZ and into con­flict with eight parachutists; a Chi­nook and a Ven­tus glider that came into prox­im­ity near Wan­tage due to late-/non-sight­ings; a Navajo and Mooney that came close in IMC with­out ap­pro­pri­ate ATS; and an Ex­tra con­duct­ing an over­head join at Peter­bor­ough-con­ing­ton, as be­low.

The Board’s ‘Air­prox of the Month’ was that in­volv­ing the Ex­tra pi­lot, who is reg­is­tered as hard-of-hear­ing and had pre-no­ti­fied Peter­bor­ough-con­ing­ton that he would ef­fec­tively be car­ry­ing out a ra­dio-fail­ure over­head join at a pre­de­ter­mined time. ‘Un­for­tu­nately, the mes­sage did not get through to the A/G op­er­a­tor and so there was a cer­tain amount of con­fu­sion when the Ex­tra pi­lot trans­mit­ted blind his in­ten­tions, which were un­for­tu­nately ei­ther stepped-on or dis­torted by in­ter­fer­ence of some sort,’ says the re­port. ‘The Ex­tra pi­lot went on to con­duct a text­book over­head join ac­cord­ing to Con­ing­ton’s pro­ce­dures, but un­for­tu­nately didn’t see the EV97 that was down­wind. For his part, the EV97 pi­lot saw the Ex­tra late, and thought it was in an in­ap­pro­pri­ate po­si­tion be­cause he didn’t think its pi­lot had fol­lowed the cor­rect over­head join.

Apart from the un­for­tu­nate fact that the Ex­tra pi­lot didn’t see the EV97, the key learn­ing points were: the Ex­tra pi­lot to pre­fix his calls with “trans­mit­ting blind, re­ceiver fail­ure” to make it clear that he wouldn’t hear any trans­mis­sions; re­view pro­ce­dures at Con­ing­ton to en­sure ef­fec­tive and timely pass­ing of mes­sages; pilots to be clear about their air­field join­ing pro­ce­dures so that they know the ex­pected tracks; and be aware of any likely con­flict points in the cir­cuit just in case other air­craft are join­ing ‘ra­dio-fail­ure’ for real and may not see you al­ready es­tab­lished in the cir­cuit.’

Shoreham Hunter ac­ci­dent an­niver­sary AAIB state­ment

David Miller, AAIB Chief In­spec­tor of Air Ac­ci­dents, is­sued this state­ment on 21 Au­gust. ‘To­day marks the first an­niver­sary of the Shoreham Air Dis­play ac­ci­dent, the worst in the UK since the Farn­bor­ough Air­show in 1952. Our thoughts are with all those af­fected by this tragedy.

‘We have pub­lished three Spe­cial Bul­letins which have in­cluded safety rec­om­men­da­tions to pre­vent fu­ture sim­i­lar ac­ci­dents. Our fi­nal re­port (which is ex­pected to be pub­lished later this year) will in­te­grate and ex­pand on those pre­vi­ous bul­letins, which dealt with sys­temic is­sues, and cover the tech­ni­cal as­pects of the ac­ci­dent it­self.’

Rock­well Com­man­der 114B: see ‘Poor weather, fatal out­come,’ op­po­site

Piper Saratoga II TC suf­fered ‘un­ex­plained power loss’: see story be­low

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