Fatal Accident News 2018

AEROPLANES

10 Oct
Cessna 172 Skyhawk: G-BGSV  Nr Beverley Airfield, Yorkshire
The aircraft took off from Beverley Airfield at 10.26 for Midlem airfield, nr Selkirk, Scotland, so that the occupants could visit relatives.  The non-pilot passenger who had flown with the pilot on a number of previous occasions, needed to be back that evening.  They landed at 10.26 hrs and returned to the airfield later in the afternoon.  After starting the engine an unusual noise was heard and was shut down.  The exhaust pipe had detached from No 3 cylinder because one of the two threaded exhaust studs in the cylinder was missing as were the nut and washer from the remaining stud.   An LAA Inspector on the airfield was able to provide the required parts but explained that as the aircraft was not an LAA Permit aircraft he could not sign the Certificate of Release to Service for the repair.  The pilot was seen to reattach the exhaust pipe.  The aircraft departed at 16.10 hrs and would thus arrive after dark at Beverley airfield, which has no lighting and is in a rural area with little cultural lighting,   The pilot had held a PPL for 25 years, having acquired a share in the aircraft in 1993, He had qualified for an IMC in 1994, the most recent renewal had been in August 2001 valid for 25 months.  He did not hold a Night Rating and there was no night flying recorded in his log book.  With Durham Tees Valley closed until 17.30 hrs, the pilot ignored the option of diverting to Humberside for which he said he had enough fuel.  The aircraft arrived overhead Beverley at 18.14 hrs, sunset being 17.15, it was dark with no moon.  The pilot telephoned a friend who drove to the airfield where he shone his car headlights onto the touch down area of runway 12.  The aircraft was seen to be circling and descending to the west of the airfield before descending vertically and disappearing from view.  The wreckage was located at 22.47 hrs in a small copse 1.2 nm from the airfield.  Both occupants had been killed on impact.  It is likely the pilot became disoriented allowing the nose to pitch down too steeply when in a descending turn near the final approach.  The 76 year old pilot had flown 586 hours of which 546 were on type.  (AAIB Bulletin 8/2019)  


10 June            
Grob G109B: G-KHEH - Nr Raglan, Monmouthshire
The Instructor who owned the touring motor glider was asked by another club member, a qualified glider pilot with over 260 gliding hours, for some field landing practice.  The aircraft took off from Usk Airfield at 09.47 and was seen about four miles north of the airfield.  A number of witnesses heard it close to the field selected for a PFL, their description of the normally quiet engine when at idle varied, some describing it as loud whilst others that it was misfiring or spluttering.  The aircraft struck a dead oak tree removing two metres of the right wing tip causing it to crash inverted at a steep angle into the field beyond, killing both occupants.  The dead tree lay between two other large trees in full leaf.  Nearby witnesses rushed to assist but to no avail. The impact marks on the tree were approx 57ft agl.  The engine had been producing considerable power at impact.  A tablet computer recovered from the wreckage showed that on a previous flight practicing field landings the minimum height achieved by the instructor had been 350ft agl.  Based on reported temperatures and dew points at the time of the accident serious carburettor icing would have been possible at descent power on the Grob 2500E1 engine.   The collision with the tree was probably due either to them not seeing the dead tree until too late and misjudging their distance from it or the engine failing to respond when they expected to climb away.  The 68 year old pilot had flown 550 hours with 27 on type and 2,100 hours gliding.  (AAIB Bulletin 7/2019)

! June             
Rihn DR-107 One Design: G-CEPZ: Nr Optand Airfield, Sweden
The single seat aircraft crashed in woodland about 200 metres from the runway killing the pilot, a 34 year old Foreign Doctor working in Sweden.  The aircraft is reported to have carried out a successful series of aerobatic manoeuvres, then disappeared while returning to the airfield.  A few hours later it was found in dense forest having crash in a steep nose-down attitude.  It was noted that the canopy was some distance away. The pilot’s body was still strapped into the aircraft. . The aerobatic aircraft was constructed in the USA in 1996.   The aircraft, while still nominally on the UK register, had been delivered to its new owner in Sweden in the previous weeks and was due to be transitioned to the Swedish register.   As the aircraft was amateur built and below 2,250 kg, the Swedish Authority has no obligation to investigating the accident.  (Source: Various).   


13 May            
Cessna 208B Grand Caravan:   G-KNYS: Nr. Clonbullogue Airfield, Ireland
The aircraft took off from Runway Rw 27 at Clonbullogue Airfield, Co. Offaly at approximately 13.13 hrs with the pilot, in the left-hand cockpit seat, a young child passenger in the right-hand cockpit seat and 16 skydivers occupying two bench seats in the main cabin.  When the aircraft was over the airfield at approximately 13,000 feet, the 16 skydivers exited from the aircraft as planned.   As the aircraft was returning to the airfield, the pilot radioed that he was on “left base 5”. No further radio transmissions were received.   A short while later the aircraft crashed in a forested area at Ballaghassan, Co. Offaly, approx. 2.5  nm north-west of the airfield.  The aircraft was destroyed and the pilot and passenger were killed. There was no fire.  The impact was such that the entire front section of the aircraft, forward of the main wheels, was below the surface of a peat bog.  An examination of the wreckage showed that trailing edge flaps were extended to approx 20 deg.

The Pilot was a male, aged 47 years who held a CPL(A) which was initially issued by the UK CAA on 1 April 2010. The licence contained the following four ratings: Instrument, Cessna SET (Single Engine Turbine), MEP (Multi-Engine Piston) (land), and SEP (Single-Engine Piston) (land). The Pilot’s Cessna SET rating was revalidated on 4 February 2017 following the completion of a Proficiency Check conducted by a CAA-approved Flight Examiner on that day.  The rating was valid until 28 February 2019.  Records indicate that on 4 May 2018, the Pilot underwent a Class 1 medical examination (required for a CPL) administered by a UK-based Aeromedical Examiner (AME). The Pilot’s Class 2 Medical Certificate, required for the Pilot’s PPL(A), had an expiry date of 20 March 2019.

The aircraft had a single PWC PT6A-114A turboprop engine, driving a three-blade, variable-pitch propeller. The engine was disassembled and examined by the AAIU with the assistance of the engine manufacturer. There was no evidence of pre-impact anomalies observed on the examined engine components and indications were that the engine was producing power at impact.  (AAIU Ireland Interim Report)

19 April            
Cessna 152: G-UFCO - Nr Crumlin, Co. Antrim, N. Ireland
The pilot had hired the aircraft, from a local flying club based at Newtownards Airport so that he and a passenger who specialised in aerial photography, could photograph properties with the intention of subsequently selling the photographs. The passenger had regularly flown with the pilot, around 15 times a year for the last 14 years. The passenger would provide a route plan, around various properties, and the pilot would then fly the route. It is not known what, if any, financial arrangements were made between the pilot and the passenger.  The aircraft took off at 10.47 hrs and was later seen circling over an area before suddenly nose diving into the ground followed by a large explosion and intense fire.  Bystanders were unable to assist.  Both occupants were killed.  Radar recordings showed it had been flying right hand orbits at an average speed of 60 kts TAS and at heights varying between 500 and 300 ft agl; bank angles up to 45 deg had been used.  It is likely that the stall-warner would have been sounding which may have meant that the pilot and passenger became accustomed to it thereby reducing its value.  The aircraft was probably close to its maximum weight at take off and towards the forward cg.  The aircraft was engaged in aerial photography thus coming within the scope of Specialised Operations requiring a strategy for the evaluation and mitigation of the risks associated with flying at low level.  There was no evidence that it had been carried out or for an associated check list to be produced.  The Club stated they were not aware the aircraft was being used for photographic purposes.  The 77 year old pilot had flown 18,383 hours with 900 on type.  (AAIB Bulletin 3/2019).


8 January
Piper PA28-161 Cherokee Warrior lll:  G-WAVS: Bredon Hill, Overbury, Worcs
An instructor was ferrying the aircraft from its base at Coventry Airport to Gloucester Airport, its maintenance base.  He was accompanied by a student pilot who was approaching the navigation phase and the flight would provide additional experience. Another Coventry based aircraft, a Cessna F150 was also flying to Gloucester at about the same time.  The student prepared a  standard route used by the school for such flights on a half million chart, the highest terrain on or near the route was 1,048 amsl and the maximum elevation figure was 1,400 ft amsl.  The Cessna 150 departed at 12.06 hrs and the accident aircraft two minutes later.   Both crews conducted briefs and consulted the weather independently, there was no combined brief and no supervision by the flying school management (none was required).  

Southwest of Stratford, the two aircraft followed a very similar track, both maintaining an altitude of approximately 1,000 ft.  The cloudbase in the area was approximately 1,000 ft amsl with freezing conditions forecast in cloud.  The crew of the Cessna stated later that visibility reduced as the aircraft flew further south and west, and reported having to make frequent use of carburettor heating.  Witnesses in that area of Elmley Castle described the weather as “quite foggy”, they said they heard an aircraft flying “low” before appearing out of the cloud.  Shortly afterwards the aircraft struck trees near the summit of Bredon Hill at an elevation of approximately 940 ft, coming to rest in a field killing both occupants. 

The instructor is believed to have contacted Wellesbourne Airfield to check the en route weather and was told that a pilot had reported a cloudbase of approximately 800 ft agl,   Wellesbourne does not produce TAFS or METARS.  The instructor was not known to use GPS navigation or flight planning software and did not carry a tablet or smart phone that could employ such systems. There is no requirement to do so.  The experienced instructor was also an examiner and was the only salaried member of the Instructional Staff at Coventry.  He held a CPL(A) and Instrument Rating (Restricted) (IRR) and had approximately 5,700 hours flying experience.  Aircraft from the school were regularly flown to Gloucester and he had flown the route often.  Witnesses reported that the instructor appeared concerned about the conditions for the flight to Gloucester, giving the impression that he was unhappy with the plan but there is no evidence that he raised any such concerns with the higher management of the flying school.  The weather conditions forecast for the flight were better than those required for flight under VFR and by the school’s Operations Manual.  Although the instructor’s IRR permitted him to do so, climbing into cloud was not a safe option because the aircraft was not equipped for flight in the icing conditions forecast to be present. Therefore, the crew had either to try to find more favourable conditions or continue operating in poor visibility at low altitude.

Given the student’s lack of experience it was unlikely he could have offered significant assistance to the instructor, having completed approximately 19 hours of flying training, including some navigation training prior to the accident flight and had not previously flown the route from Coventry to Gloucester.  (AAIB Bulletin 12/2018)

HELICOPTERS

27 October                      
Agusta AW169: G-VSKP: King Power Stadium, Leicester
After several flights that day the helicopter landed at King Power Stadium, was parked on the centre circle of the pitch, on a north-easterly heading, and was shut down at 18.47 hrs.  Between 19.00 hrs and 19.30 hrs the pilot and four passengers boarded the helicopter for a flight to London Stansted Airport. The helicopter started up at 19.34 hrs and at 19.37 hrs it lifted from the centre circle, yawed 15° left and moved forward a few metres. The helicopter then began a climb on a rearward flight path while maintaining a northerly heading.  Gear retraction started as it passed through a height of approximately 320 ft. The climb then paused.  Heading changes consistent with the direction of pedal movements were recorded initially, then the helicopter entered an increasing right yaw contrary to the pilot’s left pedal command. The helicopter reached a radio height of approximately 430 ft before descending with a high rotation rate. The helicopter struck the ground in an approximately upright position on a stepped concrete surface, with the landing gear retracted, and rolled onto its left side. The helicopter was rapidly engulfed in an intense post-impact fire killing all 5 occupants. Stadium staff and emergency services were quickly at the scene but were not able to gain access to the helicopter because of the intensity of the fire.

The evidence gathered to date shows that the loss of control of the helicopter resulted from the tail rotor actuator control shaft becoming disconnected from the actuator lever mechanism thus preventing the feedback mechanism for the tail rotor actuator from operating and the tail rotor actuator from responding to yaw control inputs.   Loss of the feedback mechanism rendered the yaw stops ineffective, allowing the tail rotor actuator to continue changing the pitch of the tail rotor blades until they reached the physical limit of their travel, resulting in an uncontrollable right yaw.  (AAIB S1/2018 dated 14 Nov 2018 and S2/2028 dated 6 Dec 2018, investigation continues)

13 June
Aerospatiale AS350B2 Ecuriel: G-PLMH: Loch Scadavay, North Uist, Western Isles
The helicopter was engaged on an under-slung load operation and had successfully transported a boat (Boat 1) from South Uist to Loch Hunder when they were requested to move another boat from Loch Scadavay to a site 14 nm to the North East.   Boat 1 weighing about 500 kg had been moved vertically using the bow mounted lifting eye.  Although boat 2 was lighter, the lifting eye was felt to be unsuitable.   The Task Specialist Ground (TSG) proposed transporting it on its side, with the strops tied in place with ropes, which the pilot agreed with making a general comment about boats being challenging agreed with the importance of flying slowly with Boat 2.

There were a number of eyewitnesses of the lifting of Boat 2, which indicated that it started to swing and spin soon after departure. The TSG immediately radioed “slow down, slow down” to the pilot. Although he did not receive a reply, it appeared to the TSG that the helicopter slowed down.  Recorded data showed that the helicopter’s groundspeed reduced to 25 kt, at an altitude of about 170 ft amsl.  Eyewitnesses reported that within seconds of Boat 2 spinning, it lifted in to the air independently of the helicopter, like a “kite” paused momentarily, then lifted further up and over the tail boom of the helicopter.  One witness remarked “[it] all happened really fast”.  The helicopter moved erratically and altered track increasingly to the left, momentarily maintained altitude, before entering a steep nose-first descent towards the loch, striking the water with a descent rate of about 3,600 ft/min and a groundspeed of 40 kt.  It came to rest on its left side, almost fully submerged. The pilot, who was wearing an immersion suit, was fatally injured.  Subsequent inspection of the wreckage revealed that the load and lifting line appeared to have been jettisoned from the helicopter’s lifting hook.  Inspection of the wreckage in-situ by a diver showed the lifting chain was wrapped around the tail boom and horizontal stabilisers.  Its upper end had been released from the hook on the underside of the helicopter, and its lower end remained attached to the strops secured to Boat 2.   The lifting chain had contacted the tail rotor blades, severely damaging them such that the tail rotor would no longer be effective in controlling the torque of the main rotor and would most likely have caused severe vibration. The lifting chain became entangled around the tail boom and stabiliser surfaces despite it being released from the helicopter’s lifting hook by the pilot. The weight of the lifting chain and the attached boat at the end of the tail boom would mean the helicopter was outside of its balance limits and would have become uncontrollable. 

The pilot’s flying helmet was found floating next to the wreckage and was still attached to the helicopter by its audio communication electrical leads with no evidence of a significant impact.  The chin strap buckle was not secured.  The TSG could not recall noticing if the pilot’s helmet chin strap had been fastened during the duty. The post-mortem found that he had died because of a severe head injury and drowning.  The pilot’s seat structure had failed, compromising the degree of restraint of the pilot in the accident. The seat met the standards required at the time of certification, however new standards do not have to be retrospectively applied to previously certified designs. The manufacturer had made available an improved, stronger seat with improved attachment strength and optional energy-absorption.  It had not been fitted on this helicopter and nor was it required to be.  

The pilot had been flying helicopters professionally since 1986, including military, offshore, and air ambulance. He had flown for the operator previously, but his most recent employment began in September 2016 and had a total helicopter flight time of around 9,260 hrs. The operator’s records suggest the pilot’s total AS350 flight time was around 1,890 hrs.  Before joining the operator in 2016, the pilot quoted a total of 2,100 hours in underslung loads. The operator reported that he had subsequently performed an estimated 4,072 lifts for them. The TSG had worked in helicopter SPOs since 2005. He joined the operator in June 2006, and they described him as being very experienced.  (AAIB Bulletin 8/2019)  

30 May     
       
Bell 206B3 Jet Ranger: G-OPEN: Nr Aldborough, North Yorkshire
The pilot was planning to fly from Husthwaite in North Yorkshire, where the helicopter was kept, to Walton Wood airfield nr. Pontefract for its annual maintenance check which was due the following day. This was a route the pilot had flown many times.  It is not known what weather information he obtained prior to the flight. The pilot had a SkyDemon account, but this had not been accessed for several months. However, there are many other sources of meteorological information which he may have consulted.   The cloud base en route was forecast to be between 300 ft and 700 ft with a possibility of visibility below the cloud reducing to 3,000 m.  He lifted off at 12.16 hrs

Numerous witnesses near the accident site reported hearing the helicopter whilst in cloud sounding very loud, likely caused by a combination of ‘blade slap’, by the helicopter being at low altitude and the pilot making large control inputs whilst trying to control the helicopter.  The helicopter was seen by one witness to emerge from cloud and track across the sky before spinning one and half times and then rapidly descending. Numerous witnesses saw the helicopter in its final descent.  With a cloud base of 400 to 500 ft over the accident site the pilot would have had very little time to regain control  having exited the cloud.  A witness recalled it taking approximately 15 seconds from first seeing the helicopter emerge from the mist to the impact with the ground and catching fire.  Several people ran to the accident site, but the fire was too intense to get close to the scene.  The air ambulance pilot that landed at the site 17 minutes afterwards reported cloud base at 400 to 500 ft with visibility 3 to 5 km on scene with challenging conditions which required his local knowledge and an air ambulance exemptions to operate.

The pilot held a helicopter Private Pilot’s Licence (PPL(H)) with a Bell 206 rating which was valid until 31 August 2018. He initially qualified in 2006.  He had recorded total flying hours of 254.5 hours including 126.1 hours as pilot in command.  The pilot had not flown for 77 days prior to the accident flight and had only flown for 30 minutes in the last 10 months. The weather conditions during this 30 minute flight had been good.  The pilot was not qualified to fly in instrument meteorological conditions. The PPL(H) training syllabus includes ‘basic instrument awareness’ in case of inadvertently entering into poor visibility or cloud. The pilot’s basic instrument awareness was refreshed during the training undertaken in 2017.  There are no recency requirements for pilots of privately-owned helicopters flying solo. To fly with passengers, EASA regulations require the pilot to have completed three takeoffs and landings within the preceding 90 days.

The flight was to take the helicopter for its annual maintenance check, due the following day. This may have created a perception that the flight needed to go ahead on this day. However, the maintenance company stated that an extension could have been obtained and that this had been done in the past and the co-owner indicated that he would have been able to operate the flight at another time.  A number of people who knew the pilot were very surprised he had decided to go ahead with the flight given the prevailing conditions.  It could not be determined why the helicopter entered cloud but it is probable that the pilot was distracted or became disorientated in the poor weather conditions. Having entered cloud it is likely that he became spatially disorientated and was unable to maintain control  (AAIB Bulletin 3/2009).




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