AAIB Bulletin: 9/2011

CONTENTS

SPECIAL BULLETINS
S2/2011 Britten-Norman BN2A-26 Islander VP-MON 22-May-11 1

COMMERCIAL AIR TRANSPORT

FIXED WING
DHC-8-402 Dash 8 G-JEDR 30-Nov-10 7
Piper PA-23-250 Aztec N40267 23-Apr-11 11
Saab-Scania SF340B G-LGNI 16-Dec-10 12

ROTORCRAFT
Sikorsky S-92A G-IACC 30-Mar-11 13

GENERAL AVIATION
FIXED WING
Casa 1-131E Series 2000 Jungmann G-RETA 03-July-11 18
Cessna 120 G-BPWD 02-Jun-11 19
Cessna 182S Skylane G-BXZM 24-Feb-11 21
DH87B Hornet Moth G-ADNE 03-Jun-11 24
Jabiru SK G-HINZ 17-Apr-11 25
Piper PA-28-140 Cherokee G-ATPN 02-May-11 26
Piper PA-28R-200 Cherokee Arrow G-AYAC 13-Jul-11 28
Pitts S-1S Special G-STYL 27-Jun-11 29
Pitts S-2A Pitts Special G-ODDS 02-Jul-11 30
SIAI-Marchetti SF-260D N405FD 09-Apr-11 31
Wolf WII Boredom Fighter G-BMZX 08-May-11 32

ROTORCRAFT
EC120B Colibri G-FEDA 04-Jun-11

SPORT AVIATION / BALLOONS

Cyclone AX3/503 G-MYRO 07-May-11 34
Flight Design CTSW G-OMSA 01-Jun-11 35
Mainair Scorcher G-MVBE 02-Jul-11 37
Rans S6-ES Coyote II G-CBZG 30-Apr-11 38
Rans S6-ESD XL (Modified) Coyote II G-MZOZ 19-Jun-11 39
Rotorsport UK MTOSport G-CGGV 05-Jun-11 40
Rotorsport UK MT-03 G-RSMT 03-Jul-11 41
Thruster T600N 450 G-KIPP 29-May-11 43
X’air 582(2) G-BZGN 29-Jun-11 44

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AAIB Bulletin: 9/2011

CONTENTS (Continued)

ADDENDA and CORRECTIONS

None

List of recent aircraft accident reports issued by the AAIB 45

(ALL TIMES IN THIS BULLETIN ARE UTC)

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AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04

SERIOUS INCIDENT

Aircraft Type and Registration: Britten-Norman BN2A-26, Islander, VP-MON

No & Type of Engines: 2 Lycoming O540 piston engines

Year of Manufacture: Not known

Date & Time (UTC): 22 May 2011 at 2154 hrs

Location: John A Osborne Airport, Montserrat

Type of Flight: Commercial Air Transport (Passenger)

Persons on Board: Crew - 1 Passengers - 7

Injuries: Crew - None Passengers - None

Nature of Damage: None

Commander’s Licence: Commercial Pilot’s Licence

Commander’s Age: 34 years

Commander’s Flying Experience: 3,600 hours (of which 2,000 were on type)
Last 90 days - 13 hours
Last 28 days - 13 hours

Information Source: AAIB Field Investigation

Synopsis

While attempting to land on Runway 28 the aircraft there was insufficient runway ahead in which to stop
skidded after the commander applied the brakes. As a the aircraft the commander steered the aircraft onto the
result the commander performed a touch-and-go and grass verge in an attempt to stop it before the end of the
positioned for another approach to Runway 28. On prepared surface. The aircraft came to rest beside the
landing after the second approach the aircraft skidded runway, 46 m from its end. There were no injuries to the
again when brakes were applied, and the commander passengers and no damage to the aircraft. This was the
continued with the landing roll. However, believing commander’s first landing on Runway 28.

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.
The investigation is being carried out in accordance with The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996, Annex 13
to the ICAO Convention on International Civil Aviation and EU Regulation No 996/2010.
The sole objective of the investigation shall be the prevention of accidents and incidents. It shall not be the purpose of such an investigation to
apportion blame or liability.
Extracts may be published without specific permission providing that the source is duly acknowledged, the material is reproduced accurately and is
not used in a derogatory manner or in a misleading context.

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AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04

A previous serious landing incident at John A Osborne perform a touch-and-go and to make another approach
airport, involving the same operator, is also being to Runway 28. The passengers, ATCOs and AFRS
investigated by the AAIB, which is responsible for personnel stated that the aircraft appeared to have
investigating accidents and serious incidents that occur touched down approximately a third to halfway along
in the UK Overseas Territories. As a result of initial the runway.
investigations three safety recommendations have been
made. All times in this special bulletin are UTC. Local On short final during the second approach the ATCO
time in Montserrat is 4 hours behind UTC. informed the pilot the wind was from 320° at 3 kt. The
pilot stated that he touched down just past the runway
History of the flight threshold marker and the aircraft skidded again on the
initial application of the brakes, however, he elected to
The aircraft was on a scheduled flight from VC Bird
continue with the landing roll. Most of the witnesses
Airport, Antigua, West Indies, to John A Osborne Airport,
stated that the aircraft landed just before the Abbreviated
Montserrat. The departure and cruise from Antigua
PAPIs (APAPIs)2 for Runway 28, which are located
were uneventful. As the aircraft approached Montserrat
approximately 190 m from the Runway 28 threshold.
the pilot was instructed to join left hand downwind for
As he continued the landing roll he continued to ‘pump’
Runway 10 and informed that the wind was from 090°
the brakes; however, he judged he might overrun the
at 5 kt. Approximately three minutes later the ATCO
runway. As a result he elected to steer the aircraft right
advised the pilot that the wind was now from 360° at
onto the grass verge, approximately 156 m from the
3 kt. The pilot replied that he would nevertheless like to
end of the paved surface, in an attempt to slow down
conduct an approach to Runway 10. However the ATCO
the aircraft more effectively. The aircraft came to rest
added that there were clouds at approximately 600 ft aal1
on the grass approximately 46 m from the end of the
drifting from the west with visibility of approximately
paved runway surface. The runway was described as
6 km. As a result the pilot requested Runway 28. He
‘damp’ by the pilot and most of the witnesses.
was instructed to report on final for Runway 28 and
advised that the wind was from 350° at 4 kt. When the
After the pilot had shut down the aircraft’s engines he
pilot reported that he was approximately 3 nm from
vacated the aircraft, followed by the passengers. There
landing the ATCO informed him that there was a light
were no injuries to the passengers and no apparent
rain shower at the airfield. Shortly thereafter the ATCO
damage to the aircraft. After the passengers had been
reported that he could see VP-MON and cleared the
driven to the terminal in an airport vehicle the pilot started
aircraft to land on Runway 28, reporting a surface wind
the aircraft’s engines and taxied it to the apron without
from 300° at 4 kt.
requesting permission from ATC. Having informed
the operator’s chief pilot and sought some engineering
The pilot stated that he touched down in the area
advice from an off-island maintenance organisation the
of the Runway 28 identification numbers. After he
pilot left the airport.
applied the brakes the aircraft skidded, so he decided to
Footnote
Footnote 2
Abbreviated PAPIs consist of two lights to indicate the aircraft’s
1
aal means ‘above aerodrome level’. runway approach angle to the pilot; PAPIs have four.

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AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04

The following morning the pilot flew the aircraft empty The reported conditions at 2100 hrs were surface
to Anguilla for a scheduled maintenance inspection. wind from 110° at 12 kt, visibility in excess of 10 km,
BROKEN cloud at 1,600 ft aal, temperature 26°C, dew
Notification
point 25°C and QNH 1014 mb. There had been recent
The locally based Accident Investigation Manager rain at the aerodrome and there was rain to the west.
(AIM) was informed of the incident by Montserrat ATC
The reported conditions at 2200 hrs were surface wind
at approximately 2200 hrs (all times in this report are
from 320° at 4 kt, visibility of 6 km, light showers of
UTC) and arrived at the airport at 2238 hrs. Initially
rain and thunder storms, BROKEN cloud at 600 ft aal,
he was unable to inform the AAIB by telephone, and
and FEW cumulonimbus clouds at 1,000 ft aal. The
made contact at 1230 hrs the following day. After
temperature and dew point were both 25°C and the QNH
further enquiries the AAIB travelled to Montserrat on
was 1015 mb.
13 June 2011 to conduct a field investigation.
Pilot’s experience
Runway inspection

The pilot of VP-MON had over 2,000 hrs experience on

The runway was inspected by the AIM and latterly by
the Britten-Norman Islander and had started working
the AAIB. They noted a skid mark approximately 24 m
for the operator on 11 May 2011. On 13 May 2011
long made by the aircraft’s right main tyres that started
he successfully completed a flight check to operate at
approximately 191 m from the beginning of the paved
Montserrat; however, only takeoffs and landings from
area of Runway 28 (163 m from the threshold), 12 m
Runway 10 were completed. This incident occurred on
before the Runway 28 APAPIs.
the pilot’s first landing on Runway 28.

The aircraft’s tyre marks continued along the runway Previous serious landing incident
until the left and right tyre marks left the paved surface
about 115 m and 148 m from the end of the paved surface On 17 April 2011 another Britten-Norman Islander

respectively. aircraft, registration VP-MNI, operated by the same

operator as VP-MON, departed the side of the runway
Weather information at John A Osborne Airport, Montserrat. The aircraft had
departed from VC Bird Airport, Antigua, and was making
The Terminal Aerodrome Forecast (TAF) for John A
an approach to Runway 10 at John A Osborne Airport
Osborne Airport issued at 1000 hrs on 22 May 2011
at about 1915 hrs. After a normal touchdown the pilot
stated that the surface wind was expected to be calm
applied the brakes and noticed that there was no response
and the visibility in excess of 10 km, with SCATTERED
from the right brake pedal. While maintaining directional
cloud at 2,200 ft aal. There was a 30% chance that
control with the rudder the pilot tried to “pump” the
between 1200 hrs on 22 May and 1200 hrs on 23 May
brake pedals but this had no effect on the right brakes. To
there would temporarily be showers of rain. The surface
avoid departing the end of the runway the pilot allowed
wind was expected to become 10 kt from 120° between
the aircraft to turn left onto grass just beyond the taxiway
1200 hrs and 1600 hrs.
exit. The aircraft struck an embankment located 20 m
north of the runway edge, approximately 150 m from the

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AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04

end of the runway. The impact, which was estimated by There is one windsock located to the north of the Runway
the pilot to be at approximately 10 kt, resulted in damage 10 threshold.
to the nose structure and caused the nose landing gear
leg to collapse. The left wing tip leading edge was also There is a wireless weather station in the ATC tower with
damaged when it struck the embankment. The seven the anemometer mounted on the roof. This is currently
passengers were able to exit the aircraft via the main the primary device used to display current wind to the
door after the aircraft came to rest. ATCOs. There is also a mast-mounted anemometer, on
the grass, between the fire station and the windsock but
The investigation by the aircraft owner’s engineering this is only partially serviceable as the display, which
representatives revealed that the right brake had failed is on the ATCO’s console, receives only wind direction
due to trapped air in the right brake hydraulic line. One of information. There is another mast-mounted anemometer
the right brake assembly O-ring seals had been replaced north of the tower, which has not been commissioned.
prior to the incident flight to address a hydraulic oil leak. The aerodrome operator commented that this will be
The brakes had been tested following this work and were relocated to the grass area west of the taxiway and
found to be working correctly. The investigation continues commissioned. They plan to have this completed by end
and is focussing on brake maintenance procedures. of August.

Aerodrome information
There is a ‘Griptester’ continuous runway friction
The Aeronautical Information Publication states the measuring device available for use at the aerodrome,
following declared distances for John A Osborne Airport, however it was last used in 2007. It requires calibrating
see Table 1. before it can be used and there are no personnel at the
airport trained in its operation.
There are no overrun areas on either runway. At the end
of each runway is a vertical drop in excess of 200 ft. See
Figure 1 for a diagram of the airfield.

RWY designator TORA3 (m) ASDA4 (m) TODA5 (m) LDA6 (m) Remarks
10 553 553 623 540 THR DISP 30 M
28 553 553 830 540 THR DISP 30 M

Table 1

Footnotes
3
Takeoff Run Available (TORA). The distance from the point on the surface of the aerodrome at which the aeroplane can commence
its takeoff run to the nearest point in the direction of takeoff at which the surface of the aerodrome is incapable of bearing the weight of the
aeroplane under normal operating conditions.
4
Accelerate Stop Distance Available (ASDA). The distance from the point on the surface of the aerodrome at which the aeroplane can
commence its takeoff run to the nearest point in the direction of takeoff at which the aeroplane cannot roll over the surface of the aerodrome
and be brought to rest in an emergency without the risk of accident.
5
Takeoff Distance Available (TODA). Either the distance from the point on the surface of the aerodrome at which the aeroplane can
commence its takeoff run to the nearest obstacle in the direction of takeoff projecting above the surface of the aerodrome and capable of
affecting the safety of the aeroplane, or one and one half times the takeoff run available, whichever is the less.
6
Landing distance available (LDA). The length of runway which is declared available and suitable for the ground run of an aeroplane landing.

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AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04

Figure 1

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AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04

Aerodrome manual
Safety Recommendation 2011-078

The John A Osborne Airport aerodrome manual states:

The operator of John A Osborne Airport, Montserrat,
in consultation with Air Safety Support International7,
‘9 Runway Surface friction Measurement
should revise its operations manual to permit pilots to
9.1 A continuous friction measuring device is operate only to and from the runway on which they have
available. been flight checked.
9.2 In order to provide a record of the reduction in
Safety Recommendation 2011-079
friction characteristics with time, friction testing
is carried out periodically but at not less than The operator of John A Osborne Airport, Montserrat
six-monthly intervals by the Operations Officer should ensure that a runway friction assessment is carried
and the results reported to the Duty ATCO. out at the earliest opportunity by a qualified person using
Friction testing may also be carried out when the suitable equipment.
Aerodrome Manager so decides e.g. following a
runway incident or particularly heavy rain.’ The investigation continues. A full report will be
published in due course.
Due to the absence of trained personnel the aerodrome
operator has been unable to meet these requirements.

Safety Recommendations

The following Safety Recommendations are made:

Safety Recommendation 2011-077

The operator of John A Osborne Airport, Montserrat,

should install a windsock and anemometer adjacent to
the Runway 28 threshold.

Footnote
7
Air Safety Support International, a subsidiary company of the
UK Civil Aviation Authority, has been designated by the Governor of
Montserrat to perform the civil aviation regulatory tasks on behalf of
Published 21 July 2011 the Governor.

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AAIB Bulletin: 9/2011 G-JEDR EW/C2010/11/04

INCIDENT

Aircraft Type and Registration: DHC-8-402 Dash 8, G-JEDR

No & Type of Engines: 2 Pratt & Whitney Canada PW150A turboprop engines

Year of Manufacture: 2003

Date & Time (UTC): 30 November 2010 at 1902 hrs

Location: Bournemouth Airport, Dorset

Type of Flight: Commercial Air Transport (Passenger)

Persons on Board: Crew - 4 Passengers - 69

Injuries: Crew - None Passengers - None

Nature of Damage: Damage to frangible ‘touch runway’ switch

Commander’s Licence: Airline Transport Pilot’s Licence

Commander’s Age: 48 years

Commander’s Flying Experience: 9,000 hours (of which 765 were on type)
Last 90 days - 168 hours
Last 28 days - 39 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

and further enquiries by the AAIB

Synopsis

As the aircraft approached touchdown following a decided to carry out an ILS approach to Runway 08 at
flap 0° approach, the pilot increased the pitch attitude Bournemouth Airport. The weather conditions reported
to control the rate of descent and the aft lower at Bournemouth Airport were wind from 050° at 10 kt,
fuselage of the aircraft struck the runway. One Safety 10 km visibility, broken cloud at 1,500 ft aal, and a
Recommendation was made. temperature of 1°C.

History of the flight

Seven miles from touchdown on the final approach to
The aircraft was on a VOR approach to Southampton Bournemouth Airport, the aircraft’s landing gear was
Airport in icing conditions when, as the first stage down, its speed was stabilised at a Vref of 150 kt IAS
of flap was selected, the amber FLAP POWER caution and its attitude was 5° nose-up. At 1,000 ft aal, the
illuminated on the Caution and Warning Panel (CWP) commander disconnected the autopilot and began to fly
and the flaps remained up. The crew calculated that manually, in accordance with the Emergency Check List
the runway at Southampton Airport was not long (ECL). When the aircraft was within approximately
enough for a flap 0° approach in icing conditions and 2 nm of the runway, the co-pilot began to call out the

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AAIB Bulletin: 9/2011 G-JEDR EW/C2010/11/04

aircraft’s pitch attitude. As the aircraft approached the

‘Descent control below 200 ft agl must be through
touchdown point, the commander perceived a high rate
power lever management rather than adjusting
of descent and increased the pitch attitude to reduce it.
pitch.’
The co-pilot called “Pitch 8°, don’t pitch any more”
but, as the aircraft touched down, a Master Warning was The manufacturer commented further that:
triggered and the crew observed the touched runway
caption illuminate on the CWP. The aircraft vacated ‘The result of small power lever movement ahead
the runway and taxied to a parking stand, where the of flight idle is an immediate reduction in the
pilots carried out a normal shutdown. An inspection of sink rate even before there is an actual increase
the aft lower fuselage of the aircraft revealed that the in power due to the effectiveness of lift due to
frangible touch runway detection switch was broken. slipstream.’

Comments from the commander Operator’s investigation

The commander commented that, although he was aware The operator’s investigation of the incident, which
of the ECL requirement to avoid pitch attitudes in excess included an interview of the crew and analysis of flight
of 6° at touchdown, he found the temptation to flare the data downloaded from the aircraft, highlighted some
aircraft to reduce the rate of descent overwhelming. He anomalies in the company’s manuals. The ECL for a
also thought that the advice in the ECL to gradually landing with an abnormal flap configuration (flap 5° or
reduce power to achieve flight idle at touchdown might flap 0°) instructs pilots to:
have contributed to the aircraft’s high rate of descent.
In addition, the commander reported that the wind ‘Reduce power gradually to achieve flt idle at

dropped significantly as the aircraft approached the touchdown.’

runway – an assessment confirmed later by the operator

In Part B4 of the operator’s Operations Manual, the
following flight data analysis – which might have caused
section that deals with landing with an abnormal flap
some windshear to be present in the final stages of the
configuration states that:
approach.

AAIB investigation into a similar event ‘Power should be reduced to flt idle at
touchdown and the nose-wheel promptly lowered
The report of an AAIB investigation into a tail strike to the ground.’
incident involving another DHC-8-402 Dash 81
referred to the manufacturer’s Service Letter The Airplane Flight Manual (AFM) for the aircraft
DH8‑400‑SL-00-020, which advised operators to considers abnormal flap landings and states:
include in their procedures an alert call at 5º pitch
attitude and stated that: ‘Power should be reduced gradually to achieve
flt idle at or just prior to touchdown.’
Footnote
In all cases, there is a caution to avoid pitch attitudes in
1
AAIB Bulletin 7/2010; aircraft registration G-ECOZ, which was
not carrying out a flap 0° approach. excess of 6° at touchdown.

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AAIB Bulletin: 9/2011 G-JEDR EW/C2010/11/04

Flight data showed that the commander began reducing normal landings only with respect to those procedures
power to flt idle when the aircraft was below given in the AFM section on abnormal flap landings.
approximately 30 ft agl. Consequently:

Discussion with the manufacturer

‘all the normal expected handling activities
The operator believed that the ECL requirement associated with power management for approach
to reduce power gradually to achieve flt idle at airspeed, descent rate and pitch attitude control
touchdown contradicted the manufacturer’s advice are relevant [to an abnormal flap landing] and
to use power to manage the rate of descent below expected to be executed by the pilot flying.’
200 ft agl. The manufacturer offered a further
explanation to the company, which was subsequently At light weights in the flap 5° configuration, the power

reiterated to the AAIB: levers would need to be selected to flt idle just prior
to, rather than at, touchdown and so the AFM abnormal
‘With the aircraft flying at the correct Vref, the flap procedure covered both conditions of power
power levers are intended to be selected to management. In addition:
flight idle immediately prior to the main
wheels arriving on the runway surface. In the ‘power lever movement toward flt idle should

abnormal flap condition, the [difference is that] be gradual to avoid a sudden pitch attitude

power levers are put to flight idle “at” ahead change.’

of “just prior to” touchdown. The pitch attitude

The manufacturer believed that the AFM contains
for a flap 0 or 5 degree landing, when stabilized
adequate information to enable pilots to control the rate
at the correct Vref, will give a pitch attitude of
of descent at maximum pitch attitude and concluded
between 5 and 6 degrees, which, from a pilot
that, in this incident, the appropriate pilot action required
handling perspective, should suggest a flare is not
the:
possible and power will be maintained to main
wheel contact followed by promptly lowering the
‘application of power coincidental with lowering
nosewheel to the runway.’
of the pitch attitude to the allowed 6°.’

The AFM states in the section on normal landing Rate of descent

procedures that:
An aircraft with a typical VREF of 120 kt in a
‘To decrease the landing descent rate, when 10 kt headwind would require a rate of descent of
the landing descent rate is higher than desired, 582 ft/min to maintain a 3° glidepath. During the incident
power will be required in the landing flare approach, flight data showed that the groundspeed of the
through touchdown.’ aircraft between 1,000 ft and 20 ft agl varied between
131 and 139 kt, with a typical value of 136 kt. This
The manufacturer stated that procedures in the case groundspeed required a rate of descent of 720 ft/min to
of abnormal flap landings differed from those of maintain a 3° glidepath, representing a 24% increase

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AAIB Bulletin: 9/2011 G-JEDR EW/C2010/11/04

from a typical approach. The operator required its pilots The manufacturer considered that sufficient information
to practise a flap 0° approach in the simulator once every was provided in the AFM to enable crews to control high
three years. rates of descent during abnormal flap landings. A note
in the AFM section regarding normal landings indicated
As G-JEDR descended between 300 and 100 ft agl, its that power may remain applied until touchdown to
rate of descent was between 700 and 800 ft/min. The reduce the rate of descent and the manufacturer stated
rate of descent increased to 1,000 ft/min as the aircraft that this technique is also applicable to the abnormal flap
descended to 30 ft agl and then reduced progressively to landing case. The manufacturer also commented that, in
200 ft/min at touchdown. The reduction in rate of descent abnormal flap landings, the pitch attitude is so close to
corresponded to an increase in aircraft pitch attitude from the pitch limit that a flare is not possible and power will
6° nose-up at 30 ft agl to 9° nose-up immediately before be maintained until main wheel contact.
touchdown. The power levers were retarded slightly as
the aircraft passed 100 ft agl and retarded to idle below With regard to landing with abnormal flap, the current
30 ft agl. edition of the ECL instructs pilots to reduce thrust
gradually to achieve flt idle ‘at’ touchdown, meaning
Analysis
that power reduction will begin while the aircraft is still
The rate of descent required for a flap 0° approach is airborne. In this respect, the ECL instructions describe
significantly higher than for a normal approach but power lever control in a flap 5° landing at light aircraft
the operator’s pilots practise flap 0° approaches in the weight. However, as a source of guidance for pilots who
simulator only once every three years. Consequently, rarely fly or train for abnormal flap approaches, the ECL
the incident aircraft pilot’s perception of a high rate of should contain the most complete information that it is
descent might be expected of most of the operator’s practical to provide. Therefore, the following Safety
pilots when flying a flap 0° approach. The aircraft’s Recommendation is made:
rate of descent was already higher than required when
Safety Recommendation 2011-081
the pilot began to reduce power towards flt idle in
accordance with the ECL instructions. The reduction in It is recommended that Bombardier Aerospace amends
power would probably have increased the rate of descent the DHC-8-402 Dash 8 emergency checklist section
further in the absence of any other action. However, the concerning abnormal flap landings to reflect their advice
pilot increased the aircraft pitch attitude at the same time, that power will be maintained until main wheel contact.
and the aft lower fuselage struck the runway.

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AAIB Bulletin: 9/2011 N40267 EW/G2011/04/24

ACCIDENT

Aircraft Type and Registration: Piper PA-23-250 Aztec, N40267

No & Type of Engines: 2 Lycoming TI0-540 SER piston engines

Year of Manufacture: 1973

Date & Time (UTC): 23 April 2011 at 1815 hrs

Location: Virgin Gorda Airport, British Virgin Islands

Type of Flight: Comercial Air Transport (Non-Revenue)

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Underside of left wing, flap, gear doors, propeller, main
gear and actuator damaged

Commander’s Licence: Commercial Pilot’s Licence

Commander’s Age: 33 years

Commander’s Flying Experience: 4,500 hours (of which 200 were on type)
Last 90 days - 200 hours
Last 28 days - 45 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The left main landing gear collapsed when the aircraft before coming to rest on the left side of the runway,
landed on Runway 03 at Virgin Gorda Airport, British where the pilot shut down and vacated it without injury.
Virgin Islands. The pilot stated that he had selected the The landing gear actuator for the left main gear had
landing gear down, observed three green landing gear failed in overload. It is likely that the left main landing
position lights and carried out a normal landing. As gear was not fully locked down, which resulted in the
the aircraft decelerated on the runway, the pilot heard actuator being subjected to excessive loads that caused
the landing gear warning horn and the aircraft rolled it to fail. The investigation did not determine why the
to the left until its left wing and propeller contacted left landing gear was not fully locked down.
the runway. The aircraft skidded for a further 100 ft

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AAIB Bulletin: 9/2011 G-LGNI EW/C2010/12/03

INCIDENT

Aircraft Type and Registration: Saab-Scania SF340B, G-LGNI

No & Type of Engines: 2 General Electric CO CT7-9B turboprop engines

Year of Manufacture: 1989

Date & Time (UTC): 16 December 2010 at 1555 hrs

Location: Kirkwall Airport, Orkney Islands

Type of Flight: Commercial Air Transport (Passenger)

Persons on Board: Crew - 3 Passengers - 17

Injuries: Crew - None Passengers - None

Nature of Damage: None

Commander’s Licence: Airline Transport Pilot’s Licence

Commander’s Age: 43 years

Commander’s Flying Experience: 4,100 hours (of which 3,200 were on type)
Last 90 days - 125 hours
Last 28 days - 17 hours

Information Source: AAIB Field Investigation

Synopsis

When landing in a strong crosswind on a slush covered broken cumulonimbus cloud at 1,000 ft, temperature
runway the nosewheel steering system did not operate -2°C, dewpoint -5°C and sea level pressure 1002 mb.
and, initially, the power levers could not be moved
into the beta range. When the aircraft decelerated to Runway 27 was reportedly covered with slush to
taxi speed the nosewheel steering system operated depths between 3 mm and 5 mm. On landing, the
normally. It is probable that delayed closure of the aircraft commander, who was pilot flying, gave the
mainwheel weight-on-wheels switches caused both co‑pilot control of the control yoke, in accordance
problems. with normal procedures. He attempted to select
the beta range (ground pitch control) of propeller
History of the flight
operation by moving the power levers aft. Initially
The aircraft departed Inverness Airport at 1510 hrs on he was unable to do so and they remained in the flight
a scheduled passenger flight to Lerwick Airport, where idle position. At the same time he attempted to use
it landed at 1555 hrs. Weather conditions reported at the nosewheel steering but was unable to operate it, so
the time were surface wind from 330° at 27 kt, visibility used a combination of rudder and differential braking
7,000 m, light showers of hail, few cloud at 700 ft, to steer the aircraft. Shortly after commencing

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AAIB Bulletin: 9/2011 G-LGNI EW/C2010/12/03

braking he was able to select the power levers into the Nosewheel steering system
beta range. When the aircraft had slowed to taxiing
The nosewheel steering system has a single hydraulic
speed the commander again tried to use the nosewheel
actuator. An electrically operated shutoff valve prevents
steering system and found that it responded normally.
hydraulic pressure from reaching the steering control
The aircraft taxied to a parking stand without further
valve in flight. There is a deflection switch in the
incident. A subsequent engineering investigation did
system that detects the castor angle of the nosewheel.
not find any related technical defects.
This switch operates at a castor angle of 20° ± 5°. The
Flight idle stop system shutoff valve is opened by applying electrical power
through the following switches in series.
The purpose of the flight idle (FI) stop system is to
prevent the pilot from selecting the beta range in flight. Nosewheel deflected by Nosewheel deflected by
less than 20°±5° more than 20°±5°
It consists of an automatically operated mechanical
stop arm located within the control quadrant which 1. Nose landing gear 1. Left or Right
downlock weight-on-wheels
physically blocks power lever movement below flight
2. Steering wheel 2. Nosewheel deflection
idle when the aircraft is in flight. The stop is opened microswitch switch
by a solenoid, allowing unrestricted movement of the 3. Nosewheel deflection 3. Ground handling
power levers, when the following conditions are met: switch lockout switch
4. Ground handling
Left or right inboard or lockout switch
outboard wheel speed
Left or right
greater than 25 kt Analysis
landing gear AND
OR
extended Slush covering the runway at Lerwick may have delayed
left or right weight on
wheels detected acceleration of the main landing gear (MLG) wheels to
above 25 kt. This, together with any delay in closure
The manufacturer stated that the Saab 340 has of the weight-on-wheels switches, would have delayed
“relatively stiff” main undercarriage oleos and that opening of the FI stop and initially prevented the pilot
propeller wash at flight idle may result in sufficient from moving the power levers to the beta range.
wing lift that the weight of the aircraft is slow to settle
fully onto its wheels after landing. Consequently, in During landing on a slush covered runway in a

normal operation it may be wheel speed rather than crosswind of the magnitude reported, it is likely that

weight on wheels that causes the FI stop to open. Then, the nosewheel would castor before the nosewheel

when the power levers are moved to the beta range the steering was engaged. If the castor angle exceeded

resulting reduction in propeller wash will allow the 20° ± 5°, power for the nosewheel steering system

aircraft to settle fully onto the main oleos allowing the would be routed through the MLG weight‑on‑wheels

weight‑on‑wheels switches to close. switches rather than the nose landing gear downlock.
Nosewheel steering would not then be available until
closure of a MLG weight-on-wheels switch or until the
castor angle reduced below 20° ± 5°.

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AAIB Bulletin: 9/2011 G-LGNI EW/C2010/12/03

Safety action taken Conclusion

The manufacturer has taken action to publish suitable The investigation determined that castoring of the
warnings in the Aircraft Operations Manual to warn nosewheel when landing on a slippery surface in a
crews of the possibility that: crosswind could render the nosewheel steering system
inoperative until closure of a weight-on‑wheels switch.
‘1. When landing on a slippery surface there could Delay in closure of weight-on-wheel switches, together
be a transitory delay in opening of the flight with slow acceleration of the main wheels, would
idle stop. also delay opening of the FI stop. Together these
conditions could result in the symptoms reported by
2. When landing on a slippery surface with a
the commander. Considering the safety action taken
crosswind there could be a transitory delay
by the manufacturer, no Safety Recommendations
in the nosewheel steering system becoming
were made.
operational.’

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AAIB Bulletin: 9/2011 G-IACC EW/G2011/03/18

ACCIDENT

Aircraft Type and Registration: Sikorsky S-92A, G-IACC

No & Type of Engines: 2 General Electric Co CT7-8A turboshaft engines

Year of Manufacture: 2007

Date & Time (UTC): 30 March 2011 at 0725 hrs

Location: Stand A2, Scatsta Airport, Shetland Islands

Type of Flight: Commercial Air Transport (Passenger)

Persons on Board: Crew - 2 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Left landing gear and fuselage

Commander’s Licence: Airline Transport Pilot’s Licence

Commander’s Age: 49 years

Commander’s Flying Experience: 6,430 hours (of which 1,575 were on type)
Last 90 days - 92 hours
Last 28 days - 8 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

Summary

The helicopter was ground taxied onto a parking spot and pilot to stop. In accordance with the Standard Operating
brought to a stop by the commander, who was the pilot Procedures (SOPs), the co-pilot in the left seat stated
flying. He then intended to apply the parking brake but “Disc/Brakes/Lights”. The commander levelled the disc,
inadvertently raised the collective control lever, which exerted toe pressure on the foot brakes and then intended
caused the helicopter to become airborne. He released to raise the parking brake handle. The parking brake
the collective control lever, which was lowered by the handle is located to the left of the right seat collective
collective trim system to the fully down position, and the lever hand grip (see Figure 1) and, instead of applying
helicopter landed heavily, causing damage to the landing the parking brake, the commander inadvertently raised
gear and airframe. the collective lever. The helicopter lifted approximately
six feet into the air, with a slight roll to the left, and the
History of the flight
commander instinctively released the collective lever,
The helicopter was being ground taxied onto Spot A2 by thinking it was the parking brake handle. The helicopter
the commander, who was occupying the right seat. The immediately descended and landed heavily, resulting
taxiing was under the direction of a marshaller, who, when in a ‘HARD LANDING’ caution caption on the Engine
the helicopter reached the parking position, signalled the Indication Caution Advisory System (EICAS).

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AAIB Bulletin: 9/2011 G-IACC EW/G2011/03/18

Parking
Parking brake
brake handle
handle Collective lever grip
Collective lever grip

Figure 1
Photograph of the collective lever and parking brake handle,
on the left of the pilot in the right seat

The crew advised their company of the event by radio and brake is applied and the collective lever adopts the
taxied to the North Apron in order that an engineering new ‘trim neutral’ position. Raising or lowering the
inspection could be carried out. The inspection revealed collective lever without depressing the trigger is possible
that there had been some deformation of the airframe but the pilot must overcome the resistance imposed by
structure in two places and a crack in one of the left the electromagnetic brake. If the collective is released
main landing gear wheel rims, on which the tyre had under these circumstances, the lever will rapidly return
deflated. to the previously selected ‘trim neutral’ position.

Collective trim system Safety action

The collective lever on the SK92 is equipped with As a result of the incident, the operator issued a Flying
a trim position mechanism. This incorporates an Staff Instruction (FSI), ‘Guarding Flight Controls and
electromagnetic brake, with a control trigger on the Control Handover’. This stressed the importance of
underside of the collective lever grip. When the trigger using the positive handover technique when the pilot
is depressed the electromagnetic brake is released, which flying (PF) passes control of an individual flying control
allows the collective lever to be moved up or down or controls to the pilot monitoring (PM). It includes the
freely. When the trigger is released, the electromagnetic following paragraph:

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AAIB Bulletin: 9/2011 G-IACC EW/G2011/03/18

neutral’ position. When the commander raised the

‘Before removing hands from the flight controls
collective lever, instead of the parking brake handle,
to activate other switches or controls during
lifting the helicopter into the air, he did so against the
critical phases of flight or when on ground rotors
electromagnetic brake. As the collective lever was
running, PF shall hand control of the appropriate
released, the electromagnetic brake lowered it back
flight control to PM using the standard two crew
to the MPOG position. This caused the helicopter
hand over technique and calls. This applies
to descend rapidly, resulting in a hard landing.
especially when applying the parking brake,
Subsequently, damage was discovered on the fuselage
to avoid the possibility of the collective lever
and left main landing gear.
being raised inadvertently instead of the parking
brake, unless the helicopter type is fitted with
The commander concluded that the accident was the
a collective lock and Part B SOP requires the
consequence of an unintentional and inadvertent
lock to be engaged before applying the parking
application of the collective lever, instead of the parking
brake.’
brake. As a result of this occurrence, the operator
Conclusions promptly issued a Flying Staff Instruction to ensure
that the PF or PM has control of the flying controls
After the helicopter had been brought to a stop on the
during critical phases of flight or when on the ground,
parking spot, the collective lever was lowered fully
rotors running.
and the collective trim system trigger was released
in the Minimum Pitch On Ground (MPOG) ‘trim

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AAIB Bulletin: 9/2011 G-RETA EW/G2011/07/04

ACCIDENT

Aircraft Type and Registration: Casa 1-131E Series 2000 Jungmann, G-RETA

No & Type of Engines: 1 Enma Tigre G-IV-B piston engine

Year of Manufacture: 1967

Date & Time (UTC): 3 July 2011 at 0900 hrs

Location: Approx 1.5 miles north north-west of Old Warden

Aerodrome, Bedfordshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Substantial

Commander’s Licence: Airline Transport Pilot’s Licence

Commander’s Age: 51 years

Commander’s Flying Experience: 14,500 hours (of which 12 were on type)

Last 90 days - 160 hours
Last 28 days - 57 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The pilot was practising an aerobatic routine and was uninjured and able to vacate the aircraft unaided. He
performing a stall turn to the left when the engine reported that the engine had stopped due to the limited
stopped. The aircraft was beyond gliding range of an negative g capability of the carburettor and that a restart
airfield and, after confirming correct cockpit selections, was not possible as the aircraft was not fitted with a
the pilot unsuccessfully attempted to restart the engine by starter and the coarse pitch of the propeller did not allow
diving and yawing the aircraft. The aircraft overturned it to windmill.
during the subsequent forced landing. The pilot was

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AAIB Bulletin: 9/2011 G-BPWD EW/G2011/06/02

ACCIDENT

Aircraft Type and Registration: Cessna 120, G-BPWD

No & Type of Engines: 1 Continental Motors Corp O-240-E piston engine

Year of Manufacture: 1946

Date & Time (UTC): 2 June 2011 at 0945 hrs

Location: Field adjacent to Hucknall Airfield, Nottinghamshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - 1 (Minor) Passengers - 1 (Minor)

Nature of Damage: Left main landing gear, fuselage floor pan and left wing
damaged

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 70 years

Commander’s Flying Experience: 640 hours (of which 310 were on type)
Last 90 days - 2 hours
Last 28 days - None

Information Source: Aircraft Accident Report Form submitted by the pilot

Synopsis

After takeoff on a Permit to Fly renewal flight, the what they described as a momentary “flutter” from the
engine stopped. The subsequent forced landing in a engine, although it picked up again. As a precaution,
corn field adjacent to the airfield caused the left main they decided to return to Hucknall, turning to the north
landing gear to collapse. to avoid woods to the south; this presented a corn field
which the pilot judged would make an acceptable forced
History of the flight
landing field in case the engine stopped, which it did
The aircraft was being prepared for renewal of its shortly afterwards. Being unable to make the airfield,
Permit to Fly. Having performed all the usual engine the pilot landed in the field, causing the left main landing
ground run checks, the pilot and passenger, also a pilot, gear to collapse, with consequent major damage to the
taxied the aircraft to the holding point of Runway 04R aircraft and back injuries to the two occupants. They
for the magneto checks, which were satisfactory. The were, however, able to exit the aircraft unaided.
aircraft was lined up and took off normally.
Both occupants were of the opinion that the behaviour of
However, at a height of about 250 ft, both pilots detected the engine was consistent with fuel starvation. However,

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AAIB Bulletin: 9/2011 G-BPWD EW/G2011/06/02

when they removed the carburettor bowl, there was planned and any significant findings will be reported in a
ample fuel present and the accelerator pump worked future AAIB Bulletin addendum.
normally. An in-depth investigation of the engine is

© Crown copyright 2011 20

AAIB Bulletin: 9/2011 G-BXZM EW/G2011/02/09

ACCIDENT

Aircraft Type and Registration: Cessna 182S Skylane, G-BXZM

No & Type of Engines: 1 Lycoming IO-540-AB1A5 piston engine

Year of Manufacture: 1998

Date & Time (UTC): 24 February 2011 at 1256 hrs

Location: White Waltham Airfield, Berkshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 3

Injuries: Crew - 1 (Minor) Passengers - 3 (Minor)

Nature of Damage: Nosewheel, propeller, left wing spar, right wingtip, tail
and fuselage

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 44 years

Commander’s Flying Experience: 84 hours (of which 4 were on type)

Last 90 days - 8 hours
Last 28 days - 6 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

and subsequent AAIB enquiries

Synopsis

After touchdown the aircraft became airborne again and as normal but, as the aircraft passed over the runway
then bounced a number of times. A heavy touchdown threshold, he thought the aircraft was a little high.
on the nose landing gear following one of the bounces He did not consider this to be a problem as there
caused the nosewheel to detach. The propeller was sufficient runway length remaining. The aircraft
subsequently struck the ground and the nose landing gear initially touched down approximately one third of the
leg progressively dug into the soil, causing the aircraft to way along the runway. The pilot reported that while
pitch over onto its back. The pilot and three passengers the main wheels were on the ground, but before the
suffered minor injuries. nosewheel had made contact with the runway, the
aircraft encountered a dip in the runway surface. A gust
History of the flight
of wind, coincident with the aircraft coming out of the
On returning from a short flight in the local area, the dip, caused the aircraft to become airborne again. He
pilot made an approach to grass Runway 25 at White attempted to correct this by applying a small amount of
Waltham Airfield. The pilot described the approach power, but he was unsuccessful in reducing the rate of

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AAIB Bulletin: 9/2011 G-BXZM EW/G2011/02/09

descent and the aircraft touched down quite hard and Pilot’s experience
once again became airborne. Further attempts to control
The pilot held a PPL and had a total of 84 hours
the bounce were unsuccessful. The pilot was aware
flying experience, of which 22 hours were as Pilot in
of hearing a “thump” during the resulting touchdown,
Command (PIC). He had undertaken his PPL training
but at that point was not aware that the nosewheel
and subsequent flying on other aircraft types and had
had detached from the nose landing gear. The aircraft
recently been checked out by an instructor to fly the
bounced once more before finally touching down with
Cessna 182. He had a total of four hours experience on
very little forward speed. The propeller struck the
the Cessna 182. The accident flight was his first flight as
runway and the nose landing gear leg progressively
PIC on the type.
dug into the ground, causing the aircraft to pitch over
onto its back. The pilot and three passengers, who were Ground markings
wearing lap and diagonal harnesses, sustained bruising
during the accident, but were otherwise uninjured and Photographs of the accident site provided to the

were able to exit the aircraft unassisted. AAIB show ground markings consistent with a heavy
nosewheel touchdown (Figure 1). The nosewheel
The weather conditions at the time of the accident were (Figure 2) was found approximately 10 m to the right of
good, with a reported a wind of 2600 at 10 kt gusting the runway centreline. Subsequent propeller strikes and
to 15 kt. a furrow caused by the nose landing gear leg contacting
the ground are also evident (Figure 3).

Figure 1
Nosewheel impact mark

Figure 2 Figure 3
Nosewheel Propeller strike and
ground marks

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AAIB Bulletin: 9/2011 G-BXZM EW/G2011/02/09

Examination of the nosewheel There was no evidence of fatigue propagation; nor were
there any indications of pre-existing damage within the
The nosewheel yoke had fractured causing the
structure of the component.
nosewheel to separate from the landing gear. The
fracture surfaces of the yoke were examined using Discussion
a binocular microscope and a scanning electron
Ground marks indicate that the aircraft landed heavily
microscope to determine the failure mechanism. Two
on its nose landing gear after bouncing, causing the
distinct regions of fracture were evident indicating a
nosewheel to detach. The pilot elected to continue
two-stage failure process, resulting from overload of the
the landing rather than initiating a go-around and his
component. It was concluded that a crack had initially
attempts to correct the bounces were unsuccessful.
propagated upwards from the base of the yoke due to
Metallurgical examination of the failed nosewheel yoke
tensile overload caused by excessive drag loading on
did not reveal any evidence of fatigue propagation or
the nosewheel. There was also evidence of compressive
pre-existing defects which may have contributed to its
loading consistent with a hard landing. It is likely that
failure.
the nosewheel buckled under the compressive loading
after one of the bounces, causing compressive failure
The pilot considers that the accident was the result
on one side of the yoke. Drag loading is likely to have
of electing to land rather than initiating a go-around
arisen from the nosewheel impact shown in Figure 1;
immediately upon becoming airborne after the first
the depth of this mark also indicates the presence of
touchdown.
significant compressive loading.

It was not possible to determine whether the failure had

occurred progressively during multiple impacts of the
bounced landing, or solely during one of the impacts.

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AAIB Bulletin: 9/2011 G-ADNE EW/G2011/06/06

ACCIDENT

Aircraft Type and Registration: DH87B Hornet Moth, G-ADNE

No & Type of Engines: 1 de Havilland Gipsy Major 1C piston engine

Year of Manufacture: 1936

Date & Time (UTC): 3 June 2011 at 1355 hrs

Location: Unst, Shetland Islands

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - None

Nature of Damage: Right main landing gear, propeller, cowling

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 71 years

Commander’s Flying Experience: 22,994 hours (of which 524 were on type)
Last 90 days - 27 hours
Last 28 days - 9 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

Following an uneventful flight from Sumburgh, the pilot not be lowered with up elevator. The tail continued
joined the right-hand circuit for Runway 30 at Unst. to rise until the chin cowling and propeller contacted
From the windsock he estimated the wind to be from the runway. The propeller shattered and the right
270° between 15 and 20 kt. The approach and landing undercarriage partially collapsed before the aircraft
were made left wing down because of the crosswind, came to halt. The aircraft was made safe and both
with the left mainwheel contacting the ground just occupants vacated the aircraft without injury. The pilot
before the right. The aircraft skipped briefly before inspected the main undercarriage wheels and brakes
landing back onto the mainwheels. The pilot kept the and found no defects. He considered that the right
aircraft straight using full right rudder and some right wheel brake may have locked up during the landing
wheel braking during the landing roll. As the aircraft roll and caused the tail to rise.
slowed to about 20 kt the aircraft’s tail rose and could

© Crown copyright 2011 24

AAIB Bulletin: 9/2011 G-HINZ EW/G2011/04/17

ACCIDENT

Aircraft Type and Registration: Jabiru SK, G-HINZ

No & Type of Engines: 1 Jabiru Aircraft PTY 2200A piston engine

Year of Manufacture: 2000

Date & Time (UTC): 17 April 2011 at 1320 hrs

Location: Manchester Barton Airport

Type of Flight: Private

Persons on Board: Crew - 2 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Nosewheel, propeller, cabin floor, engine shock-loaded

Commander’s Licence: National Private Pilot’s Licence

Commander’s Age: 63 years

Commander’s Flying Experience: 730 hours (of which 1 was on type)

Last 90 days - 4 hours
Last 28 days - 4 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The pilot had just completed an aircraft familiarisation Both occupants were wearing lap and diagonal
flight and was returning to Barton Airport, Runway 27. harnesses and were uninjured. After the accident,
The weather was fine with a light variable wind. He the ASI was tested and found to be reading correctly.
reported that the approach was “quite normal” at The pilot was unable to identify a single cause of the
250 ft aal but, while descending through 200 ft aal, accident.
airspeed reduced and he increased engine power. The
aircraft then pitched up, down then up again before
it “suddenly pitched down”, striking the ground. The
nosewheel detached and the aircraft slid along the
runway for 30‑40 m.

© Crown copyright 2011 25

AAIB Bulletin: 9/2011 G-ATPN EW/G2011/05/11

ACCIDENT

Aircraft Type and Registration: Piper PA-28-140 Cherokee, G-ATPN

No & Type of Engines: 1 Lycoming O-320-E2A piston engine

Year of Manufacture: 1966

Date & Time (UTC): 2 May 2011 at 1240 hrs

Location: Norwich Airport, Norfolk

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - 1 (Serious)

Nature of Damage: None

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 58 years

Commander’s Flying Experience: 91 hours (of which 63 were on type)

Last 90 days - 8 hours
Last 28 days - 2 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

and subsequent AAIB enquiries

Synopsis History of the flight

After landing at Norwich Airport with a single stage Following an uneventful flight from Southend, the pilot
of flap selected, the pilot omitted to retract the flaps selected one stage of flap during approach to Norwich
when completing the ‘After Landing’ checklist. As a Airport. After landing, he taxied the aircraft as instructed
result the flaps were not secured. When the passenger by ATC and was marshalled on to the parking area. After
exited the aircraft she stepped on the flap and fell to the engine had been shut down, the passenger exited the
the ground, sustaining a serious fracture to one leg. aircraft onto the right wing and while reaching for the
The pilot considered that the accident was the result hand grip to aid her step down from the wing, she fell to
of the high workload caused by the challenging the ground. It became apparent that the flaps had not been
conditions experienced during landing and operating at raised from the first stage position and were therefore
an unfamiliar airfield, which had distracted him from unsecured. As the passenger stepped on the flap, it
properly following the checklist. moved downwards, causing her to fall. She sustained an
injury to her left leg, which was subsequently diagnosed
as a serious fracture requiring operative treatment.

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AAIB Bulletin: 9/2011 G-ATPN EW/G2011/05/11

Discussion flaps were already retracted. He did not recall touching

the flap control, and a quick glance out of the window
The pilot reported that the flight to Norwich was the
reinforced his belief that the flaps were retracted as
most distant “land away” he had attempted since gaining
the flap appeared to be aligned with the aileron. The
his PPL. He was progressively attempting longer and
pilot and passenger had flown together on a number
more complex flights in order to gain experience,
of occasions and both were familiar with the specific
and this was the first time he had landed at Norwich.
aircraft. The passenger was accustomed to exiting the
Runway 09 was in use and the reported wind was 0600
aircraft, in the manner adopted on this occasion, having
at 18 kt. The pilot found the landing challenging at
done so safely on numerous occasions.
his level of experience, given the wind conditions and
the fact that Norwich was an unfamiliar airport. He
The pilot considered that the accident was the result of
had initially considered a flapless approach, but then
high workload caused by the challenging conditions
elected to select one stage of flap. He described the
during landing and operating at an unfamiliar airfield,
landing as safe, but heavier than he generally achieved.
which had distracted him from following the checklist
In addition, taxiing at an unfamiliar airfield and the
properly. In addition, the fact that he had initially
new experience of being marshalled onto the parking
considered a flapless approach may have led to a mindset
area completely occupied his attention up to the point
that the flaps were already up. In order to prevent a
where the engine was shut down. While he recalled
similar occurrence in the future, the pilot has added
completing the ‘After Landing’ and ‘Engine Shutdown’
a further item to ensure the flaps are up, to the ‘After
checks, the pilot acknowledged that he clearly missed
Shutdown’ section of his checklist.
the ‘Flaps UP’ item. He reported that he may have
treated this checklist item superficially as he believed the

© Crown copyright 2011 27

AAIB Bulletin: 9/2011 G-AYAC EW/G2011/07/18

ACCIDENT

Aircraft Type and Registration: Piper PA-28R-200 Cherokee Arrow, G-AYAC

No & Type of Engines: 1 Lycoming IO-360-C1C piston engine

Year of Manufacture: 1969

Date & Time (UTC): 13 July 2011 at 1219 hrs

Location: Old Buckenham Airfield, Norfolk

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Damage to the propeller and lower engine cowling

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 58 years

Commander’s Flying Experience: 150 hours (of which 27 were on type)

Last 90 days - 16 hours
Last 28 days - 1.4 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The pilot reported that he completed an external check The pilot discovered that the nose landing gear was
of the aircraft while it was in its hangar at Knettishal inoperative and initiated a diversion to Old Buckenham
Airfield, about 20 nm south-west of Norwich. He then Airfield, where a visual inspection confirmed that the
pulled the aircraft out of the hangar using a tow bar nose landing gear was not visible. The aircraft landed
attached to the nosewheel. The pilot subsequently on Runway 02 on its main landing gear with the nose
boarded the aircraft having inadvertently left the tow leg not lowered, causing damage to the propeller and
bar still attached. engine cowling. Emergency services were on hand
and the pilot, who was uninjured, vacated the aircraft
The takeoff run appeared normal until rotation, at which through the cockpit door. The tow bar was still attached
point the pilot heard a loud bang and felt a kick through to the aircraft.
the rudder pedals. The pilot raised the landing gear
and retracted the flaps but the landing gear UNSAFE
warning light remained illuminated.

© Crown copyright 2011 28

AAIB Bulletin: 9/2011 G-STYL EW/G2011/06/21

ACCIDENT

Aircraft Type and Registration: Pitts S-1S Special, G-STYL

No & Type of Engines: 1 Lycoming O-320-E2D piston engine

Year of Manufacture: 1986

Date & Time (UTC): 27 June 2011 at 1700 hrs

Location: Private Airstrip, Shelsley Beauchamp, Worcestershire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Damage to left wingtip, left tailplane, fin and rudder

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 56 years

Commander’s Flying Experience: 379 hours (of which 8 were on type)

Last 90 days - 4 hours
Last 28 days - 4 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

In still wind conditions, the pilot made a sideslipping the right and nosed over into the crop, coming to rest
approach to Runway 13 at the unlicensed airstrip. The inverted. The pilot switched the ignition and battery
left sideslip provided the pilot with a clear view of the master switches to OFF and closed the fuel cock. After
final approach, and, in his report, he remarked that this releasing his harness, he found that the canopy had
was a normal approach technique for this aircraft type. jammed due to his weight bearing on it but, adjusting
The aircraft landed smoothly, in a three-point attitude, his position, the canopy opened normally and he was
touching down approximately 40 m along the 630 m able to vacate the aircraft. The pilot commented that
airstrip. During the landing rollout, the aircraft drifted adoption of a ‘wheeler’ landing technique, in which the
to the right and, despite the pilot applying left brake, aircraft touches down on the mainwheels only, would
the right wing caught in standing crop that was next have provided him with a better view of the narrow
to the 20 metre-wide runway. The aircraft yawed to runway, and may have helped avoid the accident.

© Crown copyright 2011 29

AAIB Bulletin: 9/2011 G-ODDS EW/G2011/07/02

ACCIDENT

Aircraft Type and Registration: Pitts S-2A Pitts Special, G-ODDS

No & Type of Engines: 1 Lycoming AEIO-360-A1E piston engine

Year of Manufacture: 1980

Date & Time (UTC): 2 July 2011 at 1555 hrs

Location: White Waltham Airfield, Berkshire

Type of Flight: Training

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Damage to propeller spinner, propeller blades and wheel

spats

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 27 years

Commander’s Flying Experience: 106 hours (of which 31 were on type)

Last 90 days - 10 hours
Last 28 days - 4 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The aircraft was returning from a solo aerobatic flight to the normal point on the grass runway. The pilot applied
the south of White Waltham Aerodrome. The weather the wheel brakes and the aircraft tipped forward onto
was good, with the surface wind calm, and the aircraft its nose. The pilot isolated the fuel and, having notified
was positioned for a landing on Runway 21. Following ATC of the situation, vacated the aircraft.
a normal approach, the aircraft bounced on touchdown
and the pilot performed a go-around, rejoining the The pilot and pilot’s instructor, who observed the
circuit for a second approach. On the second approach, landing, considered that the accident was caused by
the pilot maintained the normal approach speed of the brakes being applied too early and too heavily after
85 mph IAS and flared the aircraft, touching down at touchdown.

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AAIB Bulletin: 9/2011 N405FD EW/G2011/04/12

ACCIDENT

Aircraft Type and Registration: SIAI-Marchetti SF-260D, N405FD

No & Type of Engines: 1 Lycoming 0-540 piston engine

Year of Manufacture: 1990

Date & Time (UTC): 9 April 2011 at 1200 hrs

Location: Oaksey Park Airfield, Wiltshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Damage to propeller and wings, engine shock-loaded

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 54 years

Commander’s Flying Experience: 826 hours (of which 60 were on type)

Last 90 days - 5 hours
Last 28 days - 4 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

Oaksey Park Airfield is located 1 nm to the south-east of An Air/Ground radio service is normally provided at
the Kemble ATZ. It has two runways: 04/22 and 17/35. Oaksey Park but was not available at the time. He
Runway 17 is normally restricted to takeoffs only. The selected the landing gear down when late downwind
pilot decided to land on Runway 17 after a previous and observed a red light, which indicates that the gear
discussion about its use with the airfield owner. His is in transit, but did not check for “three greens”. The
choice of runway was based on the wind at Halfpenny aircraft landed gear-up on the grass runway. The pilot
Green (the departure airfield), which was 170° at subsequently found that the circuit breaker for the
12 kt. The pilot had not landed on this runway before landing gear had tripped.
and he flew a tight circuit to avoid the Kemble ATZ.

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AAIB Bulletin: 9/2011 G-BMZX EW/G2011/05/03

ACCIDENT

Aircraft Type and Registration: Wolf WII Boredom Fighter, G-BMZX

No & Type of Engines: 1 Continental Motors Corp A65-8F piston engine

Year of Manufacture: 1989

Date & Time (UTC): 8 May 2011 at 1115 hrs

Location: Henham Park, Southwold, Suffolk

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Lower right wing spars broken

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 44 years

Commander’s Flying Experience: 782 hours (of which 198 were on type)
Last 90 days - 11 hours
Last 28 days - N/K

Information Source: Aircraft Accident Report Form submitted by the pilot

The pilot stated that, as the aircraft was rolling out after point of the ground loop, the right lower wingtip struck
landing at a speed of about 25 mph, he became distracted the ground, bending it upwards. After the aircraft came
by a marshaller. As the pilot turned his head back in to rest, he exited the aircraft normally, having switched
line with the rollout, he realised that the aircraft was off the fuel and electrics. He attributed the accident to
yawed to the left and so he applied full right brake, but “a momentary lapse of concentration”.
was unable to arrest the swing to the left. At the final

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AAIB Bulletin: 9/2011 G-FEDA EW/G2011/06/04

ACCIDENT

Aircraft Type and Registration: EC120B Colibri, G-FEDA

No & Type of Engines: 1 Turbomeca Arrius 2F turboshaft engine

Year of Manufacture: 2000

Date & Time (UTC): 4 June 2011 at 1653 hrs

Location: Redhill Aerodrome, Surrey

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 2

Injuries: Crew - 1 (Minor) Passengers - 2 (Minor)

Nature of Damage: General damage to fuselage; main blades, tail section,

skids and floats all detached

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 32 years

Commander’s Flying Experience: 126 hours (of which 41 were on type)

Last 90 days - 17 hours
Last 28 days - 4 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

Synopsis

Control was lost during a turn whilst hover taxiing in contacted the ground, causing the helicopter to roll onto
gusting wind conditions. The right skid contacted the its right side and the main rotors to strike the ground.
ground, causing the helicopter to roll onto its side. When the helicopter came to rest, the pilot applied the
rotor brake and fuel shutoff lever before jettisoning the
History of the flight
front left door and assisting his passengers.
The helicopter was hover taxiing towards its allocated
Cause
landing pad beside a hangar. The wind at the time was
described as north-easterly at 9 kt, gusting to 21 kt. The pilot believed the initial left turn had allowed the
The pilot stated that as he approached the landing pad helicopter’s tail to be pushed by the wind, rotating it
he applied left yaw pedal to turn left. The helicopter further and more rapidly than intended. He applied
responded but continued to turn beyond the desired insufficient right yaw pedal to compensate, allowing
heading. The pilot applied right pedal in an attempt to the rate of turn to accelerate sufficiently for control to
stop the turn, but the helicopter continued to rotate at be lost.
an increasing rate until control was lost. The right skid

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AAIB Bulletin: 9/2011 G-MYRO EW/G2011/05/04

ACCIDENT

Aircraft Type and Registration: Cyclone AX3/503, G-MYRO

No & Type of Engines: 1 Rotax 503-2V piston engine

Year of Manufacture: 1994

Date & Time (UTC): 7 May 2011 at 1410 hrs

Location: Linton, Maidstone, Kent

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Damage to the propeller, nose landing gear, pod, screen,
cockpit floor tubes, left aileron and left wing

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 65 years

Commander’s Flying Experience: 244 hours (of which 62 were on type)

Last 90 days - 20 hours
Last 28 days - 11 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The aircraft was on final approach to Runway 11 at an rough ground”. The pilot initiated a go-around but was
airstrip at Linton, near Maidstone, Kent. The weather unable to prevent the aircraft from rolling to the left and
was reported to be generally good, with a light wind colliding with the ground to the north of the runway.
from the south that occasionally gusted to 12 kt. The The aircraft was badly damaged but the pilot, who was
pilot reported that “while holding off prior to flare, the uninjured, was able to vacate the aircraft normally.
aircraft was suddenly hit by a very large/freak gust of There was no fire.
wind that began to carry it sideways towards adjoining

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AAIB Bulletin: 9/2011 G-OMSA EW/G2011/06/01

ACCIDENT

Aircraft Type and Registration: Flight Design CTSW, G-OMSA

No & Type of Engines: 1 Rotax 912ULS piston engine

Year of Manufacture: 2009

Date & Time (UTC): 1 June 2011 at 1028 hrs

Location: Peterborough (Sibson) Airfield, Cambridgeshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Substantial

Commander’s Licence: National Private Pilot’s Licence

Commander’s Age: 48 years

Commander’s Flying Experience: 188 hours (of which 136 were on type)
Last 90 days - 26 hours
Last 28 days - 3 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

Synopsis

Whilst landing at Sibson, the aircraft bounced and on A flying instructor, who was taxiing an aircraft with a
the second touchdown the nose landing gear collapsed. student on board to the holding point of Runway 24,
The aircraft came to rest inverted and the pilot, who heard the radio conversation between the two pilots.
was uninjured, was able to vacate the aircraft unaided. On reaching the holding point he saw the two aircraft
The pilot was possibly distracted by the upslope to the during their final approach and landing. He observed the
displaced threshold and his proximity to the preceding first aircraft perform a touch-and-go and saw G-OMSA
aircraft. on short final descend to just above the surface of the
starter extension to the runway. It then flew up the slope,
History of the flight
at a constant height and touched down in a flat attitude
G-OMSA was being flown in loose formation with just before the runway displaced threshold. It bounced,
another, similar aircraft. On joining the circuit at touched down again in a flat attitude and the nose gear
Sibson the two pilots agreed on the radio that the other then collapsed. As the aircraft slowed, it tipped over,
aircraft would approach first to perform a touch-and-go. coming to rest inverted. The pilot was uninjured and
G-OMSA followed the other aircraft around the circuit vacated the aircraft unaided. The instructor shut his
as agreed. aircraft down and went to assist the accident pilot. He

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AAIB Bulletin: 9/2011 G-OMSA EW/G2011/06/01

reported that he thought that G‑OMSA was too close to He candidly commented that he had possibly been
the first aircraft and was expecting to see it go-around. distracted by the upslope and his proximity to the
preceding aircraft. He suggested the nosewheel may
Pilot’s comments
have caught in a divot which may have led to the nose
The pilot reported that he had not flown to Sibson gear to collapse. He intends to visit the airfield again
before and although he had self-briefed using a flight with an instructor to practise the approach and will be
guide, he was unaware of the upslope to the displaced researching new destinations more thoroughly in the
threshold of Runway 24. future.

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AAIB Bulletin: 9/2011 G-MVBE EW/G2011/07/29

ACCIDENT

Aircraft Type and Registration: Mainair Scorcher, G-MVBE

No & Type of Engines: 1 Rotax 503 piston engine

Year of Manufacture: 1988

Date & Time (UTC): 2 July 2011 at 1730 hrs

Location: Seaville, Cumbria

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - 1 (Serious) Passengers - N/A

Nature of Damage: Aircraft destroyed

Commander’s Licence: National Private Pilot’s Licence

Commander’s Age: 58 years

Commander’s Flying Experience: 65 hours (of which 65 were on type)

Last 90 days - 2 hours
Last 28 days - 1 hour

Information Source: Aircraft Accident Report Form submitted by the pilot

The pilot was returning from a local flight to land at a lower than normal, but considered that the approach
private grass airstrip near Seaville. The airstrip has a path was still acceptable. As the aircraft overflew the
single 180 m runway on a heading of approximately airstrip boundary the undercarriage struck the hedge
260°/080° and bounded by a hedge. The pilot had and the aircraft impacted the ground heavily. The pilot
landed at the airstrip before, but had previously joined suffered serious injuries and was airlifted to hospital.
overhead before flying a circuit to position for landing. The aircraft was damaged beyond economic repair.
On this occasion he positioned the aircraft onto a long
final approach for Runway 26 from an altitude of about The pilot stated that, when realising that he was below
3,000 ft and about 6 nm from the runway. As he passed his normal descent path, he should have carried out a
the position where he would normally turn from base go-around.
leg onto the final approach, he realised that he was

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AAIB Bulletin: 9/2011 G-CBZG EW/G2011/04/26

ACCIDENT

Aircraft Type and Registration: Rans S6-ES Coyote II, G-CBZG

No & Type of Engines: 1 Jabiru Aircraft Pty 2200A piston engine

Year of Manufacture: 2002

Date & Time (UTC): 30 April 2011 at 1800 hrs

Location: Runway 12, Plaistows Farm, Hertfordshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - None

Nature of Damage: Nose landing gear, engine and engine mount, safety cage
and propeller

Commander’s Licence: National Private Pilot’s Licence

Commander’s Age: 47 years

Commander’s Flying Experience: 94 hours (of which 20 were on type)

Last 90 days - 21 hours
Last 28 days - 14 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The pilot reported that, while landing on Runway 12, runway tipping the aircraft forward on to its propeller.
the aircraft bounced on its main landing gear. The The aircraft came to rest on the remains of the nose leg
pilot lowered the nose and the aircraft landed heavily and propeller spinner.
on its nose landing gear, before bouncing into the air
a second time. The aircraft then landed normally on The surface wind was reported to be down the runway
its main landing gear and, as the pilot lowered the at 10 kt. The pilot concluded that he should have held
nose landing gear on to the runway, the nose gear fork the landing attitude or gone around after the aircraft’s
detached. The nose landing gear leg dug into the grass first bounce.

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AAIB Bulletin: 9/2011 G-MZOZ EW/G2011/06/07

ACCIDENT

Aircraft Type and Registration: Rans S6-ESD XL (Modified) Coyote II, G-MZOZ

No & Type of Engines: 1 Rotax 503-2V piston engine

Year of Manufacture: 1998

Date & Time (UTC): 19 June 2011 at 0850 hrs

Location: Sywell Airfield, Northampton

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - None

Nature of Damage: Nose leg, nose cone, propeller hub

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 73 years

Commander’s Flying Experience: 976 hours (of which 976 were on type)
Last 90 days - 11 hours
Last 28 days - 2 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

After a normal touchdown on the Runway 21 at Sywell, At this point the nose landing gear collapsed and the
the pilot applied heavy braking in order to vacate the aircraft slid to a rest. Both occupants were wearing
active runway quickly. While decelerating below lap and diagonal harnesses and escaped uninjured. The
15 mph, with heavy braking still applied and the engine pilot considered that the combination of heavy braking
idling, the aircraft encountered what the pilot described and the undulated surface of the grass runway caused
as a “significant undulation in the runway surface”. the nose landing gear to collapse.

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AAIB Bulletin: 9/2011 G-CGGV EW/G2011/06/07

ACCIDENT

Aircraft Type and Registration: Rotorsport UK MTOSport, G-CGGV

No & Type of Engines: 1 Rotax 912 ULS piston engine

Year of Manufacture: 2009

Date & Time (UTC): 5 June 2011 at 0930 hrs

Location: Culbokie Airfield, Dingwall, Inverness

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - None

Nature of Damage: Damage to the nose landing gear, pod, rotor blades and
rudder

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 62 years

Commander’s Flying Experience: 184 hours (of which 103 were on type)
Last 90 days - 19 hours
Last 28 days - 9 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The gyroplane was departing from Runway 03. The The pilot made a controlled descent into a clearing
takeoff weight was 489 kg, which was within the but, due to the lack of space, this resulted in a heavy
maximum permitted takeoff weight of 500 kg. The landing. The nose landing gear detached, the underside
weather was CAVOK, with a light and variable wind of the pod was damaged and the flailing rotor struck
from the north-northeast, with occasional stronger and dislodged the rudder. The pilot and his passenger
gusts. The pilot had previously operated from the were uninjured.
airfield and the takeoff seemed to be normal.
From the evidence of witnesses who observed the
As the gyroplane began to climb, a left turn through departure, the pilot concluded that there had been a
approximately 90° was made in order to avoid some strong gust of wind which had veered through some
trees on the extended centreline. As the turn was 90°. This placed the gyroplane downwind and resulted
commenced, it was not possible to maintain the angle in the reduction in the rate of climb.
of climb and the rotor blades contacted the top of a tree.

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AAIB Bulletin: 9/2011 G-RSMT EW/G2011/07/05

ACCIDENT

Aircraft Type and Registration: Rotorsport UK MT-03, G-RSMT

No & Type of Engines: 1 Rotax 912 ULS piston engine

Year of Manufacture: 2007

Date & Time (UTC): 3 July 2011 at 1450 hrs

Location: Fine Lane, Fradley, near Lichfield, Staffordshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - 1 (Minor)

Nature of Damage: Nosewheel, fuselage, airframe, mast, rotor, propeller,

rudder and fuel tanks

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 58 years

Commander’s Flying Experience: 132 hours (of which 132 were on type)
Last 90 days - 5 hours
Last 28 days - 1 hour

Information Source: Aircraft Accident Report Form submitted by the pilot

Synopsis

The pilot reported that shortly after takeoff the aircraft pre‑flight checks, he taxied the aircraft to the holding
did not climb as expected and, with the aircraft in point for grass Runway 27. After waiting for two aircraft
level flight and throttle fully open, the aircraft did not to land, he positioned the aircraft on the threshold and
accelerate as expected. The pilot subsequently made a lined up for takeoff. The reported wind was from 270°
forced landing onto a road and the rotor impacted the at 2 kt. The pilot pre-rotated the rotor to 240 rpm
ground. and smoothly applied full throttle whilst checking the
engine indications, which appeared normal. After about
History of the flight
200 m, the aircraft became airborne and, as it reached
On the afternoon of the accident, the pilot and a the end of the runway having travelled about 430 m,
passenger had flown approximately 15 nm from Stoke its airspeed was about 60 mph (the best climb speed
Golding Airfield to Roddige Airfield. After about an Vclimb is 60-65 mph). Pulling back on the control stick
hour on the ground the pilot and his passenger prepared to climb, the pilot reported that the climb rate was very
for a flight to Otherton Airfield. No additional fuel low and so lowered the nose slightly to gain airspeed.
or baggage was uploaded and having completed his However, having levelled at approximately 15 ft above

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AAIB Bulletin: 9/2011 G-RSMT EW/G2011/07/05

a standing crop of rapeseed in an adjacent field with The reported takeoff weight of the aircraft was 434 kg,
the throttle lever in the fully open position, the aircraft which was 16 kg below the MTOW of 450 kg. The
did not accelerate as expected and airspeed remained at Pilot’s Handbook states that at MTOW at sea level,
about 65 mph. with standard atmospheric conditions, the nominal
climb rate is 600 ft/min for this aircraft and engine
Approaching a line of trees and suspended electrical combination. At 1320 hrs, which coincided with the
cables ahead, the pilot pulled back on the stick and takeoff time, the METAR for Birmingham Airport,
the aircraft climbed to about 40 ft, at which point the which is approximately 16 nm from Roddige Airfield,
passenger advised the pilot to “watch your speed” as the advised that the temperature was 22°C, the dew point
airspeed had reduced to about 30 mph (minimum speed was 08°C, QNH was 1017 mb and CAVOK. Roddige
Vmin is 25 mph at maximum takeoff weight (MTOW)). Airfield elevation is approximately 180 ft, with a
With the obstacles still ahead, the pilot positioned the calculated density altitude of about 800 ft at the time.
aircraft for a forced landing on an adjacent road. The Stoke Golding Airfield elevation is about 280 ft.
aircraft touched down heavily, tail first, before the rotor
impacted the ground at the side of the road. The aircraft The pilot stated that the preceding flight from Stoke
then came to a stop resting against some trees. Having Golding Airfield had been uneventful, with the takeoff
switched off the ignition, the pilot and passenger and climb performance appearing normal considering
vacated the aircraft unaided and moved a safe distance the atmospheric conditions and the aircraft being near
away as a fuel leak had developed. The pilot was to its MTOW. The pilot considered that shortly after
uninjured, but the passenger sustained minor injuries. takeoff from Roddige Airfield, the engine had suffered
The nosewheel, fuselage, mast, rotor, propeller, rudder an unexplained partial loss of power.
and fuel tanks were damaged.

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AAIB Bulletin: 9/2011 G-KIPP EW/G2011/05/16

ACCIDENT

Aircraft Type and Registration: Thruster T600N 450, G-KIPP

No & Type of Engines: 1 Jabiru Aircraft Pty 2200A piston engine

Year of Manufacture: 2003

Date & Time (UTC): 29 May 2011 at 0940 hrs

Location: Field adjacent to Compton Abbas Airfield

Type of Flight: Training

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - 1 (Minor) Passengers - 1 (Minor)

Nature of Damage: Damage to fuselage, wings, rudder and landing gear,

engine shock-loaded

Commander’s Licence: National Private Pilot’s Licence

Commander’s Age: 55 years

Commander’s Flying Experience: 360 hours (of which 87 were on type)

Last 90 days - 6 hours
Last 28 days - 2 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

The pilot was conducting an air experience flight with a applying full power, the aircraft’s nosewheel struck the
passenger. He reports that, whilst on final approach to top of a hedge. The aircraft came to rest inverted in a
Runway 26, he encountered turbulence at 300 ft agl. The field, 10 m beyond the hedge line. The pilot turned the
wind at the time was reported as 250º at approximately ignition switch and battery isolator to OFF and closed
12 kt. The pilot descended to 20 ft above the runway, at the fuel valve, although fuel was leaking from the left
50 kt IAS, with the aircraft flying into wind and with left wing’s fuel filler cap. The pilot vacated the aircraft
aileron applied. The aircraft then encountered a gust of after releasing his harness, and with the assistance of
wind, causing it suddenly to lose height whilst rolling a nearby club member, he then helped the passenger
to the right, before bouncing firmly onto the runway, to leave the aircraft. Both the pilot and passenger
puncturing the right mainwheel. The aircraft yawed to sustained minor injuries in the accident.
the right and departed the runway, and despite the pilot

© Crown copyright 2011 43

AAIB Bulletin: 9/2011 G-BZGN EW/G2011/06/23

ACCIDENT

Aircraft Type and Registration: X’air 582(2), G-BZGN

No & Type of Engines: 1 Rotax 582/48-2V piston engine

Year of Manufacture: 2000

Date & Time (UTC): 29 June 2011 at 1030 hrs

Location: Sutton Bank Airfield, North Yorkshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Engine, propeller, nosewheel, tail assembly, cockpit pod,

instrument panel, fuselage tubing, control linkages

Commander’s Licence: National Private Pilot’s Licence

Commander’s Age: 68 years

Commander’s Flying Experience: 113 hours (of which 33 were on type)

Last 90 days - 6 hours
Last 28 days - 3 hours

Information Source: Aircraft Accident Report Form submitted by the pilot

On left base to the grass strip the pilot experienced just short of the runway. The aircraft travelled along
significant sink and so increased the engine power to the runway on the main gear for about 40 m before
maintain altitude. The pilot reduced power on final the nosewheel touched down. The nose gear collapsed
approach as he set the aircraft up for a crosswind and the aircraft pitched over to the inverted position
landing on Runway 20. The pilot stated that the wind before coming to rest, causing substantial damage to
at the time was from 185° at 5 kt. As he rounded out he the aircraft. The pilot, who was wearing a four-point
encountered more sink, causing the aircraft to descend harness, was uninjured and made the aircraft safe
rapidly and touchdown on the main gear in long grass before exiting.

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AAIB Bulletin: 9/2011

FORMAL AIRCRAFT ACCIDENT REPORTS

ISSUED BY THE AIR ACCIDENTS INVESTIGATION BRANCH

2009
3/2009 Boeing 737-3Q8, G-THOF 5/2009 BAe 146-200, EI-CZO
on approach to Runway 26 at London City Airport
Bournemouth Airport, Hampshire on 20 February 2007.
on 23 September 2007. Published September 2009.
Published May 2009.
6/2009 Hawker Hurricane Mk XII (IIB), G-HURR
4/2009 Airbus A319-111, G-EZAC 1nm north-west of Shoreham Airport,
near Nantes, France West Sussex
on 15 September 2006. on 15 September 2007.
Published August 2009. Published October 2009.

2010
1/2010 Boeing 777-236ER, G-YMMM 5/2010 Grob G115E (Tutor), G-BYXR
at London Heathrow Airport and Standard Cirrus Glider, G-CKHT
on 28 January 2008. Drayton, Oxfordshire
on 14 June 2009.
Published February 2010.
Published September 2010.
2/2010 Beech 200C Super King Air, VQ-TIU
6/2010 Grob G115E Tutor, G-BYUT
at 1 nm south-east of North Caicos
and Grob G115E Tutor, G-BYVN
Airport, Turks and Caicos Islands, near Porthcawl, South Wales
British West Indies on 11 February 2009.
on 6 February 2007.
Published November 2010.
Published May 2010.
7/2010 Aerospatiale (Eurocopter) AS 332L
3/2010 Cessna Citation 500, VP-BGE Super Puma, G-PUMI
2 nm NNE of Biggin Hill Airport at Aberdeen Airport, Scotland
on 30 March 2008. on 13 October 2006.
Published May 2010. Published November 2010.

8/2010 Cessna 402C, G-EYES and

4/2010 Boeing 777-236, G-VIIR
Rand KR-2, G-BOLZ
at Robert L Bradshaw Int Airport near Coventry Airport
St Kitts, West Indies on 17 August 2008.
on 26 September 2009.
Published December 2010.
Published September 2010.

AAIB Reports are available on the Internet

[Link]

© Crown copyright 2011 45