Informal translation of the BEA (Bureau d Enquêtes et d Analyses) report on the accident involving Cirrus SR22GTS N224AG on 16 November 2008

Transcription

1 Informal translation of the BEA (Bureau d Enquêtes et d Analyses) report on the accident involving Cirrus SR22GTS N224AG on 16 November 2008 The original report is available here: Important note: This is an informal document based on a Google translation edited by a pilot who has only basic French language skills. The factual content is likely to be fairly accurate, because this is easier to translate. However, it is only a rough translation of the French prose and grammar. This document is solely intended to help PPL/IR Europe members who are not French speakers understand the BEA report, which may raise useful flight safety discussion topics. Synopsis Date of accident: Sunday, November 16, 2008 at 17 h 15 (1) (1) All times are UTC unless otherwise noted Location: At sea, 15 NM north of Cherbourg Nature of flight: Travel Aircraft: Cirrus SR 22 GTS "Perspective" Owner: Private Operator: Private Persons on board: Pilot 1 - Background Information 1.1 History of flight The pilot, who owned the plane, took off from Biggin Hill Airfield (United Kingdom) at 16 h 30, to fly to the destination airfield Jersey (United Kingdom) under a VFR flight plan. The pilot flew over the Channel at FL50. Around 17 h 10, the aircraft descended to FL45. After about a minute, the controller Jersey permitted a descent to 3000 feet. The pilot began a descent with an average vertical speed of 875 feet per minute. Just before reaching the altitude of 3000 feet, the plane dropped sharply in a right turn and then hit the surface of the water about fifteen miles north of Cherbourg. Debris was found up to eight days after the accident. 1.2 Injuries The pilot died. 1.3 Damage to aircraft The aircraft was destroyed. 1.4 Information on the pilot Male, 25 years PPL (A) issued by the United Kingdom August 21, The pilot had been trained in night flight, this training had begun on October He had sent his license and log book to the Civil Aviation Authority (CAA) on 5 November 2008 for the validation of this qualification. The record sent to the CAA for the issue of this qualification was complete, but they had not yet validated his license. Experience: Total: 72 hours, including 37 as captain; In the prior six months: 61 hours; In the prior thirty days: 10 hours; On type: 25 hours, including 23 as captain; In the prior three months: 26 hours; Night: estimated 5 hours. This information is derived from the pilot's logbook. The last flight recorded was October 29, Note: the operation of a US registered aircraft outside US airspace by a pilot holding a non-us license is governed by Part 61.3 of the Federal Aviation Regulations (14 CFR). This states that an aircraft registered in the USA cannot be flown outside US airspace unless the pilot holds a US pilot certificate or a qualification issued by the state in which the aircraft is operated. [For this purpose] the FAA recognises only the state which issued the qualification.

2 1.5 Particulars of the aircraft Airframe Manufacturer: Cirrus Design Corporation Type: SR 22 GTS "Perspective" Serial #: 3089 Registration: N224AG Entered into service: June 27, 2008 Certificate of Airworthiness: Valid Airframe hours recorded to October 25, 2008: 98 hours The Cirrus SR22 Perspective is equipped with an All Glass cockpit. The autopilot can command a descent with a selected vertical speed. The stall warning consists of an audio and visual alarm on the main screen. The aircraft is equipped with backup instruments in the case of a failure of the EFIS Engine Manufacturer: Teledyne Continental Motors Type: IO-550 Serial #: Operating hours to 25 October 2008: 98 hours It was not possible to determine the amount of fuel loaded at departure Performance The maximum airspeed in normal operation of the SR22 is 177KIAS. The maneuvering speed is 133KIAS. The SR22 flight manual indicates that at a pressure altitude of 4000 feet, in ISA conditions and with 84% engine power, airspeed should be 162 knots. Cirrus recommended avoiding more than 85% of engine power in cruise Safety equipment The aircraft was equipped with a parachute system developed by Cirrus (CAPS). The maximum demonstrated deployment speed of this system is 133 knots on the Cirrus SR 22. During testing of this system, successful deployment tests were conducted at speeds of about 170 knots. However, these tests were performed on a test rig and not on an airframe. 1.6 Weather Conditions at the estimated area of the accident Météo France made the following estimate of the conditions at the time of the accident: in the accident area, the wind direction was 300 at 15 to 17 knots. The visibility was greater than ten kilometers. Visibility was between five and eight miles below possible scattered mist. The sky was completely covered with stratocumulus with a base of 1650 feet. Stratus was locally present, between 500 and 980 feet. The outside temperature was 13C. QNH was 1033 hpa. Sunset occurred at 16 h Met information available at the start of the flight The dispatcher at Biggin Hill said he had provided the pilot a weather briefing before departure. This folder contained the TAF and METARs for Biggin Hill, Gatwick, Farnborough, Southampton, Jersey, Guernsey and Alderney, and weather forecast maps issued by the UK Met Office. In the accident area, the forecast valid at 18:00 hrs included: visibility of 20 km, with isolated areas of 7 km in haze and 3,000 m in fog and light drizzle; Areas of broken to overcast Stratocumulus, with bases between 1500 and 2500 feet, and tops between 3000 and 4000 feet; Occasional broken to overcast Stratus, with bases between 400 and 1000 feet, and tops at 1500 feet. (see Annexes 3 & 4)

3 1.7 RTF The pilot was in radio contact with Jersey Zone ATC. He has not issued any radio message or selected a transponder code corresponding to an emergency or distress situation. The transcript of radio communications between the pilot and Jersey is below: About two minutes and thirty seconds before the loss of radar contact, the pilot began a descent to an altitude of 3000 feet which had been authorized by the controller, under a special VFR clearance Flight Recorders The aircraft was not equipped with a flight recorder. For this type of aircraft, regulations do not require it. However, an unprotected data recorder was installed. It has not been recovered. 1.9 Information on the wreck and the impact Pieces of the airframe, a seat and the inflatable life raft were recovered during searches commenced after the disappearance of the aircraft. They were examined at the BEA. The examination indicated that the aircraft struck the water at high speed. The high energy of the impact resulted in the airframe fragmenting into multiple pieces. Examination of the wreckage revealed no anomalies. Fuselage debris, including straps binding the parachute, were found. Examination could not determine whether the parachute was deployed prior to impact Medical and Pathological The pilot's body was not recovered. Organic elements were identified by DNA analysis as belonging to the pilot Survivability The violence of the impact was not survivable. No emergency beacon signal was received.

4 1.12 Additional Information Radar Data The analysis of data from the Avranches civil and Cherbourg military radar stations helped reconstruct part of the final moments of flight. The data from the Avranches SSR show that the pilot was on a south-westerly course in a normal descent for about two minutes until the penultimate SSR return. The last SSR return was is 1000 feet lower than the prior one. Given the rotation rate of the radar antenna and possible Mode C transponder error, the interval between these two returns indicates that the vertical velocity the aircraft could have been between 6700 and 8300 feet per minute. This last return also shows that the trajectory of the aircraft deviated to the right. The Cherbourg primary radar detected four returns after the last SSR return from Avranches. These four additional returns indicate a change in trajectory to the north-west. They do not, however, provide any indication of the altitude of the aircraft. A reconstruction of the trajectory from these radar data and a vertical profile of the end of the flight is below:

5 Evidence Relatives of the pilot explained that he used to fly with the autopilot engaged. The regular track and rate of descent suggests this was the case during the accident flight until just before the sharp descent and right turn Regulatory Special VFR in the UK [omitted; explains Special VFR in UK airspace] 2 - Analysis and Conclusion The weather information supplied to the pilot by the dispatcher showed that the flight was not feasible under VFR. The pilot, however, decided to depart. Given the straightness of the aircraft track, the pilot was likely to have been using the autopilot. Jersey ATC asked him to descend to an altitude of 3000 feet. Given the estimated weather conditions in the area of the accident, it is likely that the pilot entered cloud. The ease of operating the flight under the autopilot may have suppressed the pilot s awareness of the risks associated with flying in cloud and led him to not follow the rules applicable prohibiting him from entering cloud. The final trajectory of the aircraft shows that the autopilot was turned off, but it has not been possible to determine the reasons for this. The origins of the loss of control could not be determined. At night, above the sea and with the weather conditions present, the pilot had no outside visual references that could allow him to regain control of the aircraft. ANNEXES Annexes 1 & 2 are inserted in the text above Annex 3

6 Annex 4