AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Transcription

1 Section/division Occurrence Investigation Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY Aircraft Registration Type of Aircraft Reference: CA18/3/2/9016 ZU-CYL Date of Accident 9 July 2012 Time of Accident 1505Z Bantam B22J Type of Operation Private Pilot-in-command Licence Type Microlight Age 59 Licence Valid Yes Pilot-in-command Flying Experience Last point of departure Next point of intended landing Total Flying Hours 462,3 Hours on Type 462,3 Kobus de Villiers private airstrip, Groblersdal, Mpumalanga Kobus de Villiers private airstrip, Groblersdal, Mpumalanga Location of the accident site with reference to easily defined geographical points (GPS readings if possible) On a farm at Renosterkop in the Groblersdal area Meteorological Information Number of people on board Synopsis Temperature: 16ºC; Dew point: 04 C; Wind: 290º/04 k t; Visibility: m; QNH: 1026 hpa No. of people injured 1 No. of people killed 1 The pilot and passenger were engaged in a local, private flight assisting farmers and security personnel in a search for burglary suspects. Witnesses saw the microlight, which was flying low, pitch up its nose as the pilot attempted to clear trees. The aircraft then crashed to the ground and was destroyed. The pilot was fatally injured on impact and the passenger sustained serious injuries. The pilot became fixated on the robbery suspects while flying very low. After realising that the microlight was too close to the trees, he attempted to avoid them and the aircraft entered into a stall from which he could not recover in time. The aircraft then crashed to the ground The Probable Cause The aircraft entered into a stall at low altitude from which the pilot could not recover. Contributory factors: 1. The microlight was flying low at the time of the accident. 2. The pilot became fixated on the robbery suspects. IARC Date Release Date CA 12-12a 25 MAY 2010 Page 1 of 11

2 Section/division Occurrence Investigation Form Number: CA 12-12a Telephone number: address of originator: AIRCRAFT ACCIDENT REPORT Name of Owner/Operator : L. van Schalkwyk Manufacturer Model : Bantam B22J Nationality : South African Registration Marks : ZU-CYL Place Date : 9 July 2012 Time : 1505Z : Micro Aviation New Zealand Ltd : Renosterkop in the Groblersdal area 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 (1997), 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 given without prejudice to the rights of the CAA, which are reserved. 1. FACTUAL INFORMATION 1.1 History of flight On 9 July 2013, at approximately 1430Z, the pilot and passenger took off uneventfully from Kobus de Villiers private aerodrome with the intention of helping local farmers and security personnel in a search for suspected burglars. A robbery had occurred earlier on a farm in the Groblersdal area. The pilot and passenger were to act as spotters whilst flying, and relay any sightings of the suspects to the security personnel and farmers on the ground A witness at the foot of a mountain in the area reported afterwards that ZU-CYL flew at low level from the town of Groblersdal in an easterly direction. The microlight turned west and then east again. It flew overhead the witness, so low that it seemed as if its wheels would clip the top of the trees. The witness could clearly see the occupants. The nose of the aircraft then pulled up as the pilot tried to clear trees on the mountainside. The left wing then went down, striking the ground, and the aircraft flipped over A second witness about 500m from the crash site also saw the microlight flying low, drop its left wing and crash. He immediately alerted the emergency services, who despatched a team to the scene The pilot suffered fatal injuries during the impact sequence. The passenger sustained serious injuries and was hospitalised for six weeks. CA 12-12a 25 MAY 2010 Page 2 of 11

3 1.1.5 Following his discharge, he was interviewed about the accident but could not recall any details other than that they were flying very low while looking for robbery suspects. ZU-CYL accident site Figure 1: The location of the accident site. 1.2 Injuries to persons Injuries Pilot Crew Pass. Other Fatal Serious Minor None Damage to aircraft The aircraft was destroyed in the accident sequence. CA 12-12a 25 MAY 2010 Page 3 of 11

4 Figure 2: The wreckage of ZU-CYL. 1.4 Other damage None. 1.5 Personnel information Pilot: Nationality South African Gender Male Age 59 Licence Number Licence Type Microlight Licence valid Yes Type Endorsed Yes Ratings Conventionally-controlled microlight Medical Expiry Date 30 April 2014 Restrictions Aeroplane adapted for use with one leg Previous Accidents None Note: the pilot had one leg due to a previous surgical amputation at the hip level Flying experience: Total Hours 462,3 Total Past 90 Days Unknown Total on Type Past 90 Days Unknown Total on Type 462,3 Note: The above hours were estimated, as the pilot s logbook could not be located. The last hours in the logbook recorded on 9 November 2011 were obtained from RAASA. The last flying hours in ZU-CYL s flight folio were recorded on 1 February CA 12-12a 25 MAY 2010 Page 4 of 11

5 1.6 Aircraft information Aircraft description: The Micro Aviation B22 Bantam is a microlight designed and produced in New Zealand. It is supplied as a complete, ready-to-fly aircraft that complies with Fédération Aéronautique Internationale microlight rules as well as UK BCAR Section S regulations. It features a strut-braced high wing, a single engine in tractor configuration, an enclosed cockpit with two seats side-by-side, and fixed tricycle landing gear. As a conventional three-axis microlight, the Bantam does not rely on pilot weightshift for control. Twin seats are positioned side by side for full dual control and both crew members are well protected from the weather by an aerodynamic fibreglass pod and large wrap-around windshield Airframe Figure 3: A typical Bantam B22J aircraft. Type Bantam B22J Serial Number Manufacturer Micro Aviation New Zealand Ltd Date of Manufacture 2003 Total Airframe Hours (at time of accident) 642,3 Last Annual Inspection (Hours & Date) 631,1 25 February 2012 Hours since Last MPI 11,2 Authority to Fly Certificate(Expiry Date) 24 February 2013 C of R (Issue Date) (Present Owner) 12 August 2005 Operating Categories Private NTCA Note: The last total in the flight folio 631, 1 hours was entered on 1 February From the airframe hours, it was established that 11, 2 hours were subsequently flown until the accident. CA 12-12a 25 MAY 2010 Page 5 of 11

6 1.6.3 Engine Type Jabiru 2200 A Serial Number 22A1496 Hours since New 642,3 Hours since Overhaul TBO not reached Propeller Type P Prob wooden Serial Number N/A Hours since New 642,3 Hours since Overhaul TBO not reached Fuel During the investigation, approximately 10 litres of fuel were found in the tank. The latter had ruptured, causing fuel to leak onto the ground. According to available evidence, the fuel in the tank was sufficient for the planned flight Weight and balance The total mass of the microlight with the two occupants on board, plus fuel and baggage, was 388kg. The maximum limit for the aircraft is 430kg. The weight of the aircraft at the time of the accident was thus 42kg below the maximum limit. 1.7 Meteorological information The following weather conditions at the site and time of the accident were obtained from the South African Weather Service: No meteorological observations are available for Groblersdal the closest weather station used to estimate surface conditions in this case is the Witbank automatic weather station (FAWI). CAVOK conditions were observed over the interior of the country, including the area of the aircraft accident. According to the significant weather chart, scattered clouds were expected over Limpopo and in the vicinity of Groblersdal on this day. The available observational data on this day include a satellite image which shows no cloud over Groblersdal. A rough estimate of other meteorological variables can be made from the METAR obtained from the Witbank automatic weather station. Actuals The METAR messages below were recorded by an automatic weather station at Witbank (FAWI) for the two consecutive hours estimated for the time of occurrence of the aircraft accident: CA 12-12a 25 MAY 2010 Page 6 of 11

7 Station: FAWI Date: FAWI Z AUTO 29004KT //// // ////// 16/04 Q1026= FAWI Z AUTO 30002KT //// // ////// 13/04 Q1027= 1.8 Aids to navigation The aircraft was equipped with standard navigation equipment as approved by the regulator for the aircraft type. No defects with equipment were reported prior to the flight. 1.9 Communications The aircraft was equipped with standard communication equipment as approved by the regulator for the aircraft type. No defects with the equipment were reported before the flight Aerodrome information The accident occurred in dense bush on a privately owned farm in the Renosterkop area in Groblersdal at coordinates S , E " and at an elevation of ft Flight recorders The aircraft was not equipped with a flight data recorder or a cockpit voice recorder. Neither was required by the relevant aviation regulations Wreckage and impact information During the accident flight, the microlight was seen flying low. The left wing dropped and the aircraft struck the ground The on-site investigation and wreckage analysis revealed that the engine had moved downwards, destroying the cockpit, the aerodynamic fibreglass pod and the windshield. The left wing sustained damage and the canvas tore from the metal structure. The left main landing gear broke off and was found approximately 6 m from the main wreckage. The rudder, horizontal stabilizer, vertical stabilizer and elevators sustained little or no damage. The wreckage was localised at the impact site. Most of the debris, such as the canvas covering, engine composite coverings and propeller fragments, were found within a 1 m radius of the wreckage There was no evidence of in-flight structural wing failure. All control surfaces were accounted for at the site. Although flight control cable runs were disrupted by the impact forces, pre-accident control integrity was established. The fuel selector was found in the on position and there was fuel in the filter, fuel lines and carburetor. The fuel was free of contaminants. CA 12-12a 25 MAY 2010 Page 7 of 11

8 Figures 4 to 7: The aircraft wreckage, showing the extensive damage to the cockpit and left wing Medical and pathological information The pilot was the holder of a valid medical certificate as a microlight aircraft pilot. This was valid until 30 April According to the post-mortem autopsy report, the cause of death of the pilot was blunt force trauma to the chest The results of the toxicology tests were unavailable at the time of compiling this report. Should any of these results, once received, have a bearing on the performance of the pilot at the time of the accident, this will be considered as new evidence and the investigation re-opened Fire There was no evidence of fire in flight or after the impact Survival aspects CA 12-12a 25 MAY 2010 Page 8 of 11

9 The impact forces sustained during the accident were not considered survivable The on-site inspection showed that most of the cockpit area had been crushed in by the impact Tests and research The engine was taken to an approved AMO for a test and/or strip, which was carried out by a licensed aircraft maintenance engineer (AME). The engine was found to turn freely. It was restarted and functioned normally. In addition, no damage was discovered that could have led to an in-flight stoppage Organisational and management information The aircraft was operated privately by the pilot/owner It was maintained by an Approved Person accredited by the SACAA and rated on the aircraft Additional information According to the SACAA records, there was no application or approval of a modification to the aircraft for paraplegic use The aircraft was not fitted with a stall warning system Stalls The following information was taken from the Bantam (B22J) flight manual: Caution: The aircraft gives little warning of an impending stall. For some configurations of load, power setting and flap setting, the aircraft may not exhibit any pre-stall buffet. In all configurations, the aircraft gives little warning of an impending stall. Depending on the load, power setting and flap setting, the aircraft may or may not exhibit any pre-stall buffet. However, flight testing has demonstrated that the B22J in the stall is very docile, the aircraft remains fully controllable throughout and the height loss is small when recovered immediately. The onset of the stall is evidenced by a drop in the nose altitude together with a loss of altitude. Nose-down pitch will not be greater than 5 degrees below level flight attitude. If the aircraft is unbalanced, there may be a tendency for a wing drop. To recover, apply full power and lower the nose. Prevent yaw with the rudder until the controls become fully effective and the aircraft has recovered from the stall. Raise the nose once recovery has been effected and regain any lost altitude. If recovery is prompt altitude loss will not exceed 40 ft. CA 12-12a 25 MAY 2010 Page 9 of 11

10 Whilst the ailerons remain effective up to the stall, recovery should be effected with neutral ailerons. Any attempt to apply opposite aileron in the case of a wing drop must be avoided as this action may exacerbate the wing drop situation. Should a wing drop, apply opposite rudder to prevent yaw while effecting the recovery Useful or effective investigation techniques None 2. ANALYSIS 2.1 The pilot and passenger were on a local flight with the intention of assisting farmers and security personnel in a search for suspected burglars. During the flight, ZU-CYL was seen by witnesses flying low over trees. The nose of the microlight was seen pulling up as the pilot attempted to clear trees on a mountain. The left wing then dropped and the aircraft crashed to the ground. 2.2 The final manoeuvres of ZU-CYL, as reported by the witnesses, included an incipient spin to the left and were consistent with microlight s stall characteristics. The investigation eliminated the possibility of structural failure to the aircraft, an engine failure or an airframe defect. There was also no evidence of pilot incapacitation and the weather conditions at the time were not considered to have contributed to the accident. 2.3 Based on the information above, it is concluded that the pilot became fixated on the robbery suspects while flying very low. After realising that the microlight was too close to the trees, he attempted to avoid them and the aircraft entered into a stall from which he could not recover in time. The aircraft then crashed to the ground. 3. CONCLUSION 3.1 Findings The pilot held a valid pilot s licence and a valid aviation medical certificate issued by a CAA-approved medical examiner The aircraft was in possession of a valid Authority to Fly certificate At the time of the accident, the aircraft was maintained by an Approved Person, accredited by the SACAA The engine was operating normally and there was sufficient fuel on board the aircraft at the time of the accident The weight and balance of the aircraft was below the maximum allowable limits for the aircraft. CA 12-12a 25 MAY 2010 Page 10 of 11

11 3.1.6 Fine weather prevailed at the time, and the weather was not considered to be a factor in the accident The aircraft was seen to be flying low The aircraft was not fitted with a stall warning system There was no application or approval of a modification to the aircraft for paraplegic use 3.2 Probable cause The aircraft entered into a stall at low altitude from which the pilot could not recover. 3.3 Contributory factors The microlight was flying low at the time of the accident The pilot became fixated on the robbery suspects. 4. SAFETY RECOMMENDATIONS 4.1 It is recommended that whenever a particular pilot has a paraplegic restriction put on their pilot licence; it should be aligned with the aircraft authority to fly certificate in order to ensure that the aircraft is modified in such a way as to cater for the identified disability. 5. APPENDICES 5.1 None CA 12-12a 25 MAY 2010 Page 11 of 11