Fatal Accidents in the UK 2015
Some factors found during the accident investigation are NOT necessarily causes.
Rockwell Commander 114B: Isle of Man Register 2-ROAM: Blackpool Airport Approach
The aircraft took off from Ronaldsway Airport, Isle of Man at 08.36 on a private VFR flight to Blackpool Airport. Although the weather was better at Ronaldsway, the Blackpool TAF predicted the lowest visibility on arrival would be about 1,400 m in heavy rain with broken cloud 300 ft above the aerodrome. The aircraft tracked towards Blackpool through the Morecombe Bay oil and gas rig helicopter traffic zone at an altitude of 800 ft and groundspeed of 115 kts. Blackpool was providing a procedural service as it does not have radar. The pilot had several RT discussions with Blackpool about the weather conditions. About 7nm from the airport it descended to 500 ft and then at about 5 nm to 400 ft. The groundspeed reduced progressively to less than 60 kts, the lowest groundspeed seen on the Warton radar was 48 kts with the final return showing the aircraft at 200 ft descending and 57 kts. The aircraft crashed into the sea. Some wreckage and pilot’s belongings were recovered, the pilot is missing presumed dead. Several helicopters pilots in the search operations remarked upon the cloud, poor visibility and ‘fishbowl’ effect they encountered and one commented on the opportunity for the pilot to have been disoriented. The 73 year old PPL pilot who had obtained his licence in late 2014 had an estimated 200 hours of which at least 100 were on type. He had no instrument flying qualifications. The lowest recorded ground speed was below the range of stall speeds for the aircraft, and it is possible that the aircraft stalled at a low height from which recovery was not possible. Part of the RTF recording included a high-pitched tone suggestive of the audio stall warning fitted to many light aircraft and the steep impact attitude found by the engineering investigation, are consistent with this hypothesis. The available evidence suggests that the aircraft may have stalled at a height from which recovery was not possible. The engine was producing power at the point of impact with the sea. (AAIB Bulletin 7/2016).
Piper PA46-350P Malibu Mirage: N186CB - Nr Churchinford, Somerset
Beech 200 Super King Air: G-BYCP - Nr. Chigwell, Essex
The non-commercial flight from Stapleford Aerodrome to RAF Brize Norton with two company employees on board (including the pilot) was to pick up two passengers for onward travel. The pilot in the left hand seat (the aircraft commander) held a CPL and another pilot, an ATPL, occupied the right. He flew for the same operator, but his licence was valid on the Bombardier Challenger 300 and Embraer ERJ 135/145 and not on the King Air. At approximately 09.15 hrs, trees were visible just beyond the end of Runway 22L, indicating that visibility was at least 1,000 m and the pilot decided that conditions were suitable for departure. After takeoff, the aircraft climbed on a track of approximately 205°M and, when passing approx. 750 ft amsl (565 ft aal), began to turn right. The aircraft continued to climb in the turn until it reached 875ft amsl (690 ft aal) when it began to descend. The descent continued until the aircraft struck some trees at the edge of a field approximately 1.8 nm southwest of the aerodrome (Figure 3). The pilot and passenger were both fatally injured. A witness approx. 30 m north-east of where the aircraft struck the trees saw the aircraft in a nose-down attitude right wing slightly low fly ‘full pelt’ into the trees.
There was contradictory evidence as to whether or not the left inboard flap was fully extended at impact but it was concluded that the aircraft would have been controllable even if there had been a flap asymmetry. The evidence available suggested a loss of control while in IMC followed by an unsuccessful attempt to recover the aircraft to safe flight. It is possible that the pilot lost control through a lack of skill but this seemed highly unlikely as he had just completed an extensive period of supervised training. The post-mortem examination of the pilot found evidence of an acute dissection of a coronary artery the presence of which indicated that he might have suffered symptoms ranging from impaired consciousness to sudden death. The coronary artery dissection might have occurred spontaneously or have been the result of forces transmitted through the body during the accident sequence, and pathology alone was unable to resolve these opposing possibilities. However, the report stated that: ‘if there is no other cause identified for the crash then it is both possible and plausible that this was the precipitating factor.’ Acute dissection of a coronary artery is a rare event which can occur spontaneously and is difficult to predict through medical examinations or ECGs. Incapacitation of the pilot, followed by an attempted recovery by the additional crew member, was a possibility consistent with the evidence and supported by the post-mortem report. Without direct evidence it could not be stated unequivocally that the pilot became incapacitated. On the balance of probabilities, however, it was likely that the pilot lost control of the aircraft due to medical incapacitation and the additional crew member was unable to recover the aircraft in the height available.
The use of email ‘Engineering Reports’ to record aircraft technical defects on the 34 year old aircraft circumvented the requirements of EASA Part M regulation M.A.403 for correctly recording defects in the aircraft Technical Log and aircraft maintenance records. A review of the ‘Engineering Report’ e-mails, over nine months of operation immediately preceding the accident flight, revealed a high number of defects that were not recorded in the aircraft technical log, and for which rectification actions were not recorded in the aircraft’s technical records. It was clear that the operator was aware of the aircraft’s defect history and that it used the content of the ‘Engineering Report’ e-mails to coordinate defect rectification during the scheduled Phase 1 Maintenance Inspection in June 2015. Where defects were rectified in this manner, the interval was well outside MEL allowable time limits. Despite these findings however, the investigation found no evidence that the defects recorded in the ‘Engineering Reports’ directly contributed to the accident. The 40 year old pilot had flown 1,941 hours with 162 on type. (AAIB Bulletin 10/2016).
Cessna 150F: G-ATKF - Hinton-in-the-Hedges Airfield, Northants
The student pilot was undergoing training for a PPL and during the morning had flown six glide approaches with an instructor. The flight was solo consolidation of glide approaches. The wind was from 320 deg at 7 kts with broken cloud at 4,000 ft and a visibility of 10km+. Witnesses said the pilot had made two or three circuits using 700 metre long RW 24 before the approach which led to the accident. Solo students are instructed to go-around if the aircraft main wheels are not firmly on the ground by marker cones on either side of the runway. Following a bounced landing in line with or just beyond the marker cones, the student applied power and the aircraft lifted off and began climbing gently. For reasons that could not be determined, he extended the flaps but did not control the aircrafts natural tendency to pitch up when flaps are lowered. The airspeed reduced and the aircraft stalled and began to rotate to the left probably because it was entering a spin with insufficient height to recover. It struck the ground in a steep nose down attitude killing the 39 year old pilot who had flown 33 hours, all on type. His training had commenced on 6th June 2015 and he soloed on 17th August after 22 hours instruction. (AAIB Bulletin 7/2016)
This aircraft has a weight greater than 5,700 kg and would therefore normally be excluded from this site.
Hawker Hunter T7: G-BXFI - Shoreham Airport
The aircraft was inspected and refuelled, including under-wing tanks, to full at its base North Weald before taking off to display at Shoreham Airport, which lies 7 ft amsl and where the temperature was 24 deg C. After a flypast the aircraft entered a gentle climbing right turn to 1,600 ft amsl, executing a Derry turn to the left and then commenced a descending left turn to 200ft amsl, approaching the display line, located on the far side of the main runway and 230 metres from the crowd line, at an angle of about 45º. The aircraft then pitched up into a manoeuvre with both a vertical component and roll to the left, becoming almost fully inverted at the apex of the manoeuvre at a height of approximately 2,600 ft amsl. During the descent the aircraft accelerated and the nose was raised but the aircraft did not achieve level flight before it struck the westbound carriageway of the A27 at its junction with Old Shoreham Road. A number of vehicles and by-standers were struck resulting in 11 deaths and a severe fire. The pilot was seriously injured and it is not as yet clear if ejection had been attempted. Two image recording cameras were mounted within the cockpit, one on the aft cockpit bulkhead between the two seats, giving a partial view of the pilot and instrument panel and the other a view over the nose through the windscreen. To date no abnormal indications have been identified, throughout the flight, the aircraft appeared to be responding to the pilot’s control inputs. The ATPL pilot held a valid Display Authorisation (DA), issued by the UK CAA, to display the Hawker Hunter to a minimum height of 100 ft during flypasts and 500 ft during Standard category aerobatic manoeuvres. He had flown 40 hours on Type out of his total of 14,249 hours. The large amount of video and photographic material continues to be analysed. (AAIB Special Bulletin S3/2015).
Piper PA34 Seneca (Danish Registered) - Newquay, Cornwall
The aircraft crashed at about 7.35 pm in woodland close to the runway while landing at Newquay following a flight from Blackbushe killing the sole occupant, the 68 year old pilot. (Source: ASN & media).
Folland Gnat T1 MK1 - G-TIMM Approx 1 nm of Oulton Park, Cheshire
The aircraft was being operated from Hawarden in order to carry out a formation display with another Folland Gnat T Mk 1 at Oulton Park, Cheshire. The display was led by the pilot of G-TIMM. During the solo part of the display the aircraft was making a second aileron roll at low level when from video evidence, at an angle of bank of 107 deg to the left, the nose attitude dropped relative to the horizon. The pilot applied the appropriate roll input, probably in an attempt to recover but then applied an inappropriately timed pitch input which led to a high rate of descent. The aircraft departed from controlled flight and made the situation irrecoverable in the height available. The aircraft impacted trees bisected by a minor road approx 1 nm north of Oulton Park. The pilot was killed having made no attempt to eject. The aircraft had entered the first roll approx 73 kts slower than the normal entry speed of 300 kts possibly to allow the second Gnat to vacate the display line. There were issues during recovery action and investigation with the status of ejector seat cartridges The pilot’s experience and currency were considered to be contributory factors. In July 2000 while in RAF service an ECG indicated the pilot had a medical condition and he did not return to flying duties. A January 2003 ECG for a Class 2 medical on behalf of the CAA showed no indication of its presence, he did not mention the previous problem. The 39 year old PPL pilot had flow a total of 706 hours with 218 on type since April 2005. Three Safety Recommendations are made on: minimum aerobatic heights; managing the risk of loss of aircraft control; and medical examination requirements for pilots of high performance aircraft. (AAIB Bulletin 5/2016).
Embraer EMB505 Phenom 300 HZ-IBN: Blackbushe Airfield, Hants
The Saudi Arabian registered 8/9 seat executive jet was landing at Blackbushe Airfield after a private flight from Milan Malpensa. After manoeuvres to remain clear of microlight aircraft in the circuit, the aircraft’s TCAS gave a ‘clear of conflict’ when HZ-IBN was 1.1 nm from the runway threshold, at 1,200 ft aal at a speed of 146 KIAS, with the landing gear down and flap 3 selected. At the landing weight of 6,522 kg the target threshold speed was 108 KIAS. The aircraft continued its approach at approximately 150 KIAS. Between 1,200 and 500ft aal the rate of descent averaged approximately 3,000 fpm, and at 500 ft aal was 2,500 fpm. The aircraft’s TAWS generated six ‘pull up’ warnings on final approach. The aircraft crossed the threshold of Runway 25 at approximately 50 ft aal at 150 KIAS. Tyre marks made by the aircraft at touchdown indicated that it landed approximately 710 m beyond the threshold of Runway 25 (length 1,059 metres) and only 438m from the far end of the paved surface. Data from the aircraft’s CVFDR indicated that the groundspeed at touchdown was 135 kt and it is estimated that it would have required 616 metres to stop. The aircraft over-ran the runway and collided with a one metre high earth bank becoming airborne again briefly, before colliding with parked cars and was consumed intense fire killing the pilot and the three passengers. The 57 year old pilot held an ATPL and had flown approx. 11,000 hours with 1,180 on type and 5 hrs in the previous 28 days. (AAIB Special Bulletin S2/2015).
Beech 95-B55 Baron: G-RICK: West of Abernyte, Dundee, Scotland
The aircraft took off from
Inverness to position it to
McEnzie Edge 360: G-EDGJ: Old Buckenham, Norfolk
The pilot was a very experienced and well regarded pilot who was a regular aerobatic competitor who had been the British Aerobatics Advanced Champion in 2012 & 2013 and a member of the British team at the European and World Aerobatic Championships. Arriving in the aircraft from RAF Marham he was given the airfield details and stated his intention to join from the west and perform some aerobatic manoeuvres overhead Old Buckenham for the Press Day before landing. He flew three vertical manoeuvres before descending to a height of 100 to 150 ft and pitching up to 45 degrees into a gyroscopic tumbling manoeuvre at an estimated 300 to 400 ft. The aircraft failed to complete the manoeuvre successfully and entered an erect spin and made about 1½ turns before striking the ground without any apparent attempt by the pilot to recover from the spin. An intense fire broke out at the crash site about 150 metres from the RW 07 threshold. The pilot had been killed on impact. The difference in elevation between Marham and Old Buckenham is 117 ft, if the pilot had failed to reset his altimeter to the local QFE he was given on arrival over the radio, it would have over-read by the same amount. The aerobatic manoeuvre was entered at relatively low speed and height, which may have been due in part to a lack of recent aerobatic practice and the use of a new or improvised aerobatic sequence. The investigation concluded that the aircraft entered the spin as a result of inappropriate control inputs, which also precluded a recovery. The pilot was found to have been suffering from a serious and previously undiagnosed heart condition, (acute coronary artery thrombosis) which had the potential to affect his ability to perform aerobatic manoeuvres safely which could have produced incapacitating symptoms at a critical stage in the flight. The last personal and aircraft log book entries for an aerobatic flight was on 21st December 2014, the next entry being a test flight on 16th April, six days before the accident. However, the pilot had made three social media posts with photographs which indicated three aerobatic flights in G-EDGJ in the period 6th December 2014 to 20th January 2015 there being no entries in his personal or the aircraft log books. The pilot signed a declaration on 16th April when the Permit to Fly was renewed stating the recorded hours were accurate. The recorded hours did not include the flights indicated on social media. The 61 year old pilot had flown 1,290 hrs with 265 on type.
morning the pilot had made a short flight from his strip to RAF Marham, nr
Kings Lynn Norfolk where it had been arranged that he would fly as a passenger
in an RAF Tornado. At the Station Medical Centre he underwent a
pre-flight medical examination, nothing adverse was detected and he was passed
as fit to fly appearing to be a fit and well individual. The 1 hr 35
minute flight consisted of medium level transits at FL100 and 140 to and from
Piper PA28 – 140: G-BHXK: nr Loch Etive, Oban, Argyle & Bute Scotland
The aircraft was on a flight from
Alpi Pioneer 400: G-CGVO: Nr Popham Airfield, Hants
The aircraft took off in poor weather from Bembridge Airfield, Isle of Wight for a VFR flight to Bidford Airfield, near Evesham, Worcs. However, occasional low cloud and poor visibility may have precluded flight that was clear of cloud and in sight of the surface at all times. As the aircraft approached Popham Airfield it was seen by several witnesses manoeuvring as if preparing to land, before continuing in what appeared to be a low level, left-hand circuit. Whilst in the circuit, the aircraft stalled and struck trees before impacting with the ground. The pilot and a passenger died at the scene, the other passenger survived with serious injuries. A damaged throttle position sensor wire on the turbocharged Rotax 914F engine was identified which was likely to have resulted in the engine manifold air pressure limit being exceeded causing the engine to seize in flight. The 50 year old pilot had flown a total of 201 hours with 5 on type. Although there was no record of the pilot having completed appropriate ‘differences training’ he did have experience with retractable landing gear and variable pitch propellers, it was thought unlikely to be relevant. Four Safety Recommendations were made covering aircraft/engine design. (AAIB Bulletin 3/2016)
Bell 206B Jet Ranger: G-RAMY: Nr Creg-ny-Baa, Isle of Man
The helicopter took off for the Isle of Man at about 05.30 from a private site at Woburn, Beds with two passengers. At 07.44 the pilot reported to Ronalsdway that he had the destination in sight and the controller passed him the wind of 230 deg at 22 kts gusting to 33 kts. He landed at the un-prepared private site at Creg-Ny-Baa at about 07.46, disembarked the passengers and shut down. He took off again 08.05 from the site which is 2 nm inside the northern edge of the Class D Control Zone surrounding Ronaldsway Airport, no communications were received by Ronaldsway ATC. With a wind from 220 to 230 deg gusting to 46 kts the helicopter was seen to take off and turn right onto a NE track and the fuselage began to oscillate in roll. The fuselage then rotated in yaw beneath the rotor disc, more than once, and the nose of the helicopter pitched up into the rotor disc, being destroyed as it did so. The fuselage fell to the ground where the impact killed the pilot. Examination of the wreckage showed that there had been a catastrophic in-flight failure of the helicopter’s main rotor mast with clear evidence that this had been due to heavy ‘mast bumping’ contact between the teeter (‘static’) stops on the main rotor head and the main rotor mast. This was consistent with the observed behaviour of the helicopter, where the pilot appears to have been attempting to control the aircraft in turbulent conditions. The terrain SW of Creg-Ny-Baa is in a valley which appeared to funnel the wind towards the accident site and the turn in the nearby road is known as ‘Windy Corner’. An air ambulance pilot with over 25 years experience and over 8,500 hrs in helicopters including seven years air ambulance operations in the Isle of Man who had landed an AS355 Ecuriel 2 helicopter at the accident site, was of the opinion that conditions were entirely unsuitable for a limited hour private pilot. The 48 year old accident pilot had a PPL(H) with 786 hours including 71 on type. An instructor had discussed the flight with him the day before the accident including ‘low g’ and ‘mast bumping’. There are no wind limits published in the Bell 206 Flight Manual. The pilot had not received appropriate training in mountain flying techniques and the associated hazards. (AAIB Bulletin 6/2016).
Dragon Chaser: G-CHNP - Nr Pitsford Water, Northants
The single seat de-regulated flex-wing microlight took off from Northampton/Sywell aerodrome and was later seen by several witnesses flying low near Pitsford Water before it turned and descended. Witnesses recalled hearing the aircrafts engine and some believed its tone changed or had ceased. It struck the ground and somersaulted. Two of the witnesses ran to the aircraft and attempted to give first aid but the 71 year old pilot had been fatally injured. Conditions were suitable for carburettor icing and the field into which the aircraft crashed would have been suitable for a forced landing. It was concluded from the propeller damage that the engine was probably producing significant power. The pilot had not obtained the landowners permission to land so an intentional landing seems unlikely. The pilot had soloed in August 2009 after 46 hours of dual instruction and obtained his NPPL in April 2010. He purchased a Dragonfly microlight which he flew regularly. He had a total of 242 hours with 2 on type. (AAIB Bulletin 8/2016).
Pegasus Quik: G-CBYE: Enstone, Oxon
After taking off to fly a circuit with a passenger the aircraft was seen turning turned onto final approach for the Northside grass Runway 08, the aircraft’s speed and the sound of its engine seemed normal. Some observed that, at approximately 100ft agl, the pilot appeared to work hard to control the aircraft. They thought he may have encountered rough air or “rotor effect” and associated this with the gusty wind which was veering southerly. It was seen to touch down approx. 145 m before the end of the 550 m grass runway. After landing, it slowed down before accelerating and the engine note was heard to increase. The pilot’s original intention was believed to have been to touch-and-go, provided the passenger was content. It is possible that the pilot was unaware of how close he was to the end of the runway and applied power to take off again before appreciating that there was insufficient runway remaining. Alternatively, he may have been attempting a full-stop landing but realised the aircraft was not slowing down sufficiently and made a last minute decision to attempt a touch-and-go. However, having slowed to approximately 30 mph and with no more than 65 m of the runway remaining, there was insufficient distance left to take off. After touchdown it veered to the right it went through a wire fence and collided with a vehicle trailer and other equipment before coming to rest with the nose embedded under the trailer, killing both occupants. The post-mortem reports stated that the pilot and passenger both died from multiple injuries. The pilot gained a NPPL in June 2006, after completing a course of flying training on flex-wing microlights at Enstone and purchased the aircraft in November 2005. It was the only aircraft he flew after that, except for a trial flight in a Piper PA-28 in April 2013. That instructional flight was his only recorded flight with an instructor after 2006. The pilot did not have a current Microlight Rating and had not flown a microlight with an instructor for nine years. It was possible that he did not appreciate how the rating system worked and had apparently mis-understood a question about this on his flying club Renewal Form. Although he was in recent flying practice, the pilot had logged only nine flying hours in the preceding two years. Information available after the accident showed that the aircraft was at least 33 kg overweight when the collision occurred. Data provided by the aircraft designer indicated that the distance available from the point of touchdown may have been insufficient to bring the overweight aircraft to a complete halt. However, even if the aircraft had not been over-loaded, there was insufficient distance remaining to take off again from the point at which power was re-applied. The extra weight is considered to have been a contributory factor to the accident. The 62 year old pilot had flown 212 hours of which 163 were on type. (AAIB Bulletin 1/2016)
Ikarus C42: G-CEDR: Newtownards Airfield, Northern Ireland
The pilot was practising circuits. As he prepared for the flight, he spoke to another pilot who described him as being in a cheerful mood and appearing to be in good health. About fifty minutes into the flight, just after an increase in power during a touch-and-go landing on runway 04, the aircraft was seen to enter a climbing left turn at low height. As it continued to climb, the angle of bank was seen to increase steadily until at a height of 80 to 100 ft the nose dropped and the aircraft descended, striking the grass to the left of the runway in a steep nose-down attitude. The pilot was fatally injured. The weather was CAVOK with a wind of less than 5 kts from 040 deg. A test pilot was unable to replicate a combination of power and control inputs likely to cause the aircraft to behave as witnessed in the accident. Inspection did not reveal any evidence of a pre-existing defect or restriction in the aircraft flying controls. The pilot was found to have a considerably enlarged heart which could potentially have produced a degree of distraction or incapacitation but there was no definite pathological evidence to indicate they had done so but does not preclude the possibility. If a medical event had occurred it is likely it would have been sudden rather than insidious in its onset. The 55 year old NPPL holder had flown 89 hours with 23 on type. (AAIB Bulletin 4/2016).
Schleicher K8B: G-DETD: Aston Down, Glos
The glider was seen to circle the airfield several times before diving vertically into the ground, killing the sole occupant, the 57 year old pilot. A hearing at the Gloucester Coroners Court revealed that the police had found a suicide note at the pilot’s home. (Source: ASN).