AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Transcription

1 Section/division Occurrence Investigation Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY Reference: Aircraft Registration ZU-CDL Date of Accident 28 August 2009 Time of Accident Type of Aircraft Magni Gyro M16 Type of Operation Private 1000 Z Pilot-in-command Licence Type Private Age 53 Licence Valid Yes Pilot-in-command Flying Experience Total Flying Hours Hours on Type Last point of departure Next point of intended landing Aggenys (FAAG). Northern Cape Province Vredendal (FAVR). Northern Cape Province Location of the accident site with reference to easily defined geographical points (GPS readings if possible) Vaalputs GPS. S30º E018º Northern Cape. Altitude 3425 ft Meteorological Information CAVOK Number of people on board 1+0 No. of people injured 0 No. of people killed 1 Synopsis The pilot of the gyroplane involved in the accident was part of a group of three gyroplanes flying in loose formation en route from Augrabies to Vredendal (FAVR).Two pilots in the loose formation attempted to communicate with the third pilot as he was behind them in the loose formation in the vicinity of Vaalputs (FAVA) airstrip. When they received no reply, they turned their aircraft around and started flying back the direction from which they came, to look for the third pilot. The two pilots found the third aircraft ablaze. Unable to render assistance, they continued their journey to Vredendal from where they reported the accident to the person in charge of the air show being held at Vredendal aerodrome. After an apparent collision with electrical power lines, the pilot was incapacitated and the aircraft impacted the ground. The pilot was fatally injured in the accident.the gyrocopter was destroyed during the accident sequence and both power cables were severed. Probable Cause The aircraft collided with electrical wires, where after the pilot was incapacitated and the aircraft collided with the ground. IARC Date Release Date CA 12-12a 23 FEBRUARY 2006 Page 1 of 13

2 Section/division Occurrence Investigation Form Number: CA 12-12a Telephone number: address of originator: AIRCRAFT ACCIDENT REPORT Name of Owner/Operator : F.M.L.Morais Manufacturer : Magni Gyro Model : Magni M16 Nationality : Portuguese Registration Marks : ZU-CDL Place Date : 28 August 2009 Time : 1000Z : Vaalputs in the Northern Cape 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 The pilot of one of the three gyroplanes stated that they took off early morning on 27 August 2009 from Tedderfield airpark (FATA) for a cross-country flight to the Vredendal air show in the Northern Cape The gyroplanes first landed at Delareyville where fuel was transferred from additional fuel containers secured to the aft seat into the aircrafts fuel tanks. The three aircraft were then flown to Kuruman (FAKU) and then to Upington (FAUP) for refuelling, and finally to a private airstrip at Augrabies, where the pilots spent the night with a friend On 28 August 2009, the three gyroplanes departed from the Augrabies private airstrip with full tanks (and full additional fuel containers) and headed along the Orange River down to Aggenys The pilots emptied their additional fuel into their main tanks and after takeoff from Aggenys, they headed directly over Vaalputs (FAVA) to Vredendal (FAVR) at a ground speed of approximately 120 mph. The three gyroplanes were flying in loose formation at approximately 4000 ft (AMSL). The accident gyrocopter was following behind the two other gyroplanes The three gyroplane pilots were communicating on radio frequency MHz with each other during the flight. Approximately 3 miles outbound of Vaalputs, the accident gyroplane pilot went off air and failed to respond on his radio. CA 12-12a 23 FEBRUARY 2006 Page 2 of 13

3 1.1.6 The pilots of the other two gyroplanes decided to backtrack in the direction they were flying from to search for the third gyroplane. After backtracking for approximately three minutes, they spotted the burning wreckage on the ground. Unable to render assistance, the two remaining pilots continued their journey to Vredendal, where they reported the accident to the person in charge of the air show being held at Vredendal aerodrome The person in charge of the air show requested the South African Police Services air wing, who were also at the air show, to fly to the accident site The pilot was fatally injured in the accident and the aircraft destroyed. 1.2 Injuries to Persons Injuries Fatal Serious Minor None 1.3 Pilot 1 - Crew - Pass. - Other - Damage to Aircraft The aircraft was destroyed in the accident. Picture 1 showing aircraft wreckage at accident site located at GPS coordinates S30º E018º CA 12-12a 23 FEBRUARY 2006 Page 3 of 13

4 1.4 Other Damage Other damage was caused to the electrical cabling which was severed by the gyroplane as it struck the cables. Picture 2 Picture 3 Picture 2 shows the severed cable. Picture 3 shows the mast to which it was mounted. 1.5 Personnel Information Nationality Licence Number Licence valid Ratings Medical Expiry Date Restrictions Previous Accidents Portuguese Gender Male XXXXX Licence Type Yes Type Endorsed None 30 April 2012 Must wear hearing protection 29 December Age 53 Private Yes The pilot was involved in an accident at Paradise Beach on 29 December The pilot had intended to carry out a touch and go landing on the beach. The left-hand main wheel dug into the sand, causing the gyrocopter to roll over. Flying Experience: Total Hours Total Past 90 Days Total on Type Past 90 Days Total on Type Unknown Unknown Because the pilot s logbook was destroyed in the accident, the information tabulated above was taken at the last application for renewal of his pilot s licence on 3 April CA 12-12a 23 FEBRUARY 2006 Page 4 of 13

5 1.6 Aircraft Information Airframe: Type Magni M16 Serial Number M16 TTT-008 Manufacturer Magni Gyro Date of Manufacture 2000 Total Airframe Hours (At time of Accident) Last MPI (Date & Hours) 6 March Hours since Last MPI Unknown Authority to fly (Issue Date) 10 March 2009 C of R (Issue Date) (Present owner) 19 April 2000 Operating Categories Private Engine: Type Rotax 914UL Serial Number Hours since New 450 Hours since Overhaul Unknown The engine hours at the time of the accident were downloaded from the turbo control unit The aircraft was last refuelled with automotive fuel at Aggenys from a 25-litre container transported on the rear passenger seat of the two-seater aircraft. Propeller: Type Arplast Ecoprop Serial Number Unknown Hours since New Unknown Hours since Overhaul Unknown 1.7 Meteorological Information The following meteorological report (ref: JS16/7/ ) was obtained from the South African Weather Service. As no official observations are available at the place of the accident, the most likely weather conditions at the place of the accident are indicated in the table below. Wind direction 020º Wind speed 15kt Visibility CAVOK Temperature 23ºC Cloud cover none Cloud base none Dew point 1ºC 1.8 Aids to Navigation The aircraft was equipped with the standard navigation equipment which was serviceable at the time of the accident. CA 12-12a 23 FEBRUARY 2006 Page 5 of 13

6 1.9 Communications During the flight the pilots were communicating with each other about their intentions on MHz Aerodrome Information None, as the accident did not occur at or in the vicinity of an aerodrome Flight Recorders The aircraft was not fitted with a flight data recorder (FDR) or cockpit voice recorder (CVR), and neither was required by the applicable regulations Wreckage and Impact Information The accident occurred at a location away from an aerodrome at GPS coordinates S30º E018º During the onsite investigation process, the following was observed: Main rotor blades The main rotor blades sustained impact damage and only partially fire damage. The damage caused to the main rotor blades was as a result of their impacting the ground. A large piece of one of the rotor blades was located approximately 10 metres away from the main wreckage. A leading edge section of one main rotor blade exhibited signs of impacting the electrical wires. Impact point of main rotor with electrical wires. Picture 4 showing point of impact of rotor with wires. CA 12-12a 23 FEBRUARY 2006 Page 6 of 13

7 Landing Gear The nose gear was located approximately 10 metres to the right of the main wreckage. Evidence found was that the nose gear broke off after the aircraft impacted the ground. The damage caused to the nose wheel was as a result of a high load placed on the nose wheel. The left hand and right hand main gear had substantial impact and fire damage. Main wreckage The aircraft was found lying on its right hand side and having evidence of impact damage and destroyed by fire. The cockpit was totally destroyed by the post impact fire that erupted. Engine There was substantial fire damage caused to the engine during the post impact fire. All electrical wiring, rubber pipes and belts that formed part of the engine was also damaged in the post impact fire. The engine was still in its original location on the aircraft. The engine showed signs of rotating at high speed at the time of impact. Ground scars The first ground impact scars were found approximately 87 metres from the point of impact with the electrical wires. The impact scars were identified as caused by the right-hand main wheel, followed by the main fuselage scar. The nose wheel impacted the ground approximately 13 m from the first scar. Approximately 12 m further the main fuselage impacted the ground. Approximately 20 m forward of the wreckage, the aircraft tail section and main rotor impacted the ground. Approximately 38 m further, the main wreckage came to rest. Propeller The propeller was destroyed in the accident sequence. The propeller showed signs of turning at high speed. A piece of propeller blade was found approximately 12 m in front of the wreckage in the direction of flight. The aircraft rolled over onto its right-hand side before it came to a halt The propeller and main rotor blade damage was consistent with an engine producing power at impact The aircraft was destroyed by the post-impact fire Medical and Pathological Information The medical and pathological reports state that the cause of death was burn wounds The pilot also had a fracture of the parietal bone. These bones are found in the human skull and form, by their union, the sides and roof of the cranium. CA 12-12a 23 FEBRUARY 2006 Page 7 of 13

8 There was no evidence to suggest that the pilot suffered any sudden illness or incapacity which might have affected his ability to control the aircraft prior to the impact with the electrical wires Fire There was no evidence of an in-flight fire The post-impact fire that erupted was limited to the aircraft fuselage The two other pilots arrived at the scene of the accident and found the aircraft ablaze but were unable to render any assistance to its occupant Survival Aspects The intensity of the heat from the fire did not allow the two other gyroplane pilots to approach the aircraft to render any assistance to its occupant The lack of cell phone coverage due to the remoteness of the area, combined with the lack of a suitable place to land, caused the two remaining pilots to elect to continue their journey and alert the authorities as soon communications became available The aircraft design only allowed for a seating configuration of two seats. The pilot in command sits in the front seat and the passenger in the only rear seat. There are two safety belts, one allocated to each of the seating areas. The evidence found at the accident site shows that the pilot was restrained with the safety belts provided in the aircraft at the time of the accident, and as such did not have an opportunity to free himself from the aircraft after the aircraft finally came to a stop. The pilot was fatally injured in the accident The accident was not survivable due to the magnitude of the deceleration forces and the severity of the post impact fire Tests and Research The aircraft s turbo control unit (TCU) was removed and sent for further analysis. The software version on this type of TCU (Version TLR45) logs information at intervals of 6 minutes. The TCU monitors eight channels of information The number 1 in the first column indicates that the engine is running and the number 0 in column one indicates that the engine has been switched off Column 2 indicates the engine hours Channels 1 to 8 monitor various aircraft parameters and are recorded at six-minute intervals The number 0 at engine hours occurred during the stop at Aggenys (FAAG), where the three gyroplanes stopped to refuel and the pilot switched off the engine. CA 12-12a 23 FEBRUARY 2006 Page 8 of 13

9 The aircraft flew for another approximately 48 minutes after start up as calculated from the engine hours in column The electrical power supplied to the TCU was still connected when the engine cut at 450 hours, as column 1 does not indicate a zero The analysis of the TCU by the manufacturer s representative concluded that most of the flight was done at cruise speed and that the engine was running normally. Picture 3 shows the information obtained from the TCU. Height calculations from TCU download Channel 3 of the TCU download indicates ambient air pressure around the aircraft The last ambient pressure read out from the TCU was 898 mb. According to the ICAO standard atmosphere table, a pressure of 898 mb would equate to an altitude of approximately ft. The altitude at the accident site is approximately 3425 ft. Subtracting the approximate altitude of the aircraft from the approximate altitude of the accident site; we derive an altitude of approximately ft (AGL) Because no accurate temperature readings had been recorded for the specific flight level at which the aircraft may have been flying, the height at which the aircraft was flying could not be determined conclusively. CA 12-12a 23 FEBRUARY 2006 Page 9 of 13

10 The ICAO standard atmosphere does not take into account pressure variations brought about by high- or low-pressure weather systems over the area at the time of the accident Organizational and Management Information The aircraft was privately operated by the owner The aircraft was maintained by an approved person Additional Information The on-site investigation measured the height of the electrical mast. The mast was found to be approximately 6 m in height The maintenance manual of the aircraft states the height of the aircraft from the bottom of the wheels to the top of the mast is approximately 2.7 m The left-hand earpiece of the pilot s headset and the sun visor were found approximately 20 m from the electrical wire mast The pilot s helmet was found approximately 170 m from the electrical mast. The top of helmet had a cavity, approximately 5 cm in diameter, on the left-hand side. The cavity was caused by the electrical wire impacting the helmet after it was severed by the gyroplane s main rotor blade The SACAA Accident and incident Investigation Division produced a report on the causes of wire strike accidents in South Africa up to 2008 (Ref 11/9/2009). It states: 6 Data Analysis The data gathered shows that wire strike accidents are more prevalent in private operations, followed by agricultural operations and then training. Some causes of wire strike accidents in private operations. 6.1 Wire strike accident reports revealed the following as some of the causes of wire strike accidents: Non-adherence to specified minimum altitude (unlawful low flying). Some of the accidents occur when a pilot attempts to do an emergency landing in the field which may have high-tension wires. Failure to look out due to distractions. Poor visibility (clouds, fog, sun). 6.2 Why are there fewer accidents in aerial operations in comparison with private operations? On consultation with various low-flying operations, the following was uncovered: CA 12-12a 23 FEBRUARY 2006 Page 10 of 13

11 Pilots share information regarding dangers Prevalent safety culture and no compromise on safety. Multi-crew operations extra pair of eyes often available. Strict adherence to regulations. Situational awareness. 7 Recommendations Adherence to prescribed minimum heights and refrain from illegal low flying. Always be on the lookout. Share information re danger zones with fellow pilots. Proper planning using up to date maps. Ask people who are familiar with the area about any wires. Always do an observation flight prior to low-flying operations. Be on the lookout for high-tension wires in valleys Useful or Effective Investigation Techniques None. 2. ANALYSIS 2.1 Inspection of the gyrocopter s rotor blade revealed marks associated with the impact of a metal cable. Evidence of a broken electrical power line was found on the scene. The investigator is of the opinion that these marks on the rotor blade were caused by the electrical cable. 2.2 The investigator is of the opinion that the engine operation was normal at the time of the accident, as the damaged propeller blades were scattered as far as 12 meters forward of the flight path. This is an indication of the high centrifugal force produced by the engine. The aircraft made contact with the ground 170 meters past the power lines, which indicated that the aircraft was flying at a relatively high forward speed, which would not have been possible, if the engine was not being operated at normal power. 2.3 The downloaded information from the aircraft s TCU further confirms that the engine was operating normally at the time of the accident. 2.4The aircraft struck the electrical wires with its main rotor blades, which suggests that the aircraft was flying approximately 3 m above ground level (AGL) when it struck the electrical wires. 2.5 After the collision with the power lines, the severed, recoiling power line struck the pilot on the head. The force of the blow of the power line was so severe that it caused the helmet that the pilot was wearing to break. This break compromised the integrity of the helmet, resulting in a fracture to the head of the pilot. CA 12-12a 23 FEBRUARY 2006 Page 11 of 13

12 2.6 The pilot s left-hand earpiece and sun visor were also impacted by the electrical wire and were found approximately 20 m from the electrical wire. The sun visor was still intact, which suggests that the pilot was using it at the time of impact with the wires as it was a sunny day. The wearing of the sun visor further degraded the ability of the pilot to see the electrical wires, resulting in the collision with the wires. 2.7 The resulting impact forces caused the pilot to lose control of the aircraft resulting in the aircraft s impacting the ground. 2.8 As no official temperature observations are available at the place of the accident, the altitude at which the aircraft was flying could not be determined conclusively. 3. CONCLUSION 3.1 Findings The pilot was licensed and held the appropriate gyroplane rating for the aircraft The aircraft had a valid authorisation to fly There was no evidence of any defect or malfunction in the aircraft prior to the accident that could have contributed to the accident The aircraft was structurally intact prior to impacting the electrical wires in the accident sequence as no aircraft debris was found prior to impact with the electrical wires All control surfaces were accounted for, and all damage to the aircraft could be attributed to severe impact forces The aircraft was destroyed by impact forces and a post-impact fire Due to the destruction of the aircraft by the post-impact fire, it could not be determined whether pre-impact failure or system malfunction contributed to this accident The propeller blade damage was consistent with an engine producing power at impact The pilot was flying at a low level, failed to observe the power lines and collided with the lines The aircraft departed from controlled flight after colliding with the power lines and impacted with the ground Based on the autopsy and medical reports, there was no evidence to indicate that the pilot s performance was degraded by physiological factors prior to impact with the electrical wires The accident was not survivable, due to the magnitude of the impact forces with the electrical cables and the intensity of the post-impact fire. CA 12-12a 23 FEBRUARY 2006 Page 12 of 13

13 3.2 Probable Cause/s 3.2.1The aircraft collided with electrical wires, where after the pilot was incapacitated and the aircraft collided with the ground. 4. SAFETY RECOMMENDATIONS 4.1 It is recommended that an article be published in the Safety Link magazine alerting pilots to the hazards associated with power and telephone lines. The wire strike report published by the SACAA should also be included in the magazine. This recommendation has already been actioned by the relevant departments within the SACAA. 4.2 It is recommended that the Manufacturer of the TCU make the unit more robust and fireproof to help investigators in determining the causes of accidents. 4.3 It is recommended that the TCU be downloaded as part of the annual inspection and that a copy of the printout be attached to the aircraft logbook. This will enhance the oversight abilities of the SACAA. 4.4 Equip SACAA inspectors with the necessary equipment to download the data from the TCU to enable the SACAA to enhance their oversight ability. 5. APPENDICES 5.1 None Report reviewed and amended by the Advisory Safety Panel on 16 March END- CA 12-12a 23 FEBRUARY 2006 Page 13 of 13