AIRCRAFT INCIDENT REPORT AND EXECUTIVE SUMMARY

Transcription

1 Section/division Accident and Incident Investigations Division Form Number: CA 12-12b AIRCRAFT INCIDENT REPORT AND EXECUTIVE SUMMARY Reference: CA18/3/2/0823 Aircraft Registration ZU-BBG Date of Incident 01 February 2011 Time of Incident 1120Z Type of Aircraft Piper PA28R-180 (Veteran) Type of Operation Private Pilot-in-command Licence Type Private Age 67 Licence Valid Yes Pilot-in-command Flying Experience Total Flying Hours Hours on Type Last point of departure Next point of intended landing Volksrust aerodrome (FAVU) KwaZulu-Natal Volksrust aerodrome, (FAVU) KwaZulu-Natal Location of the incident site with reference to easily defined geographical points (GPS readings if possible) Open grass covered field 50km north of Hluhluwe KwaZulu-Natal; GPS co-ordinates S E Meteorological Information The weather was fine; South Easterly at 5-7kt; Temperature 26 C Number of people on board No. of people injured 0 No. of people killed 0 Synopsis On 01 February 2011 the pilot accompanied by a passenger departed Volksrust aerodrome (FAVU) in Kwazulu-Natal on a private local flight when the engine suddenly stopped during the flight, approximately 27nm north of Hluhluwe. The pilot was then committed to execute a forced landing on a flat grass covered area on a hill in close vicinity of trees and mountainous area ahead with the undercarriage retracted and with full flaps. During the forced landing however, the aircraft sustained some damage to the right hand flap, the engine lower cowling and propeller blade tips. The pilot and passenger sustained no injuries during the forced landing. It was concluded that the oil port on the vacuum pump drive extension was not drilled at the engine factory causing the shaft to seize due to lack of lubrication and the dowel pin at the assessor main drive gear on the crankshaft to fail. As a result theengine driven components stopped functioning causing the engine to fail. Probable Cause Unsuccessful forced landing following an engine failure. Contributory Factor: Mechanical failure. IARC Date Release Date CA 12-12b 23 FEBRUARY 2006 Page 1of 8

2 Section/division Accident and Incident Investigations Division Form Number: CA 12-12b AIRCRAFT INCIDENT REPORT Name of Owner/Operator :Kemp J & van Deventer D Partnership Manufacturer :Piper Aircraft Corporation Model :Piper PA-28R-180 (Veteran) Nationality :South Africa Registration Marks :ZU-BBG Place :Upslopeon hill27nm north of Hluhluwe Date :01 February 2011 Time :1120Z 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 01 February 2011 the pilot accompanied by a passenger departed Volksrust aerodrome (FAVU) in Kwazulu-Natal on a private local flight when the engine suddenly stopped during the flight, approximately 27nm north of Hluhluwe. The pilot was then committed to execute a forced landing on a flat grass covered area on a hill in close vicinity of trees and mountainous area ahead. The forced landing was executed with the undercarriage retracted and with full flaps selected It was concluded that the oil port on the vacuum pump drive extension was not drilled at the engine factory causing the shaft to seize due to lack of lubrication and the dowel pin at the main drive gear on the crankshaft to fail. As a result all theengine driven components stopped functioning causing the engine to fail During the forced landing however, the aircraft sustained some damage to the right hand flap, the engine lower cowling and propeller blade tips The pilot and passenger sustained no injuries during the forced landing. CA 12-12b 23 FEBRUARY 2006 Page 2of 8

3 1.2 Injuries to persons Injuries Pilot Crew Pass. Other Fatal Serious Minor None Damage to aircraft The aircraft sustained damage to the right hand flap, lower engine cowling and propeller blade tips. 1.4 Other damage There was no otherdamage sustained during the forced landing. 1.5 Personnel information Pilot-in-command Nationality South African Gender Male Age 67 Licence Number Licence Type Private Licence valid Yes Type Endorsed Yes Ratings Test Pilot Rating class 2 Medical Expiry Date 15 December 2012 Restrictions Corrective lenses Previous Accidents Nil Flying Experience Total Hours Total Past 90 Days 0.0 Total on Type Past 90 Days 0.0 Total on Type CA 12-12b 23 FEBRUARY 2006 Page 3of 8

4 1.6 Aircraft information Airframe Type Piper P28R-180 Veteran Serial No. 28R Manufacturer Piper Aircraft Corporation Date of Manufacture 1968 Total Airframe Hours (at time of incident) Last Annual Inspection) (Date &Hours) 24 September Authority to Fly (Issue Date) 05 October 2010 Authority to Fly (Expiry Date) 02 October 2011 C of R (Issue Date) (Present Owner) 01 December 2004 Operating Categories Private Authority to Fly Engine Propeller Type SUPERIOR XP Serial No. 36J Hours since New Hours since Overhaul Not yet reached Type Hartzell-HC-C3YR-1RF Serial number CH4757E Hours since New 25.8 Hours since Overhaul Not yet reached FIGURE 1: SHOWS AIRCRAFT AFTER WAS REPAIRED 1.7 Meteorological information The weather conditions as indicated below was reported by the pilot:. Wind direction Variable Wind speed kt Visibility >5km Temperature 26 C Cloud cover Nil Cloud base N/A Dew point Unknown CA 12-12b 23 FEBRUARY 2006 Page 4of 8

5 1.8 Aids to Navigation The aircraft was equipped with standard navigation equipment as per theequipment list approved by the Regulator for the aircraft type. No defects were reported prior to the flight 1.9 Communications The aircraft was equipped with standard communication equipment as per theequipment list approved by the Regulator for the aircraft type. No defects were reported at the time of the incident Aerodrome Information The incident did not occurnear an aerodrome but on the up-slope of a hill, 27nm north of Hluhluweat a mountainous area in Kwazulu-Natal Flight Recorders The aircraft was not fitted with a cockpit voice recorder or flight data recorder. Neither was required by regulations to be fitted to this type of aircraft Wreckage and impact information During the flight, the engine suddenly stopped and the pilot was committed to execute a forced landing on a flat grass covered surface on a hill. The aircraft came to rest with the flaps fully extended and the undercarriage retracted within 50 metres. The right hand flap, lower cowling and propeller blade tips were substantially damaged Medical and pathological information Not applicable Fire There was no post or pre impact fire Survival aspects This was considered as a survivable incident as the pilot and passenger were properly restrained by the aircraft safety harnesses andno damage was caused to the cockpitor fuselage area. The low impact forces during the forced landing also prevented any injuries to the occupants. CA 12-12b 23 FEBRUARY 2006 Page 5of 8

6 1.16 Tests and research The total engine operational hours since new installed into aircraft at the time of the incident was hours It was concluded when the engine was dismantled that the oil port on the vacuum pump drive extension was not drilled at the engine factory causing the shaft to seize due to lack of lubrication and the dowel pin at the assessor main drive gear on the crankshaft to fail. As a result all die engine accessories stopped functioning causing the engine to stop The aircraft engine overhaul facility at Richards Bay that inspected the engine concluded that due to the fact that the oil port was not drilled at the engine factory, the vacuum pump drive shaft lubrication was depended on splash lubrication during engine operation when the engine failure finally occurred at hours since new Organizational and management information According to available information, the aircraft was maintained by an aircraft maintenance organisation (AMO) as per the requirements of manufacturer and the Regulator The Authority to Fly for the aircraft was issued on 05 October 2010 with the expiry date being 02 October Additional information None Useful or effective investigation techniques None. 2 ANALYSIS 2.1 The pilot and passenger was on a local private flight when the engine suddenly stopped (failed) and the pilot committed to execute a forced landing on a flat grass CA 12-12b 23 FEBRUARY 2006 Page 6of 8

7 covered surface of a hill in close vicinity of trees and a mountainous area ahead with full flaps and the undercarriage retracted. 2.2 The aircraft came to rest during the forced landing within 50 metres on the grass covered area. 2.3 The aircraft sustained substantial damage to the right hand flap and wing tip, lower cowling and propeller blade tips. 2.4 According to available documentation, the aircraft had been maintained by an AMO as required by the manufacturer. 2.5 The oil port on the vacuum pump drive extension was not drilled at the engine factory causing the shaft to seize due tolack of proper lubrication and the dowel pin at the main drive gear on the crankshaft to fail. As a result, the engine driven components stopped functioning. The engine overhaul facility at Richards Bay also concluded that the shaft in question depended only on splash lubrication during engine operation until the engine failed after operating for hours 3. CONCLUSIONS 3.1 Findings The pilot carried out a forced landing on a flat grass covered surface of a hill after the engine failed during flight The pilot was correctly licensed and type rated to conduct the private flight and the holder of a valid aviation medical certificate that was issued by a CAA approved medical examiner According to available documentation, the aircraft was correctly maintained by an approved aircraft maintenance organisation.(amo) The weather conditions were fine and did not contribute to the cause of the incident The aircraft engine overhaul facility at Richards Bay that inspected the engine concluded that due to the fact that the oil port was not drilled at the engine factory, the vacuum pump drive shaft lubrication was depended on splash lubrication during engine operation when the engine failure finally occurred at hours since new. 3.2 Causes Unsuccessful forced landing following an engine failure. 3.3 Contributory Factor: Mechanical failure. CA 12-12b 23 FEBRUARY 2006 Page 7of 8

8 4. SAFETY RECOMMENDATIONS 4.1 None. 5. APPENDICES 5.1 None Compiled by: Francois de Bruyn. Date:... For: Director of Civil Aviation Investigator-in-charge: Date:.. Co-Investigator:.. Date:. CA 12-12b 23 FEBRUARY 2006 Page 8of 8