Z A V R Š N O I Z V J E Š Ć E

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1 REPUBLIKA HRVATSKA Agencija za istraživanje nesreća u zračnom, pomorskom i željezničkom prometu Odjel za istrage nesreća u zračnom prometu KLASA: /17-02/07 URBROJ: / Zagreb, 16. srpnja Z A V R Š N O I Z V J E Š Ć E O NESREĆI ZRAKOPLOVA PIPER PA-28, REGISTARSKE OZNAKE D-EERD 16. LIPNJA 2017, U BLIZINI ZRAČNE LUKE MALI LOŠINJ AIN04-FR-3

2 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj OBJAVA IZVJEŠĆA I ZAŠTITA AUTORSKIH PRAVA Ovo izvješće izradila je i objavila Agencija za istraživanje nesreća u zračnom, pomorskom i željezničkom prometu (u daljnjem tekstu: AIN) na temelju članka 6. stavka 1. i 2. Zakona o osnivaju Agencije za istraživanje nesreća u zračnom, pomorskom i željezničkom prometu (Narodne novine broj 54/13), članka 7. stavka 1. i 2. Statuta Agencije za istraživanje nesreća u zračnom, pomorskom i željezničkom prometu, članka 16. Uredbe (EU) br. 996/2010 Europskog Parlamenta i Vijeća o istragama i sprečavanju nesreća i nezgoda u civilnom zrakoplovstvu, odredaba Zakona o zračnom prometu (Narodne novine broj 69/09, 84/11, 54/13, 127/13 i 92/14), te na temelju poglavlja 6. Dodatka 13 ICAO. Nitko ne smije proizvoditi, reproducirati ili prenositi u bilo kojem obliku ili na bilo koji način ovo izvješće ili bilo koji njegov dio, bez izričitog pisanog dopuštenja AIN. Ovo izvješće može se slobodno koristiti isključivo u obrazovne svrhe. Za sve dodatne informacije kontaktirajte AIN. Cilj istraga koje se odnose na sigurnost, ni u kojem slučaju nije utvrđivanje krivnje ili odgovornosti. Istrage su neovisne i odvojene od sudskih ili upravnih postupaka i ne smiju dovoditi u pitanje utvrđivanje krivnje ili odgovornosti pojedinaca. Završno izvješće ne može biti korišteno kao dokaz u sudskom postupku koji ima za cilj utvrđivanje građanskopravne ili kaznenopravne odgovornosti pojedinca. AIN04-FR-03 Stranica 2/14

3 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj SADRŽAJ PODACI O DOGAĐAJU...4 ISTRAGA...4 KRATKI SADRŽAJ ČINJENICE I INFORMACIJE PODACI O LETU OZLIJEĐENE OSOBE OŠTEĆENJE ZRAKOPLOVA DRUGA OŠTEĆENJA PODACI O OSOBAMA PODACI O ZRAKOPLOVU METEOROLOŠKI PODACI KOMUNIKACIJA AERODROMSKE INFORMACIJE PODACI O UDARU I OSTACIMA ZRAKOPLOVA MEDICINSKE INFORMACIJE SPAŠAVANJE I ASPEKTI PREŽIVLJAVANJA TESTIRANJE I ISTRAŽIVANJE DODATNE INFORMACIJE ANALIZA ZAKLJUČAK NALAZI UZROK SIGURNOSNE PREPORUKE AIN04-FR-03 Stranica 3/14

4 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj PODACI O DOGAĐAJU Vrsta događaja: Nesreća Datum: 16. lipnja Lokalno vrijeme: 12:30 Mjesto: Zračna luka Mali Lošinj/Ćunski-Kandija Vrsta zrakoplova: Avion Proizvođač / model: Piper Aircraft/PA Registarska oznaka: D-EERD Vlasnik: Flugunion Seitenstetten-Biberbach Operator: Flugunion Seitenstetten-Biberbach Broj osoba u zrakoplovu: Tri Ozljede: Tri teško ozlijeđene osobe Oštećenja na zrakoplovu: Potpuno uništen ISTRAGA Agencija za istraživanje nesreća u zračnom, pomorskom i željezničkom prometu dobila je informaciju o nesreći istoga dana od strane AKZP-a i MUP-a. KRATKI SADRŽAJ Dana oko 12:30 sati, srušio se zrakoplov Piper PA-28 nakon neuspjelog prilaza na Zračnu luku Mali Lošinj. U zrakoplovu su se nalazile tri osobe, pilot i dva putnika. U ovoj nesreći su tri osobe pretrpjele teške tjelesne ozljede. Zrakoplov je u potpunosti uništen. Neposredni uzrok ove nesreće je gubitak uzgona nakon neuspjelog prilaza zrakoplova. Istragom je utvrđeno da je do nesreće došlo zbog nepravilnog održavanja brzine i položaja zrakoplova nakon neuspjelog prilaza i započinjanja procedure ponovnog prilaza. AIN nije izdala sigurnosnu preporuku. 1. ČINJENICE I INFORMACIJE 1.1. PODACI O LETU Odvijanje leta Na dan nesreće, pilot i dva putnika su poletjeli sa Zračne luke Tivat, Crna Gora, prema Zračnoj luci Mali Lošinj. Let je prijavljen pod VFR uvjetima. Let se odvijao prema planu uz dalmatinsku obalu bez poteškoća. Dolaskom u školski krug Zračne luke Mali Lošinj iz smjera juga i kontaktiranja aerodromske kontrole leta, zrakoplov započinje prilaz za uzletno sletnu stazu smjer 20. Zrakoplov ulazi u down wind leg, zatim cross wind leg te base leg za stazu, smjer 20 (Slika 1). AIN04-FR-03 Stranica 4/14

5 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj Slika 1. Putanja prilaza zrakoplova na Zračnu luku Mali Lošinj (GPS uređaj) Tijekom slijetanja, netom prije dodira kotača sa uzletno sletnom stazom, zrakoplov se zanosi u lijevu stranu, nakon čega pilot odlazi u go-around. Pilot dodaje punu snagu motora i radi odmah lijevi zaokret. Zrakoplov započinje penjanje u pravocrtnom letu pod malim kutom penjanja nakon čega započinje drugi lijevi zaokret te tada pada u lijevi kovit. U tom trenutku zrakoplov nema dovoljnu visinu za izvlačenje iz kovita i pada na brdovit teren koji je prekriven šumom i niskim raslinjem. Temeljem svjedočenja očevica, također pilota sa važečom pilotskom dozvolom, koji je nesreću promatrao s aerodroma, napravljena je rekonstrukcija putanje leta zrakoplova nakon odluke pilota zrakoplova da ide u go around (Slika 2). AIN04-FR-03 Stranica 5/14

6 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj Slika 2. Rekonstruirana putanja zrakoplova označena crvenom bojom, kako ju opisuje očevidac 1.2. OZLIJEĐENE OSOBE Ozlijeđeni Posada Putnici Ostali smrtno ozbiljno malo / ništa OŠTEĆENJE ZRAKOPLOVA Zrakoplov je pretrpio znatna strukturalna oštećenja (Slika 3) navedena u nastavku: - trup zrakoplova je po cijeloj dužini deformiran, - nosač motora je pukao na mjestu nekoliko spojeva, - oba kraka propelera su savijena, - instrument ploča je na nekoliko mjesta deformirana. Na desnom krilu se nalazi nekoliko strukturalnih oštećenja: - odvajanja oplate od rebara krila na samom vrhu krila, - odvajanje desnog krilca od krila, - savijena ramenjača krila, - puknuće oplate na nekoliko mjesta cijelom dužinom krila. Na lijevom krilu se nalazi nekoliko strukturalnih oštećenja: - oplata je savijena na nekoliko mjesta cijelom dužinom krila, - oplata odvojena od rebara krila na nekoliko mjesta. Nakon pada zrakoplova nije došlo do požara. AIN04-FR-03 Stranica 6/14

7 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj Slika 3. Zrakoplov D-EERD na mjestu nesreće 1.4. DRUGA OŠTEĆENJA Uslijed pada je oštećeno nekoliko okolnih stabala. Zbog puknuća oplate i odvajanja cijevi za gorivo, u tlo je istekla nepoznata količina goriva PODACI O OSOBAMA Pilot Muška osoba, austrijski državljanin rođen godine. Pilot je u predmetnoj nesreći upravljao zrakoplovom s lijevog prednjeg sjedišta, te je pretrpio teške tjelesne ozljede. Posjeduje pilotsku dozvolu izdanu od strane Austro Control-a sa slijedećim ovlaštenjima: MEP, SEP, TMG, Night,. Ima dugogodišnje iskustvo u letenju zrakoplovom od čak 37 godina. U Knjižici letenja ima upisanih 2557 sati naleta. Također posjeduje ovlaštenje instruktora i ispitivača za pilote. Iz navedenog možemo zaključiti da je pilot iskusan u upravljanju zrakoplovom. AIN04-FR-03 Stranica 7/14

8 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj Putnik 1 Muška osoba, austrijski državljanin rođen godine. Osoba je sjedila na prednjem desnom sjedištu te zadobila teške tjelesne ozljede Putnik 2 Muška osoba, austrijski državljanin rođen godine. Osoba je sjedila na zadnjem lijevom sjedištu te zadobila teške tjelesne ozljede PODACI O ZRAKOPLOVU Piper PA / Piper Aircraft, općenito Vrsta zrakoplova: Proizvođač / model: MTOW: Avion Piper Aircraft/PA28-181, Archer II 1156 kg Piper PA-28 zrakoplov je nisko krilni jednomotorni klipni zrakoplov metalne konstrukcije. Trup zrakoplova nije pod tlakom. Stajni trap se ne uvlači, i tipa je tricikl. Trup zrakoplova ima jedna vrata sa desne strane koja služe za ulazak posade i putnika u zrakoplov. Ovaj model zrakoplova ima ugrađena četiri sjedala. Namjena ovog zrakoplova je višestruka. Tako ovaj zrakoplov može služiti privatnim korisnicima za prijevoz putnika i prtljage, zatim školskim centrima za školovanje pilota kao i u druge sportske svrhe. Piper PA / Piper Aircraft, registarske oznake D-EERD Registarska oznaka: D-EERD Serijski broj zrakoplova: Serijski broj motora: L A Vlasnik: Flugunion Seitenstetten-Biberach Operator: Flugunion Seitenstetten-Biberach Godina proizvodnje: Predmetni zrakoplov upisan je u njemački registar civilnih zrakoplova godine. Ukupan nalet zrakoplova upisan u Knjižicu zrakoplova do nesreće iznosi sata, dok je ukupan broj ciklusa Pogonsku grupu čini jedan motor Lycoming O-360-A4M sa 180 KS (134 kw) sa ugrađenim propelerom fiksnog koraka sa dva kraka METEOROLOŠKI PODACI U vrijeme nesreće 16. lipnja u 12:37 LT, meteorološki podaci izmjereni u Zračnoj luci Mali Lošinj ukazuju na stabilno vrijeme bez oborina, s dobrom vidljivošću i slabim sjeverozapadnim vjetrom. Meteorološki uvjeti bili su povoljni za letenje predmetnim zrakoplovom i nisu bili direktni uzročnik ove nesreće. Vjetar u trenutku slijetanja je puhao iz smjera 270, brzinom od 5-7 čvorova. AIN04-FR-03 Stranica 8/14

9 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj 1.8. KOMUNIKACIJA Pilot je putem radio veze komunicirao s kontrolom zračnog prometa na Zračnoj luci Mali Lošinj AERODROMSKE INFORMACIJE Zračna luka Mali Lošinj je registrirana za javni domaći i međunarodni promet. Nalazi se na otoku Lošinju. Ima uzletno-sletnu stazu dužine 900 m, širine 30 m, smjera Opremljena je navigacijskim uređajem za neprecizni instrumentalni prilaz zrakoplova. Zračna luka sadrži jednu uzletno sletnu stazu, te dvije staze za voženje i stajanku za parkiranje zrakoplova. Na stajanki se također nalaze dva hangara za parkiranje i održavanje zrakoplova. Operator zračne luke je tvrtka Zračno pristanište Mali Lošinj d.o.o. koja također obavlja djelatnost komercijalnog prijevoza putnika sa svoja tri zrakoplova. Tijekom ljetne turističke sezone, na zračnoj luci se odvija velik broj operacija malih zrakoplova u privatne i komercijalne svrhe. S obzirom na postavljen smjer USS-e, u ljetnoj sezoni pojavom maestrala, pretežno puše bočni vjetar na uzletno sletnu stazu PODACI O UDARU I OSTACIMA ZRAKOPLOVA Zbog nedovoljne visine za izvlačenje zrakoplova iz kovita, zrakoplov se srušio na strmovit, šumom i niskim raslinjem obrasli teren (slika 4). Udaljenost mjesta pada zrakoplova od sredine praga uzletno sletne staze 20 je približno 500 metara. Slika 4. Mjesto nesreće zrakoplova D-EERD Oštećenja na zrakoplovu i okolnim stablima ukazuju da je zrakoplov prošao kroz krošnje stabala te na kraju udario u tlo (Slika 5). AIN04-FR-03 Stranica 9/14

10 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj Slika 5. Prikaz slomljenih grana i dijelova zrakoplova na krošnji okolnih stabala (označeno crvenim krugom na slici) Vlasnik zrakoplova je nakon izvršenog očevida organizirao izvlačenje zrakoplova sa mjesta nesreće. Izvlačenje ostataka zrakoplova je, zbog nepristupačnosti terena, izvršeno helikopterom privatne tvrtke za prijevoz tereta zrakom. Ostaci zrakoplova su premješteni na Zračnu luku Mali Lošinj te su dalje preuzeti od vlasnika MEDICINSKE INFORMACIJE U predmetnoj je nesreći pilot koji se nalazio na prednjem lijevom sjedalu, prošao sa višestrukim teškim tjelesnim ozljedama. Putnik koji se nalazio na prednjem desnom sjedalu je zadobio teške tjelesne ozljede. Putnik koji se nalazio na zadnjem lijevom sjedištu je zadobio teške tjelesne ozljede. Sjedala zrakoplova su opremljena sigurnosnim pojasevima koja se vežu preko struka u dvije točke. Pilot i oba putnika su bili vezani tijekom predmetne nesreće. AIN04-FR-03 Stranica 10/14

11 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj Osoba na prednjem lijevom sjedalu - pilot Nakon nesreće smješten je u bolnicu KBC Rijeka u kritičnom stanju. Liječnici osobu stavljaju u induciranu komu jer je pretrpjela teške tjelesne ozljede, odnosno ima poli traume više unutarnjih organa. Osoba na prednjem desnom sjedalu putnik 1 Putnik koji se nalazio na prednjem desnom sjedalu je zadobio teške tjelesne ozljede u vidu prijeloma lijeve nadlaktične kosti i prijeloma C6 vratnog kralješka. Primljen je u bolnicu van životne opasnosti. Osoba na stražnjem lijevom sjedalu putnik 2 Putnik koji se nalazio na stražnjem lijevom sjedalu je zadobio teške tjelesne ozljede u vidu loma lijeve ruke, slomljenog kažiprsta lijeve ruke te posjekotine iznad lijevog oka SPAŠAVANJE I ASPEKTI PREŽIVLJAVANJA Nakon pada zrakoplova u 10:37 UTC, kontrolor zračnog prometa je obavijestio vatrogasce i policiju te im dao precizne informacije o mjestu pada. Nakon 20 minuta neuspjelog traganja zbog nepreglednosti terena, polijeće zrakoplov Cessna 172 u vlasništvu Zračne luke Mali Lošinj, kako bi se što preciznije locirao zrakoplov. U 11:06 UTC, zrakoplov je lociran i vatrogasne i policijske službe su upućene na točno mjesto nesreće. Pilot i putnici su prebačeni helikopterom u KBC Rijeka TESTIRANJE I ISTRAŽIVANJE Iako informacije dobivene tijekom očevida nisu upućivale na tehnički problem sa zrakoplovom, napravljen je pregled zrakoplova na mjestu nesreće. Analiza tehničke ispravnosti zrakoplova Zrakoplov je tijekom udara u tlo znatno oštećen, i nemoguće je sa stopostotnom sigurnošću utvrditi tehničku ispravnost zrakoplova. Međutim, na zrakoplovu tijekom tehničkog pregleda, koliko su oštećenja dozvoljavala, nije pronađen očigledan mehanički kvar koji bi potencijalno onemogućio rad jednog od sustava na zrakoplovu. Sva pronađena oštećenja svojim karakteristikama upućuju da su nastala zbog udara u tlo ili u neku prepreku, poput okolnih stabala. Tehnička dokumentacija Pregledom tehničke dokumentacije utvrđeno je da je zrakoplov u trenutku nesreće imao važeću potvrdu o plovidbenosti te ostale obavezne dokumente (certifikat o buci zrakoplova, dozvola za rad radio stanice, potvrdu o registraciji zrakoplova, policu osiguranja). Također je pronađena potvrda o izvršenju 50 satnog pregleda zrakoplova, dana , na ukupnom naletu zrakoplova od sati i 2825 slijetanja. AIN04-FR-03 Stranica 11/14

12 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj DODATNE INFORMACIJE Knjižica zrakoplova U knjižici zrakoplova nisu pronađene znatne neispravnosti osim činjenice da u knjižicu zrakoplova D- EERD nije upisano vrijeme trajanja letova izvršenih godine. Izjave očevica i sudionika nesreće Izjava očevica 1 (kontrolor zračnog prometa) - koji se nalazio u kontrolnom tornju Zračne luke Mali Lošinj, putem Obveznog izvješća o događaju povezanim sa sigurnošću Očevidac navodi da je nakon upute za slijetanje na stazu 20, pri vjetru iz smjera 270 i brzini vjetra od čvorova, zrakoplov D-EERD dobio odobrenje za slijetanje. Nakon neuspjelog slijetanja bez dodira staze, zrakoplov je zatražio go-around. Nakon odobrenja kontrolora za go-around proceduru, zrakoplov skreće lijevo i postiže brzinu, međutim iznenada se zrakoplov rotira oko horizontalne osi i pada. Kontrolor nakon pada zrakoplova obavještava vatrogasnu i policijsku jedinicu i koordinira potragu za zrakoplovom. Izjava očevica 2 (pilot) - koji se nalazio na Zračnoj luci Mali Lošinj i gledao predmetni zrakoplov Očevidac navodi da se zrakoplov nalazio u finalnom prilazu za stazu 20. Nakon neuspjelog prilaza, umjesto da penje u pravcu staze, zrakoplov je odmah napravio lijevi penjući zaokret u cross wind. Kut penjanja zrakoplova je bio mali i brzina zrakoplova se činila malom. Nakon nekog vremena zrakoplov je krenuo izvoditi lijevi zaokret u down wind, te pao u kovit nakon stupnjeva zaokreta. Očevidac procjenjuje da visina zrakoplova u tom trenutku nije bila veća od 100 metara od terena. Očevidac je pilot u tvrtki Zračno pristanište Mali Lošinj d.o.o. koja je operator aerodroma i operator zrakoplova za prijevoz putnika. Izjava očevica 3 (pilot) - koji se nalazio u obiteljskoj kući u ulici Kandija, nedaleko mjesta nesreće Kroz prozor obiteljske kuće, očevidac navodi kako je odjednom vidio zrakoplov u nepravilnom položaju te je čuo glasan zvuk motora (rad motora na visokim okretajima). Zatim mu je zrakoplov nestao iz vidokruga te je čuo zvuk udarca zrakoplova u tlo. Očevidac je letio na komercijalnim putničkim zrakoplovima 27 godina. Izjava pilota zrakoplova koji se nalazio na prednjem lijevom sjedištu zrakoplova i upravljao zrakoplovom Pilot predmetnog zrakoplova je izjavio kako se ne sjeća pojedinosti sa leta. Izjava putnika koji se nalazio na prednjem desnom sjedištu zrakoplova Nakon odobrenja za slijetanje na stazu 20, netom prije dodira sa USS-om, zrakoplov se pomaknuo u lijevu stranu. Pilot je donio odluku da ide u go around i da će napraviti novi prilaz. Tijekom penjanja kada je zrakoplov bio iznad šume, desno krilo je propalo, možda uslijed naleta vjetra. Nakon toga brzina zrakoplova znatno pada te zrakoplov gubi uzgon i ruši se. Putnik posjeduje pilotsku PPL dozvolu od 2011 godine te ima upisanih 112 sati naleta. AIN04-FR-03 Stranica 12/14

13 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj Izjava putnika koji se nalazio na zadnjem lijevom sjedištu zrakoplova Netom prije dodira sa USS-om zrakoplov se pomaknuo u lijevu stranu. Pilot je izjavio da ide u go around i napravio je lijevi zaokret, započeo penjanje, te je dodao punu snagu motora. Iznad šume je zrakoplov počeo padati. 2. ANALIZA Izjave putnika zrakoplova kao i očevidaca nesreće ne upućuju na tehnički kvar zrakoplova kao uzrok predmetne nesreće. Pregled zrakoplova na mjestu nesreće također ne upućuje na tehničke propuste koji su mogli dovesti do nesreće. Tehnička dokumentacija zrakoplova je uredna. Nakon neuspjelog prilaza pilot zrakoplova, nakon donošenja odluke da ponovi proceduru prilaženja, odmah radi lijevi zaokret u penjanju. Nakon prvog lijevog zaokreta zrakoplov započinje penjanje pod malim kutom. Nakon nekoliko sekundi zrakoplov započinje i drugi lijevi zaokret ali nema dovoljnu brzinu te gubi uzgon i pada u šumu. U vrijeme nesreće, meteorološka situacija na području Zračne luke Mali Lošinj bila je povoljna za letenje. U trenutku slijetanja puhao je slab bočni vjetar iz smjera 270 brzinom od čvorova, koji je uobičajen za spomenuti period godine. Nisu postojale meteorološke pojave koje bi mogle ugroziti let. 3. ZAKLJUČAK 3.1. NALAZI - Meteorološki uvjeti u vrijeme nesreće bili su povoljni za letenje predmetnim zrakoplovom, - Pilot je uredno komunicirao s kontrolom zračnog prometa na Zračnoj luci Mali Lošinj, - Motor je radio uredno tijekom cijelog leta, te na punoj snazi tijekom go around -a, - Istragom nije utvrđena tehnička neispravnost na zrakoplovu, - Tehnička dokumentacija zrakoplova je uredna, - Pilot posjeduje važeću pilotsku dozvolu, - Zrakoplov je zadovoljavao sve zakonom propisane uvjete, - Procedura neuspjelog prilaza nije izvršena na ispravan način, - Pogrešna procjena položaja i parametara zrakoplova u odnosu na situaciju u kojoj se zrakoplov nalazio UZROK Neposredni uzrok Neposredni uzrok predmetne nesreće je gubitak uzgona zrakoplova nakon neuspjelog prilaza zrakoplova za uzletno sletnu stazu, smjer 20. Do gubitka uzgona zrakoplova došlo je zbog premale brzine zrakoplova. AIN04-FR-03 Stranica 13/14

14 AGENCIJA ZA ISTRAŽIVANJE NESREĆA U ZRAČNOM, POMORSKOM I ŽELJEZNIČKOM PROMETU Završno izvješće , Mali Lošinj 4. SIGURNOSNE PREPORUKE U predmetnom slučaju, AIN nema sigurnosnu preporuku. Odgovorni istražitelj Dejan Ćurik AIN04-FR-03 Stranica 14/14

15 THE REPUBLIC OF CROATIA Air, Maritime and Railway Traffic Accident Investigation Agency Air Traffic Accident Investigation Department CLASS: /17-02/07 No: / Zagreb, 16 July 2018 F I N A L R E P O R T ON ACCIDENT OF THE AIRCRAFT PIPER PA-28, REGISTRATION D-EERD 16 JUNE 2017, NEAR MALI LOŠINJ AIRPORT AIN04-FR-3

16 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj PUBLICATION OF REPORT AND COPYRIGHT This report has been made and published by the Air, Maritime and Railway Traffic Accident Investigation Agency (hereinafter: AIA) pursuant to Article 6 section 1 and 2 of the Act on Establishment of the Air, Maritime and Railway Traffic Accident Investigation Agency (Official Gazette no 54/13), Article 7 Section 1 and 2 of the Statute of the Air, Maritime and Railway Traffic Accident Investigation Agency, Article 16 of the Regulation (EU) No 996/2010 of the European Parliament and of the Council on the Investigation and Prevention of Accidents and Incidents in Civil Aviation, provisions of the Air Traffic Act (Official Gazette no 69/09, 84/11, 54/13, 127/13 and 92/14), and pursuant Chapter 6 of the Annex 13 ICAO. This report or any part thereof shall not be produced, reproduced or transmitted in any form or in any manner, without the express written consent of AIA. This report may be freely used for educational purposes only. For all further information contact AIA. The aim of the investigation relating to safety is in no case determination of guilt or liability. Investigations are independent and separate from court or administrative proceedings and should not prejudice determination of guilt or liability of individuals. The final report cannot be used as evidence in court proceedings whose aim is determining civil or criminal liability of individuals. AIN04-FR-03 Page 2/14

17 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj CONTENT INVESTIGATION...4 SUMMARY FACTS AND INFORMATION FLIGHT INFORMATION INJURIES DAMAGE TO THE AIRCRAFT OTHER DAMAGE PERSONAL INFORMATION AIRCRAFT INFORMATION METEOROLOGICAL INFORMATION COMMUNICATION AIRPORT INFORMATION INFORMATION ON IMPACT AND AIRCRAFT REMAINS MEDICAL INFORMATION RESCUE AND SURVIVAL ASPECTS TESTING AND INVESTIGATION ADDITIONAL INFORMATION ANALYSIS CONCLUSION FINDINGS CAUSES SAFETY RECOMMENDATION AIN04-FR-03 Page 3/14

18 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj OCCURRENCE INFORMATION Type of the occurrence: Accident Date: 16 June 2017 Local time: 12:30 Place: Mali Lošinj Airport/Ćunski-Kandija Type of the aircraft: Aeroplane Manufacturer / model: Piper Aircraft/PA Registration: D-EERD Owner: Flugunion Seitenstetten-Biberbach Operator: Flugunion Seitenstetten-Biberbach Number of persons aboard: Three Injuries: Three severely injured persons Damage to the aircraft: Completely destroyed INVESTIGATION The Air, Maritime and Railway Traffic Accident Investigation Agency (AIA) received information on the accident the same day from Croatia Control and Ministry of the Interior. SUMMARY On 16 June 2017 around 12:30 pm, the Piper PA-28 aircraft crashed after an unsuccessful approach to Mali Lošinj Airport. There were three persons on the aircraft, a pilot and two passengers. In this accident, three people suffered severe injuries. The aircraft was completely destroyed. The direct cause of this accident was the aircraft stall, after a missed approach of the aircraft. It was established in the investigation that the accident occurred due to improper maintaining of the aircraft s speed and position after a missed approach and commencement of the go-around procedure. AIA issued no safety recommendation. 1. FACTS AND INFORMATION 1.1. FLIGHT INFORMATION Flight On the day of the accident, the pilot and two passengers took off from Tivat Airport, Montenegro, towards Mali Lošinj Airport. The flight was reported under VFR conditions. The flight proceeded according to the plan along the Dalmatian coast without difficulty. Upon arrival at Mali Lošinj Airport pattern from south direction and upon contacting the airport tower control, the aircraft begun approach to the runway direction 20. The aircraft entered downwind leg, then the cross wind leg and the base leg to the runway, direction 20 (Picture 1). AIN04-FR-03 Page 4/14

19 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj Picture 1 The aproach path of the aircraft towards Mali Lošinj Airport (GPS device) During the landing, just before the wheel touched the runway, the aircraft was shifted to the left, after which the pilot starts with a go around procedure. The pilot added full power to the engine and immediately turned left. The aircraft begun climbing in a straight flight line at a small climbing angle, after which it started the second left turn and then fell to the left tailspin. At that time, the aircraft did not have enough altitude to pull out from the tailspin and crashed in a hilly terrain covered with forest and low vegetation. Based on an eyewitness statement, also a pilot with a valid pilot license, who observed the accident from the airport, a reconstruction of the aircraft flight path after the pilot's decision to go around was made (Picture 2). AIN04-FR-03 Page 5/14

20 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj Picture 2 Reconstructed path of the aircraft marked in red, as it s described by the eyewitness 1.2. INJURIES Injuries Crew Passengers Others fatal serious minor/none DAMAGE TO THE AIRCRAFT The aircraft suffered significant structural damage (Picture 3), listed below: - the aircraft fuselage was deformed throughout its length, - the engine mount broke in several joints, - both propeller blades were bent, - the instrument panel was deformed in several places. There were several structural damages on the right wing: - detaching of skin from the wing ribs at the very top of the wing, - separating of the right aileron from the wing, - bent wing spar, - breakage of the skin at several places along the entire length of the wing. There were several structural damages on the left wing: - skin was bent in several places along the entire length of the wing, - skin was detached from the wing ribs in several places. After the crash of the aircraft there was no fire. AIN04-FR-03 Page 6/14

21 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj Picture 3 Aircraft D-EERD at the crash site 1.4. OTHER DAMAGE Due to the crash, several surrounding trees have been damaged. Due to the braking of the skin and the detaching of the fuel pipes, an unknown quantity of fuel has leaked into the ground PERSONAL INFORMATION Pilot Male person, an Austrian citizen born in In the subject accident, the pilot controlled the aircraft from the front left seat and suffered severe bodily injuries. He holds a pilot license issued by "Austro Control" with the following authorisations: MEP, SEP, TMG, Night. He has a long experience in flying aircraft of 37 years. He has 2557 flight hours recorded in the Flight log. He also possesses authorisation to fly as instructor and pilot examiner. It can be concluded from the said that the pilot is experienced in flying the aircraft. AIN04-FR-03 Page 7/14

22 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj Passenger 1 Male person, an Austrian citizen born in The person was sitting in the front right seat and suffered severe bodily injuries. Passenger 2 Male person, an Austrian citizen born in The person was sitting in the back left seat and suffered severe bodily injuries AIRCRAFT INFORMATION Piper PA / Piper Aircraft, general Type of the aircraft: Manufacturer / model: MTOW: Aeroplane Piper Aircraft/PA28-181, Archer II 1156 kg Piper PA-28 aircraft is a low-wing single engine aircraft of metal construction. The fuselage of the aircraft is not pressurized. The landing gear in non-retractable, type tricycle. The aircraft fuselage has one door on the right for entry of the crew and passengers on the aircraft. This model of the aircraft has four seats. The purpose of this aircraft is multiple. Therefore, this aircraft can be used by private users to transport passengers and luggage, then by school pilot training centres as well as for other sports purposes. Piper PA / Piper Aircraft, registration D-EERD Registration: D-EERD Aircraft serial number: Engine serial number: L A Owner: Flugunion Seitenstetten-Biberach Operator: Flugunion Seitenstetten-Biberach Year of manufacture: 1976 The aircraft is registered in the German Civil Aviation Register in The total aircraft flight hours entered in the Aircraft logbook until the accident was hours, while the total number of cycles was The power plant consists of one engine Lycoming O-360-A4M with 180 hp (134 kw) with a built-in constant speed propeller with two blades METEOROLOGICAL INFORMATION At the time of the accident on 16 June 2017 at 12:37 LT, the meteorological information measured at Mali Lošinj Airport indicated a stable weather with no precipitation, with good visibility and poor northwest wind. AIN04-FR-03 Page 8/14

23 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj Meteorological conditions were favourable for flying the subject aircraft and were not a direct cause of this accident. At the time of landing the wind was blowing from direction 270, at a speed of 5-7 knots COMMUNICATION The pilot communicated with the air traffic control at Mali Lošinj Airport via radio communication AIRPORT INFORMATION Mali Lošinj Airport is registered for public domestic and international traffic. It is located on the Island of Lošinj. It has a runway of 900 m in length, 30 m of width, direction It is equipped with a navigation device for non-precision instrumental approach of aircraft. The airport has only one runway, two taxiways and apron for parking of the aircraft. There are also two hangars for parking and maintenance of aircraft. The airport operator is the company AIRPORT MALI LOŠINJ Ltd., which also carries out the commercial transport of passengers with their three aircraft. During the summer tourist season, a large number of small aircraft operations for private and commercial purposes are conducted at the airport. Considering the runway orientation, during the summer season when mistrals appears, mostly the side wind is blowing on runway INFORMATION ON IMPACT AND AIRCRAFT REMAINS Due to the insufficient altitude for pulling the aircraft from the tailspin, the aircraft crashed on a steep, woody, low vegetation terrain (Picture 4). The distance of the aircraft crash site to the runway 20 threshold is approximately 500 meters. Picture 4 Aircraft D-EERD crash site AIN04-FR-03 Page 9/14

24 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj Damage to the aircraft and the surrounding trees indicate that the aircraft passed through the tree tops and eventually crashed to the ground (Picture 5). Picture 5 Overview of broken branches and parts of aircraft on the top of surrounding trees (marked with a red circle in the picture) After the site inspection, the owner of the aircraft organized the removal of the aircraft from the accident site. Due to the inaccessibility of the terrain, the removal of the remains of the aircraft was carried out by a private air cargo helicopter company. The remains of the aircraft have been moved to Mali Lošinj Airport and were taken over by the owner MEDICAL INFORMATION In the subject accident, the pilot who was in the front left seat suffered multiple severe bodily injuries. The passenger who was in the front right seat suffered severe bodily injuries. The passenger who was in the back left seat suffered severe bodily injuries. All aircraft seats are equipped with lap seat belts. Pilot and passengers were using fastened seat belts during the flight and the accident. AIN04-FR-03 Page 10/14

25 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj Person in the front left seat - pilot After the accident, the pilot was hospitalized in Clinical Hospital Center Rijeka in critical condition. He was put in an induced coma as he suffered severe bodily injuries, that is, he had poly trauma of multiple internal organs. Person in the front right seat passenger 1 The passenger who was in the front right seat suffered severe bodily injuries in the form of fractures of the left humerus and the fracture of the C6 cervical vertebrae. He was admitted to a hospital out of danger. Person in the back left seat passenger 2 The passenger who was in the back left seat suffered severe bodily injuries in the form of a fracture of the left arm, a broken left hand forefinger, and a cuts over the left eye RESCUE AND SURVIVAL ASPECTS After the aircraft crashed at 10:37 UTC, the air traffic controller informed the fire department and the police and provided them with accurate information on the location of the crash. After 20 minutes of unsuccessful search due to inaccessibility of the terrain, Cessna 172 aircraft owned by Mali Lošinj Airport took off in order to locate the aircraft as precisely as possible. At 11:06 UTC, the aircraft was located and the fire and police departments were sent to the exact location of the accident. The pilot and the passengers were transferred by helicopter to Clinical Hospital Center Rijeka TESTING AND INVESTIGATION Although the information received during the inspection did not indicate a technical problem with the aircraft, an aircraft inspection was carried out at the accident site. Analysis of the technical condition of the aircraft Upon the impact of the aircraft to the ground the aircraft was significantly damaged, and it was impossible to determine the airworthiness of the aircraft with the full certainty. However, during the technical inspection of the aircraft, to the extent possible due to the damages, no apparent mechanical failure that would potentially disable the operation of one of the aircraft systems could be found. All found damages with their characteristics indicate that they were caused by impact to the ground or some obstacle, such as surrounding trees. Technical documentation By examination of the technical documentation it was established that at the time of the accident the aircraft had a valid airworthiness certificate and other compulsory documents (aircraft noise certificate, radio license, aircraft registration certificate, insurance policy) at the time of the accident. Furthermore, a certificate of release of a 50-hour aircraft inspection, dated 23 May 2017 on the total of hours and 2825 landings was found. AIN04-FR-03 Page 11/14

26 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj ADDITIONAL INFORMATION Aircraft logbook No significant errors were found in the aircraft logbook save for the fact that in the D-EERD aircraft logbook the duration of the flights made on 14 June 2017 was not recorded. Statements of eyewitnesses and accident participants Statement of eyewitness 1 (air traffic controller) who was located at the Mali Lošinj Airport control tower, via Aviation Safety Report The eyewitness stated that after the instruction to land on runway 20, at wind direction 270 and wind speeds of knots, the D-EERD aircraft was given landing clearance. After an unsuccessful landing without touchdown, the aircraft requested go-around. After the controller approved the go-around, the aircraft turned to the left and achieved speed, however suddenly the aircraft rotated around the horizontal axis and crashed. After the crash, the controller notified the fire and police unit and coordinated the search for the aircraft. Statement of eyewitness 2 (pilot) who was located at the Mali Lošinj Airport and watched the subject aircraft The eyewitness stated that the aircraft was in the final approach to the runway 20. After the unsuccessful approach, instead of climbing in the direction of the runway, the aircraft immediately made the left turn in cross wind. The flight angle of the aircraft was small and the speed of the aircraft seemed small. After some time, the aircraft started to make the left turn in downwind and dropped into the tailspin after degrees of rotation. The eyewitness stated that at that time the aircraft altitude was not more than 100 meters from the ground. The eyewitness is a pilot at the company AIRPORT MALI LOŠINJ Ltd. which is the operator of the airport and operator of the aircraft for the passenger transportation. Statement of eyewitness 3 (pilot) who was located at the family house in Kandija street, near accident site The eyewitness stated that through the window of the family house he suddenly saw the aircraft in an unusual position and heard a loud engine sound (engine running at high speed). Then the aircraft disappeared from his sight and he heard the sound of an aircraft crashing to the ground. The eyewitness has been flying commercial passenger aircraft for 27 years. Statement of the pilot who was located in the front left seat of the aircraft and operated the aircraft The pilot of the subject aircraft stated that he has no recollection of details of the flight. Statement of the passenger who was in the front right seat of the aircraft After clearance for landing on runway 20, just before touchdown on the runway, the aircraft moved to the left. The pilot made the decision to go around and to make a new approach. During climbing when the aircraft was above the trees, right wing fell down, possibly due to the gust of wind. After that, the aircraft's speed dropped significantly, and the aircraft stalled and crashed. The passenger has a PPL license from 2011 and has 112 flight hours. AIN04-FR-03 Page 12/14

27 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj Statement of the passenger who was in the back left seat of the aircraft Before the touchdown to the runway, the aircraft moved to the left. The pilot stated that he would go around and he made the left turn, started climbing, and added the full power to the engine. The aircraft began falling above the forest. 2. ANALYSIS Statements of passengers on the aircraft as well as accident eyewitnesses do not indicate a technical malfunction of the aircraft as a cause of the accident. Also, the inspection of the aircraft at the accident site does not indicate any technical malfunction that could lead to the accident. The technical documentation of the aircraft is in order. After the unsuccessful approach, the pilot of the aircraft, after making a decision to repeat the approach procedure, immediately made the left turn in climbing. After the first left turn, the aircraft started climbing at a low angle. After a few seconds the aircraft started the second left turn, however, it did not have sufficient speed and aircraft stalled and crashed into the woods. At the time of the accident, the meteorological situation in the area of Mali Lošinj Airport was favourable for flying. At the time of landing, a side wind was blowing from direction 270 at a speed of knots, which is common for the aforementioned period of the year. There were no meteorological events that could endanger the flight. 3. CONCLUSION 3.1. FINDINGS - At the time of the accident the meteorological conditions were satisfactory for flying the subject aircraft, - The pilot duly communicated with the air traffic control at Mali Lošinj Airport, - The engine performed smoothly throughout the flight, and at full power during the go around, - The investigation did not found any technical malfunction on the aircraft, - The technical documentation of the aircraft is in order, - The pilot holds a valid pilot license, - The aircraft met all legally prescribed conditions, - The missed approach was not performed correctly, - Incorrect assessment of the position and parameters of the aircraft in regard to the situation in which the aircraft was. AIN04-FR-03 Page 13/14

28 AIR, MARITIME AND RAILWAY TRAFFIC ACCIDENT INVESTIGATION AGENCY Final Report 16 June 2017, Mali Lošinj 3.2. CAUSES Direct cause The direct cause of this accident was aircraft stall after missed approach of the aircraft to the runway, direction 20. Stall occurred due to the insufficient aircraft speed. 4. SAFETY RECOMMENDATION In this case, AIA has no safety recommendation. Investigator in charge Dejan Ćurik AIN04-FR-03 Page 14/14