AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Transcription

1 Section/division Accident and Incident Investigations Division Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY Aircraft Registration Type of Aircraft Reference: CA18/2/3/9312 ZU-EDB Date of Accident 15/04/2014 Time of Accident 1630Z MAGNI GYRO Pilot-in-command Licence Type Pilot-in-command Flying Experience Last point of departure Next point of intended landing COMMERCIAL PILOT Type of Operation Training (Part 141) Age 22 Licence Valid Valid Total Flying Hours Hours on Type 11.3 Morningstar private aerodrome Western Town Morningstar private aerodrome - Western Town Location of the accident site with reference to easily defined geographical points (GPS readings if possible) On Blouberg Farm, Cape Town at GPS co-ordinates S E at an elevation of 649ft Meteorological Information Number of people on board Synopsis Wind: 16018kt, Temperature: 19, Due Point: 09, Clouds: 030, Visibility: Good, 1+0 No. of people injured 0 No. of people killed 1 The student pilot was undergoing type training on the Magni gyro and aerial application training. That morning of the accident the pilot carried out this flight exercise with his instructor prior to the accident flight. The student pilot then went solo to repeat the exercise that afternoon. ZU-EDB was expected back at Morningstar airfield at approximately 1600Z. The City of Cape Town fire services was operating on the western site of Blouberg Hill in Cape Town area when they noticed a fire. Upon closer inspection they saw that a gyrocopter was on fire. They extinguished the fire and reported the aircraft accident to FACT ATC. The pilot was fatally injured and the aircraft was consumed by fire. The investigation revealed that the aircraft stalled during a downwind turn of the exercise and crashed resulting with the pilot being fatally injured in the process. Probable Cause Poor Technique/Airmanship Contributing factors Lack of experience for that type of aircraft and the type of operation (aerial application) Failure to follow aircraft flight manual recommendations. SRP Date 08 November 2016 Release Date CA 12-12a 20 NOVEMBER 2015 Page 1 of 14

2 Section/division Accident and Incident Investigation Division Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT Name of Owner : Klopper L P Name of Operator : Morningstar Flight Academy Manufacturer : Magni Gyro Model : Magni M16 Nationality : South African Registration Marks : ZU-EDB Place : Blouberg Farm, Western Town Date : 15/04/2014 Time : 1630Z All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. Purpose of the Investigation: In terms of Regulation of the Civil Aviation Regulations (2011) this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish legal liability. Disclaimer: This report is produced without prejudice to the rights of the CAA, which are reserved. 1. FACTUAL INFORMATION 1.1 History of Flight On the 15 April 2014 around 0800Z, ZU-EDB took off with the student pilot and his Instructor on a mission to carry out training exercise as indicated in the Morningstar student progress report records, the exercise was aerial application runs and turns practise over the field. This included co-ordinated low-level turns to practice for accuracy during aerial applications. These exercises with the instructor were concluded uneventfully at a height of 100m above ground level (AGL) according to the instructors At about 1400Z in the afternoon the student pilot took off for a solo flight to practice what he had learned earlier in the day. The student never returned at the time he was expected. His instructor took-off in another gyro to go and look for him in the area he was supposed to be practising, minutes into his (instructor) flight, the instructor was contacted by Cape Town International Tower to inform him about the aircraft accident in that area. The aircraft accident was reported by the city of Cape Town fire service to the Cape Town international airport, when they noticed the smoke as they were operating in that area after they went to investigate the source of the smoke. CA 12-12a 20 NOVEMBER 2015 Page 2 of 14

3 1.1.3 The aircraft was consumed by post impact fire and the pilot was fatally injured. The onsite investigation revealed that the aircraft lost lift during a downwind turn as the pilot was following a pattern during this exercise, refer to Figure 6 (constructed flight path for the practice). The loss of lift during a downwind turn was supported by the wreckage as found on site and the effect that, no wetness mark around the accident site to indicate any point of impact with the ground. Furthermore the wreckage was confined to one area. 1.2 Injuries to Persons Injuries Pilot Crew Pass. Other Fatal Serious Minor None Damage to Aircraft The aircraft was destroyed in the accident by fire and the wreckage was confided to one area. Refer to figure 1, 2 and figure 3 below showing the remains of ZU-EBD. Figure 1, showing the wreckage and vegetation consumed by fire. Figure 2 Figure 3 Note: figure 2 and figure 3 show the close up of figure 1 the wreckage. CA 12-12a 20 NOVEMBER 2015 Page 3 of 14

4 1.4 Other Damage The farm vegetation was consumed by fire. This farm was mainly grass for cattle grazing. Refer to figure Personnel Information Nationality South Africa Gender Male Age 22 Licence Number Licence Type CPL Licence valid Valid Type Endorsed Type not endorsed Ratings Yes Medical Expiry Date 31/08/2014 Restrictions Previous Accidents None None according to SA CAA records It should be noted that the pilot did not have this aircraft type endorsement as he was still busy with his training. Flying Experience: Total Hours Total Past 90 Days 11.3 Total on Type Past 90 Days 11.3 Total on Type Aircraft Information Airframe: Type MAGNI GYRO M16 Serial Number MTTF-007 Manufacturer MAGNI GYRO Date of Manufacture 1999 Total Airframe Hours (At time of Accident) Last MPI (Date & Hours) 5/2/ Hours since Last MPI Authority to fly (Issue Date) 08/10/2013 C of R (Issue Date) (Present owner) 12/9/2013 Operating Categories Authority to fly, certificate part 62 training CA 12-12a 20 NOVEMBER 2015 Page 4 of 14

5 Engine: Type ROTAX 914 UL Serial Number Hours since New Hours since Overhaul Propeller: Type Serial Number unknown unknown Hours since New Hours since Overhaul TBO not yet reached The propeller type and serial number could not be confirmed, as RAASA and the aircraft operator could not confirm them. However the aircraft had a valid authority to fly part 62 training. 1.7 Meteorological Information Wind direction 180 Wind speed 16KT Visibility Good Temperature 19 C Cloud cover FEW Cloud base 030 Dew point 09 C The weather info as provided in the table above is taken from South African Weather Service, aircraft accident report, record reference; ZU-EDB Aids to Navigation The aircraft was equipped with standard navigational equipment as approved by the regulator for the aircraft type. There were no recorded defects that the navigation system was unserviceable prior to or during the flight. 1.9 Communications The aircraft was equipped with standard communication equipment as approved by the regulator for the aircraft type and there were no recorded defects prior to or during the flight 1.10 Aerodrome Information The accident occurred on Blouberg Farm, Cape Town at GPS co-ordinates E at an elevation of 649ft. CA 12-12a 20 NOVEMBER 2015 Page 5 of 14

6 1.11 Flight Recorders The aircraft was not equipped with a Flight Data Recorder (FDR) or a Cockpit Voice Recorder (CVR) and neither was required by the regulations; however the Magni Gyro was fitted with the turbo control unit (TCU). The TCU could not be downloaded as it was damaged by post impact fire. See photo below Wreckage and Impact Information ZU-EDB TCU photo after the accident The aircraft wreckage was found concentrated in one area and most major components of the aircraft were accounted for. No marks on the ground were observed that could have been suggested in particular a point of impact with the ground. As the aircraft wreckage was found in one place although consumed by post-impact fire About 100 meters of vegetation around the accident site was consumed by post impact fire. Refer to figure 4. Figure 4 showing how the wreckage was found on the accident site Medical and Pathological Information The post-mortem report concluded that the cause of death was due to multiple injuries with charring Fire The aircraft was consumed by post impact fire. CA 12-12a 20 NOVEMBER 2015 Page 6 of 14

7 1.15 Survival Aspects The accident was not considered survivable due to the high impact forces; the pilot was badly injured during the impact followed by post impact fire that consumed the aircraft. The investigation also confirmed that during the post impact fire the pilot was still strapped to his seat Tests and Research The investigation focused on the type of operation the aircraft was involved in, the aircraft performance limitations as well as the pilot (student pilot). As reported to the investigator. The pilot was undergoing type training for the Magni gyro aircraft type and at the sometime training to perform aerial applications using Magni gyro aircraft when the fatal accident occurred. The investigation revealed that the pilot was recently hired by the company in Cape Town which operates Magni Gyro aircrafts for the purpose of aerial application in farms around Cape Town. The pilot was then sent for training on the aircraft type as well as aerial application training, as he was not rated on the Magni gyro and had no aerial application training or experience. Figure 5 below is the copy of the student progress report as obtained from the flying school. The student progress report shows the flight mission for the student that led to the fatal accident as the student had to sign the report after his flight. The following observations were made, based on the progress report and the interview with the school regarding the fatal flight. 1. The pilot training, the exercises completed 2. The pilot flight hours on the type. (7.7 hrs dual and 3.6 hrs solo) 3. The area at which the practice was taking place. Refer to figure 6 below. 4. The altitude the learner was supposed to practice was at 100m AGL 5. The flight pattern the learner had to follow as discussed with his instructor. Figure 5 the copy of the last entry to the pilot training progress report CA 12-12a 20 NOVEMBER 2015 Page 7 of 14

8 Following the interview with the school, the flight path as constructed as shown below in figure 6, this is base on the information provided by the School to the investigator, as indicated before the instructor went flying with the student pilot in the morning of the accident In addition to the flight path pattern as shown on figure 6 below. The investigator was also told that the operation was carried out at the height of 100m AGL over the field next to the accident site as indicated, furthermore the student pilot used the farm fencing poles as his marks to issue that he was not flying over the same sport during his exercise, as the aircraft was not fitted with the device for aerial application Due to the information provided by the school. A clear picture of the operation was established by the investigator and the amount of work the student pilot was faced with during each turn. As well as the flight height (100m AGL) the student need to maintain during this exercise. The flight path as per the pattern the pilot was following according to the training school instructor Wind direction as per the official weather report was 18016KT Starting point of the pattern Figure 6 constructed flight path for the practice Organizational and Management Information The school have approval for this type of training as this is classified as Owner training according to the regulator The academy management appeared to have a system in place, which they were following for the general flight training, which was not very specific for the gyro aircraft and aerial application training The kept good records of students and they training Additional Information None 1.19 Useful or Effective Investigation Techniques None CA 12-12a 20 NOVEMBER 2015 Page 8 of 14

9 2. ANALYSIS 2.1 The Man The pilot was training on the Magni Gyro although he was the holder of a commercial pilot licence with total flying hours. He just started his training on the Auto Gyro as well as aerial application training making use of the Magin Gyro. At the time of the accident the pilot had a total of 11.3 hours on the Magin Gyro, which comprised of 7.7 dual and 3.6 solo. According to the flight school where the pilot was doing his training, the pilot was ready for basic aerial application practice (crop spraying application) with the above training hours as he was describe as fast learner by his instructor. The amount of work the pilot was experiencing during the turn could have contributed to the accident as he had to turn and line up the aircraft with his marks on the ground (fencing poles of the farm) for his runs over the field while he still maintain the needed speed to sustain lift. 2.2 The Machine The were no abnormalities found on aircraft records, as well as on the aircraft wreckage that could have contributed to the accident during the aircraft records and wreckage examinations. The aircraft was serviceable and no defect was recorded before the fatal flight. However the operation the pilot was engaged in (aerial application practice), was out of the safe operating limits of the aircraft as indicated in the Magin Gyro M16 Tandem Trainer Flight Manual on page 66 paragraph 3.13 unusual manoeuvers, Appendix 3 Height velocity diagram and Appendix 4 manoeuvre limitations. Failure to compile with this set conditions compromised the aircraft performance characteristics. 2.3 The Environment The weather condition as provided by the South African Weather Service had no impact on the accident. Although during the turn the pilot was attempting when the aircraft accident happened, the wind direction was 180 degrees with the speed of 16KT which acted as the tail wind to the aircraft. As per the Magni Gyro Flight Manual page 66 this condition should be avoided as it may be fatal to the occupants especial at low altitude which the pilot was operating at. See figure 6 above and figure 7 below. CA 12-12a 20 NOVEMBER 2015 Page 9 of 14

10 See warning 3. CONCLUSION Figure 7: Copy of the flight manual page 66 Using the available information from the operator about the flight, the pilot and the area where the operation took place. As indicated on figure 5 to figure 7 the following conclusions were reached. The aircraft was operated out of its safe operations limits as recommended by the manufacture for safe operation. The pilot experience on the aircraft type and the type of operation was very low since he was still busy with his training. This made the exercise (aerial application) he was practicing to be even more dangerous. CA 12-12a 20 NOVEMBER 2015 Page 10 of 14

11 3.1 Findings The aircraft was registered and had a valid authority to fly certificate The aircraft had no defect that we recorded prior to the accident The school have approval for this type of training as this is classified as Owner training according to the regulator The ATO had a training program in place which they followed, which was based on fixed wing aircraft training not the gyro The pilot training was accelerated based on his flying experience of the fixed wing aircraft The aircraft was operated out of its safe operations limits as recommended by the manufacture for safe operation The school when to look for the student when he passed his flight time. 3.2 Probable Cause/s Poor Technique/Airmanship Contributing factors Lack of experience on the aircraft type and the type of operation (aerial application) Pilot failure to follow aircraft flight manual recommendations 6. SAFETY RECOMMENDATIONS 4.1 It is recommended that Director of Civil Aviation review the approval of this aircraft type (Magni Gyro) for agricultural use, as this operation poses a risk to safety as aircraft are operated outside of the manufacture s recommendations. Secondly it is recommended that SACAA review the ATO approval for pilot s training on this aircraft types. CA 12-12a 20 NOVEMBER 2015 Page 11 of 14

12 5. APPENDICES CA 12-12a 20 NOVEMBER 2015 Page 12 of 14

13 CA 12-12a 20 NOVEMBER 2015 Page 13 of 14

14 CA 12-12a 20 NOVEMBER 2015 Page 14 of 14