AAIB Bulletin 11/2023

TO REPORT AN ACCIDENT OR INCIDENT

PLEASE CALL OUR 24 HOUR REPORTING LINE
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 Air Accidents Investigation Branch
Farnborough House AAIB Bulletin: 11/2023
Berkshire Copse Road
Aldershot GLOSSARY OF ABBREVIATIONS
Hants GU11 2HH
aal above airfield level kt knot(s)
ACAS Airborne Collision Avoidance System lb pound(s)
ACARS Automatic Communications And Reporting System LP low pressure
Tel: 01252 510300
ADF Automatic Direction Finding equipment LAA Light Aircraft Association
Fax: 01252 376999 AFIS(O) Aerodrome Flight Information Service (Officer) LDA Landing Distance Available
Press enquiries: 0207 944 3118/4292 agl above ground level LPC Licence Proficiency Check
http://www.aaib.gov.uk AIC Aeronautical Information Circular m metre(s)
amsl above mean sea level mb millibar(s)
AOM Aerodrome Operating Minima MDA Minimum Descent Altitude
APU Auxiliary Power Unit METAR a timed aerodrome meteorological report
ASI airspeed indicator min minutes
ATC(C)(O) Air Traffic Control (Centre)( Officer) mm millimetre(s)
ATIS Automatic Terminal Information Service mph miles per hour
ATPL Airline Transport Pilot’s Licence MTWA Maximum Total Weight Authorised
AAIB investigations are conducted in accordance with BMAA British Microlight Aircraft Association N Newtons
BGA British Gliding Association NR Main rotor rotation speed (rotorcraft)
Annex 13 to the ICAO Convention on International Civil Aviation, BBAC British Balloon and Airship Club Ng Gas generator rotation speed (rotorcraft)
EU Regulation No 996/2010 (as amended) and The Civil Aviation BHPA British Hang Gliding & Paragliding Association N1 engine fan or LP compressor speed
CAA Civil Aviation Authority NDB Non-Directional radio Beacon
(Investigation of Air Accidents and Incidents) Regulations 2018. CAVOK Ceiling And Visibility OK (for VFR flight) nm nautical mile(s)
CAS calibrated airspeed NOTAM Notice to Airmen
cc cubic centimetres OAT Outside Air Temperature
The sole objective of the investigation of an accident or incident under these CG Centre of Gravity OPC Operator Proficiency Check
Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PAPI Precision Approach Path Indicator
CPL Commercial Pilot’s Licence PF Pilot Flying
purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true PIC Pilot in Command
CVR Cockpit Voice Recorder PM Pilot Monitoring
DME Distance Measuring Equipment POH Pilot’s Operating Handbook
Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed PPL Private Pilot’s Licence
or blame or determine liability, since neither the investigation nor the reporting EASA European Union Aviation Safety Agency psi pounds per square inch
ECAM Electronic Centralised Aircraft Monitoring QFE altimeter pressure setting to indicate height above
process has been undertaken for that purpose. EGPWS Enhanced GPWS aerodrome
EGT Exhaust Gas Temperature QNH altimeter pressure setting to indicate elevation amsl
EICAS Engine Indication and Crew Alerting System RA Resolution Advisory
EPR Engine Pressure Ratio RFFS Rescue and Fire Fighting Service
ETA Estimated Time of Arrival rpm revolutions per minute
ETD Estimated Time of Departure RTF radiotelephony
FAA Federal Aviation Administration (USA) RVR Runway Visual Range
FDR Flight Data Recorder SAR Search and Rescue
FIR Flight Information Region SB Service Bulletin
FL Flight Level SSR Secondary Surveillance Radar
ft feet TA Traffic Advisory
AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAF Terminal Aerodrome Forecast
http://www.aaib.gov.uk g acceleration due to Earth’s gravity TAS true airspeed
GNSS Global Navigation Satellite System TAWS Terrain Awareness and Warning System
GPS Global Positioning System TCAS Traffic Collision Avoidance System
GPWS Ground Proximity Warning System TODA Takeoff Distance Available
hrs hours (clock time as in 1200 hrs) UA Unmanned Aircraft
HP high pressure UAS Unmanned Aircraft System
hPa hectopascal (equivalent unit to mb) USG US gallons
IAS indicated airspeed UTC Co-ordinated Universal Time (GMT)
This bulletin contains facts which have been determined up to the time of compilation. IFR Instrument Flight Rules V Volt(s)
ILS Instrument Landing System V1 Takeoff decision speed
Extracts may be published without specific permission providing that the source is duly acknowledged, the material is
IMC Instrument Meteorological Conditions V2 Takeoff safety speed
reproduced accurately and it is not used in a derogatory manner or in a misleading context.
IP Intermediate Pressure VR Rotation speed
IR Instrument Rating VREF Reference airspeed (approach)
Published 10 November Cover picture courtesy of Marcus Cook
ISA International Standard Atmosphere VNE Never Exceed airspeed
© Crown copyright 2023 ISSN 0309-4278 kg kilogram(s) VASI Visual Approach Slope Indicator
KCAS knots calibrated airspeed VFR Visual Flight Rules
Published by the Air Accidents Investigation Branch, Department for Transport KIAS knots indicated airspeed VHF Very High Frequency
Printed in the UK on paper containing at least 75% recycled fibre KTAS knots true airspeed VMC Visual Meteorological Conditions
km kilometre(s) VOR VHF Omnidirectional radio Range
AAIB Bulletin: 11/2023

CONTENTS

SPECIAL BULLETINS / INTERIM REPORTS

None

SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS

Aircraft Accident Report No: 2/2023

Sikorsky S-92A G-MCGY 4-Mar-22 3

AAIB FIELD INVESTIGATIONS

COMMERCIAL AIR TRANSPORT

FIXED WING
None
ROTORCRAFT
None

GENERAL AVIATION
FIXED WING
None
ROTORCRAFT
None

SPORT AVIATION / BALLOONS

None

UNMANNED AIRCRAFT SYSTEMS

None

AAIB CORRESPONDENCE INVESTIGATIONS

COMMERCIAL AIR TRANSPORT

DHC-6 Series 310 (Twin Otter) G-CBML 13-Mar-23 19

GENERAL AVIATION
Pierre Robin R2160 G-BLWY 16-Apr-23 25
Pioneer 300 G-OWBA 26-Mar-23 28
Piper PA-28-140 G-AVLG 26-Jun-23 32
Piper PA-28R-201 G-WAMS 10-Aug-23 35

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AAIB Bulletin: 11/2023

CONTENTS Cont
AAIB CORRESPONDENCE INVESTIGATIONS Cont

SPORT AVIATION / BALLOONS

None

UNMANNED AIRCRAFT SYSTEMS

None

RECORD-ONLY INVESTIGATIONS

Record-Only UAS Investigations reviewed: August / September 2023 39

MISCELLANEOUS

ADDENDA and CORRECTIONS

None

List of recent aircraft accident reports issued by the AAIB 43

(ALL TIMES IN THIS BULLETIN ARE UTC)

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AAIB Bulletin: 11/2023

Summaries of
Aircraft Accident Reports
This section contains summaries of
Aircraft Accident (‘Formal’) Reports
published since the last AAIB monthly bulletin.

The complete reports can be downloaded from

the AAIB website (www.aaib.gov.uk).

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Air Accident Report: 2/2023 G-MCGY AAIB-28045

Aircraft Accident Report No: 2/2023

This report was published on 2 November 2023 and is available in full
on the AAIB Website www.aaib.gov.uk

Report on the accident to

Sikorsky S-92A, G-MCGY
at Derriford Hospital, Plymouth, Devon
on 4 March 2022

Registered Owner and Operator: Bristow Helicopters Ltd

Aircraft Type: Sikorsky S-92A

Nationality: British

Registration: G-MCGY

Place of Accident: Derriford Hospital, Plymouth, Devon

Date and Time: 4 March 2022 at 1055 hrs
All times in this report are UTC

Introduction
The Air Accidents Investigation Branch (AAIB) were notified of this accident on 4 March 2022,
the day that it occurred. In exercise of his powers, the Chief Inspector of Air Accidents
ordered an investigation to be carried out in accordance with the provisions of retained
Regulation (EU) 996/2010 (as amended) and the UK Civil Aviation (Investigation of Air
Accidents and Incidents) Regulations 2018.

The sole objective of the investigation of an accident or serious incident under these
regulations is the prevention of accidents and serious incidents. It shall not be the purpose
of such an investigation to apportion blame or liability.

In accordance with established international arrangements, the National Transportation

Safety Board (NTSB) in the USA, representing the State of Design and Manufacture of
the helicopter, appointed an Accredited Representative to the investigation. The helicopter
operator, the hospital Helicopter Landing Site (HLS1) Site Keeper2, and the UK Civil Aviation
Authority (CAA) also assisted with the investigation.

Summary
The helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a
casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The
helicopter flew to Derriford Hospital (DH), Plymouth which has a Helicopter Landing Site
(HLS) located in a secured area within one of its public car parks. During the approach
Footnote
1
Hospital Helicopter Landing Sites are also referred to as HHLS in some documents.
2
The HLS Site Keeper is the owner of the HLS, as identified in CAA publication CAP 768, ‘Safeguarding
Aerodromes’.

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Air Accident Report: 2/2023 G-MCGY AAIB-28045

and landing, several members of the public in the car park were subjected to high levels of
downwash from the landing helicopter. One person suffered fatal injuries, and another was
seriously injured.

The investigation identified the following causal factors:

1. The persons that suffered fatal and serious injuries were blown over by high
levels of downwash from a landing helicopter when in publicly accessible
locations near the DH HLS.

2. Whilst helicopters were landing or taking off, uninvolved persons were not
prevented from being present in the area around the DH HLS that was
subject to high levels of downwash.

The investigation identified the following contributory factors:

1. The HLS at DH was designed and built to comply with the guidance
available at that time, but that guidance did not adequately address the
issue of helicopter downwash.

2. The hazard of helicopter downwash in the car parks adjacent to the HLS
was not identified, and the risk of possible injury to uninvolved persons was
not properly assessed.

3. A number of helicopter downwash complaints and incidents at DH were

recorded and investigated. Action was taken in each case to address the
causes identified, but the investigations did not identify the need to manage
the downwash hazard in Car Park B, so the actions taken were not effective
in preventing future occurrences.

4. Prior to this accident, nobody at DH that the AAIB spoke to was aware
of the existence of Civil Aviation Publication (CAP) 1264, which includes
additional guidance on downwash and was published after the HLS at
DH was constructed. The document was not retrospectively applicable to
existing HLS.

5. The operator of G-MCGY was not fully aware of the DH HLS Response
Team staff’s roles, responsibilities, and standard operating procedures.

6. The commander of G-MCGY believed that the car park surrounding the DH
HLS would be secured by the hospital’s HLS Response Team staff, but the
copilot believed these staff were only responsible for securing the HLS.

7. The DH staff responsible for the management of the HLS only considered
the risk of downwash causing harm to members of the public within the
boundary of the HLS and all the mitigations focused on limiting access to
this space.

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8. The DH staff responsible for the management of the HLS had insufficient
knowledge about helicopter operations to safely manage the downwash
risk around the site.

9. The HLS safety management processes at DH did not result in effective

interventions to address the downwash hazard to people immediately
outside the HLS.

10. HLS safety management processes at DH did not identify that the mitigations
for the downwash hazard were not working well enough to provide adequate
control of the risk from downwash.

11. Communication between helicopter operators and DH was ineffective in

ensuring that all the risks at the DH HLS were identified and appropriately
managed.

12. Safety at hospital HLS throughout the UK requires effective information

sharing and collaboration between HLS Site Keepers and helicopter
operators but, at the time of the accident, there was no convenient
mechanism for information sharing between them.

Following this accident, Safety Action was taken by the helicopter operator, Derriford
Hospital and NHS England Estates to control and mitigate the risk. The specific action
taken is detailed in paragraph 4.2.1 of this report. Additional action by Derriford Hospital
and NHS England Estates to improve safety, as described in paragraph 4.2.2 of this report,
is either planned or in progress.

Helicopters used for Search and Rescue and Helicopter Emergency Medical Services
(HEMS) perform a vital role in the UK and, although the operators of these are regulated by
the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are
not. It is essential that the risks associated with helicopter operations into areas accessible
by members of the public are fully understood by the HLS Site Keepers, and that effective
communication between all the stakeholders involved is established and maintained.
Therefore, nine Safety Recommendations have been made to address these issues, and
these are listed in paragraph 4.1 of this report.

Findings

The accident flight

1. The crew were properly licensed and qualified to conduct the flight and
were well rested. They all had extensive experience of flying SAR missions
in both RN and civilian operations.

2. The operator had procedures and training in place to help crews to mitigate
the effects of downwash.

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3. The crew were aware of possible downwash issues during the task to pick
up the casualty and during the approach to Derriford Hospital.

4. Whilst the crew had two potential hospitals with similar flight times to
transport the casualty to the Emergency Department, they chose Derriford
because it would be the most expeditious for their hypothermic casualty.

5. To benefit from a small headwind component, the crew elected to make the
approach on the DH designated westerly flight path for the approach.

6. The helicopter’s landing weight was 23,080 lb/10,468 kg, which was within
the weight limit for the HLS.

7. The co-pilot was the PF for the landing as he had the better field of view to
perform the approach and landing onto the HLS.

8. The crew conducted a dynamic risk assessment while inbound to Derriford,

as required by the operator’s Operations Manual.

9. The crew were aware that the helicopter’s downwash would be blown over
the car park.

10. The crew had briefed to conduct a go-around should they see anything that
they considered could be affected by the helicopter’s downwash.

11. Shortly before landing, the winchman informed the crew that the casualty
needed urgent medical attention.

12. At about 200 ft agl, the winch operator saw a person in the undershoot in
the car park and advised the co-pilot. The co-pilot, who could also see
them, did not consider their presence to be an issue.

13. The co-pilot believed he saw two people (one who he noted had long hair)
to the left of the HLS wall, by the southwestern corner, and a man entering
his car in the undershoot who he assessed would not be affected.

14. CCTV evidence shows that a person with long hair was on her own at the
south-west corner of the HLS and was the one who was later observed by
the co-pilot running to the south-eastern corner of the HLS to assist the
injured persons.

15. Three people in Car Park B were blown over by rotor downwash from the
landing helicopter.

16. It is unlikely that the flight crew saw the people who were blown over.

17. If a late go-around had been performed, the greater downwash would have
increased the risk of incurring damage or injury over a larger area around
the HLS.

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18. The downwash from the landing S92 affected most of Car Park B to varying
degrees with several objects observed to have been affected.

19. Paramedics from an ambulance waiting in Car Park B were alerted by a

member of the public and tended to those who had been injured without
delay.

20. One pedestrian, who was in Car Park B, was blown over and subsequently
died of her injuries; the relative accompanying her was also blown over and
suffered minor injuries.

21. Another pedestrian, also in Car Park B, was blown over and suffered serious
injuries.

22. Safety signs for pedestrians were provided that were well maintained, legible
and repeated throughout Car Park B. However, they were ineffective in
changing pedestrian behaviour during helicopter takeoffs and landings.

23. The relative of the fatally injured person was aware of the signs on the
wall of the HLS but felt they did not reflect the level of danger they warned
against.

24. The seriously injured pedestrian did not notice the warning signs.

25. The behaviour of the injured people on the day of the accident was typical
of people within that environment and situation.

DH HLS site findings

26. The DH HLS had been operating for seven years and records indicated
there had been over 2,500 landings, of which around 140 were SAR type
helicopters.

27. The DH HLS was built in accordance with the guidance material available
at the time.

28. The advice provided in the guidance at the time was inconsistent between
the different types of HLS and could lead to an interpretation that downwash
was not a factor for an HLS on a mound, such as the DH HLS.

29. The DH HLS is intentionally situated close to the ED so that casualties can
be transferred quickly. This is a busy area for pedestrian and vehicular
movements.

30. An independent helicopter adviser was used during the feasibility stage of
the helipad design.

31. The feasibility report recommendations were consistent with HBN 15-03,
ICAO Annex 14 version 3 and ICAO heliports manual version 3.

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32. The feasibility report considered the effects of downwash but downplayed
the potential effects and concluded that most of the downwash would be
confined to the DH HLS surface.

33. Involvement of the helicopter adviser by the designers was informal.

34. The hospital Trust believed the downwash hazard was adequately controlled
by the design of the DH HLS.

35. The feasibility report made recommendations about managing the DH HLS
site and downwash hazard that were over and above the available guidance
at the time.

36. The hospital Trust did not implement the recommendation in the feasibility
report to manage the public areas outside the DH HLS.

37. The hospital Trust’s ‘Standard Operating Procedure’ and the ‘On-site
Operational Procedure and Response to an Emergency Incident’ for the
HLS did not include any operational procedures for managing the areas
outside the HLS boundary.

38. The hospital Trust was not aware of the additional guidance published in
CAP 1264 until after this accident.

39. DH issued the document Helicopter Operations Using the Hospital Landing
Site, Derriford Hospital, Plymouth (which included the designated flight
paths) to numerous helicopter operators including that of G-MCGY.

40. The operator of G-MCGY interpreted the designated flight paths as advisory.

41. One helicopter operator was sent, but could not locate, a copy of this
document containing the designated flight paths; this was thought to be due
to a change of personnel and may have been missed during the handover.

42. This other operator developed their own flight path which was outside one
of the designated flight paths, and this was not communicated to DH.

43. In 2023, another helicopter operator advised DH that they had developed a
new flight path outside of those that DH had previously published, and this
has been acknowledged by DH.

44. DH was unaware of the significance that helicopter operators using the DH
HLS considered the designated flight paths to be advisory only.

45. The operator of G-MCGY used the No 1 AIDU’s, Helicopter Landing Sites
- Hospitals United Kingdom as an HLS directory, and internal document
Compatibility of UK Hospital Sites with UKSAR Aircraft Types which lists
what HLS are approved, and not approved, for its helicopters to operate
into.

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46. The No 1 AIDU entry for DH states, ‘Best approach heading 090’, but there
is no reference to the south-westerly designated flight path. The entry for
DH also contained other discrepancies including the layout.

47. About a month after the HLS opened, a third party, on behalf of the
operator of G-MCGY, conducted an aerial survey to establish the obstacle
environment around the DH HLS for performance considerations for
helicopter operations.

48. The operator of G-MCGY did not carry out a specific risk assessment of the
HLS at DH after a site visit in July 2015.

49. The operator of G-MCGY was sent a copy of the On-site Operational
Procedure and Response to an Emergency Incident but their headquarters
could not locate it. The operator’s Newquay base did not have a copy of it
and neither did any other operators that used the HLS at DH.

50. None of the helicopter operators that used the HLS at DH had a copy of
the hospital Trust’s ‘Standard Operating Procedure’ for the HLS Response
Team staff at DH.

51. The helicopter operator of G-MCGY did not have a copy of any of the
standard operating procedures used by HLS Response Teams at any other
hospital HLS within the operating area of its Newquay base.

52. The helicopter operator and the commander believed that the hospital’s
HLS Response Team staff were responsible for ensuring the HLS and its
surrounding areas were secured before an arrival. The co-pilot believed
that these staff only opened the gates for ED staff and helicopter crews to
access the HLS.

53. Although, prior to the helicopter’s arrival, the hospital’s HLS Response
Team had secured the HLS, they did not secure the surrounding areas, nor
were they required to do so.

54. On the day of the accident, the HLS Response Team followed the standard
operating procedure as specified except for wearing the correct PPE.

55. Security personnel at the hospital were not always able to fulfil the duties
specified in the standard operating procedure prior to the arrival of a
helicopter because, at times, they may be dealing with other incidents at
DH.

DH HLS safety management findings

56. The Trust’s risk management policy was consistent with the Health and
Safety Regulations and HSE guidance.

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57. There were no competency requirements for personnel responsible for

managing the DH HLS.

58. DH’s HLS management team had insufficient knowledge of helicopter

operations to make effective risk assessments for uninvolved persons being
exposed to hazards associated with the HLS.

59. The DH HLS risk assessor had not received sufficient training in risk
assessment and risk management.

60. A lack of mutual understanding resulted in ineffective communications

between the HLS Site Keeper and the helicopter operators who used the
HLS.

61. A number of helicopter downwash complaints and incidents at DH were

recorded and investigated. The hospital Trust were aware of two previous
downwash related events that had resulted in minor injury. Although action
was taken on each occasion to prevent a reoccurrence, this did not result
in changes being made to the management of Car Park B during helicopter
takeoffs and landings.

62. Although reviews of the risk assessments for the HLS and Car Park B were
conducted, the reviews did not identify that the downwash hazard in Car
Park B was not adequately controlled.

63. The pedestrians that were injured were within 50 m of the centre of the HLS,
and in the area that should be designated as a downwash zone for heavy
helicopters for HLS built after 2016 (in line with CAP 1264). HBN15-03,
which was in place in 2015, did not require a 50 m downwash zone for any
type of HLS.

64. Even for smaller HEMS helicopters, downwash in Car Park B can be
sufficient to blow people over.

65. The oversight and assurance activity by the DH management did not detect
that the people and processes in place were inadequate to identify and
mitigate the risks associated with the DH HLS.

General HLS findings

66. Hospital HLS in the UK are unlicensed. Local planning permission is

required but there are no aviation regulatory requirements controlling their
construction or operation.

67. There is limited aviation competence, resource and centralised support

within the NHS for managing hospital HLS.

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68. There were no competency requirements for personnel responsible for

managing hospital HLS in any guidance documents in place at the time of
the accident.

69. Hospital HLS managers would benefit from enhanced guidance on how to
risk assess their sites and the range of potential mitigations that might be
used to reduce the risk of uninvolved persons being exposed to hazards
associated with the HLS.

70. Updated HLS design guidance was published by the CAA as CAP 1264
after the Derriford HLS was completed. CAP 1264 specifies a larger safety
zone of up to 65 m for heavy helicopters like the S92.

71. CAP 1264 is not retrospectively applicable to existing HLS.

72. CAP 738 contains useful guidance on downwash zones but this is not
included in CAP 1264.

73. In the absence of a centralised database, there is no convenient mechanism

for HLS Site Keepers to promulgate site information to all the helicopter
operators that might use it.

74. It would be beneficial to the industry to have access to a centralised

database that can by updated rapidly in an operational environment by HLS
Site Keepers and helicopter operators.

75. CAP 1864, Onshore Helicopter Review Report, published in 2019, issued
Action 23, which was to work towards a ‘unified’ hospital HLS database.
The OnSLG was established with one of its tasks being to work on this.

76. The progress of relevant national safety initiatives has been slow with a lack
of State-level leadership to support and coordinate the efforts of the parties
involved.

Safety Recommendations and Action

Safety Recommendations

The following Safety Recommendations have been made:

Safety Recommendation 2023-028

It is recommended that the UK Civil Aviation Authority includes the appropriate

downwash guidance relevant to hospital helicopter landing sites in one published
document.

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Safety Recommendation 2023-029

It is recommended that the UK Civil Aviation Authority, in conjunction with the

Onshore Safety Leadership Group and the relevant NHS organisations in the
UK, develop and promulgate enhanced risk management guidance for hospital
helicopter landing sites, and provide information on the range and use of
potential mitigations for the protection of uninvolved persons from helicopter
downwash.

Safety Recommendation 2023-030

It is recommended that NHS England Estates, in conjunction with the

Onshore Safety Leadership Group and the UK Civil Aviation Authority, develop
competency requirements, and introduce training, for all hospital helicopter
landing site managers that includes, as a minimum, a basic introduction to
helicopter operations and safety management practices appropriate for such
facilities.

NHS England Estates should seek participation from the healthcare organisations
in Scotland, Wales, and Northern Ireland to develop these competency
requirements.

Safety Recommendation 2023-031

It is recommended that NHS England Estates review all existing hospital

helicopter landing sites for which it has responsibility against the latest guidance
and instigate appropriate actions to minimise the risk of injury from downwash
to uninvolved persons.

Safety Recommendation 2023-032

It is recommended that NHS Wales Health Boards and Trusts review all existing
hospital helicopter landing sites for which they have responsibility against the
latest guidance and instigate appropriate actions to minimise the risk of injury
from downwash to uninvolved persons.

Safety Recommendation 2023-033

It is recommended that NHS Scotland Assure review all existing hospital

helicopter landing sites for which it has responsibility against the latest guidance
and instigate appropriate actions to minimise the risk of injury from downwash
to uninvolved persons.

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Safety Recommendation 2023-034

It is recommended that the Northern Ireland Health and Social Care Trusts review
all existing hospital helicopter landing sites for which they have responsibility
against the latest guidance and instigate appropriate actions to minimise the
risk of injury from downwash to uninvolved persons.

Safety Recommendation 2023-035

It is recommended that the Onshore Safety Leadership Group (OnSLG), in

conjunction with the UK Department for Transport, facilitate and support the
development and introduction of a dedicated national hospital helicopter landing
sites (HLS) database that can be updated in an operational environment by
helicopter operators and hospital HLS Site Keepers.

In addition to helicopter operators and other stakeholders, the OnSLG should

seek participation from the healthcare organisations in England, Scotland,
Wales, and Northern Ireland.

Safety Recommendation 2023-036

It is recommended that the UK Department for Transport, in conjunction with

the Onshore Safety Leadership Group, establish and lead a national initiative
to improve the protection of uninvolved persons from helicopter operations at
hospital helicopter landing sites (HLS).

This initiative should have sufficient authority, representation, resources, and

expertise to ensure that coordination between the various risk owners and
stakeholders is effective.

The various stakeholder roles and responsibilities (in particular those of HLS
Site Keepers and helicopter operators) should be clear to all those involved,
and the planning, design, and ongoing risk management of hospital HLS should
be considered appropriately.

Safety Actions

Action taken

As a result of this accident, Safety Action was taken by various organisations as set out
below.

Action taken by the operator of G-MCGY

The approval for its S92 and AW189 helicopters to operate into the HLS at DH
was removed from its FSI until further notice.

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Since the accident, more frequent reviews of the FSI are being conducted and
additional information has been added for each site as to whether it has facilities
for it to be secured and by whom, ie coastguard rescue team, police and/or
hospital staff.

Action taken by the DH HLS Site Keeper

No helicopters >5,000 kg MTOW were permitted to land on the HLS at DH until

further notice. A Notice To Airmen was issued to publicise.

Car Park B was closed to all vehicles other than ambulances until further notice.

All pedestrian movements in Car Park B would be controlled during all future
helicopter landings and takeoffs.

All pedestrian movements on the public highway pavement along Derriford Road
would be controlled as far as reasonably practical during helicopter operations,
but DH has no legal authority to prevent pedestrian movements on the public
highway.

The risk assessment for Car Park B was amended to include an assessment of
the risk to pedestrians from helicopter downwash.

Additional visual and audible signs around the landing pad on the main
pedestrians’ routes around the location have been installed.

Yellow hatched floor markings have been installed outside each of the gated
entrances to the pad, warning pedestrians not to stand in that location to view
helicopters landing or taking off.

Audible message points around the external walls of the landing pad, activated
by the security team once they reach the pad, have been installed. The audible
message will warn pedestrians of helicopter movements, the risks of downwash
and asking them to move to a different location quickly.

Action taken by the QEH HLS Site Keeper

As a result of the incident involving G-RESU, the hospital has established a

monthly road sweeping programme.

Action taken by NHS England Estates

They have hosted online events for stakeholders at NHS hospitals to draw
attention to the guidance in CAP 1264 on the safe and compliant design and
management of HLS sites amongst the industry and local planning authorities.

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Air Accident Report: 2/2023 G-MCGY AAIB-28045

Action taken by the HSE

On 10 May 2023, the HSE wrote to all NHS Trust and Board Chief Executives
with a ‘reminder of legal health and safety duty and how it should be discharged
to effectively manage risk associated with hospital helipad use.

Action planned or in progress

As a result of this accident, the following Safety Action is planned or in progress.

Action planned or in progress by the DH HLS Site Keeper

● Designs to secure and control access to Car Park B have been finalised
and works are currently being tendered.

● The procedures for the security staff were reviewed with additional
responsibilities added. These procedures were issued to security staff and
are being trialled in conjunction with advice from an aviation consultant
appointed by DH. They had not been approved for wider circulation at the
time of publication of this report.

Action planned or in progress by NHS England Estates

● They have instigated a national data collection with all NHS hospital Chief
Executives in England to seek assurance on levels of compliance with the
standards in CAP 1264 and to identify any staff training requirements. The
results of this had not been made available at the time of publication of
this report, but they are intended to inform NHS England Estates of any
additional next steps that may be required.

● NHS England Estates, working with the CAA, is considering introducing a

package to develop training in ground operations and oversight of hospital
HLS facilities. The objective is to roll out such a training programme to
the Accountable Managers of all the hospital HLS in England, Wales, and
Scotland.

● They are working with other hospital HLS towards a common database for
all operators.

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AAIB Bulletin: 11/2023

AAIB Correspondence Reports

These are reports on accidents and incidents which
were not subject to a Field Investigation.

They are wholly, or largely, based on information

provided by the aircraft commander in an
Aircraft Accident Report Form (AARF)
and in some cases additional information
from other sources.

The accuracy of the information provided cannot be assured.

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AAIB Bulletin: 11/2023 G-CBML AAIB-29036

SERIOUS INCIDENT

Aircraft Type and Registration: DHC-6 Series 310 (Twin Otter), G-CBML

No & Type of Engines: 2 Pratt & Whitney Canada PT6A-27 turboprop

engines

Year of Manufacture: 1980 (Serial no: 695)

Date & Time (UTC): 13 March 2023 at 1535 hrs

Location: St Mary’s Airport, Isles of Scilly

Type of Flight: Commercial Air Transport (Passenger)

Persons on Board: Crew - 2 Passengers - 15

Injuries: Crew - None Passengers - None

Nature of Damage: None

Commander’s Licence: Commercial Pilot’s Licence

Commander’s Age: 63 years

Commander’s Flying Experience: 9,700 hours (of which 5,000 were on type)
Last 90 days - 67 hours
Last 28 days - 21 hours

Information Source: Aircraft Accident Report Form submitted by the

commander and further enquiries conducted by
the AAIB

Synopsis

Whilst landing in gusty crosswind conditions the commander was unable to keep the aircraft
on the paved surface so elected to go around. The aircraft travelled approximately 12 m
across adjacent grass before getting airborne again. No damage was caused to the aircraft.

History of the flight

The Twin Otter was undertaking a scheduled flight from Land’s End Airport to St Mary’s
Airport in the Isles of Scilly. Several flights had been cancelled earlier in the day due to the
strong winds at St Mary’s. By the early afternoon reports indicated the wind had reduced
slightly with the 1450 hrs METAR giving the surface wind from 220° at 22 kt. As this was
now within the aircraft limits the commander decided it was safe to undertake the flight. The
aircraft departed Land’s End Airport at 1510 hrs.

The commander made a visual approach to Runway 27 at St Mary’s, electing to land with
full flap. When the aircraft was cleared to land, ATC reported the surface wind as “210° at
19 kt, maximum 27 kt”. As the aircraft approached the runway ATC gave an instant wind
check of “210° at 20 kt”. The aircraft touching down at 1534 hrs.

The commander reported that the initial touchdown was smooth but slightly further down
the runway than ideal due to the aircraft floating slightly. Once all three wheels were on the

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AAIB Bulletin: 11/2023 G-CBML AAIB-29036

ground, he was about to select reverse when the right wing started to lift. He recalled that
he reduced the in-to-wind aileron to lower the right wing but the left wing then “rose quite
violently and the aircraft started to veer to the left, weathercocking into wind, now only on
the nose and right main wheels”. The commander reported that he was unable to lower
the left wing or stop the aircraft drifting to the left. As the aircraft approached the edge of
the runway he decided to go around and applied full power. The co-pilot selected Flap 10.

The co-pilot’s recollection was that the approach was stable and the initial touchdown was
normal but the aircraft then started to “wheelbarrow on two wheels and pull to the left”. At
this time he had the sense that the right wing was lifting. He recalled checking the control
column and seeing the ailerons were around the neutral position. As the aircraft left the
paved surface he recalled the commander calling “going around” and applying full power,
and he instinctively selected Flap 10.

The aircraft travelled across the grass to the left of the runway before becoming airborne.
Once airborne it accelerated in ground effect as the flaps retracted and was then able to
climb away. Once level the flight crew discussed returning to the mainland but decided to
make a second approach. The second visual approach was uneventful, and the aircraft
landed without further incident at 1539 hrs.

Inspection after landing revealed no damage to the aircraft. Tyre marks were found leaving
the runway just past the runway intersection and extending approximately 12 m onto the
grass (Figure 1).

It was stated in the commander’s and ATC report that two local pilots witnessed the incident
and reported that at the time of landing there were two significant gusts of wind punctuated
by a short lull.

Aerodrome information

St Mary’s Airport has two runways, 14/32 and 09/27, as shown in Figure 2. Runway 27
is 522 m long and 18 m wide and has a declared LDA of 501 m. The AIP1 contains the
following warning:

‘Pilots should exercise extreme caution when landing and taking-off at this
aerodrome, which is markedly hump-backed. The gradients increase to as
much as 1 in 13 at the runway ends.

Turbulence and/or windshear may affect the final half mile of approaches to all
runways and may be increased by valley effect and/or structures when using
Runways 09, 14 or 27.’

Footnote
1
AIP – Aeronautical Information Publication, available at https://nats-uk.ead-it.com/cms-nats/opencms/ en/
Publications/AIP/ [accessed 3 June 2023].

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AAIB Bulletin: 11/2023 G-CBML AAIB-29036

Figure 1
Tyre marks found on Runway 27 leaving the runway to the left

Figure 2
Figure 2
Aerial view of St Mary’s Airport showing where the aircraft departed the runway
(for orientation the yellow markings seen in Figure 1 can be seen in this view
to the right of the point the aircraft left the paved surface)

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AAIB Bulletin: 11/2023 G-CBML AAIB-29036

Aircraft performance

The company crosswind limit for the Twin Otter is 27 kt on a dry or wet runway. The company’s
operations manual specifies lower limits for commanders with less than 150 hours P1 on
type, for co-pilots and for night landing at St Mary’s.

The manual states ‘if a significant cross wind is unavoidable consideration to using flap 20
for landing should be made if the runway is of suitable length’. The manual requires full flap
to be used for landing on Runway 27 at St Mary’s if the headwind component is less than
12 kt.

Meteorology

The METAR issued at 1520 hrs gave a surface wind from 220° at 22 kt, visibility 8 km, cloud
few at 1,400 ft, temperature 12°C, dewpoint 9°C and a sea level pressure of 987 hPa. The
runway conditions were wet/wet/wet (condition code 5/5/5).

The full requirements for meteorological observations at aerodromes are specified in

CAP 7462. Reported surface wind direction and speed is the average taken over a ten
minute period immediately preceding the time of the observation. A gust is only reported
if, within that period, the wind exceeds the mean wind speed by 10 kt or more. The wind
direction is referenced to True North. When ATC reports the wind to aircraft for takeoff and
landing, the direction is expressed in degrees Magnetic and the reading is averaged over
the previous two minutes. Gusts are still reported if the wind exceeds the mean wind speed
by 10 kt or more in the last 10 minutes. Variations in wind direction is reported when the
total variation in direction over the previous ten-minute period is 60° or more.

Flight crew

The commander had a total of 9,700 hours flying experience including 5,000 hours on the
Twin Otter. He was a training captain for the operator and held Class Rating Instructor and
Examiner (CRI/CRE) ratings.

The co-pilot had a total of 1,300 hours including 1,000 hours on the Twin Otter.

Organisational information

The operator had identified the risk of a runway excursion at St Mary’s due to the narrow and
short runway within their Safety Management System. It had put the following mitigations
in place to manage the risk:

● ‘SOPs contain specific weather limits for St Mary’s for pilots of limited
experience.

Footnote
2
CAP746 – ‘Requirements for meteorological observations at aerodromes’ available at https://www.caa.
co.uk/ [accessed 3 June 2023].

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AAIB Bulletin: 11/2023 G-CBML AAIB-29036

● SOPs state pilots in command have to be checked out with a base trainer
before taking off or landing at St Mary’s.

● ATC report mean and max wind on R/T to better estimate max cross-wind.

● SOPs state approach must be stabilised to continue to land.

● Maximum reduced cross wind at night introduced.

● No pilot can land or depart St Mary’s without prior circuit training by a CRE/
CRI.’

The operator stated that prior to this occurrence these mitigations had been effective.

Following the operator’s review of this incident, it intends to display a live wind plot in the
Land’s End crew room, provided by the Met Office, which shows the surface wind direction
and strength for St Mary’s for the last 30 minutes. It is intended that this will give flight crew
a better understanding of the frequency of wind gusts before they depart. It will also display
a live web cam from St Marys to give a view of the weather conditions.

The chief pilot is also considering if the 12 kt headwind requirement for using Flap 20 may
be reduced for aircraft below maximum landing weight. It is intended that this may allow
greater use of Flap 20 in crosswind conditions. This would not have helped in this incident
as the aircraft was close to the maximum landing weight.

Analysis

As the aircraft approached Runway 27, ATC reports suggest there was a headwind
component of approximately 10 - 15 kt and a crosswind component from the left of
approximately 16 – 23 kt.

It is likely that as the aircraft touched down it experienced a lull in the wind which meant
the commander had too much in-to-wind aileron at that moment. However, as he reduced
the aileron, the wind increased, such that he then had insufficient aileron to keep the
wings level. As the airspeed decreased and the flight controls became less effective the
commander was unable to keep the aircraft on the runway.

The co-pilot recalled seeing the ailerons around the neutral position after landing so it is
also possible that the commander reduced the in-to-wind aileron too much on landing and
this caused the right roll.

The commander’s quick actions to initiate a go-around avoided the consequences of any
further ground excursion. Landing with Flap 20 may have made it easier to manage the
crosswind, but, with possibly only 10 kt of headwind the commander considered full flap
was required to ensure the aircraft would stop within the runway distance available.

ATC is only required to report gusts if the wind speed exceeds the average by 10 kt or
more in the preceding ten minutes. This can mean that there are significant variations in
the wind which are not reported. ATCOs can provide maximum wind or instant wind, as

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AAIB Bulletin: 11/2023 G-CBML AAIB-29036

they did at St Mary’s, if they consider this would assist the pilots. This information can
also be requested from ATC.

The operator has provided additional live wind information to their pilots in their crew
room to give a better indication of the frequency and intensity of gusts over the previous
30 minutes. It is thought this will assist its pilots by giving them more knowledge about the
wind conditions they are likely to experience in St Mary’s.

Conclusion

It is likely that the combination of the gusting wind and the amount of in-to-wind aileron
applied caused the aircraft to roll right and weathercock into wind. This caused the aircraft
to veer left and leave the paved surface. The commander’s decision to go around prevented
a more serious outcome.

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AAIB Bulletin: 11/2023 G-BLWY AAIB-29100

SERIOUS INCIDENT

Aircraft Type and Registration: Pierre Robin R2160, G-BLWY

No & Type of Engines: 1 Lycoming O-320-D2A piston engine

Year of Manufacture: 1980 (Serial no: 176)

Date & Time (UTC): 16 April 2023 at 1530 hrs

Location: Deenethorpe Airfield, Northamptonshire

Type of Flight: Training

Persons on Board: Crew - 2 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Transparent panel over the rear area of the

cockpit detached. Slight damage to the right
flap and wing
Commander’s Licence: Commercial Pilot’s Licence

Commander’s Age: 48 years

Commander’s Flying Experience: 2,685 hours (of which 2,325 were on type)
Last 90 days - 115 hours
Last 28 days - 50 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot and further enquiries made by the AAIB

Synopsis

During an aerobatic training flight, a transparent panel over the rear area of the cockpit
detached and fell away. The aircraft landed without further incident. The panel detached
due to its leading edge dis-bonding from its support frame, allowing the airflow to get under
this edge and cause the panel to fail.

History of the flight

The aircraft was on an aerobatic training flight over open countryside. A clearing turn was
carried out at 100 kt and about 60° angle of bank when the transparent panel over the rear
right-side of the cockpit detached and fell away from the aircraft. The aircraft returned to the
airfield without further incident. Both occupants were uninjured, but the aircraft sustained
minor damage on the right wing, flap and rear fuselage.

Aircraft examination

There are two (left and right) transparent panels over the rear area of the cockpit which
extend from the edge of the fuselage to a central ridge frame (Figure 1).

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AAIB Bulletin: 11/2023 G-BLWY AAIB-29100

Figure 1
Cockpit transparent panels and associated structure

The panels are bonded to the fuselage structure and supporting framework by a sealing
adhesive. In addition, a line of screws along the side and rear edge of the panel secures
the panel to the fuselage. A capping strip, held in place by screws, is fitted over the edges
of each panel where they attach to the ridge frame.

The panel had broken away leaving jagged edged pieces of the panel attached to the side,
rear and ridge frames; the screws and adhesive bond were still in place. The leading edge
of the panel, where it attaches to a hoop frame just behind the seats (Figure 2) appears
to have dis-bonded completely from the frame. It also appears to have taken parts of the
canopy weather seal with it. A narrow bead of the adhesive sealant remained on the hoop
frame. Examination of the left transparent panel found the bond along the hoop frame had
started to come apart and could be lifted under finger pressure.

Probable cause

Although it is not fully clear what initiated the detachment of the panel, it is likely that the
bond on part of the leading edge, were it attaches to the hoop frame, had failed. The
upward force on the panel in flight was sufficient to open a gap and allow the airflow to pass
between the frame and panel causing it to break.

It is known that polymethyl methacrylate1 (PMMA) materials such as used in the panel
do not tolerate adverse loads which can induce flexing or distortion from their preformed
shape. This often results in the material rapidly cracking along rigidly held edges and
breaking apart, which in this event can be seen by the remaining jagged panel pieces
trapped under the screws.
Footnote
1
PMMA is more commonly known by trademarks such as Perspex and Plexiglas.

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AAIB Bulletin: 11/2023 G-BLWY AAIB-29100

Figure 2
Dis-bonded area and canopy seal on the hoop frame

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AAIB Bulletin: 11/2023 G-OWBA AAIB-29063

ACCIDENT

Aircraft Type and Registration: Pioneer 300, G-OWBA

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

Year of Manufacture: 2013 (Serial no: LAA 330-15155)

Date & Time (UTC): 26 March 2023 at 1620 hrs

Location: North Weald Aerodrome, Essex

Type of Flight: Training

Persons on Board: Crew - 2 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Damage to the left wing and left main landing
gear retraction mechanism

Commander’s Licence: Commercial Pilot’s Licence

Commander’s Age: 27 years

Commander’s Flying Experience: 2,900 hours (of which 17 were on type)

Last 90 days - 81 hours
Last 28 days - 20 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot

Synopsis

During the landing roll the left main landing gear collapsed because the landing gear was
not in the down and locked position. Examination could not positively identify the reason
that the gear was not locked down, however it is considered likely that the landing gear had
not been set up correctly after a recent part replacement.

History of the flight

A student pilot was landing with a slight crosswind from the left. Just before the flare the
instructor added right rudder and left aileron before they made a ‘smooth and symmetrical’
touchdown. The instructor recalled that after approximately 5 seconds the aircraft started
to veer to the left. He then noticed that the left wing had contacted the runway. The aircraft
departed the runway and struck a runway light. Assessment of the aircraft after the accident
identified that the left main landing gear had collapsed.

During the previous flight, when the landing gear was lowered for landing, the right main
landing gear green light did not illuminate, indicating that it was not down and locked.
The pilot, who was the instructor of the accident flight, flew the aircraft past the tower
and received confirmation that the gear was visually down. He then made a successful
landing. He discussed the event with the maintainer who advised making an adjustment
to the right main gear down microswitch as it was considered likely that, during recent

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AAIB Bulletin: 11/2023 G-OWBA AAIB-29063

maintenance in which landing gear actuation system components were replaced, the
microswitch position may not have been correctly set.

Aircraft information

The Alpi Pioneer 300 is a small two-seat, low-wing aircraft, of mainly wooden construction.
The aircraft is fitted with electrically operated retractable tricycle landing gear (Figure 1).

The nosewheel retracts rearwards and the mainwheels retract outwards into wheel wells on
the underside of the wings. An electric motor drives a retraction/extension gearbox which
drives jack screws that, when lowering the landing gear, extend the mechanisms. Once at
full travel an over-centre mechanism locks the gear in the down position. Microswitches
sense that the mechanisms are in the down and locked position and illuminate green lights
on the instrument panel indicating their respective landing gear leg’s position.

Right main landing Right main landing

gear leg gear support

Manual landing gear

extension handle
Retraction group
Main Landing gear
screw jacks
Left main landing
gear support

Main landing gear over-

centre mechanisms
Left main landing
gear leg

Nose landing gear

Figure 1
Alpi Pioneer 300 landing gear configuration

In August 2022, approximately three flying hours before the accident, the main landing gear
extension/retraction mechanism was replaced due to several components, including the
jack screws, gearbox shafts and jack screw universal joints, being distorted and bent. The
left over-centre arm assembly was also found to be coming away from the spar box fixing
bolts, so was replaced.

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AAIB Bulletin: 11/2023 G-OWBA AAIB-29063

Aircraft examination

The left main landing gear threaded bar had buckled, fracturing towards its outboard/
extended end (Figure 2).

Figure 2
Buckled and fractured G-OBWA left main gear jack screw

A scuff mark was identified in the wheel well (Figure 3), which indicated that the tyre had
contacted the wheel well wall. Assessment of the wheel identified that the tyre fitted was
not specified in the maintenance manual and was 2 inches wider than the specified tyre.

Figure 3
G-OBWA left wheel well (underside of wing) showing scuffing

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AAIB Bulletin: 11/2023 G-OWBA AAIB-29063

Analysis

When an outward side load is applied to the landing gear the load path should be through
the over-centre mechanism and into the airframe. However, as the jack screw was buckled
it indicated that the load path was through the extension/retraction mechanism and that the
gear was not locked down during the landing.

With the damage to the components, it was not possible to establish why the mechanism
was not locked down; however, it is considered possible that the landing gear had not been
correctly set up when the new components had been installed. As the jack screw had failed
whilst in the extended position, it is considered unlikely that the issue identified with the
incorrect tyre being fitted was linked to the landing gear failure.

The landing gear indication issue that occurred during the flight before the accident may
have been related to the landing gear not travelling to the full extent when being lowered,
rather than a maladjusted microswitch. A more thorough investigation of the issue may have
identified the over-centre mechanism issue and prevented the failure of the screw jack.

This event serves as a reminder for all issues to be fully investigated to understand their root
cause. Even if an easy fix may, on the face of it, rectify a fault an underlying issue may remain.

The installation of the incorrect tyre, although unrelated to the landing gear failure, also
serves as a reminder to ensure that only components included in the defined parts list
should be fitted to an aircraft.

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AAIB Bulletin: 11/2023 G-AVLG AAIB-29324

SERIOUS INCIDENT

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

No & Type of Engines: 1 Lycoming O-320-E3D piston engine

Year of Manufacture: 1967 (Serial no: 28-23358)

Date & Time (UTC): 26 June 2023 at 1050 hrs

Location: Near Thruxton Aerodrome, Hampshire

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: None

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 25 years

Commander’s Flying Experience: 90 hours (of which 37 were on type)

Last 90 days - 15 hours
Last 28 days - 0 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot and enquiries made by the AAIB

Synopsis

During preparation for a flight from Bournemouth Airport to Thruxton Aerodrome, the pilot
noted that ‘11 US gal’ was recorded in the aircraft Technical Log (Tech Log), which would be
sufficient fuel for this short flight. However, during the approach to Thruxton the aircraft ran
out of fuel, and the pilot conducted a successful forced landing in a field.

It was established that the quantity of fuel recorded in the Tech Log was incorrect and there
was insufficient fuel onboard to complete the flight to Thruxton.

History of the flight

The aircraft was being flown from Bournemouth Airport to Thruxton Aerodrome where it
would be refuelled before being flown to its base at Middle Wallop Airfield. The pilot joined
left base at Thruxton for a landing on Runway 25. He completed his downwind checks and
as he turned onto Final, the engine began to run roughly and lost power. The pilot switched
to the right fuel tank which appeared to have no effect on the engine power. Realising he
would not make the runway threshold, he selected a field just to the right of the extended
centre line and carried out an uneventful forced landing. The aircraft was undamaged and
the pilot uninjured.

Shortly after landing the pilot established, by running the fuel pump and checking the fuel
pressure, that the left fuel tank was empty and that some fuel remained in the right tank.

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AAIB Bulletin: 11/2023 G-AVLG AAIB-29324

Circumstances leading to the fuel exhaustion

Fuel on board at the start of the flight

Following its annual inspection at Bournemouth, the pilot was asked to collect the aircraft.
At Bournemouth he checked the Tech Log and satisfied himself that the work had been
completed and certified. He also noted that the fuel recorded in the log was ‘11 US gal’.
The pilot decided to refuel the aircraft at Thruxton and then continue to Middle Wallop as he
considered that the quantity of fuel in the aircraft would be sufficient for the 20-minute flight,
with a reserve.

While carrying out the A-Check the pilot was unable to find the fuel tank dipstick in the
aircraft. As no other suitable dipstick was available, he checked the fuel levels by looking
into each tank through the filler cap. At this point he believed he saw an amount of fuel
which he reported “matched my expectations believing I knew how much fuel was on board”.
He also noted that the fuel gauges were “off the stops” and so assumed there was fuel in
the tanks. However, calculations based on this aircraft and the route flown, suggested that
rather than 11 US gal, there was only between 5 and 7 US gal of usable fuel in the aircraft
fuel tanks at the start of the flight. It is not known what the distribution of fuel was between
the two tanks.

Fuel onboard on arrival at Bournemouth

The Tech Log showed that there was 11 US gal of fuel on board the aircraft before it was
flown to Bournemouth for the maintenance. However, the Tech Log had not been completed
following the flight to Bournemouth and, therefore, there was no record of the amount of
fuel remaining in the aircraft when it landed. There was also no record of the amount of fuel
used during the engine runs carried out during the maintenance.

Confirmation bias

The aircraft operator had a fuel account at Thruxton as Avgas is not always easily available
at Middle Wallop where the aircraft is based. It was, therefore, normal practice to refuel
at Thruxton. Refuelling at Bournemouth was not considered as the pilot thought he had
enough fuel in the aircraft for the first part of the flight. Moreover, refuelling at Thruxton
followed by a very short flight to Middle Wallop, would ensure the aircraft had the maximum
amount of fuel onboard for flying the next day.

Comment

The pilot attempted to rectify the loss of engine power by switching to the right fuel tank.
When this appeared to have no effect, he took immediate action to conduct a forced landing
in a field rather than try to stretch the glide to make the runway. Had he not done so, the
outcome may have been different.

On this occasion, the pilot believes that when he looked in the fuel tanks at Bournemouth,
he experienced confirmation bias because he was expecting to see fuel present based on
what he read in the Tech Log.

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AAIB Bulletin: 11/2023 G-AVLG AAIB-29324

The pilot was misled by the entry in the Tech Log, which had not been completed after the
last flight, as to the quantity of fuel on board the aircraft. Fuel, and oil, might be consumed
during a period of maintenance, and therefore any quantities of fluid entered in the Tech Log
prior to the start of the maintenance should be treated with caution.

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AAIB Bulletin: 11/2023 G-WAMS AAIB-29467

SERIOUS INCIDENT

Aircraft Type and Registration: Piper PA-28R-201, G-WAMS

No & Type of Engines: 1 Lycoming IO-360-C1C6 piston engine

Year of Manufacture: 2001 (Serial no: 2844050)

Date & Time (UTC): 10 August 2023 at 1525 hrs

Location: Stapleford Aerodrome, Essex

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - None

Nature of Damage: Right wingtip underside damaged and flap bent

Commander’s Licence: Commercial Pilot’s Licence

Commander’s Age: 23 years

Commander’s Flying Experience: 1,420 hours (of which 50 were on type)

Last 90 days - 120 hours
Last 28 days - 40 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot

Synopsis

During the landing run the main right landing gear collapsed and the aircraft slewed off
the runway. The landing gear collapsed because the landing gear selector had been
inadvertently knocked towards the gear up position during touchdown.

History of the flight

The aircraft was returning to Stapleford Aerodrome after a cross channel flight. The pilot
landed the aircraft and as it slowed to approximately 30 kt, the aircraft tilted to the right.
The pilot initially thought the right tyre was flat. However, the wingtip suddenly dropped and
contacted the runway, causing the aircraft to slew to the right and off the paved surface.

The pilot made the aircraft safe and vacated the aircraft along with his passenger.

Cause

The pilot had configured the aircraft for landing and confirmed that the landing gear
was down and locked. However, during touchdown his passenger, also a qualified pilot
occupying the left seat1, dropped a tablet device into the footwell. The passenger was

Footnote
1
The aircraft commander in this case was flying the aircraft from the right seat stated that as an instructor, he
finds it more comfortable to do so when pleasure flying with a passenger.

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AAIB Bulletin: 11/2023 G-WAMS AAIB-29467

concerned the device would interfere with the rudder pedals during the landing, so hastily
retrieved it. During its retrieval he inadvertently knocked the landing gear selector out of its
guard towards the gear up position. Despite immediately repositioning the selector, the
gear had unlocked.

Pilot’s comments

To mitigate the risk of a similar occurrence in the future, the pilot will undertake the following
actions:

● For general pleasure flights in complex aircraft, his passengers will occupy
the right seat.

● Brief passengers to stow and secure loose or unnecessary items prior to

critical phases of a flight.

● Brief the passengers to ensure that they inform him if they interact with any
of the aircraft controls at any stage of the flight.

© Crown copyright 2023 36 All times are UTC

AAIB Bulletin: 11/2023

AAIB Record-Only Investigations

This section provides details of accidents and incidents which
were not subject to a Field or full Correspondence Investigation.

They are wholly, or largely, based on information

provided by the aircraft commander at the time of reporting
and in some cases additional information
from other sources.

The accuracy of the information provided cannot be assured.

© Crown copyright 2023 37 All times are UTC

AAIB Bulletin: 11/2023 Record-only UAS investigations reviewed: August - September 2023

Record-only UAS investigations reviewed: August - September 2023

3 Aug 2023 DJI Mavic 2 Yoxford, Suffolk

The remote pilot was operating with visual line of sight with a colleague
as observer when the UA collided with a tree at a height of approximately
5 metres. The UA fell to the ground with damage to the rotors.

9 Aug 2023 Windracers Thorney Island, West Sussex

Ultra-UAS, G-WNDA
A trainee remote pilot under instruction was practising touch-and-go’s on
Runway 29. During one landing the aircraft touched down on its nose
wheel and the nose wheel became dislodged from the wheel hub. The
aircraft climbed away and during the subsequent landing the aircraft
drifted left and the right wingtip made contact with the runway.

12 Aug 2023 Model Aircraft Elvington Airfield, North Yorkshire

Mitsubishi A6M Zero
During a forced landing after engine failure, the model aircraft was caught
by a gust of wind and it fell to the ground.

17 Aug 2023 DJI M300 Strathaven, South Lanarkshire

The UAS was carrying out a survey of a castle, which was closed to
the public, and had completed two successful flights. Two minutes into
the third flight the remote pilot received a ‘strong interference detected’
warning. The UA subsequently struck the castle.

21 Aug 2023 DJI Inspire 1 Sennybridge, Powys

Following successful pre-flight checks, the UA took off. However, at
a height of about 10 m, it reported a ‘battery critical, land immediately’
warning and fell to the ground where it suffered substantial damage.

3 Sept 2023 Model Aircraft Pontefract, West Yorkshire

Airworld Hawk
The model jet aircraft lost elevator control. It flew into a field, struck the
ground and was destroyed.

5 Sept 2023 Model Aircraft E-Flite Telford, Shropshire

Evolution
The model aircraft flew beyond visual line of sight at 100 ft height and 200
ft distance, and was not recovered.

7 Sept 2023 DJI Inspire 2 Northolt, London

The controller lost link to the UA 20 seconds into the flight. The UA
subsequently flew beyond visual line of sight and was not found.

© Crown copyright 2023 39 All times are UTC

AAIB Bulletin: 11/2023 Record-only UAS investigations reviewed: August - September 2023

Record-only UAS investigations reviewed: August - September 2023 cont

7 Sept 2023 DJI Mavic Enterprise 2 Chacewater, Cornwall

Whilst recording footage the UA was manoeuvring at head height along
a road with overhead cables. The road dipped downhill and the operator
had not realised that the UA had climbed relative to the wires, which it hit
and subsequently fell to the ground.

28 Sept 2023 DJI Air 2S Bourn Airfield, Cambridgeshire

The UA was being flown 40 m from the remote operator and at a height of
15 m when it suddenly lost lift and dropped to the ground. The cause of
the loss of power was not determined.

30 Sept 2023 Model Aircraft FMS Near Battlesbridge, Essex

Skytrainer
The control link to the model aircraft was lost and the aircraft flew into the
ground. It was not recovered.

© Crown copyright 2023 40 All times are UTC

AAIB Bulletin: 11/2023

Miscellaneous
This section contains Addenda, Corrections
and a list of the ten most recent
Aircraft Accident (‘Formal’) Reports published
by the AAIB.

The complete reports can be downloaded from

the AAIB website (www.aaib.gov.uk).

© Crown copyright 2023 41 All times are UTC

 AAIB Bulletin: 11/2023

TEN MOST RECENTLY PUBLISHED

FORMAL REPORTS
ISSUED BY THE AIR ACCIDENTS INVESTIGATION BRANCH

3/2015 Eurocopter (Deutschland) 2/2018 Boeing 737-86J, C-FWGH

EC135 T2+, G-SPAO Belfast International Airport
Glasgow City Centre, Scotland on 21 July 2017.
on 29 November 2013. Published November 2018.
Published October 2015.
1/2020 Piper PA-46-310P Malibu, N264DB
1/2016 AS332 L2 Super Puma, G-WNSB 22 nm north-north-west of Guernsey
on approach to Sumburgh Airport on 21 January 2019.
on 23 August 2013. Published March 2020.
Published March 2016.
1/2021 Airbus A321-211, G-POWN
2/2016 Saab 2000, G-LGNO London Gatwick Airport
approximately 7 nm east of on 26 February 2020.
Sumburgh Airport, Shetland Published May 2021.
on 15 December 2014.
Published September 2016. 1/2023 Leonardo AW169, G-VSKP
King Power Stadium, Leicester
1/2017 Hawker Hunter T7, G-BXFI on 27 October 2018.
near Shoreham Airport Published September 2023.
on 22 August 2015.
Published March 2017. 2/2023 Sikorsky S-92A, G-MCGY
Derriford Hospital, Plymouth,
Devon
1/2018 Sikorsky S-92A, G-WNSR
on 4 March 2022.
West Franklin wellhead platform,
North Sea Published November 2023.
on 28 December 2016.
Published March 2018.

Unabridged versions of all AAIB Formal Reports, published back to and including 1971,
are available in full on the AAIB Website
http://www.aaib.gov.uk

© Crown copyright 2023 43 All times are UTC

 Air Accidents Investigation Branch
Farnborough House AAIB Bulletin: 11/2023
Berkshire Copse Road
Aldershot GLOSSARY OF ABBREVIATIONS
Hants GU11 2HH
aal above airfield level kt knot(s)
ACAS Airborne Collision Avoidance System lb pound(s)
ACARS Automatic Communications And Reporting System LP low pressure
Tel: 01252 510300
ADF Automatic Direction Finding equipment LAA Light Aircraft Association
Fax: 01252 376999 AFIS(O) Aerodrome Flight Information Service (Officer) LDA Landing Distance Available
Press enquiries: 0207 944 3118/4292 agl above ground level LPC Licence Proficiency Check
http://www.aaib.gov.uk AIC Aeronautical Information Circular m metre(s)
amsl above mean sea level mb millibar(s)
AOM Aerodrome Operating Minima MDA Minimum Descent Altitude
APU Auxiliary Power Unit METAR a timed aerodrome meteorological report
ASI airspeed indicator min minutes
ATC(C)(O) Air Traffic Control (Centre)( Officer) mm millimetre(s)
ATIS Automatic Terminal Information Service mph miles per hour
ATPL Airline Transport Pilot’s Licence MTWA Maximum Total Weight Authorised
AAIB investigations are conducted in accordance with BMAA British Microlight Aircraft Association N Newtons
BGA British Gliding Association NR Main rotor rotation speed (rotorcraft)
Annex 13 to the ICAO Convention on International Civil Aviation, BBAC British Balloon and Airship Club Ng Gas generator rotation speed (rotorcraft)
EU Regulation No 996/2010 (as amended) and The Civil Aviation BHPA British Hang Gliding & Paragliding Association N1 engine fan or LP compressor speed
CAA Civil Aviation Authority NDB Non-Directional radio Beacon
(Investigation of Air Accidents and Incidents) Regulations 2018. CAVOK Ceiling And Visibility OK (for VFR flight) nm nautical mile(s)
CAS calibrated airspeed NOTAM Notice to Airmen
cc cubic centimetres OAT Outside Air Temperature
The sole objective of the investigation of an accident or incident under these CG Centre of Gravity OPC Operator Proficiency Check
Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PAPI Precision Approach Path Indicator
CPL Commercial Pilot’s Licence PF Pilot Flying
purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true PIC Pilot in Command
CVR Cockpit Voice Recorder PM Pilot Monitoring
DME Distance Measuring Equipment POH Pilot’s Operating Handbook
Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed PPL Private Pilot’s Licence
or blame or determine liability, since neither the investigation nor the reporting EASA European Union Aviation Safety Agency psi pounds per square inch
ECAM Electronic Centralised Aircraft Monitoring QFE altimeter pressure setting to indicate height above
process has been undertaken for that purpose. EGPWS Enhanced GPWS aerodrome
EGT Exhaust Gas Temperature QNH altimeter pressure setting to indicate elevation amsl
EICAS Engine Indication and Crew Alerting System RA Resolution Advisory
EPR Engine Pressure Ratio RFFS Rescue and Fire Fighting Service
ETA Estimated Time of Arrival rpm revolutions per minute
ETD Estimated Time of Departure RTF radiotelephony
FAA Federal Aviation Administration (USA) RVR Runway Visual Range
FDR Flight Data Recorder SAR Search and Rescue
FIR Flight Information Region SB Service Bulletin
FL Flight Level SSR Secondary Surveillance Radar
ft feet TA Traffic Advisory
AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAF Terminal Aerodrome Forecast
http://www.aaib.gov.uk g acceleration due to Earth’s gravity TAS true airspeed
GNSS Global Navigation Satellite System TAWS Terrain Awareness and Warning System
GPS Global Positioning System TCAS Traffic Collision Avoidance System
GPWS Ground Proximity Warning System TODA Takeoff Distance Available
hrs hours (clock time as in 1200 hrs) UA Unmanned Aircraft
HP high pressure UAS Unmanned Aircraft System
hPa hectopascal (equivalent unit to mb) USG US gallons
IAS indicated airspeed UTC Co-ordinated Universal Time (GMT)
This bulletin contains facts which have been determined up to the time of compilation. IFR Instrument Flight Rules V Volt(s)
ILS Instrument Landing System V1 Takeoff decision speed
Extracts may be published without specific permission providing that the source is duly acknowledged, the material is
IMC Instrument Meteorological Conditions V2 Takeoff safety speed
reproduced accurately and it is not used in a derogatory manner or in a misleading context.
IP Intermediate Pressure VR Rotation speed
IR Instrument Rating VREF Reference airspeed (approach)
Published 10 November Cover picture courtesy of Marcus Cook
ISA International Standard Atmosphere VNE Never Exceed airspeed
© Crown copyright 2023 ISSN 0309-4278 kg kilogram(s) VASI Visual Approach Slope Indicator
KCAS knots calibrated airspeed VFR Visual Flight Rules
Published by the Air Accidents Investigation Branch, Department for Transport KIAS knots indicated airspeed VHF Very High Frequency
Printed in the UK on paper containing at least 75% recycled fibre KTAS knots true airspeed VMC Visual Meteorological Conditions
km kilometre(s) VOR VHF Omnidirectional radio Range
AAIB Bulletin 11/2023

AAIB Bulletin 11/2023

AAIB Bulletin 11/2023

TO REPORT AN ACCIDENT OR INCIDENT

PLEASE CALL OUR 24 HOUR REPORTING LINE
01252 512299

AAIB
Air Accidents Investigation Branch