Aaib Bulletin

AAIB Bulletin

8/2018

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: 8/2018
Berkshire Copse Road
Aldershot GLOSSARY OF ABBREVIATIONS
Hants GU11 2HH
aal above airfield level lb pound(s)
ACAS Airborne Collision Avoidance System LP low pressure
ACARS Automatic Communications And Reporting System LAA Light Aircraft Association
Tel: 01252 510300 LDA Landing Distance Available
ADF Automatic Direction Finding equipment
Fax: 01252 376999 AFIS(O) Aerodrome Flight Information Service (Officer) LPC Licence Proficiency Check
Press enquiries: 0207 944 3118/4292 agl above ground level m metre(s)
http://www.aaib.gov.uk AIC Aeronautical Information Circular MDA Minimum Descent Altitude
amsl above mean sea level METAR a timed aerodrome meteorological report
AOM Aerodrome Operating Minima min minutes
APU Auxiliary Power Unit mm millimetre(s)
ASI airspeed indicator mph miles per hour
ATC(C)(O) Air Traffic Control (Centre)( Officer) MTWA Maximum Total Weight Authorised
ATIS Automatic Terminal Information Service N Newtons
ATPL Airline Transport Pilot’s Licence NR Main rotor rotation speed (rotorcraft)
AAIB investigations are conducted in accordance with BMAA British Microlight Aircraft Association N g Gas generator rotation speed (rotorcraft)
BGA British Gliding Association N1 engine fan or LP compressor speed
Annex 13 to the ICAO Convention on International Civil Aviation, BBAC British Balloon and Airship Club NDB Non-Directional radio Beacon
EU Regulation No 996/2010 and The Civil Aviation (Investigation of BHPA British Hang Gliding & Paragliding Association nm nautical mile(s)
CAA Civil Aviation Authority NOTAM Notice to Airmen
Air Accidents and Incidents) Regulations 2018. CAVOK Ceiling And Visibility OK (for VFR flight) OAT Outside Air Temperature
CAS calibrated airspeed OPC Operator Proficiency Check
cc cubic centimetres PAPI Precision Approach Path Indicator
The sole objective of the investigation of an accident or incident under these CG Centre of Gravity PF Pilot Flying
Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PIC Pilot in Command
CPL Commercial Pilot’s Licence PNF Pilot Not Flying
purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true POH Pilot’s Operating Handbook
CVR Cockpit Voice Recorder PPL Private Pilot’s Licence
DME Distance Measuring Equipment psi pounds per square inch
Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed QFE altimeter pressure setting to indicate height
or blame or determine liability, since neither the investigation nor the reporting EASA European Aviation Safety Agency above aerodrome
ECAM Electronic Centralised Aircraft Monitoring QNH altimeter pressure setting to indicate
process has been undertaken for that purpose. EGPWS Enhanced GPWS elevation amsl
EGT Exhaust Gas Temperature RA Resolution Advisory
EICAS Engine Indication and Crew Alerting System RFFS Rescue and Fire Fighting Service
EPR Engine Pressure Ratio rpm revolutions per minute
ETA Estimated Time of Arrival RTF radiotelephony
ETD Estimated Time of Departure RVR Runway Visual Range
FAA Federal Aviation Administration (USA) SAR Search and Rescue
FDR Flight Data Recorder SB Service Bulletin
FIR Flight Information Region SSR Secondary Surveillance Radar
FL Flight Level TA Traffic Advisory
ft feet TAF Terminal Aerodrome Forecast
AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAS true airspeed
g acceleration due to Earth’s gravity TAWS Terrain Awareness and Warning System
http://www.aaib.gov.uk TCAS Traffic Collision Avoidance System
GPS Global Positioning System
GPWS Ground Proximity Warning System TGT Turbine Gas Temperature
hrs hours (clock time as in 1200 hrs) TODA Takeoff Distance Available
HP high pressure UAS Unmanned Aircraft System
hPa hectopascal (equivalent unit to mb) UHF Ultra High Frequency
IAS indicated airspeed USG US gallons
IFR Instrument Flight Rules UTC Co-ordinated Universal Time (GMT)
This bulletin contains facts which have been determined up to the time of compilation. ILS Instrument Landing System V Volt(s)
IMC Instrument Meteorological Conditions V1 Takeoff decision speed
Extracts may be published without specific permission providing that the source is duly acknowledged, the material is
IP Intermediate Pressure V2 Takeoff safety speed
reproduced accurately and it is not used in a derogatory manner or in a misleading context. IR Instrument Rating VR Rotation speed
ISA International Standard Atmosphere VREF Reference airspeed (approach)
Published 9 August 2018 Cover picture courtesy of Stephen R Lynn
(www.srlynnphotography.co.uk) kg kilogram(s) VNE Never Exceed airspeed
KCAS knots calibrated airspeed VASI Visual Approach Slope Indicator
© Crown copyright 2018 ISSN 0309-4278 KIAS knots indicated airspeed VFR Visual Flight Rules
KTAS knots true airspeed VHF Very High Frequency
Published by the Air Accidents Investigation Branch, Department for Transport km kilometre(s) VMC Visual Meteorological Conditions
Printed in the UK on paper containing at least 75% recycled fibre kt knot(s) VOR VHF Omnidirectional radio Range
AAIB Bulletin: 8/2018
CONTENTS
SPECIAL BULLETINS / INTERIM REPORTS
None
SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS
None
AAIB FIELD INVESTIGATIONS
COMMERCIAL AIR TRANSPORT

FIXED WING
None
ROTORCRAFT
None
GENERAL AVIATION
FIXED WING
Piper PA-28RT-201 Cherokee Arrow IV G-BHAY 11-Sep-17 3
ROTORCRAFT
None
SPORT AVIATION / BALLOONS

None
AAIB CORRESPONDENCE INVESTIGATIONS
COMMERCIAL AIR TRANSPORT

Sikorsky S-92A G-CHHF 29-Jan-18 23
GENERAL AVIATION
Cessna 140 G-HALJ 05-Mar-18 27
Denney Kitfox Mk 3 G-KTTY 09-Jun-18 28
DH82A Tiger Moth G-AXBW 17-Apr-18 29
Europa G-RICS 20-Apr-18 31
Piper PA-18-150 Super Cub G-RWCA 07-Apr-18 32
Piper PA-24-250 Commanche N7832P 18-Feb-18 35
SPORT AVIATION / BALLOONS

P&M Aviation PulsR G-FFFA 18-Apr-18 36
P&M Aviation Quik GT450 G-CEZX 02-Jun-18 38
© Crown copyright 2018 i All times are UTC

CONTENTS Cont
AAIB CORRESPONDENCE INVESTIGATIONS Cont
SPORT AVIATION / BALLOONS Cont

Pegasus Quik G-CEMZ 12-May-18 40
Quik GT450 G-TBLB 09-Apr-18 42
Skyranger J2.2(2) G-MARO 19-May-18 43
UNMANNED AIRCRAFT SYSTEMS

None
MISCELLANEOUS
ADDENDA and CORRECTIONS

Jetstream 4100 G-MAJC 16-Oct-17 47
List of recent aircraft accident reports issued by the AAIB

(ALL TIMES IN THIS BULLETIN ARE UTC)
© Crown copyright 2018 ii All times are UTC

AAIB Field Investigation Reports

A Field Investigation is an independent investigation in which
AAIB investigators collect, record and analyse evidence.
The process may include, attending the scene of the accident

or serious incident; interviewing witnesses;
reviewing documents, procedures and practices;
examining aircraft wreckage or components;
and analysing recorded data.
The investigation, which can take a number of months to complete,

will conclude with a published report.
© Crown copyright 2018 1 All times are UTC

AAIB Bulletin: 8/2018 G-BHAY EW/C2017/09/03
ACCIDENT
Aircraft Type and Registration: Piper PA-28RT-201 Cherokee Arrow IV, G-BHAY
No & Type of Engines: 1 Lycoming IO-360-C1C6 piston engine
Year of Manufacture: 1979 (Serial no: 28R-7918213)
Date & Time (UTC): 11 September 2017 at 0956 hrs
Location: Wolferton, Norfolk
Type of Flight: Private
Persons on Board: Crew - 1 Passengers - 1
Injuries: Crew - 1 (Fatal) Passengers - 1 (Fatal)
Nature of Damage: Engine front fuselage, wings and landing gear

severely disrupted
Commander’s Licence: Private Pilot’s Licence
Commander’s Age: 58 years
Commander’s Flying Experience: 1,129 hours (of which 406 were on type)
Last 90 days - 15 hours
Information Source: AAIB Field Investigation
Synopsis
The aircraft was en route from London Southend Airport to Newcastle International Airport.
Over the Wash, the pilot reported that the aircraft’s engine was rough running and he turned
towards the coast, during which time the engine failed. During the forced landing it is likely
that the aircraft stalled and then struck a berm (the old sea wall) with a high rate of descent.
The pilot and his passenger were fatally injured.
Whilst it could not be positively determined why the aircraft stalled, the investigation
revealed that the aircraft’s engine had not been maintained according to the manufacturer’s
instructions whilst it was not used for long periods and parked outside.
History of the flight
Background information
The aircraft had been based at Newcastle International Airport and the pilot flew it via France
to Menorca, Spain, in July 2017.
In September 2017, the pilot and passenger flew the aircraft back from Menorca, through
France, bound for Newcastle. On 10 September they landed at London Southend Airport
after the pilot decided to divert, due to inclement weather, en route to Newcastle and elected
to stay overnight.

Accident flight
On 11 September 2017 the pilot planned to continue from Southend to Newcastle. Prior
to departure the occupants were seen to take about an hour preparing the aircraft. The
aircraft took off at 0908 hrs.
At 0953 hrs, when the aircraft was over the Wash after crossing the Norfolk coast, the pilot
transmitted a mayday to the Distress and Diversion Cell (D&D) on 121.5 MHz, stating he
had a “very rough running engine,” that the aircraft was at 3,300 ft amsl, descending, and
he would turn south towards RAF Marham. A short time later he transmitted “that’s smoke
now i think we’ve got an electrical fire…”. About one minute later he transmitted “engine
has failed”. At this point the aircraft was at about 1,400 ft amsl and D&D informed the pilot
the aircraft was 13.5 nm from RAF Marham, to which the pilot replied he would not make
it. The controller suggested Great Massingham 9 nm away but the pilot replied he would
not make that either and, as the aircraft was passing 1,200 ft amsl, he added “it’s gonna
be a field”. This was the last transmission received from the aircraft and was 30 seconds
before the last radar contact. Figure 1 shows some of the radio transmissions relative to
the radar track.
Figure 1
View looking to the west of last seven minutes of the radar track
(altitudes are Mode C ±50 ft, corrected to the QNH 988 hPa)
The aircraft was witnessed at low level just prior to the accident. One witness, about 0.3 nm
north-north-west of the accident site, stated that he saw the aircraft flying at about 300 ft agl
in a southerly direction over farmland. At the time, he was not aware of any engine noise.
When the aircraft was close to the berm (the old sea wall), at about 40 ft agl, he saw it “drop
vertically” and disappear from his view.

Another witness, who was working in a field about 0.25 nm south-west of the accident site,
stated that he first saw the accident aircraft at a low altitude, flying in about a southerly
direction towards the old sea wall. The aircraft had its landing gear down and the propeller
was not turning as one blade was stationary, pointing vertically up. When it was about
twice the height of the trees on the old sea wall, the aircraft “turned right and stalled”. The
nose dropped quickly and the aircraft struck the berm.
All the witnesses commented that the weather was fine, with the wind strong, from the
west.
The accident site was about 2.5 m south-west of Snettisham, Norfolk. Two of the
witnesses were at the scene quickly and administered first aid to the occupants. Police
and paramedics arrived soon after, as did an air ambulance helicopter and a Coastguard
helicopter. However, the occupants were declared deceased at the scene.
Meteorology
An aftercast produced by the Met Office stated that there was a deep area of low pressure
centred over the northern North Sea with strong winds on its southern and southwestern
flanks. The forecast low-level winds valid for 1200 hrs across East Anglia and the
Wash were expected to be from 260° at 30 kt at 1,000 ft amsl and from 260° at 35 kt at
2,000 ft amsl.
Observations from RAF Marham at 0950 hrs and Norwich Airport at 1020 hrs recorded
wind from 230° at 14 to 23 kt with some gusts higher. Marham recorded FEW clouds at
1,900 ft aal, SCATTERED clouds at 2,700 ft aal and BROKEN clouds at 3,500 ft aal. At
both airfields the visibility was greater than 10 km and the QNH was 988 hPa.
The aircraft was on approximately a southerly track as it flew back towards the coast.
A surface wind from 230° at 15 kt, would give an airspeed about 12 kt greater than the
ground speed calculated from the radar returns.
Medical information
Post-mortem examinations were carried out on the pilot and passenger by a consultant
histopathologist who concluded that both died as a result of multiple injuries sustained in
the accident. Toxicology test for drugs and alcohol for the pilot were negative and a level
of 1.9% of carboxyhaemoglobin was recorded.
A review of the reports at the RAF Centre of Aviation Medicine concurred that the injuries
sustained by the pilot and passenger were consistent with decelerations sustained by
the aircraft impacting the ground and, given the level of carboxyhaemoglobin recorded,
it was unlikely that they had been exposed to excess carbon monoxide prior to their
deaths.

Aircraft’s information manual
The ‘Piper Arrow IV Information Manual’ states in the ‘ENGINE POWER LOSS IN FLIGHT’
checklist ‘trim for 79 KIAS’. It also states in the section titled ‘STALLS’:
‘An approaching stall is indicated by a stall warning horn which is activated

between five and ten knots above the stall speed [58 to 63 KIAS]…
The gross weight stalling speed of the Arrow IV with power off and full flaps is
53 KIAS. With flaps up this speed is increased 6 KTS...’
Recorded information
Radar returns from the aircraft were recorded for the flight starting shortly after takeoff
from Southend and stopping when the aircraft was about 0.25 nm from the accident site.
The returns included height information (rounded to the nearest 100 ft) and indicated that
the cruise altitude for the flight was about 4,300 ft amsl. A composite radar track of the
last 17 minutes of flight from the Cromer and Debden radar heads is shown in Figure 2
and an expanded plot of the final phase is shown in Figure 1.
Figure 2
Portion of radar track of G-BHAY – final 17 minutes

The aircraft crossed the coastline at 0951:30 hrs and started to descend 30 seconds later.
After a further 1 minute 17 seconds (about 3 nm from the coastline crossing) the pilot made
the MAYDAY radio transmission (RTF) to D&D (Figure 1).
The pilot then commenced a 180° turn to the left1 during which he passed his MAYDAY
message and reported the aircraft’s altitude as 3,300 ft. He completed the message about
halfway through the turn, as the sound from the engine (recorded on the RTF) became
distinctively rough sounding. The aircraft had descended about 600 ft since the initial
MAYDAY call.
At 0954 hrs, with the aircraft now on a reciprocal heading, the pilot changed the radar
transponder Mode A squawk to 77002. He then turned the aircraft further to the left towards
the nearest point on the coastline, which he crossed 90 seconds later, at about 1,800 ft amsl.
At this point he reported the “engine has failed”, before turning onto a southerly track parallel
to the coastline. This was just over five minutes since the aircraft started descending over
the Wash and about 2.5 minutes after the initial MAYDAY call.
The aircraft continued to descend with the pilot making a RTF transmission at 0956:45 hrs
stating that he was “passing one thousand two hundred feet now” and that “it’s gonna be
a field”. The last radar return was at 0957:23 hrs with the aircraft at about 500 ft amsl,
0.25 nm to the north of the eventual accident site. The average descent rate during the
descent from 4,300 ft was about 700 ft/min and groundspeed averaged over the last minute
was 60 kt.
Aircraft description
The Piper PA-28RT Cherokee Arrow IV is a four-seat, all-metal, low-wing, single-engine

aeroplane fitted with a ‘T’ tailplane and retractable tricycle landing gear.
The aircraft has conventional flying controls, mechanical trim in the elevator and rudder
systems and three-position trailing edge flaps, operated mechanically by a floor-mounted
lever in the cockpit. The stall warning system consists of a small pivoted tab, on the leading
edge of the left wing, which moves upwards with the onset of stall and sets off an electrical
warning buzzer in the cockpit.
The landing gear is retracted by an electrohydraulic system, with hydraulic pressure

supplied by an electric pump in the rear fuselage. The landing gear is operated by a
two‑position toggle lever in the cockpit, next to the engine and propeller controls, and
below are three landing gear status indicators. There was a landing gear automatic
extension system originally included on the PA-28RT models but in G-BHAY this feature
had been removed.
Footnote
1
At this point, the coastline closest to the aircraft was behind and to its right at less than 2 nm.
2
7700 is the code to indicate to ATC that the aircraft is in distress. It shows ATC and other radar listening
stations that an aircraft is in difficulties and enables position and altitude information to be seen.

The aircraft is fitted with a Lycoming IO-360-C1C6 four-cylinder piston engine, normally
aspirated with mechanical fuel injection and driving a two-blade constant speed propeller.
The cylinders are numbered one to four3 and the lubricating oil pump is driven directly from
the end of the crankshaft. There are two overhead valves per cylinder, opened by rockers
and push rods and closed by dual concentric springs. There is a single camshaft driven
by the crankshaft through the first stage of the accessory gear train and hydraulic tappets
and followers lift the push rods. The crankshaft is a single piece forging, carried on three
main white metal bearings and oilways through the crankshaft enable the delivery of oil
to the big‑end bearings. There is a centrifugal bobweight damper between the No 3 and
No 4 big‑end bearings.
Engine lubrication is by a wet-sump system with a capacity of up to eight quarts of engine oil,
six quarts being considered the normal level shown on a calibrated dip stick. Oil pressure
is generated by the single-stage gear pump and oil is drawn from the bottom of the sump
and delivered by the pump through a cartridge filter into the galleries and drillings within the
crankcase to distribute it around the engine. Oil to lubricate the main and big-end bearings
is delivered through the main bearing webs in the crankcase and the pistons and cylinders
are spray-lubricated from jets beneath each cylinder. Oil from the camshaft lifters passes
along the pushrod tubes into the rocker boxes to lubricate the rockers valves and springs
and used oil from the rocker boxes drains through external tubes into the sump. Used oil
from the crankshaft, pistons and cylinders drains directly back into the sump.
The engine has aluminium alloy pistons, each fitted with two piston rings and an oil control
ring. The oil control ring consists of a dual-rail bevelled edge ring, backed by a continuous
coil spring. There are four oil drain holes, spaced around the oil control ring grove through
the piston skirt.
The engine drives a two-blade variable pitch constant speed propeller. The pitch control
of the blades is by a piston and spring assembly which uses engine oil metered through a
mechanical governor driven by the accessory gearbox on the rear of the engine. Propeller
rpm is set by a lever next to the throttle in the cockpit.
The ignition system consists of two engine-driven magnetos and two spark plugs per cylinder.
Ignition and the magnetos are controlled by a four-position key switch in the cockpit.
Maintenance history
The aircraft had a comprehensive set of maintenance records and journey log and had
a valid Airworthiness Review Certificate scheduled to expire on 18 March 2018 following
its annual inspection on 14 March 2017. The last entry in the journey log was on
13 August 2017 and showed 31 hours remaining to its 50-hour check.
The aircraft had been owned by a syndicate since 1987 and was usually kept in a hangar
at Newcastle International Airport, maintained on behalf of the syndicate by an aircraft
Footnote
3
The No 1 and No 2 cylinders are on the front right and left side of the engine and the No 3 and No 4 cylinders
are on the rear right and left side of the engine.

maintenance company based at Carlisle. The aircraft log book shows that it had been flown
by only two different people, with most of the flying by the accident pilot.
Only one flight (in October 2015) was recorded in the journey log between January 2015
and October 2016. The aircraft had been parked outside at Newcastle, some 9 nm from
the sea, from November 2015 to July 2016, including a prolonged period of inclement
weather during December 2015. It is not known whether measures were taken to prevent
deterioration to the aircraft or its engine during the long period of parking.
The annual maintenance requirements during the period of inactivity of October 2015 to
October 2016 had not been carried out. On 10 October 2016, the aircraft was authorised
for a single ferry flight from Newcastle to Carlisle for the now-overdue annual maintenance
inspection, this flight was recorded in the journey log as 20 minutes. The aircraft was then
stored in a hangar at Carlisle and eventually underwent its most recent annual maintenance
inspection, during March 2017.
Annual inspection
The March 2017 annual inspection was carried out in accordance with CAP 766 Light
Aircraft Maintenance Programme. This included an engine oil and filter change and the
engine was recorded as running on Aero Castrol 80+. An engine compression check was
carried out and all the four cylinders were found to be satisfactory (‘73 or 74 over 80’),
within the limits laid down by the engine manufacturer. There were no defects recorded in
the documentation during the annual inspection. When the aircraft was released to service
it was recorded as having accumulated 4,881:30 airframe hours, 1,065:45 engine hours
and the propeller overhaul had zeroed its flying hours. The engine was last overhauled on
26 May 20044 and had thus consumed just over 50% of its 2,000-hour overhaul life at the
time of the accident.
Aircraft usage since the annual inspection
After the March 2017 annual inspection, all the flying recorded in the log was by the
accident pilot and included flights over several days through France, arriving in Menorca
on 12 July 2017. The journey from Newcastle to Menorca was via Le Touquet, Fleres, La
Roche-sur-Yon and Carcassonne and totalled a flying time of 10 hours and 45 minutes.
Whilst flying to Carcassonne, the pilot encountered a landing gear problem whereby it did
not satisfactorily indicate locked down. After visual confirmation with ATC he landed safely
and then flew on to Menorca with the gear down. In Menorca, he had three replacement
landing gear microswitch assemblies shipped and a local aircraft mechanic replaced the
microswitches on the left and right main landing gears.
Three 45-minute flights were recorded whilst the aircraft was in Menorca, between 17 July
and 13 August 2017.
Footnote
4
The time between overhauls may be carried out on a calendar 12 year or 2,000 flying hours basis. The
operator/owner can decide to apply either. The majority of engines are overhauled on a flying hours basis
but require regular inspections and checks to ensure serviceability as they often take more than 12 years to
accrue 2,000 flying hours.

Engine anti-deterioration measures
The engine contains ferrous and non-ferrous alloys; the external surfaces have anti‑corrosion
treatments such as paint or metallic plating, the internal surfaces in general rely on the
properties of the lubricating oil for protection. However, many of the internal surfaces are
subjected to heat and corrosive products during the combustion process which are kept
at bay by additives within the oil. When the engine stops running the internal surfaces
and components are left with a coating of oil but if the engine is not run for a period this
coating becomes less effective, especially if an engine is subjected to a moisture-laden
environment. Ferrous components such as the cylinder liners, crankshaft and connecting
rods can develop surface corrosion in the form of rust. In areas where there may be more
reactive deposits from the combustion process, such as the cylinder liners, surface corrosion
may develop into pitting corrosion.
There are methods to prevent deterioration by a process known as ‘inhibiting’ and the engine
manufacturer, Lycoming, issued specific guidance on this in Service Letter Number L180B,
dated 13 November 2001.
Accident site
The accident site was on private agricultural land towards the top of a berm (the old sea
wall) which formed part of the secondary inland sea defences on the north Norfolk coast.
There was a line of coniferous trees to the west of the accident site, visible in Figure 3; these
were about 25 ft high.
Figure 3
Accident site

The pilot was found in the left front seat and his passenger in the right front seat and the
aircraft was upright on a northerly heading, complete except for the upper engine cowling
which had detached during the impact and landed nearby. The windscreen had fragmented
and the fuselage distorted in the severe vertical deceleration, so that the door frames and
roof section were cut and folded back by the emergency services to release the pilot and
passenger. The landing gear had been in the down position but the nose gear had been
forced back up into its bay by the impact. The right main landing gear had been forced
rearwards and detached from the wing whilst the left had remained attached but was also
distorted rearwards.
One of the propeller blades was intact and the other blade had bent backwards under
the nose of the aircraft. The propeller showed no signs of rotating when the aircraft hit
the ground. There were no ground marks behind the aircraft and the only ground marks
apparent were within the ‘footprint’ of the aircraft which were only visible after the aircraft
was lifted during recovery.
Both wing tanks contained fuel and approximately 40 imp gal (48 US gal) were drained from
the fuel tanks at the accident site. The top of the engine was exposed and the crankcase
had a large hole near the base of the No 4 cylinder, exposing the remains of the No 4 piston
connecting rod. Figure 4 shows the damage to the crankcase.
Figure 4
Crankcase damage
The battery was damaged and was disconnected and made safe at the accident site.
The ignition master key had bent and was found on the cockpit floor; the key switch was
damaged but appeared to be in the both position.

The pilot and passenger were wearing three-point safety harnesses which had been cut
by the emergency services during the rescue operation. The safety harness webbing,
attachment points and buckles were intact and in good condition.
The luggage bay included items used in the care and maintenance of the aircraft, with a
plastic storage box carrying nine 1-litre plastic engine oil containers. Four were labelled
Total Aero DM 15W50 and five were labelled AeroShell W15W-50, all labelled in French.
The four Total containers were empty. Three microswitch assemblies were found in one
of the flight bags with associated paperwork, two in a used condition and one still in its
manufacturer’s packaging.
After the initial examination the wings were removed to enable recovery to the AAIB
headquarters for more detailed examination.
Aircraft examination
Structure
Detailed examination showed that the rudder, tailplane and elevator were attached
correctly and relatively undamaged but that the area beneath the engine and cockpit
around the fire wall was crushed and severely buckled upwards and rearwards by the
vertical deceleration when the aircraft struck the berm. The entire underside of the
fuselage was covered in engine oil and oil was still seeping from fuselage skin joints
and seams. Figure 5 shows the condition of the forward underside of the fuselage and
Figure 6 shows oil seeping from the fuselage skin joints.
Figure 5
Forward underside of the fuselage

Figure 6
Oil seeping from the fuselage skin joints
Flying controls
There was continuity of the pitch and yaw flying controls up to the instrument panel although
the elevator controls had detached from the yoke shaft linkages due to the disruption of the
firewall and cockpit floor. The elevator trim wheel position indicator showed a down (dn) trim
setting. There was no evidence of any disconnection or restriction of the controls in flight
and marks between the flaps and wings made during the impact, and the linkage and lever
positions, showed that two stages of flap had been set.
Cockpit and instruments
The nature of the impact meant that little extra useful information could be extracted from
the cockpit instruments, except for the barometric altimeter setting of 987 hPa.
None of the circuit breakers had tripped. The aircraft systems master switches were
consistent with an interrupted engine-out forced landing: battery master switches on, fuel
pump off, landing and anti-collision lights on and the pitot heat off. The transponder
‘squawk’ was set at 7700.
The stall circuit breaker was correctly set and there was electrical continuity to the warning
buzzer. The stall tab fitted to the left wing leading edge was undamaged and correctly
opened and closed the circuit when tested. The buzzer was removed and bench tested and
was found to operate correctly.
There was no evidence of fire within the aircraft or in any of its components and systems.

Survivability
The lack of ground marks behind the aircraft at the accident site and relatively flat impact
with the ground suggest the aircraft was rapidly brought to a stop by the berm. Although the
pilot and passenger were wearing their harnesses they received fatal injuries due to the rapid
vertical deceleration as the aircraft hit the ground and the structural deformation of the cockpit
area and the proximity of solid objects, such as the control yoke and instrument panel.
Propeller and engine examination
The propeller examined showed that, apart from the bent blade, the propeller was in an
‘as new’ condition which reflected its low usage since its recent overhaul and there was no
indication of pre-impact damage.
The engine was examined externally prior to strip down. The equipment fitted to the rear of
the engine and accessory gearbox, and the fuel system components, were in good condition
except some impact damage when the aircraft struck the ground.
The spark plugs were removed and examined. The No 1 and No 2 cylinder pairs of spark
plugs were heavily carbon-contaminated, with thick granular carbon. The No 2 cylinder pair
of spark plugs had no visible gap between the electrodes. In contrast, the No 3 and No 4
cylinder pairs of spark plugs were clean, with insulators and electrodes light grey-brown in
appearance, indicative of a normal ignition process.
The oil dip stick was not in contact with any oil and was dry. The underside of the sump was
covered in a film of engine oil, although there were no obvious signs of leakage or weeping
joints around the engine. However, as observed at the accident site, the crankcase had
a large hole in its upper surface through which could be seen the remains of the No 4
connecting rod big-end. There was also sign of a partial rupture near the camshaft forward
end where a piece of debris had become trapped between one of the cam lobes and the
crankcase. The internal crankcase web above the sump had also been holed by debris
impact.
The crankshaft was in one piece and but showed signs of rubbing and discolouration due
to excessive heat on the rear main journal, the No 4 crankpin and the No 2 crankpin. There
were also debris impact marks on the surfaces of the No 3 and No 4 crankpin surfaces.
Figure 7 shows the overheated condition of the No 4 crankpin.
The camshaft, pushrods and valve gear were undamaged. However, the hydraulic lifters
and followers near the crankcase hole had been ejected and were found loose in the engine
bay. In addition, several of the other cam followers were damaged because of debris impact.
When the engine was disassembled approximately one quart of lubricating oil was found
within the engine lubrication system, heavily contaminated with ferrous and non-ferrous
metallic debris. The oil pump was undamaged, free to rotate and could produce an oil flow.
The filter was intact and the element not blocked, although it contained fine debris. The oil
pick-up strainer gauze tube within the sump was completely blocked with metallic debris
along its length.

Figure 7
No 4 crankpin condition
Cylinder, piston and connecting rod examination
The No 1 and No 2 cylinder liners had linear scoring within the piston-swept area. There
was heavier localised scoring where debris had been picked up on the piston skirt and
small areas of pitting corrosion were present in both cylinders, were smoothed by the action
of the piston and oil control rings. The pitting corrosion was more prevalent in the No 2
cylinder and heavier pitting corrosion was present at the top of both cylinders, outside the
piston‑swept area. Figure 8 shows the corrosion in the No 2 cylinder.
The piston skirts were heavily scored on their lower surfaces5 due to debris entrapment.
All the piston rings were in place but were jammed in their grooves by distortion from
the scoring and the No 2 oil control ring was clogged with oily sludge and was slightly
distorted.
Significant evidence of ‘blow-by’ was present on both the No1 and No 2 piston skirts, with
associated carbon build-up around the piston crowns. The connecting rods were still
attached to the crankshaft but were dry of oil and showed evidence of excessive heat,
with the big-end bearings starting to disintegrate.
Footnote
5
In a horizontally opposed engine such as in the case the pistons are considered to present an upper and
lower surface to the cylinders.

Figure 8
An example of the pitting corrosion in the No 2 cylinder
By contrast the No 3 and No 4 pistons were in better condition and had stopped in their
respective cylinders when their big ends detached from the crankshaft. There was no
evidence of blow-by and no scoring of the piston skirts. However, the underside of the
pistons was covered in multiple debris strike marks and the No 3 connecting rod was bent
and twisted and its half-cap, end bolts and bearing shells pulverised. The No 4 connecting
rod and associated parts had similar damage and fragments of the No 3 and No 4 bearings
had evidence of excessive heating and swaging whilst under load. Figure 9 shows the
condition of the pistons and damage to the connecting rods.
Figure 9
Pistons and connecting rods

Analysis
Operational aspects
The aircraft approached the coastline west of Snettisham, Norfolk, about 2 nm north of the
accident site, at about 1,800 ft amsl. The last radar return was at about 500 ft amsl and
0.25 nm to the north of the accident site.
The aircraft’s ground speed during the last few radar returns was about 60 kt. The wind
recorded at Marham and Norwich was from 230° at 14 to 23 kt with some higher gusts. As
the aircraft flew on a southerly track, the airspeed would have been about 12 kt greater than
the ground speed; around 72 kt. Whilst this was less than the published recommended
glide speed of 79 kt, it was 13 kt above the ‘clean stall’ speed of 59 kt and 19 kt above
the ‘full flaps’ stall speed. The witness evidence, that the aircraft was subsequently seen
to stall before impacting the ground, was consistent with the ground impact, with high
vertical deceleration and low forward speed. It could not be determined when or why the
aircraft’s airspeed reduced further, towards the stall speed, but as the wind recorded was
also gusting by up to an additional 10 kt, the aircraft could have stalled partly due to a
decrease in its airspeed due to the windshear caused by the gusty wind conditions.
As the master switches were on, the aircraft’s stall warning buzzer should have sounded.
Given the stressful situation the pilot was in it is possible that he did not hear it or did not
hear it in time to respond correctly. Additionally, given the low height at which the aircraft
was seen to stall, the pilot may have been reluctant to attempt a recovery, by pitching the
aircraft down, as he may have been conscious of the vicinity of trees to the west along the
berm and wanted to attempt to clear them before lowering the nose.
Witnesses stated that they saw the aircraft with the landing gear lowered before the
accident. Examination of the aircraft after the accident found that ‘Flaps 2’ was selected,
and appeared to be trimmed for this configuration, the battery master switches were on
and the fuel pump was off. Given these facts, it is reasonable to believe that the pilot had
secured the aircraft for a forced landing and chosen a field in which to complete it before
the accident. However, it could not be determined which field he intended to land in. Had
he turned the shorter distance back towards land, right rather than left, this would have
given him more height and time over land with which to make his field choice. He may
have turned left as he was sitting in the left seat; this was the more instinctive direction
from the left seat and the land was easier to see from this seat.
Carboxyhaemoglobin levels and lack of evidence in the aircraft indicate that, despite the
pilot’s report to ATC, there was no fire. The pilot may have thought this due to fumes
entering the cabin through the aircraft’s ventilation system when the engine was failing.
Engineering
It is clear from the evidence that the engine suffered a catastrophic failure which led to its
eventual stoppage.

The No 1 and No 2 pistons show significant exhaust ‘blow-by’ and contamination of the oil
control rings and this led to the severe fouling of the No 2 cylinder spark plugs. This was
probably the point where the pilot detected the engine rough running and prompted his
mayday call. It is known that blow-by can cause pressurisation of the crankcase which in
turn causes oil to be ejected from the breather. The breather exit tube is situated behind
the nose landing gear bay on the underside of the aircraft and excessive oil loss through
the breather tends to cover the area behind the breather and be carried by the airflow
rearwards, consistent with the oil-soaked fuselage underside in this case.
As the oil was lost, the temperature of the remaining oil started to rise and this, along with
the reduced quantity, meant that lubrication of the main and big-end bearings degraded. It
is possible the oil pressure drop had an additional effect on the propeller, causing its pitch
to ‘hunt’ against the main spring in the blade pitch mechanism; this would have manifested
itself as an engine pulsation exacerbating the roughness of the engine running experienced
by the pilot.
From the rough running report to engine stop was about 2.5 minutes, heard in the background
of the ATC recordings. At some point the big-end bearings started liberating wear debris
and the evidence indicates that this was happening whilst the oil pump was attempting to
draw oil from the sump, explaining the almost total clogging of the oil pick-up strainer with
bearing material. This would cause a worsening effect on the bearings as the oil pump
struggled to maintain pressure and flow.
In general, big-end bearings are the first to suffer as a lubricating system starts to fail. In
this case, the No 4 big-end loosened as its bearing overheated, disintegrated and induced
stresses in the half-cap bolts, which failed, allowing the connecting rod to detach from the
crankshaft. This allowed the connecting rod free to flail as the engine continued to run for
its last few seconds, with the No 4 big-end half-cap, bolts and bearing remains becoming
caught up in the bobweight damper sweeping them around between it and the No 3 big-end
and connecting rod, causing it to disintegrate. The No 4 connecting rod eventually forced
its way out of the crankcase and the engine stopped.
It is noted that in similar engine failure cases in the past, AAIB experience suggests that the
No 4 piston, cylinder and associated components are usually the first to degrade and suffer
damage.
Initiating conditions
Between November 2015 and July 2016 the aircraft was parked outside at Newcastle
International Airport, nine miles from the sea and in inclement weather conditions. There
is no evidence that the engine had been inhibited during the aircraft’s period of inactivity
and it is likely that corrosion took hold during this period. This was evident in the No 1 and
No 2 cylinder walls, with localised pitting corrosion at the top of the cylinder and within
the piston-swept area. The engine manufacturer’s Service Letter (Number L180B, dated
13 November 2001) is clear on the actions to be taken to prevent engine deterioration and
notes that active corrosion can occur in a short period of time.

The subsequent annual check, in March 2017, included a compression check, within
acceptable limits. Although this is considered a good indication of cylinder, piston ring and
valve interaction, it does not necessarily show how well the oil control ring is performing
or whether the piston and oil control rings, or the cylinder walls, are starting to deteriorate.
There is no requirement to visually check the internal surfaces of the cylinders and pistons
at an annual check, so the corrosion would remain undetected and the compression test
result would not give cause for concern.
The journey log shows that from October 2015 to March 2017, only 20 minutes were
recorded as having been flown. From March 2017, the journey log showed 18 hours and
40 minutes up to 13 August 2017. If the pilot flew a similar route back through France as he
had flown outbound, it is possible that an additional 10 hours was accrued, taking the total
hours since the annual inspection to approximately 29 hours. Taking this usage pattern
into account, it is likely that most of the deterioration around the No 1 and No 2 pistons and
cylinders occurred since the annual inspection in March 2017.
Oil consumption
Discussions with the maintenance organisation suggest that it was usual for this pilot to be
well prepared and to carry extra tools, spares, fluids and personal equipment in the aircraft.
Four empty oil containers were found in the aircraft but there was no record as to when the
oil was replenished and, based on 4 litres over 29 hours, an oil consumption rate of about
0.13 litres per hour is reasonable over that period. However, engine oil consumption tends
to increase as an engine deteriorates and it is likely that this was the case in this engine.
Staff at the maintenance organisation also suggested that the pilot was particular in his
preparations for flight and that it is unlikely that the pilot would have taken off from Southend
without the oil dip stick showing at least the recommended level of six quarts in the sump.
It is not known whether the pilot had to replenish the oil at Southend to achieve that level
but it means that five quarts were lost during the 40 minute flight from Southend to the point
where the engine stopped. This suggests a rapidly increasing degradation of the engine
during this flight and this degradation may have started before he landed at Southend,
without having yet become apparent to the pilot.
Reported smoke in the cockpit
Despite the report of smoke in the cockpit made during the radio transmission, no evidence
of fire could be found in the aircraft. It is therefore likely the smoke was due to overheated
oil fumes or smoke exiting the engine through the crankcase breach, filling the engine bay
and then surrounding the nose of the aircraft before being drawn into the cabin ventilation
and heating system.
Conclusion
The accident was likely the result of the aircraft stalling at a low height from which there was
insufficient height to recover, during an attempted forced landing following a catastrophic
engine failure.

The engine failure was due to oil loss caused by damage and premature wear to the oil
control rings. The engine had been inactive for several months, and probably had not
been inhibited in accordance with the manufacturers guidance, leading to the formation of
corrosion within the engine.

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.

AAIB Bulletin: 8/2018 G-CHHF EW/G2018/01/06
SERIOUS INCIDENT
Aircraft Type and Registration: Sikorsky S-92A, G-CHHF
No & Type of Engines: 2 General Electric CT7-8A turboshaft engines
Year of Manufacture: 2011 (Serial no: 920158)
Date & Time (UTC): 29 January 2018 at 1405 hrs
Location: On approach to Scatsta Airport, Shetland
Type of Flight: Commercial Air Transport (Passenger)
Injuries: Crew - None Passengers - None
Nature of Damage: None
Commander’s Licence: Airline Transport Pilot’s Licence
Commander’s Flying Experience: 8,332 hours (of which 4,439 were on type)
Information Source: Aircraft Accident Report Form submitted by the

pilot and inquiries made by the AAIB
Synopsis
During a final approach to land at Scatsta the nose landing gear (NLG) failed to extend
despite being recycled and the use of the emergency blowdown system. The crew
declared a PAN and the decision was taken for ground crew to lever the NLG down
manually. This was successfully carried out and the helicopter landed safely. It was
found that the automatic nosewheel self-centring mechanism had not operated, causing
the nosewheels to jam the nose leg in its bay. The exact cause of the failure of the NLG
to centre the nosewheels could not be determined. The operator has taken three safety
actions.
The helicopter was on final approach to Runway 24 at Scatsta after having completed a
routine passenger flight from the Magnus offshore platform. The crew lowered the landing
gear in accordance with the approach checklist. Although the main landing gear status
lights, left and right, showed green, the NLG red unlkd caption remained. The flight crew
informed ATC that there might be a technical issue and the helicopter was flown in a visual
holding pattern but an emergency was not declared at that point. The crew followed the
operator’s ‘Emergency Operations Procedure (EOP) 8/3’, recycling the landing gear and
twice attempted a blowdown emergency extension, but these actions were unsuccessful.
The crew then declared a PAN and sought engineering advice over the radio.

The crew flew a low-level circuit during which ATC confirmed that the nose gear had not
lowered. Further engineering advice was sought and after considering various options, the
decision was taken to attempt to manually release the NLG externally. The crew briefed
the passengers and the helicopter was hover-taxied onto the apron with the emergency
services present and under marshalling supervision. The pilot stabilised the helicopter
with its mainwheels in contact with the ground and with the nose held in the air to allow
the release of the NLG. The pilot then signalled one of the operator’s engineering staff to
approach the helicopter. The engineer observed that the nosewheels were not centred
and by using a suitable length lever, he was able to re-align the wheels. The nose leg then
extended with a green ‘down and locked’ indication and the crew settled the helicopter on
the ground. A safety ground lock was fitted and the helicopter shut down without further
incident.
Helicopter description
The Sikorsky S-92A is a large twin-engine utility helicopter, designed to carry up to

19 passengers and certified for dual-pilot VFR and IFR, day and night operations.
Landing gear
The helicopter is fitted with retractable landing gear consisting of double-wheel air/oil shock
absorbers. The main landing gear is installed in the sponsons each side of the fuselage
just aft of the cabin area, and the castering nosewheel within a wheel bay beneath the
cockpit. The nose gear is non-steerable but its design allows for a 360° caster and has
a damper fitted to prevent nosewheel shimmy during taxiing. Differential braking and tail
rotor thrust are used to steer the helicopter during taxiing. The nose gear includes a feature
which self‑centres the wheels during retraction and the manufacturer comments that, when
properly serviced, the nose gear should self-centre at all angles up to 180°.
The helicopter is fitted with a landing gear emergency extension system which consists of
3,000 psi nitrogen-filled bottles attached to the nose, left and right landing gear hydraulic
actuators. An emer dn switch is located on the landing gear control panel which activates
a solenoid valve to release the gas charge into the extension side of the actuator. The
blowdown facility works regardless of the position of the landing gear control handle.
Engineering investigation
Following this incident, the helicopter was withdrawn from service and placed on jacks
to carry out fault diagnosis. Retraction checks found that the nosewheels did not initially
automatically centre but after several retraction cycles the nosewheels did centre and then
continued to work normally. However, the operator thought it prudent to reject the NLG.
The complete NLG assembly was replaced with a serviceable item and after functional
testing, the helicopter was released to service. The NLG was made safe by discharging its
gas pressure and was returned to the manufacturer for examination.
The examination showed the NLG was in a good, but well used, overall condition. There
was evidence of leakage around the hydraulic port and 3,250 ml of hydraulic fluid was
drained out of the NLG (the correct quantity should be 3,890 ml). It was observed that the

NLG was covered in ‘oily/dirty’ deposits, with water and grease residue present on the lower
piston tube and the lower cylinder cap not tightened to the correct torque. The exact cause
of the failure of the centring mechanism could not be identified. The NLG was then rebuilt,
charged and tested; it held its charge and the self-centring mechanism operated correctly.
Manufacturer’s experience of previous events
The helicopter manufacturer has investigated six reports of previous events where the NLG
was off-centre, jammed in the wheel well and failed to extend either by the primary or
secondary means. The manufacturer attributed this to improper servicing, whereby a low
oil or nitrogen charge in the strut results in the self-centring cams not interlocking correctly,
allowing the wheels to remain off-centre when the aircraft weight is ‘off-wheels’ prior to
retraction. In September 2017 the manufacturer issued a letter to operators highlighting this
potential problem and the importance of correct fluid quantity and gas charge in the NLG.
Emergency operating procedures (EOPs)
On the incident flight the crew carried out ‘EOP 8/3, Landing Gear Will Not Extend’. The
crew later observed that this procedure does not appear to take into account the situation
where, despite the emergency blowdown actions being taken, the helicopter remains in an
asymmetric landing gear configuration. However, ‘EOP 8/2, Landing with the gear retracted’
directs the crew to place the aircraft in a low hover, disembark the passengers and then,
after preparations to cushion the helicopter by ground staff, land as soon as practicable.
It also advises using the flotation gear to assist in stabilising the helicopter. In this case
the crew took these procedures into consideration but, because they were landing at a
maintenance base, they had the advantage of additional expertise on hand and the time
to identify and rectify the problem. They therefore opted for the action of levering the NLG
down. The crew consider that ‘EOP 8/3’ should cross refer to ‘EOP 8/2’ as the normal action
to be taken when maintenance base expertise is not available.
Analysis
Engineering
Although the operator was able initially to replicate the problem, the NLG then started to
self‑centre during repeated tests. However, mindful of the consequences of the same
problem happening again, away from a maintenance base, the decision was taken to return
the NLG to the manufacturer.
It is possible that the mechanical defect was so minor as not to leave any evidence to be
found at the manufacturer. The manufacturer observed that the signs of leakage around the
hydraulic port, and the oily deposits on the NLG, suggested a possible loss of oil by seepage
which found its way around the NLG external surfaces. However, the reduced fluid quantity
cannot be relied upon to support this notion as it is possible some of the oil was lost during
the discharging process, after ground testing and prior to despatch to the manufacturer. In
the absence of mechanical evidence, it is not possible to draw a conclusion as to the cause
of the malfunction of the NLG self-centring.

Operations
The crew observed that ‘EOP 8/3’ did not lead into actions to be taken in ‘EOP 8/2’ if the
problem with the landing gear remained after the prescribed attempts to lower the landing
gear. Although the operator considered both EOPs to be correct, it was acknowledged
that ‘EOP 8/3’ needs to direct the crew to ‘EOP 8/2’ more clearly. In this case the problem
was solved externally using the knowledge and expertise available at the landing site.
However, this could not be relied upon, showing the need to align the EOPs for use in a
similar incident away from a maintenance base.
Conclusion
The exact cause of the failure of the NLG to centre the nosewheels during retraction
could not be determined. However, the operator has taken steps to inform its staff of a
potential cause identified in previous cases by the manufacturer. The incident has also
highlighted a discontinuity in the operator’s emergency procedures, which have also
been addressed.
Safety actions
To reduce the risk of nosewheels not self-centring during retraction, the operator is
undertaking the following safety actions:
●● The manufacturer’s letter, ‘S92A Nose Landing Gear – Improper

Servicing’, dated 19 September 2017, will be re-iterated to the operator’s
engineering staff.
●● S-92A crews will be reminded of the need to ensure the nosewheels are
not canted off-centre after taxiing prior to takeoff (although this does not
appear to have been a factor in this incident).
●● The operator has also reviewed the EOPs and EOPs 8/2 and 8/3 have
been amended and re formatted as EOP 13/2 and 13/4. EOP 13/2 now
draws the crew’s attention to EOP 13/4 and the actions to be taken to
ensure a safe landing with the leading gear retracted, or in an asymmetric
configuration.

AAIB Bulletin: 8/2018 G-HALJ EW/G2018/03/01
ACCIDENT
Aircraft Type and Registration: Cessna 140, G-HALJ
No & Type of Engines: 1 Continental Motors Corp C85-12F piston

engine
Date & Time (UTC): 5 March 2018 at 1355 hrs
Location: Peterborough Conington Airfield, Cambridgeshire
Type of Flight: Training
Persons on Board: Crew - 2 Passengers - None
Injuries: Crew - None Passengers - N/A
Nature of Damage: Damage to propeller, cowling, wingtip and

engine shock‑loaded


pilot
The flight was the second training sortie of the day with the same student and consisted
of three landings and two go-arounds after bounced landings. After touching down on the
planned final landing, the student started to lose directional control. The instructor took
control but did not have sufficient time to communicate this. Reacting to the situation,
the student applied the brakes, tipping the aircraft onto its nose. The occupants were
uninjured but the aircraft was damaged. The instructor stated that he should have taken
control sooner but there was not much time to react.

AAIB Bulletin: 8/2018 G-KTTY EW/G2018/06/10
ACCIDENT
Aircraft Type and Registration: Denney Kitfox MK3, G-KTTY
No & Type of Engines: 1 Rotax 582 piston engine
Year of Manufacture: 1994 (Serial no: PFA 172-12001)
Date & Time (UTC): 9 June 2018 at 1738 hrs
Location: Manchester Barton Airport
Type of Flight: Training
Nature of Damage: Slight bend to right main landing gear. Tailwheel

shear pin failed. Hairline cracks to left and right
fibreglass downward winglets


pilot
The handling pilot had recently bought G-KTTY and had arranged for type conversion
training through the Light Aircraft Association. The accident flight was the owner’s second
training detail and started with circuit practice at Manchester Barton Airport. On the
first circuit, the aircraft landed firmly due to a high sink rate at touchdown. On the next
circuit the flight parameters at the threshold were similar, resulting in a second baulked
landing go‑around. In the initial stages of this go-around, the aircraft’s nose pitched up
significantly and the aircraft stalled, leading to a wing drop and heavy landing on the right
main landing gear. Shortly after touchdown, the right wingtip came into contact with the
runway, precipitating a ground loop through 180° to the right, during which the left wingtip
also touched the ground before the aircraft came to rest on its wheels.
The pilot reported that the incident was a result of his lack of familiarity with the nose-up
attitude required for a go-around. He found it difficult to perceive the correct climb attitude
due to the aircraft’s nose obscuring forward vision of the horizon; the lack of an artificial
horizon for cross‑reference further hindered his assessment of the required pitch attitude.

AAIB Bulletin: 8/2018 G-AXBW EW/G2018/04/08
ACCIDENT
Aircraft Type and Registration: DH82A Tiger Moth, G-AXBW
No & Type of Engines: 1 De Havilland Gipsy Major 1C piston engine
Date & Time (UTC): 17 April 2018 at 1100 hrs
Location: Wishanger Park, Frensham, Surrey
Nature of Damage: Damage to landing gear, wings, propeller and

engine cowling
Last 90 days - 1 hour

pilot
The pilot in command (PIC), flying in the front seat, was providing familiarisation training
for a new syndicate member, who was in the rear seat. The wind was assessed to be
approximately 12 kt at 25° from the left; within, but close to, the crosswind limit for the
takeoff. The PIC was satisfied that the new syndicate member was a capable pilot and
allowed him to have control for the takeoff. During the takeoff roll, the aircraft became
airborne 5 kt below the normal ‘unstick’ speed. At this time, the PIC called “airspeed” and
was about to take control when a gust lifted the left wing. The right wing stalled, causing
the aircraft to descend and turn to the right from a height of approximately 10 ft. The
aircraft struck a wooden fence running parallel to the grass runway and came to rest on
its nose with a buckled landing gear (Figure 1).
The PIC considered that, although the new syndicate member showed good confidence in
being able to cope with gusty conditions, he should have demonstrated a gusty crosswind
takeoff before allowing the less experienced pilot to take off in such conditions.

AAIB Bulletin: 8/2018 G-AXBW EW/G2018/04/08
Figure 1
G-AXBW where it came to rest to the right of the grass strip

AAIB Bulletin: 8/2018 G-RICS EW/G2018/04/15
ACCIDENT
Aircraft Type and Registration: Europa, G-RICS
No & Type of Engines: 1 Rotax 912 ULS piston engine
Year of Manufacture: 1997 (Serial no: PFA 247-12747)
Location: Baynards Farm, Ellens Green, Surrey

Injuries: Crew - 1 (Minor) Passengers - N/A
Nature of Damage: Substantial
Commander’s Licence: National Private Pilot’s Licence
Commander’s Flying Experience: 434 hours (of which 385 were on type)

pilot
The accident occurred on landing after a brief flight in the local area; the weather was
benign. The pilot flew a stable approach with full flaps into a slight headwind. However,
at touchdown, the aircraft bounced about three feet and he elected to go around.
He set full power with the propeller in full fine pitch, but then lost directional control; the
nose yawed to the left and the left wing dropped. He noted that the loss of directional
control seemed rapid at the low speed being flown. The nose and left wingtip struck the
grass 10 m from the edge of the runway and the aircraft slid a further 10 m off the side
of the grass strip. The pilot suffered only minor injuries but the aircraft was severely
damaged.
The pilot, who had landed many times at this airstrip, thought that his limited flying in the
previous four months could have been a factor. He also commented that pilots of “aircraft
that have ‘springy’ undercarriages would benefit from occasional touch-and-go practice
at a suitable airfield”.

AAIB Bulletin: 8/2018 G-RWCA EW/G2018/04/03
ACCIDENT
Aircraft Type and Registration: Piper PA-18-150 Super Cub, G-RWCA
No & Type of Engines: 1 Lycoming O-320-A2B piston engine
Year of Manufacture: 1982 (Serial no: 18-8309010)
Location: Beccles Airfield, Suffolk
Nature of Damage: Propeller blade bent, engine shock-loaded and

damage to wings, fin, rudder and windscreen

pilot
Synopsis
The pilot made a precautionary landing at Beccles Airfield following an engine oil leak and
a reduction in oil pressure. This was the first time that the pilot had landed a tailwheel
aircraft on a hard surface. During the ground run the aircraft started to ground loop, then
nosed over and came to rest inverted.
A photograph of the aircraft taken by the pilot following the accident is at Figure 1.
The pilot departed from his home airfield at Crowfield, near Norwich, on a cross country
flight in a PA-18-150 aircraft fitted with a tailwheel.
When the aircraft was abeam Lowestoft, at a height of 1,900 ft, the pilot became aware
that oil was dripping onto his left leg. As the oil pressure was satisfactory, at approximately
70 psi, he decided to return to Crowfield which was approximately 20 to 25 minutes away.
However, the oil continued to drip onto his leg and cockpit floor, and the oil pressure
reduced to 60 psi, which was at the bottom of the green arc on the oil pressure gauge.
The oil temperature was normal. The pilot, therefore, decided to make a precautionary
landing at Beccles, which was close by. While the pilot did not make an emergency radio
call, he did advise the radio operator at Beccles of the situation and joined the circuit late
downwind to land on Runway 09.

Figure 1
Accident site
(photograph by permission of the pilot)
The pilot was concerned that the engine might fail and, therefore, decided to fly a high
approach, initially aiming for a touchdown point halfway along the concrete section of
the runway with the intention of stopping on the grass section of the runway. However,
following a subsequent exchange with the radio operator at the airfield, the pilot believed
that he was only permitted to land on the concrete section of the runway. This would have
been his first landing of a tailwheel aircraft on a hard surface.
The pilot reported that there was a 10 kt crosswind and he was slightly fast and high as
he crossed the threshold with full flap selected. The aircraft floated for some distance
and bounced following the initial touch down before settling down in a three-point landing
attitude. The pilot was aware of the end of the concrete section of the runway approaching
and attempted to correct a yaw to the right by the application of full left rudder; he did not
apply the wheel brakes. However, as the aircraft decelerated it yawed to the right and the
main wheels ran onto the grass and the soft ground at the edge of the runway, causing
the aircraft to slowly nose over and come to rest in an inverted attitude. The pilot was
uninjured.
Beccles Airfield
Beccles Airfield has one runway, aligned 09/27. The surface of the first 500 m of
Runway 09 is concrete and the remaining 250 m is covered in grass. The LDA is 624 m.
A Google Earth image of the airfield is at Figure 2.

Concrete surface Grass surface

Rwy 09
Figure 2
Beccles Airfield

AAIB Bulletin: 8/2018 N7832P EW/G2018/02/09
ACCIDENT
Aircraft Type and Registration: Piper PA-24-250 Commanche, N7832P
No & Type of Engines: 1 Lycoming 0-540 Series piston engine
Year of Manufacture: 1962 (Serial no: 24-3052)
Date & Time (UTC): 18 February 2018 at 1330 hrs
Location: Chiltern Air Park, Oxfordshire

Nature of Damage: Damage to propeller and fuselage underside


pilot
The pilot had departed from Benson airfield to carry out circuits at Chiltern Air Park which
is located 4 nm south of Benson. He had spoken to the owner of Chiltern Air Park to
obtain permission and check the runway conditions. After joining the circuit at Chiltern
he omitted to select the landing gear down during his downwind checks. During the
base and final legs he was focussed on avoiding ‘noise abatement’ areas, and although
he recalled performing a ‘reds, blues, greens’1 ‘touch drill’ check, he did not consciously
check that the green landing gear lights were on. The aircraft touched down lightly on the
grass and came to rest on its underside.
The pilot stated that due to the short distance between Benson and Chiltern it was a very
quick transition from climb-out, departure checks before needing to focus on joining the
circuit. His focus on maintaining a good look-out for other aircraft and correctly joining
the circuit contributed to him rushing his downwind checks. He thinks he said the word
“undercarriage” on the downwind check but carried out a ‘touch drill’ without manually
selecting the gear down.
Footnote
1
The ‘reds, blues, greens’ check on finals is to check that the red mixture lever and blue propeller speed lever
are set to full forward and that three landing gear lights are illuminated green to indicate that all three landing
gear legs are down and locked.

AAIB Bulletin: 8/2018 G-FFFA EW/G2018/04/11
ACCIDENT
Aircraft Type and Registration: P&M Aviation PulsR, G-FFFA
Location: Manton Airfield, Wiltshire
Nature of Damage: Substantial damage to wing, landing gear

fairing, fuselage and propeller

pilot
Synopsis
During landing, the left wheel struck the edge of a hollow which caused the aircraft to
bounce and roll to the right. The right wingtip touched the ground and the aircraft pirouetted
almost 180° before coming to rest on its right side.
The aircraft was being flown from Cotswold Airport, Gloucester to the manufacturer’s
facility, at Manton Airfield, Wiltshire for its annual inspection and renewal of the Permit
to Fly. The wind conditions were 180° at 10 kt and the pilot elected to use Runway 27,
which is a 350 m mown and rolled grass farm field strip, with a steep taxiway down to the
manufacturers facility (Figure 1).
The pilot flew a low pass at approximately 100 ft to ensure the runway was clear and then
proceeded to land normally. After approximately 100 m of the landing roll and at 30 kt, the
left wheel struck the edge of a hollow, which caused the aircraft to bounce and roll to the
right. The right wingtip touched the ground and the aircraft pirouetted almost 180° before
coming to rest on its right side (Figure 2). The pilot made the aircraft safe and exited
from the cockpit uninjured. It was later noted by the manufacturer that ground near the
threshold of Runway 27 may have been disturbed by animal activity.

AAIB Bulletin: 8/2018 G-FFFA EW/G2018/04/11
Accident site
X
27
Taxiway

Figure 1
Accident site – Manton Airfield, Wiltshire

Figure 2
G-FFFA after landing

AAIB Bulletin: 8/2018 G-CEZX EW/G2018/06/01
ACCIDENT
Aircraft Type and Registration: P&M Aviation Quik GT450, G-CEZX
Date & Time (UTC): 2 June 2018 at 1330 hrs
Location: Abergavenny Airfield, Monmouthshire
Nature of Damage: Extensive damage to the wing, landing gear

fairings and propeller


pilot
Synopsis
The aircraft was taking off from Abergavenny and had climbed to approximately 40
to 50 ft agl when it encountered significant turbulence. This caused the aircraft to
weathercock, roll to the right and descend, all of which the pilot was unable to counteract.
The aircraft landed heavily and as the mainwheels contacted the ground, the right wing
tip struck some shrubs near the side of the runway and spun the aircraft through 180°.
Although the aircraft remained upright, and there were no injuries to the pilot or passenger,
substantial damage was caused to the wing, propeller, landing gear and fairings. The
pilot considered the cause was likely to have been a low-speed wing stall, compounded
by the variability of the wind and the effect of the tree line alongside the runway.
The pilot had flown his aircraft from Redlands with a passenger earlier in the day and
observed that the wind and level of turbulence had increased as he crossed the River
Severn into Wales. During his approach to Abergavenny, he also observed the wind
sock was indicating the wind straight down Runway 15 and appeared to be at least 12 to
15 kt. The pilot was unhappy with his final approach, considered it to be unstable and
decided to go around. His second attempt was uneventful and he landed. After a short
stop the pilot and his passenger prepared for departure to fly to Kemble. During the
preparations they held a discussion regarding the effects of the slight upslope of the

AAIB Bulletin: 8/2018 G-CEZX EW/G2018/06/01
runway, the variable wind conditions and the parallel tree line separating the airfield from
the A40 (dual carriageway).
The pilot lined up the aircraft on Runway 15 and applied full power and held the control bar
back to allow the aircraft to build up speed on the upslope. Rotation appeared normal but
as the aircraft achieved 40 to 50 ft agl it encountered significant turbulence, causing it to
weathercock, roll to the right and descend. The pilot was unable to counteract this and,
mindful of the proximity of the road on the right, tried to steer to the left but found he had
limited control authority. The aircraft continued to descend and was now about 10 to 15 m
from the right edge of the runway, so the pilot reduced the power and landed heavily. On
landing, the right wing tip contacted shrubs at about the same time the mainwheels touched
the ground and the aircraft immediately spun around through 180° but remained upright.
The ground impact caused damage to the wing and airframe structure, propeller, mainwheel
and cockpit fibreglass fairings. The pilot and passenger were uninjured.
Discussion
In the pilot’s own analysis of the event, he considers that several factors conspired to
cause the accident. He believes that the wing stalled, resulting in the loss of control
authority, compounded by the turbulence created by the wind striking the trees. He
considers that the stall was due to the slightly low airspeed on takeoff, because of the
upslope of the runway.

AAIB Bulletin: 8/2018 G-CEMZ EW/G2018/05/14
ACCIDENT
Aircraft Type and Registration: Pegasus Quik, G-CEMZ
No & Type of Engines: 1 Rotax 912ULS piston engine
Date & Time (UTC): 12 May 2018 at 1541 hrs
Location: Carrickmore Airfield, Northern Ireland
Injuries: Crew - 1 (Minor) Passengers - N/A
Nature of Damage: Damage to trike unit and wing

pilot
The pilot stated that he was flying into Carrickmore Airfield having flown from Hunsdon,
Hertfordshire. At the time the weather was fine and the wind was from 200° at 8 kt with
“slight gusts”.
As the aircraft approached the airfield, two other aircraft transmitted that they were
back‑tracking Runway 26 to depart. As the accident aircraft turned onto final the last
departing aircraft took off. After crossing the threshold, the pilot attempted to flare the
aircraft, but it continued to descend and landed firmly on the asphalt runway. It bounced
onto grass to the right of the runway nosewheel first, causing the aircraft to nose‑over
before coming to rest on its right wing (Figure 1). The pilot was assisted out of the aircraft
having sustained minor injuries.
The pilot reported that being cold after the flight from Hunsdon may have affected his
judgment. He also believed he was distracted by the departing aircraft, causing him
to slow down to increase separation from them, and that consequently the aircraft had
insufficient airspeed to flare properly and stalled onto the runway.

AAIB Bulletin: 8/2018 G-CEMZ EW/G2018/05/14
Figure 1
G-CEMZ landing on its nosewheel

AAIB Bulletin: 8/2018 G-TBLB EW/G2018/04/05
ACCIDENT
Aircraft Type and Registration: Quik GT450, G-TBLB
No & Type of Engines: 1 Rotax 912-UL piston engine
Location: Longford Airfield, Shropshire
Injuries: Crew - N/A Passengers - N/A
Nature of Damage: Damage to pod and wing


pilot
The pilot planned to fly his aircraft from Arclid Airfield to Longford Airfield for its Permit to
Fly inspection. He noted that the weather forecast both at the departure and destination
airfields was light rain and upon arriving at Longford Airfield, the weather was worsening
but the pilot considered that it was still safe. On touchdown, the aircraft landed heavily and
bounced resulting in damage to the pod and wing.
The uninjured pilot was wearing a lap and diagonal harness and helmet. He reflected that,
during training, in the event of ‘ballooning’ on landing, he was taught to go around, but in
this case he attempted to recover the landing.

AAIB Bulletin: 8/2018 G-MARO EW/G2018/05/27
ACCIDENT
Aircraft Type and Registration: Skyranger J2.2(2), G-MARO
No & Type of Engines: 1 Jabiru 2200 Piston Engine
Year of Manufacture: 2004 (Serial no: BMAA/HB/348)
Date & Time (UTC): 19 May 2018 at 1330 hrs
Location: Strathaven Airfield, South Lanarkshire
Persons on Board: Crew -1 Passengers - 1
Nature of Damage: Right and nose landing gear, airframe, engine,

propeller, cowling and right wing damaged


pilot
The pilot was conducting touch-and-go landings to maintain skills and demonstrate the
aircraft to the passenger who was a new syndicate member. The wind was reported as
south‑south‑west at 15 kt, a few knots higher than forecast. On the third approach to
Runway 16, the aircraft was handling normally, crabbing into the crosswind during the
approach. On crossing the runway threshold the pilot rounded out and began to straighten
and flare the aircraft. The pilot sensed the aircraft begin to sink and elected to go around
but it landed hard and the nose gear and right main gear collapsed before the aircraft slid to
a stop. The occupants were uninjured.
The pilot stated that the wind conditions were more difficult than anticipated. His first choice
of runway, Runway 23, was made unavailable as a crew were setting up a banner for
a banner towing aircraft. Runway 16 was the best remaining option as a third option,
Runway 27, would have had a crosswind component at the maximum demonstrated for the
aircraft.

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).

AAIB Bulletin: 8/2018 G-MAJC EW/G2017/10/06
BULLETIN CORRECTION
Aircraft Type and Registration: Jetstream 4100, G-MAJC
Date & Time (UTC): 16 October 2017 at 0835 hrs
Location: Hawarden Airport
Information Source: Aircraft Accident Report Form
AAIB Bulletin No 7/2018, page 62 refers
In the original report, two items of safety action were omitted:
Met Office systems allow a SIGMET to be issued that contains smoke related
information and, although it is not compliant with the ICAO format or existing
templates, a test showed that it was compatible with NATS’s systems. In future
a SIGMET will be issued when NATS informs the Met Office there is significant
smoke in the atmosphere that is affecting aircraft operations.
Work is being undertaken to see whether a ‘Securité’ message broadcast on

121.500 MHz could be used to promulgate a safety message concerning smoke
in the UK FIR.
The above safety items were added to the online version prior to publication.

TEN MOST RECENTLY PUBLISHED

FORMAL REPORTS
ISSUED BY THE AIR ACCIDENTS INVESTIGATION BRANCH
1/2014 Airbus A330-343, G-VSXY 3/2015 Eurocopter (Deutschland)

at London Gatwick Airport EC135 T2+, G-SPAO
on 16 April 2012. Glasgow City Centre, Scotland
Published February 2014. on 29 November 2013.
Published October 2015.
2/2014 Eurocopter EC225 LP Super Puma
G-REDW, 34 nm east of Aberdeen, 1/2016 AS332 L2 Super Puma, G-WNSB
Scotland on 10 May 2012 on approach to Sumburgh Airport
and on 23 August 2013.
G-CHCN, 32 nm south-west of
Sumburgh, Shetland Islands Published March 2016.
on 22 October 2012.
2/2016 Saab 2000, G-LGNO
Published June 2014. approximately 7 nm east of
Sumburgh Airport, Shetland
3/2014 Agusta A109E, G-CRST on 15 December 2014.
Near Vauxhall Bridge,
Central London Published September 2016.
on 16 January 2013.
1/2017 Hawker Hunter T7, G-BXFI
Published September 2014. near Shoreham Airport
on 22 August 2015.
1/2015 Airbus A319-131, G-EUOE
London Heathrow Airport Published March 2017.
on 24 May 2013.
1/2018 Sikorsky S-92A, G-WNSR
Published July 2015.
West Franklin wellhead platform,
North Sea
2/2015 Boeing B787-8, ET-AOP
on 28 December 2016.
London Heathrow Airport
on 12 July 2013. Published March 2018.
Published August 2015.
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

Farnborough House AAIB Bulletin: 8/2018
Berkshire Copse Road
Aldershot GLOSSARY OF ABBREVIATIONS
Hants GU11 2HH
aal above airfield level lb pound(s)
ACAS Airborne Collision Avoidance System LP low pressure
ACARS Automatic Communications And Reporting System LAA Light Aircraft Association
Tel: 01252 510300 LDA Landing Distance Available
ADF Automatic Direction Finding equipment
Fax: 01252 376999 AFIS(O) Aerodrome Flight Information Service (Officer) LPC Licence Proficiency Check
Press enquiries: 0207 944 3118/4292 agl above ground level m metre(s)
http://www.aaib.gov.uk AIC Aeronautical Information Circular MDA Minimum Descent Altitude
amsl above mean sea level METAR a timed aerodrome meteorological report
AOM Aerodrome Operating Minima min minutes
APU Auxiliary Power Unit mm millimetre(s)
ASI airspeed indicator mph miles per hour
ATC(C)(O) Air Traffic Control (Centre)( Officer) MTWA Maximum Total Weight Authorised
ATIS Automatic Terminal Information Service N Newtons
ATPL Airline Transport Pilot’s Licence NR Main rotor rotation speed (rotorcraft)
AAIB investigations are conducted in accordance with BMAA British Microlight Aircraft Association N g Gas generator rotation speed (rotorcraft)
BGA British Gliding Association N1 engine fan or LP compressor speed
Annex 13 to the ICAO Convention on International Civil Aviation, BBAC British Balloon and Airship Club NDB Non-Directional radio Beacon
EU Regulation No 996/2010 and The Civil Aviation (Investigation of BHPA British Hang Gliding & Paragliding Association nm nautical mile(s)
CAA Civil Aviation Authority NOTAM Notice to Airmen
Air Accidents and Incidents) Regulations 2018. CAVOK Ceiling And Visibility OK (for VFR flight) OAT Outside Air Temperature
CAS calibrated airspeed OPC Operator Proficiency Check
cc cubic centimetres PAPI Precision Approach Path Indicator
The sole objective of the investigation of an accident or incident under these CG Centre of Gravity PF Pilot Flying
Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PIC Pilot in Command
CPL Commercial Pilot’s Licence PNF Pilot Not Flying
purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true POH Pilot’s Operating Handbook
CVR Cockpit Voice Recorder PPL Private Pilot’s Licence
DME Distance Measuring Equipment psi pounds per square inch
Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed QFE altimeter pressure setting to indicate height
or blame or determine liability, since neither the investigation nor the reporting EASA European Aviation Safety Agency above aerodrome
ECAM Electronic Centralised Aircraft Monitoring QNH altimeter pressure setting to indicate
process has been undertaken for that purpose. EGPWS Enhanced GPWS elevation amsl
EGT Exhaust Gas Temperature RA Resolution Advisory
EICAS Engine Indication and Crew Alerting System RFFS Rescue and Fire Fighting Service
EPR Engine Pressure Ratio rpm revolutions per minute
ETA Estimated Time of Arrival RTF radiotelephony
ETD Estimated Time of Departure RVR Runway Visual Range
FAA Federal Aviation Administration (USA) SAR Search and Rescue
FDR Flight Data Recorder SB Service Bulletin
FIR Flight Information Region SSR Secondary Surveillance Radar
FL Flight Level TA Traffic Advisory
ft feet TAF Terminal Aerodrome Forecast
AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAS true airspeed
g acceleration due to Earth’s gravity TAWS Terrain Awareness and Warning System
http://www.aaib.gov.uk TCAS Traffic Collision Avoidance System
GPS Global Positioning System
GPWS Ground Proximity Warning System TGT Turbine Gas Temperature
hrs hours (clock time as in 1200 hrs) TODA Takeoff Distance Available
HP high pressure UAS Unmanned Aircraft System
hPa hectopascal (equivalent unit to mb) UHF Ultra High Frequency
IAS indicated airspeed USG US gallons
IFR Instrument Flight Rules UTC Co-ordinated Universal Time (GMT)
This bulletin contains facts which have been determined up to the time of compilation. ILS Instrument Landing System V Volt(s)
IMC Instrument Meteorological Conditions V1 Takeoff decision speed
Extracts may be published without specific permission providing that the source is duly acknowledged, the material is
IP Intermediate Pressure V2 Takeoff safety speed
reproduced accurately and it is not used in a derogatory manner or in a misleading context. IR Instrument Rating VR Rotation speed
ISA International Standard Atmosphere VREF Reference airspeed (approach)
Published 9 August 2018 Cover picture courtesy of Stephen R Lynn
(www.srlynnphotography.co.uk) kg kilogram(s) VNE Never Exceed airspeed
KCAS knots calibrated airspeed VASI Visual Approach Slope Indicator
© Crown copyright 2018 ISSN 0309-4278 KIAS knots indicated airspeed VFR Visual Flight Rules
KTAS knots true airspeed VHF Very High Frequency
Published by the Air Accidents Investigation Branch, Department for Transport km kilometre(s) VMC Visual Meteorological Conditions
Printed in the UK on paper containing at least 75% recycled fibre kt knot(s) VOR VHF Omnidirectional radio Range
AAIB Bulletin 8/2018

TO REPORT AN ACCIDENT OR INCIDENT

PLEASE CALL OUR 24 HOUR REPORTING LINE
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TO REPORT AN ACCIDENT OR INCIDENT

SPECIAL BULLETINS / INTERIM REPORTS

SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS

AAIB FIELD INVESTIGATIONS

COMMERCIAL AIR TRANSPORT

SPORT AVIATION / BALLOONS

AAIB CORRESPONDENCE INVESTIGATIONS

COMMERCIAL AIR TRANSPORT

SPORT AVIATION / BALLOONS

© Crown copyright 2018 i All times are UTC

AAIB CORRESPONDENCE INVESTIGATIONS Cont

SPORT AVIATION / BALLOONS Cont

UNMANNED AIRCRAFT SYSTEMS

ADDENDA and CORRECTIONS

List of recent aircraft accident reports issued by the AAIB

© Crown copyright 2018 ii All times are UTC

AAIB Field Investigation Reports

The process may include, attending the scene of the accident

The investigation, which can take a number of months to complete,

© Crown copyright 2018 1 All times are UTC

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

Year of Manufacture: 1979 (Serial no: 28R-7918213)

Date & Time (UTC): 11 September 2017 at 0956 hrs

Location: Wolferton, Norfolk

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

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

Nature of Damage: Engine front fuselage, wings and landing gear

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 58 years

Information Source: AAIB Field Investigation

History of the flight

© Crown copyright 2018 3 All times are UTC

© Crown copyright 2018 4 All times are UTC

© Crown copyright 2018 5 All times are UTC

Aircraft’s information manual

‘An approaching stall is indicated by a stall warning horn which is activated

© Crown copyright 2018 6 All times are UTC

The Piper PA-28RT Cherokee Arrow IV is a four-seat, all-metal, low-wing, single-engine

The landing gear is retracted by an electrohydraulic system, with hydraulic pressure

© Crown copyright 2018 7 All times are UTC

© Crown copyright 2018 8 All times are UTC

Aircraft usage since the annual inspection

© Crown copyright 2018 9 All times are UTC

Engine anti-deterioration measures

© Crown copyright 2018 10 All times are UTC

© Crown copyright 2018 11 All times are UTC

© Crown copyright 2018 12 All times are UTC

Cockpit and instruments

© Crown copyright 2018 13 All times are UTC

Propeller and engine examination

© Crown copyright 2018 14 All times are UTC

Cylinder, piston and connecting rod examination

© Crown copyright 2018 15 All times are UTC

© Crown copyright 2018 16 All times are UTC

© Crown copyright 2018 17 All times are UTC

© Crown copyright 2018 18 All times are UTC

Reported smoke in the cockpit