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Air Accident Investigation Unit (Belgium)
City Atrium
Rue du Progrès 56
1210 Bruxelles
Safety Investigation Report
ACCIDENT
PILATUS PC-6
AT GELBRESSEE
ON 19 OCTOBER 2013
Réf. AAIU-2013-21
Issue date: 22 July 2015
Status: Final
AAIU-2013-21
THIS PAGE IS INTENTIONALLY

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Final report
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TABLE OF CONTENT
TABLE OF CONTENT........................................................................................................... 3
FOREWORD ......................................................................................................................... 5
SYMBOLS AND ABBREVIATIONS ...................................................................................... 6
TERMINOLOGY USED IN THIS REPORT ............................................................................ 9
SYNOPSIS ........................................................................................................................ 10
1 FACTUAL INFORMATION. ............................................................................ 12
1.1 HISTORY OF FLIGHT. .......................................................................................... 12
1.2 INJURIES TO PERSONS. ...................................................................................... 14
1.3 DAMAGE TO AIRCRAFT. ...................................................................................... 14
1.4 OTHER DAMAGE. ............................................................................................... 14
1.5 PERSONNEL INFORMATION................................................................................. 14
1.6 AIRCRAFT INFORMATION. ................................................................................... 16
1.7 METEOROLOGICAL CONDITIONS. ........................................................................ 30
1.8 AIDS TO NAVIGATION. ........................................................................................ 32
1.9 COMMUNICATION. ............................................................................................. 35
1.10 AERODROME INFORMATION. .............................................................................. 37
1.11 FLIGHT RECORDERS. ......................................................................................... 39
1.12 WRECKAGE AND IMPACT INFORMATION. .............................................................. 42
1.12.1 On-site examination of the wreckage ................................................. 42
1.12.2 Detailed examination of the wreckage ................................................ 48
1.13 MEDICAL AND PATHOLOGICAL INFORMATION ....................................................... 63
1.14 FIRE ................................................................................................................. 64
1.15 SURVIVAL ASPECTS ........................................................................................... 64
1.16 TESTS AND RESEARCH. ..................................................................................... 67
1.16.1 The horizontal stabilizer trim actuator ................................................. 67
1.16.2 Aircraft performance........................................................................... 67
1.16.3 Barrel roll in flight simulator Marchetti 260.......................................... 68
1.17 ORGANIZATIONAL AND MANAGEMENT INFORMATION. ........................................... 69
1.17.1 Operation of the aeroplane................................................................. 69
1.17.2 Operation authorization for a permanent site of parachuting activities 70
1.17.3 Special ratings for pilot performing parachute dropping flights ........... 72
1.17.4 Insurance company requirements ...................................................... 72
1.17.5 Paraclub Namur organization ............................................................. 72
Final report TABLE OF CONTENT
1.18 ADDITIONAL INFORMATION. ................................................................................ 73

1.18.1 About the management of a horizontal stabilizer trim runaway ........... 73
1.18.2 About parachuting aeroplanes’ accidents, period 1987-2014 ............. 73
1.18.3 Pilatus PC-6 accidents showing similarities........................................ 75
1.19 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES ........................................... 76
2 ANALYSIS. ..................................................................................................... 77
2.1 INFORMATION FROM WITNESSES ........................................................................ 77
2.2 WRECKAGE EXAMINATION .................................................................................. 78
2.3 COMMUNICATIONS ............................................................................................ 79
2.4 THE SEQUENCE OF THE DIFFERENT STRUCTURAL FAILURES ................................. 80
2.5 RECONSTRUCTION OF THE LAST PHASE OF THE FLIGHT ........................................ 81
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2.6 POSSIBLE MANOEUVRES .................................................................................... 86

2.6.1 Possible medical incapacitation ........................................................... 86
2.6.2 In-flight collision avoidance .................................................................. 87
2.6.3 Bird Strike ............................................................................................ 87
2.6.4 Wake vortex ......................................................................................... 88
2.6.5 Wind turbine turbulences ..................................................................... 88
2.6.6 Meteorological turbulence. ................................................................... 88
2.6.7 Intentional Manoeuvers ........................................................................ 88
2.6.8 V-n Diagram analysis ........................................................................... 93
2.6.9 Conclusion of possible manoeuvres analysis ....................................... 94
2.7 OPERATOR AND PARACHUTE CLUB ORGANIZATION .............................................. 94
2.8 WEIGHT AND BALANCE ...................................................................................... 95
2.9 USE OF RESTRAINT SYSTEMS ............................................................................. 96
2.10 USE OF OXYGEN SYSTEM ................................................................................... 98
2.11 PILOT’S SEAT AND PILOT’S BACK PROTECTION ..................................................... 99
2.12 MAINTENANCE MANUAL ................................................................................... 100
2.13 FLIGHT DATA RECORDING ................................................................................ 101
3 CONCLUSIONS. ........................................................................................... 103
3.1 FINDINGS. ....................................................................................................... 103
3.2 CAUSES. ........................................................................................................ 106
4 SAFETY RECOMMENDATIONS .................................................................. 107
4.1 SAFETY ISSUE: THE WEAKNESS OF LEGAL FRAMEWORK AND EFFECTIVE
OVERSIGHT. .................................................................................................... 107
4.2 SAFETY ISSUE: THE LACK OF MANDATORY REQUIREMENT TO INSTALL
DEVICES RECORDING FLIGHT DATA ON BOARD AEROPLANE USED FOR
PARACHUTING. ................................................................................................ 108
4.3 SAFETY ISSUE: THE WEAKNESS OF FRAMEWORK REGARDING THE TECHNICAL
REQUIREMENT OF RESTRAINT SYSTEMS FOR PARACHUTISTS ON BOARD
AIRCRAFT. ...................................................................................................... 108
4.4 SAFETY ISSUE: INSUFFICIENT BACK PROTECTION FOR THE PILOT. ....................... 109
4.5 SAFETY ISSUE: NO EASY DETERMINATION OF THE WEIGHT AND BALANCE OF
THE AEROPLANE DUE TO THE PASSENGERS NOT SITTING IN PREDETERMINED
POSITIONS. ..................................................................................................... 110
4.6 SAFETY ISSUE: GRANTING OVERLAPPING AUTHORISATIONS BY THE BCAA. ......... 110
4.7 SAFETY ISSUE: POSSIBLE ERRONEOUS INTERPRETATION OF THE
MAINTENANCE MANUAL. ................................................................................... 111
4.8 SAFETY ISSUE: LACK OF ORGANIZATIONAL STRUCTURE BETWEEN THE
Final report TABLE OF CONTENT
OPERATOR AND THE PARACHUTE CLUB. ............................................................ 112
5 APPENDICES ............................................................................................... 113

APPENDIX 1: EXTRACT OF BCAA DELIVERED AERIAL WORK AUTHORIZATION .................... 113
APPENDIX 2: EXTRACT OF BCAA DELIVERED “AUTHORIZATION FOR THE OPERATION
OF A PERMANENT SITE FOR PARACHUTE JUMPS”. ............................................... 115
APPENDIX 3: EXTRACTS OF PART SPO REGULATION REGARDING THE PARACHUTE
OPERATION AND SEATS, SEAT SAFETY BELTS AND RESTRAINT SYSTEMS .............. 118
APPENDIX 4: SPECIAL CONDITION DOCUMENT “USE OF AEROPLANE FOR
PARACHUTING ACTIVITIES. ............................................................................... 120
APPENDIX 5: ROYAL MILITARY ACADEMY FRACTOGRAPHICAL ANALYSIS ........................... 123
APPENDIX 6: HORIZONTAL STABILIZER TRIM ANALYSIS ..................................................... 127
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FOREWORD
This report is a technical document that reflects the views of the investigation team
on the circumstances that led to the accident.
In accordance with Annex 13 of the Convention on International Civil Aviation and

EU Regulation 996/2010, it is not the purpose of aircraft accident investigation to
apportion blame or liability. The sole objective of the investigation and the Final
Report is the determination of the causes, and to define recommendations in order
to prevent future accidents and incidents.
In particular, Article 17-3 of the EU regulation EU 996/2010 stipulates that the

safety recommendations made in this report do not constitute any suspicion of
guilt or responsibility in the accident.
The investigation was conducted by Luc Blendeman, Henri Metillon and Sam
Laureys.
The report was compiled by Henri Metillon and was published under the authority
of the Chief Investigator.
Notes:
1. About altitude and Flight Level: The vertical position of aircraft during climb is
expressed in terms of altitude (with feet as unit) until reaching the transition
altitude (which is 4500 ft in Brussels FIR) above which the vertical position is
Final report FOREWORD
expressed in terms of flight levels. To indicate altitudes, the local barometric

pressure at sea level (QNH) is used as altimeter setting. To indicate flight
levels, the Standard Atmosphere pressure of 1013,25 hPa is used as altimeter
setting.
2. About the time: For the purpose of this report, time will be indicated in UTC,
unless otherwise specified.
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SYMBOLS AND ABBREVIATIONS
’ Minute
° Degree
°C Degrees centigrade
AAD Automatic Activation Device of a rescue parachute
AAIU(Be) Air Accident Investigation Unit (Belgium)
ACC Area Control Center (En-route air traffic control)
AccRep Accredited Representative of a State Investigation Unit
ACTT Aircraft Total Time
AD Aerodrome
AFIS Aerodrome Flight Information Service
AFM Airplane Flight manual
AFMS Airplane Flight manual Supplement
AGL Above Ground Level
AMM Aircraft Maintenance Manual
Amp Ampere
AMSL Above Mean Sea Level
APP Approach Control Service
ARC Airworthiness Review Certificate
ASD Air Safety Directorate (Belgian Defence)
ATC(O) Air Traffic Control (Officer)
ATIS Automatic Terminal Information Service
ATPL Airline Transport Pilot Licence
ATS Air Traffic Services
BCAA Belgian Civil Aviation Authority
BCMG Becoming (used in weather reports)
BEA Bureau d’Enquêtes et d’Analyse (French authority responsible for
safety investigations into accidents or incidents in civil aviation)
CAMO Continuing Airworthiness Management Organisation
Final report SYMBOLS AND ABBREVIATIONS
CAS Calibrated airspeed

CAVOK Ceiling and Visibility OK
CERPS Centre Ecole Régional de Parachutisme Sportif de Namur
CIAIAC Comisión de Investigación de Accidentes e Incidentes de Aviación
Civil (Spanish investigation authority for accident and incidents in
civil aviation)
CG Centre of Gravity
CPL Commercial Pilot Licence
CS Certification specification
E east
EASA European Aviation Safety Agency
EBBE Beauvechain Air Base
EBBR Brussels Airport
EBCI Charleroi - Brussels South Airport
EBNM Airfield of Namur/Suarlée
EBLG Liège airport
EBMO Airfield of Moorsele
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EU European Union
EUROCAE European Organisation for Civil Aviation Equipment
FAA Federal Aviation Administration (USA)
FARs Federal Aviation Regulations (in the United States)
FDR Flight Data Recorder
FH Flight hour(s)
FIR Flight Information Region
FL Flight Level
FOCA Federal Office of Civil Aviation (Switzerland)
fps Feet per second
ft Foot (Feet)
ft/m Feet per minute
FTD Flight Training Device
FTL Flight Time Limitation
hPa Hectopascal(s)
g Acceleration due to Earth’s gravity
GDF-05 BCAA Circular Descentes en Parachute”–“Valschermspringen
ICAO International Civil Aviation Organisation
IMC Instrument Meteorological Conditions
IPC Illustrated Parts Catalog
KIAS Knots Indicated Airspeed
kgf Kilogram-force (equal to the force exerted by one kilogram of mass
on the earth surface)
km Kilometre(s)
kt Knot(s)
KTAS Knots True Airspeed
lbs Pounds
LH Left hand
LOC-I Loss of Control In-flight
m Metre(s)

MAC Mean Aerodynamic Chord
METAR Meteorological Aerodrome Report
MHz Megahertz
MSN Manufacture’s serial Number
MTOW Maximum Take-off Weight
N North
n load factor
NM Nautical mile(s)
NOSIG No significant change (used in weather reports)
NTSB National Transportation Safety Board (US)
O/H Overhaul
PIC Pilot in Command
POH Pilot’s Operating Handbook
PN Part Number
PPL Private Pilot Licence
QFE Pressure setting to indicate height above the airfield runway
QFU Magnetic bearing of the runway
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QNH Pressure setting to indicate elevation above mean sea level

RH Right hand
RPM Revolutions per Minute
RWY Runway
S.A. Sociéte Anonyme (Belgian equivalent of a public limited company)
SAIB Swiss Accident Investigation Board
SCF-NP System/Component Failure or malfunction (Non-Powerplant)
SEP Single Engine Piston rating
SET Single Engine Turbine rating
SHP Shaft Horse Power
SN Serial Number
SPO Specialised Operations
STOL Short Take-Off and Landing
TMA Terminal Control Area
TSB Transport Safety Board of Canada
ULM Ultra-Léger Motorisé (microlight aircraft)
US United States
US CARs Civil Aviation Regulations (former US legal requirements preceding
the current Title 14 of the Code of Federal Regulations – aka FARs)
US gal US (United States) Gallon
UTC Universal Time Coordinated
V As a unit: Volt.
As a quantity: Velocity or speed
VA Design manoeuvring Speed
VC Design cruise speed
VD Design diving speed
VFE Maximum flap extended speed
VFR Visual Flight Rules
VNE Never-exceed speed
VS Stall speed
VMC Visual Meteorological Conditions
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TERMINOLOGY USED IN THIS REPORT
Safety factor: an event or condition that increases safety risk. In other words, it is
something that, if it occurred in the future, would increase the likelihood of an
occurrence, and/or the severity of the adverse consequences associated with an
occurrence.
Contributing safety factor: a safety factor that, had it not occurred or existed at
the time of an occurrence, then either:
(a) the occurrence would probably not have occurred; or
(b) the adverse consequences associated with the occurrence would probably not
have occurred or have been as serious, or
(c) another contributing safety factor would probably not have occurred or existed.
Other safety factor: a safety factor identified during an occurrence investigation

which did not meet the definition of contributing safety factor but was still
considered to be important to communicate in an investigation report in the
interests of improved transport safety.
Safety issue: a safety factor that

(a) can reasonably be regarded as having the potential to adversely affect the
safety of future operations, and
(b) is a characteristic of an organisation or a system, rather than a characteristic of
a specific individual, or characteristic of an operational environment at a specific
point in time.
Safety action: the steps taken or proposed to be taken by a person, organisation

or agency on its own initiative in response to a safety issue.
Final report TERMINOLOGY USED IN THIS REPORT

Safety recommendation: A proposal of the accident investigation authority in
response to a safety issue and based on information derived from the
investigation, made with the intention of preventing accidents or incidents. When
AAIU(Be) issues a safety recommendation to a person, organization, agency or
Regulatory Authority, the person, organization, agency or Regulatory Authority
concerned must provide a written response within 90 days. That response must
indicate whether the recommendation is accepted, or must state any reasons for
not accepting part or all of the recommendation, and must detail any proposed
safety action to bring the recommendation into effect.
Safety message: An awareness which brings under attention the existence of a

safety factor and the lessons learned. AAIU(Be) can disseminate a safety
message to a community (of pilots, instructors, examiners, ATC officers), an
organization or an industry sector for it to consider a safety factor and take action
where it believes it appropriate. There is no requirement for a formal response to a
safety message, although AAIU(Be) will publish any response it receives.
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SYNOPSIS
Date and time of the accident: 19 October 2013 at 13:35
Aircraft: Pilatus PC-6/B2-H4, MSN 710
Accident location: 50°31’0.5’’ N - 4°57’1.0’’ E

Terrain elevation: around 200 m
In a field in Gelbressée, Namur, Belgium
Aircraft owner: Namur Air Promotion S.A.
Type of flight: Aerial Work - Parachute dropping
Persons on board: 11
Abstract:
The aeroplane was used for the dropping of parachutists from the parachute club
of Namur1. It was the 15th flight of the day. The aeroplane took off from the
Namur/Suarlée (EBNM) airfield at around 13:25 with 10 parachutists on board.
After 10 minutes of flight, when the aeroplane reached FL50, a witness noticed the
aeroplane in a level flight, at a lower altitude than normal. He returned to his
occupation. Shortly after he heard the sound he believed to be a propeller angle
change and turned to look for the aeroplane. The witness indicated that he saw
the aeroplane diving followed by a steep climb (major pitch up, above 45°),
followed by the breaking of the wing. Subsequently, the aeroplane went into a
spin. Another witness standing closer to the aircraft reported seeing the aeroplane
flying in level flight with the wings going up and down several times and hearing, at
the same time an engine and propeller sound variation before seeing the
aeroplane disappearing from his view. The aeroplane crashed in a field in the
territory of Gelbressée, killing all occupants. The aeroplane caught fire. A big part
of the left wing and elements thereof were found at 2 km from the main wreckage.
Occurrence type:
Loss of control-inflight (LOC-I) followed by system/component failure (non-
powerplant SCF-NP).
Final report SYNOPSIS
1
«Paraclub Namur» but officially called Centre Ecole Régional de Parachutisme Sportif de
Namur (CERPS)
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Cause(s):
The cause of the accident is a structural failure of the left wing due to a significant
negative g aerodynamic overload, leading to an uncontrollable aeroplane and
subsequent crash.
The most probable cause of the wing failure is the result of a manoeuvre intended
by the pilot, not properly conducted and ending with an involuntary negative g
manoeuvre, exceeding the operating limitations of the aeroplane.
Contributing safety factors:
• The weakness of the monitoring of the aeroplane operations by the operator.

• The lack of organizational structure between the operator and the parachute
club.
Other safety factors identified during the investigation:
• The performance of aerobatic2 manoeuvres with an aircraft not certified to

perform such manoeuvres.
• The performance of aerobatic manoeuvres by a pilot not adequately qualified
and/or trained to perform such manoeuvres.
• Transportation of unrestrained passengers, not sitting in seats during higher-
risk phases of the flight.
• The weakness of legal framework and effective oversight.
• The lack of mandatory requirement to install devices recording flight data on
board aeroplane used for parachuting.
• Insufficient back protection for the pilot.
• Lack of guidance for W&B calculations of aeroplane used for parachuting.
• Granting overlapping authorisations by the BCAA.
• Possible erroneous interpretation of the maintenance manual.
• Violations and/or safety occurrences not reported as required by the Circular
GDF-04, preventing the BCAA from taking appropriate action.
• Peer pressure of parachutists sometimes encouraging pilots to perform
manoeuvres not approved for normal category aeroplanes.
• Flying at high altitude without oxygen breathing system although required by
regulation.
Final report SYNOPSIS
2
“Aerobatic flight” means manoeuvres intentionally performed by an aircraft involving an
abrupt change in its attitude, an abnormal attitude, or an abnormal variation in speed, not
necessary for normal flight or for instruction for licenses or ratings other than aerobatic rating.
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1 FACTUAL INFORMATION.
1.1 History of flight.
On 19 October 2013, the Pilatus Porter was being used for parachute drops.
The day started normally with the first take-off at 07:21. Each flight
transported 9 or 10 passengers. Except for the first two, all the flights of that
day were conducted by the same pilot.
Flight # Time of take-off Time of drop Pilot # of passengers

1 07:21 07:39 P1 9
2 07:49 08:03 P1 10
3 08:12 08:32 P2 9
4 08:39 08:55 P2 10
5 09:02 09:18 P2 10
6 09:24 09:42 P2 10
Refuelling and lunch
7 10:24 10:40 P2 9
8 10:47 11:04 P2 9
9 11:11 11:26 P2 9
10 11:32 11:48 P2 10
11 11:54 12:13 P2 9
12 12:21 12:40 P2 10
13 12:48 13:01 P2 10
14 13:07 13:20 P2 10
15 13:25 P2 10
The aircraft’s last landing in EBNM was at 13:20 to board the next group of
10 parachutists. After the take-off, the aircraft appeared again on the radar
at 13:28 at an altitude of 1200 ft. At 13:28:52, the EBCI Air Traffic Control
Officer (ATCO) instructed the aircraft to remain at 2000 ft AMSL to allow for
crossing traffic, a B737 landing at EBCI, and to proceed further to the east.
After the crossing, the Pilatus was authorized to climb to 5000 ft. At 13:33:32,
Final report FACTUAL INFORMATION.
when the aeroplane was flying at 4400 ft, the pilot was authorized to turn
back to the drop zone and turned towards its target, the EBNM airfield.
Shortly after, a witness observed the aeroplane making a wide turn to the left.
This witness monitored the aeroplane for about 40 seconds. He indicated the
engine was making an abnormal noise which he compared with the
explosions made by the exhaust of a rally car when decelerating. Finally, the
witness heard a loud explosion ending by the dive of the aeroplane. He
believed that the sound of an explosion was caused by the “engine turbine
disintegration”.
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Figure 1: last flight approximate flight path
Another witness driving on the E42 highway saw the aeroplane performing
what he perceived as being some aerobatic manoeuvers. The aeroplane was
diving and was spinning. A moment later, he saw the wing break-up,
including the separation and falling of smaller parts.
A sailplane pilot was standing in his garden not far from the crash site. He
first heard the sound of the Pilatus which he described as being typical,
smooth and constant. He looked at the aeroplane and noticed it was flying at
a lower altitude than usual. He stopped observing after a few seconds. 30 to
40 seconds later, he heard an abnormal noise change which he thought was
a propeller pitch change or an engine power change. He looked for the
aeroplane in the sky and saw the aeroplane diving with an angle of more
than 45° immediately followed by a sharp pull-out angle of over 70°, followed
by the upwards breaking of a wing. The aeroplane went down “as in a stall”.
The witness still heard “the sound of propeller angle moving” after the wing
separation.
Another witness standing approximately at an horizontal distance of 600 m

from the aeroplane described having heard a sound change. He looked at Final report FACTUAL INFORMATION.
the aeroplane and saw the aeroplane flying horizontally, making several
significant left and right roll movements of the wings before it disappearing
from his view.
The aeroplane crashed on a field in the territory of Gelbressée, killing all

occupants. The aeroplane caught fire shortly after the impact. A big part of
the left wing, elements thereof and the right sliding door of the cabin were
found at 2 km from the main wreckage.
Of the aircraft’s occupants, 4 parachutists were ejected from the aircraft just
prior to impact.
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1.2 Injuries to persons.
Injuries Pilot Passengers Others Total

Fatal 1 10 0 11
Serious 0 0 0 0
Minor 0 0 0 0
None 0 0 0 0
Total 1 10 0 11
1.3 Damage to aircraft.
The aeroplane was entirely destroyed.
1.4 Other damage.
Minor damage to grass area and ground contamination by Jet A1 fuel and
engine oil occurred.
1.5 Personnel information.
Pilot
Sex: Male
Age: 35 years old
Nationality: Belgian
Licences: PPL licence first issued on 06 June 2001
CPL licence first issued on 23 March 2006.
ATPL licence first issued on 23 November 2011, last issued on
19 July 2013 in accordance with EASA Air Crew Regulations,
Part-FCL.
Rating: SEP (land), valid until 31 March 2014
Pilatus PC-6, valid until 30 September 2015

Cessna SET, valid until 31 July 2015
Avro RJ/Bae146, valid until 30 April 2014
Last endorsement in the pilot log book to perform parachute
dropping flights on 21 September 2013, valid until 30 November
2015
Medical: Medical certificate: Class 1&2, issued 12 November 2012, valid
(Class 1) until 23 November 2013.
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General experience:
Total experience: 2919 FH, from which 775 FH as PIC.
Among others, a practical test for aerobatics flights was passed on 19 May
2005 in order to obtain a CPL licence. However, there is no indication of any
authorization granted for the performance of aerobatics flights.
Pilatus PC-6 experience:

Qualification on PC-6 completed on 1 November 2011. The pilot’s log book
shows an accumulation of 332 FH on PC-6 since 17 March 2012, including
782 landings. The dropping flights on PC-6 show:
• An average duration of 25 minutes and 30 seconds.
• The lowest time duration is 18 minutes.
• The longest total flight time in a single day is 12:30 FH
• The highest number of landings in a single day is 34 for 12:30 FH.
The last flight as airline pilot, flying a BAe146 aeroplane, was performed on
17 October 2013 at 22:00 ending on 18 October 2013 at 01:10.
Previous 24h flight activities: The pilot flew that day 13 flights with the Pilatus.
Total flight time around 4:20 FH (20 min average).
Previous week flight activities: 08:22 FH (BAe146)
PC-6 flights over the last 6 months:

Date (2013) Hours Min Total min Landings
5 April 1 4 64 3
6 April 3 15 195 6
7 April 8 43 523 19
14 April 7 45 465 20
21 April 5 45 345 13
4 May 6 56 416 17 (Estimated)
18 May 9 12 552 22 (Estimated)
14 June 0 26 26 1
15 June 4 0 240 8
16 June 7 14 434 18
29 June 10 32 632 25
4 July 10 15 615 23
6 July 0 45 45 1
6 July 10 30 630 25
21 July 8 42 522 20
15 August 7 10 430 17
17 August 11 10 670 28
18 August 0 45 45 1
21 September 0 25 25 1
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22 September 6 22 382 15
19 October 4 20 280 12
Pilot history at EBNM airfield:

The pilot had been called to order twice in December 2012 and in July 2013
by the EBNM airfield authority for repeated violations of approved aerodrome
procedures and the performance of manoeuvres deemed inappropriate.
These occurrences were not reported to the BCAA.
1.6 Aircraft information.
General information
The Pilatus PC-6 is a single-engine high wing Short Take-Off and Landing
(STOL) utility aircraft with conventional fixed landing gear, designed by
Pilatus Aircraft of Switzerland. First flown in 1959, the PC-6 has been built in
both piston engine and turboprop powered versions. The accident aeroplane
was powered by a P&WC PT6A-27 free turbine engine.
Certification
The Pilatus PC-6’s first version had been certified by the Federal Office for
Civil Aviation (FOCA) of Switzerland in December 1959, under the Type
Certificate reference F 56-10. The aircraft complies with the US Civil Air
Regulations, Part 3 (US CAR3) as a normal category aeroplane. PC-6 is not
approved for aerobatics manoeuvres. The model PC-6/B2-H4 variant had
been approved on 20 November 1985.
General characteristics
Crew: one pilot
Capacity: up to ten passengers
Length: 10.90 m
Wingspan: 15.87 m
Height (Static): 3.20 m
Wing area: 30.15 m²
Empty weight: 1387 kg
MTOW: 2800 kg
Max zero fuel weight: 2400 kg
Centre of Gravity envelope: Up to 1450 kg = 11% to 38% MAC (3.209 m to
3.722 m from the reference line).
At 2800 kg = 32% to 38% MAC (3.608 m to 3.722 m from the reference line).
Straight line between variation points.
Powerplant: P&W Canada PT6A-27 turboprop, 550 SHP
Never exceed speed (VNE): 280 km/h (151 kt)
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Max Structural cruising (VC): 220 km/h (119 kt)

Max Manoeuvring (VA): 220 km/h (119 kt)
Max flaps extended (VFE): 176 km/h (95 kt)
Stall speed (VS): 96 km/h (52 kt) (flaps down, power off, at
MTOW)
Manoeuvring load factors: + 3.58 - 1.43
Service ceiling: 25000 ft
Figure 2: Pilatus PC-6 B2H4
Airframe:
Manufacturer: Pilatus
Type: PC-6/B2-H4 (Upgraded from an original PC-
6/B1H2 type in 1985)
Serial number: 710
Built year: 1969
State of Registry: Belgium
Certificate of Registry: N° 5269, delivered by BCAA on 5 March 2003
Certificate of Airworthiness: EASA Form 25, delivered by BCAA on 15
February 2007
Airworthiness Review Cert.: Renewal on 28 March 2013 at 15803:13 FH.
ARC was valid until 25 March 2014.
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Total Time: 16159:20 FH

Time since overhaul: 4427:55 FH (Performed 08/2002 to 02/2003)
Time since last partial O/H: 765 FH (Performed 11/2011 to 03/2012)
Total number of landings: 34903
Last 100 hour Insp/Maint: Performed 18 September 2013 at 16112:58 FH
Fuel capacity: The aeroplane was equipped with large fuel
tanks. Total usable fuel capacity was 170 US
GAL (644 litres)
Engine:
Manufacturer: Pratt and Whitney Canada
Type: PT6A-27
Serial number: PC-E41246
Engine hours: Total Time: 15273:50 FH
Time since overhaul: 764:57 FH
Propeller:
Manufacturer: Hartzell (FAA STC SA377CH)
Type: HC-D4N-3P
Serial number: FY2365
Propeller hours: Total Time: 4427:55 FH
Time since overhaul: 1161:20 FH
This type of propeller is a 4-blade, hydraulically operated constant speed

model with feathering and reverse pitch capability. Oil pressure from the
propeller governor is used to move the blades to the low pitch (blade angle)
direction. A feathering spring and blade counterweight forces are used to
move the blades to the high pitch/feather direction in the absence of governor
oil pressure. The propeller incorporates a Beta mechanism allowing reverse
thrust. The propeller is equipped with an aluminium hub with aluminium
blades. The rotation of the propeller is clockwise as viewed from the rear of
the aeroplane.
Propeller control - Beta propeller pitch in flight

The Pilatus Porter is approved to use beta pitch in flight. Beta pitch is a
concept whereby the propeller is set at a low positive pitch angle to provide a
braking effect for steep controlled descents. When engaged, the propeller
acts like a giant air brake. Beta mode is provided at airspeed below 100 KIAS
with the power lever near or at the detent.
Para dropping equipment

The aeroplane incorporated amongst others the “Optional Equipment” for
parachutist’s operations as detailed in AFM supplement 1824 (Referred to in
FOCA data Sheet F 56-10 part 2.96-21 “Optional Equipment”). The
modification encompasses the installation of a longitudinal bench, a stool, an
external foot step and several guards.
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AFM supplement 1824 indicates that the jumper’s seat belts must be
installed if required by the operating regulations. In Belgium, the installation
of belts has been required by BCAA since 2003, based on a Safety
Recommendation following another fatal crash involving the same
parachutist club and the same type of aeroplane in June 2002.
Namur Air Promotion S.A. purchased the aeroplane in 2003 without safety
belts for the occupants sitting on the bench and on the floor. The owner
installed locally manufactured restraints that were tested and accepted by
BCAA. The restraints (Single lap belts) were equivalent to Pilatus PN
112.50.06.824. At the same time, BCAA requested the installation of a
placard on the dash board indicating that the pilot is responsible for verifying
that all the occupants are properly attached before take-off.
Figure 3: location of the restraint system
Pilot’s seat and pilot’s back protection
Figure 4: picture of the pilot’s seat in the aeroplane involved in the accident
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As shown on the picture above, there is no separation between the cabin and
the cockpit and the low pilot seat’s back does not provide any protection to
the pilot’s upper body and head.
Oxygen equipment
This aeroplane was not equipped with a breathing system for pilot or
occupants.
Pilot’s operating handbook

The aircraft’s original Airplane Flight Manual (AFM) was not retrieved in the
wreckage or found elsewhere. The applicable AFM covering the PC-6/B2-H4
is identified as being “Report N°1072–20” dated 10 December 1985
(Revision 5 dated February 2013). A supplement N°1824 to the AFM refers
to parachuting operations. For skydiving operations, the maximum number of
occupants is 10, excluding the pilot.
This supplement incorporates a change, made on request by the BCAA,

showing that the following placard must be installed on the dash board:
Figure 5: Placard to be installed on dash board
The AFM of the accident aeroplane was verified and updated by the
Continuing Airworthiness Management Organisation (CAMO) during the last
airworthiness review of the aeroplane on 28 March 2013. After updating by
the CAMO, this AFM (revision 4 dated January 2003) incorporated all the
applicable temporary revisions and supplements and was in compliance with
the “Status List Documentation PC-6 dated 01 February 2013.
Flight controls
The aeroplane is equipped with a conventional flight control system for the
ailerons, elevators and rudder. Control rods and cables are used to operate
the controls. The primary flight controls feature a pilot and a co-pilot control
column for the control of the ailerons and elevator and pedals for the rudder.
Each aileron assembly has two sections joined together at the centre. A
counterweight consisting of a long heavy tube is fixed at the lower surface of
each outboard aileron. This means that the outboard aileron section is
significantly heavier than the inboard one.
Balance tabs are installed on the ailerons and the elevator to reduce the
loads required to operate these controls in flight.
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An in-flight adjustable trim tab is installed on the rudder control system. A

variable incidence horizontal stabilizer is used for the pitch trim control.
The co-pilot control column is removable and was removed for this
aeroplane.
Each wing features a flap assembly, extending from the wing root up to
middle of the wing span and consisting of two sections joined together at the
centre. There is no interaction between the aileron and the flaps. The flaps of
the crashed aeroplane were manually controlled by a hand crank located on
the ceiling of the cockpit.
Horizontal stabilizer trim system description

The stabilizer is hinged to both sides of the fuselage at the main spar
location, which is at approx. 25% MAC, allowing the trailing edge to move up
and down under the action of the pitch trim actuator. The actuator is located
in the tail section of the fuselage, below the stabilizer and remains stationary
as long as it is not electrically activated. When the pilot operates the actuator
trim switch, the trailing edge of the stabilizer is moved vertically (up/down)
allowing a modification of the stabilizer’s angle of attack.
Figure 6: drawing of horizontal stabilizer and elevator
A retracted position of the actuator will tend to put the aircraft in a nose down
position (=horizontal stabilizer trailing edge down) while an extended position
of the actuator will tend to put the aircraft in a nose up position (=horizontal
stabilizer trailing edge up).
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The movable tube of the trim

actuator is attached by a rod end
bearing to the rear lower side of the
stabilizer while the stationary end of
the actuator is attached to the
fuselage frame by a fork fitting and
a spherical bearing.
In the electrically fully retracted

position, the rod end bearing
extends 46 mm from the actuator
casing. The full stroke of the
actuator is 85.8 mm.
Figure 7: Drawing of the trim actuator, the stabilizer

trailing edge and the elevator bellcrank.
Figure 8: lateral view of the actuator. Figure 9: installation of the trim actuator
As can be seen in the figures above, the pitch trim system of the PC-6 B2H4
is fully electrically driven, while the rudder trim system is manually driven.
The horizontal stabilizer electric system incorporates a dual motor operated

linear actuator (One motor for the main and another motor for the alternate
system).
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A three-position spring loaded trim

switch is installed at each control
column grip. The system also
incorporates two relays, one to feed the
electrical motor towards nose up and
the other towards the nose down
position.
The purpose of the trim switch is to

electrically ground either the ‘up’ or the
‘down’ relay of the main trim motor.
When activated, the relay provides a
positive 28 volt supply to the Figure 10 : picture of a similar stabilizer
corresponding winding of the linear trim switch
actuator motor.
It has to be noted that it takes about 9 seconds for the actuator to move, by
the main system, from a neutral position to the nose up or nose down
(electrical) stops.
The 28 volt feed of the

stabilizer main electrical
system is provided through
an interrupt switch and a 10
amp circuit breaker.
In case of undesired pitch

trim operation, the interrupt
switch located on the
instrument panel shall,
when positioned in the
interrupt position, deactivate Final report FACTUAL INFORMATION.
both the main and the
alternate systems.
Figure 11: stabilizer trim alternate switch on the left
and interrupt switch on the right
The alternate system can be operated after having manually pulled out the
circuit breaker of the main system and repositioned the interrupt switch in the
normal position.
This procedure is described in the Airplane Flight Manual and is enclosed in

annex 6 to this report.
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Pitch trim actuator history

The pitch trim actuator identification is “Electromec” EM483-3 PN:
978.73.18.103 SN: 173. It was newly installed on 10 April 2009.
Chapter 04 of the Aircraft Maintenance Manual “AMM” n°01975 rev.17
pertaining to the Airworthiness Limitations prescribes that this actuator has to
be overhauled every 3500 hours”. The installed actuator time in service was
within the manufacturer’s limits. The next replacement was scheduled at
17645 hours ACTT.
Variation in load factor with airspeed for manoeuvres (V-n Diagram).
Figure 12: V-n diagram showing Speed versus Load factor
The flight operating strength of an aeroplane is presented on a graph called a

V-n diagram with the calibrated airspeed3 (velocity, "V") in the X-axis and the
load factor ("n" or "g") in the Y-axis. Each aeroplane model has a unique V-n
diagram defined by the certification criteria and the aeroplane design and
valid for a given weight. Certain points on the V-n diagram define key
operating airspeeds, which are intended to enable pilots to avoid structural
damage to the aeroplane due to excessive flight loads.
The diagram (also called structural envelope) describes the allowable

combination of airspeeds and load factors for safe operation.
3
Calibrated airspeed (CAS) is the indicated airspeed corrected for instrument errors and
position error. It describes the dynamic pressure acting on aircraft surfaces regardless of the
existing conditions of temperature, pressure altitude or wind.
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Any manoeuvre, gust, or combination thereof outside the structural envelope

can cause structural damage or even failure and can effectively shorten the
service life of the aircraft.
The diagram shows various boundaries. The upper horizontal line is the
positive limit load factor. For the Pilatus PC-6 B2H4 this upper limit is 3.58 as
determined in compliance with US CAR3. The lower horizontal line is the
negative limit load factor which, according to the certification specifications, is
-0.4 times the positive load factor (in this case: -1.43).
The aircraft is designed to withstand loads equal to the aeroplane’s MTOW

(2800 kg) multiplied by the limit load factors, provided in the V-n diagram of
the aeroplane. Applying a load above these factors may cause permanent
deformations to the aeroplane’s structure. Applying a load above the ultimate
load factor (which is 50% beyond the limit load factor) may cause the failure
of the primary structure.
The vertical boundary at the right side of the diagram is the maximum speed
limit VD. Above this speed, deformation and failure of the structure may also
occur. The maximum allowed airspeed is set at 90% of the speed limit (safety
margin). This speed is called VNE, or the velocity to never exceed.
The white region on the left of the diagram is edged by the so-called “stall
lines”. They represent the minimum speed to be flown at a given load factor
and maximum lift coefficient. Flying at lower airspeeds will cause the aircraft
to stall and/or start to descend. It can be observed that the curves above and
below the X-axis of the V-n diagram are not equal. This is due to the
asymmetric airfoil of the PC-6 wing. The speeds where the curves intersect
the limit load factor lines are called the manoeuvring speeds and for the sake
of this report indicated as VA (in positive load) and VA- (in negative load).
These speeds are important because when flying at speeds below the
manoeuvring speed, the aircraft will always stall before exceeding the
aeroplane’s limit factors. Final report FACTUAL INFORMATION.
When flying at higher speeds (yellow zone in the diagram), abrupt control
inputs or flying in turbulent conditions should be avoided to prevent
exceeding the limit factors.
It has been calculated that the PC-6 will stay within the envelope and
withstand gust conditions of +30 and -30 fps in a normal un-accelerated flight
(the load factor equals +1). It can be observed that the yellow zone starts at a
lower speed when submitted to negative loads (94 kt versus 119 kt) which
means that the limit load will be reached earlier. When extrapolating the
negative stall line, the speed at which the negative ultimate load factor is
reached can be determined around 115 kt.
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Weight and Balance

The aeroplane was last weighed on 28 March 2013 in the following
configuration: With full engine oil, unusable fuel and the specific equipment
for parachutist dropping installed.
A Weight & Balance computation was seldom performed before flight. A pilot
flying regularly with this aeroplane and also the president of the parachute
club confirmed that it had been determined that the PC-6 loading would not
exceed the Centre of Gravity (CG) envelope. This determination was based
on different Weight and Balance computations made together with the
instructor during all pilots’ conversion training sessions on PC-6.
During the investigation, the weight and balance of the aeroplane was
computed, based on the aeroplane data and the actual weight and position of
the occupants, (as far as it could be determined) using the following data
and/or assumptions:
• The weight of all the occupants was known.

• The position in the cabin of most of them was known.
• The average weight of the full equipment and clothing of each parachutist
was estimated to be 6 kg.
• A conservative assumption was chosen regarding the places number 6,
7, 8 and 10, for which the actual occupancy was unknown, by placing the
heavier persons forwards and the lighter backwards.
• The approximate fuel quantity was based on the number of rotations
performed since the last refuelling and a mean fuel consumption of 12.5
US GAL per rotation.
• The distance from the reference line was estimated based on the
expected position of the occupants
Figure 13: sketch showing several distances to reference line
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Figure 14: sketch of the fuselage showing the parachutists' assumed position
Arm (m) Moment

Item from ref line Mass (kg) (kgm)
Aircraft empty weight (*) 3.354 1387.3 4653.004
Pilot In Command 3 91 273
P 5 (Back to front co-pilot
seat) 3 93 279
P1 3.5 66 231
P3 4 81 324
P2 4.7 92 432.4
P4 5.45 96 523.2
P9 5.5 81 445.5
P 10 in indefinite position 3.6 96 345.6
P 8 in indefinite position 4 82 328
P 7 in indefinite position 4.7 83 390.1
P 6 in indefinite position 5.1 70 357
Estimated fuel (50 USG) 3.95 161 635.95
TOTAL 3.718 2479.3 9217.754
(*) Small co-pilot’s seat in cockpit, RH seat aft of the cabin, para bench, cabin
floor and static line attachment are included in the aircraft empty weight
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The above computation shows that the CG was very close to, or possibly
even beyond, the aft limit of the CG envelope of the aeroplane (Aft limit is
3.722 m from the reference line). Furthermore, the weight of the aeroplane
was within limits (MTOW is 2800 kg).
The AFM supplement N°1824 states in section II that the pilot in command
must pay special attention to the aeroplane’s loading. However, no guidance
is provided on how to determine the arm between the reference line and the
different parachutists, as they are actually installed on the benches and on
the floor and their respective position is difficult to be precisely determined.
Figure 15: extract of POHS N°1824
Aircraft history
The Pilatus Porter MSN 710 was built in 1969 as a PC-6/B1H2 model and
was first operated as a crop duster aeroplane by Ciba-Pilatus and
subsequently used by the Red Cross organization in Angola.
In 1989, it was purchased by a Belgian parachute club. The aeroplane was

by that time already upgraded to the PC-6/B2H4 model. On 12 March 2000, it
suffered an accident during a take-off from Moorsele (EBMO) airfield. The
aeroplane suffered significant damage.
As a consequence of this accident, the aeroplane had been repaired and

overhauled in 2002 by Pilatus Flugzeugwerke and was thereafter bought by
“Namur Air Promotion SA” in 2003. During the repairs a new 4-blade
propeller of the Hartzell HC-D4N-3P type with SN: FY2365 was installed in
accordance with FAA STC SA377CH.
The aeroplane was operated by “Namur Air Promotion SA” from that time
onwards for the purpose of parachute drops in Temploux, Namur (EBNM). It
had flown around 4420 FH since the time it was purchased by its last owner
until the date of the accident.
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Maintenance
The aircraft was maintained by an EASA Part M subpart F approved
maintenance organization. This organization was also duly approved as a
Continuing Airworthiness Management Organisation (CAMO) and as such
was in charge of both the maintenance and the airworthiness management of
the aeroplane.
Records show that the maintenance was regularly performed in accordance

with a BCAA approved “Aircraft Maintenance Program” dated 25 May 2013.
The last periodical maintenance (100 h) had been performed on 20

September 2013 at 16112:58 FH (Airframe Total Time).
The discrepancy report related to this last maintenance lists a few minor
outstanding items awaiting either the owner’s work order or the delivery of
ordered parts. One of these items concerns the replacement of the temporary
repaired LH wing outboard aileron section and another concern a possible
fuel contamination for which the aeroplane’s owner had been advised to
check his fuel supply. The remaining items were deemed insignificant in
relation to this investigation.
In accordance to common practice, the inspection schedule of the Pilatus

Maintenance Manual Chapter 5 entitled “100 Hours / Annual Inspection –
Airframe” was used to perform the scheduled maintenance. The maintenance
records were examined. These documents showed an anomaly; a task was
not signed up and the mention “NA” was entered at the item 49 (see
hereunder) even though this item is partially applicable. The personnel of the
maintenance organization was interviewed and it was determined that the
functional test (following Ref. 27-40-00) mentioned in the item 49 had been
adequately and completely performed as a part of the item 47 “Electrical
system – Examine”.
Figure 16: extract of the 100h inspection schedule showing the maintenance
to be performed on both mechanical and electrical system
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1.7 Meteorological conditions.
General Forecast – Winds – Valid 19 October 2013 from 06:00 to 18:00 at

EBBR
SURFACE 205 DEG 05-10KT (COAST 10-15KT) BECMG SW/10-15KT

AT 1000FT 210 DEG 20-25KT BECMG 230 DEG 25-30KT
AT 5000FT 230 DEG 25KT BECMG 240 DEG 35-40KT
Airports Observation reports
EBCI METARs 19/10/2013 (11:50 – 13:50 )

METAR EBCI 191150Z 18011KT 9999 FEW008 16/13 Q1009 NOSIG=
METAR EBCI 191220Z 18010KT 140V210 CAVOK 16/14 Q1009 NOSIG=
METAR EBCI 191250Z 19012KT CAVOK 16/13 Q1009 NOSIG=
METAR EBCI 191320Z 19010KT CAVOK 17/13 Q1009 NOSIG=
METAR EBCI 191350Z 18008KT 9999 FEW018 17/14 Q1009 NOSIG=
EBLG METARs 19/10/2013 (11:50 – 13:50 )

METAR EBLG 191150Z 20011KT CAVOK 17/13 Q1009 NOSIG=
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Observation data (EBCI)
Weather radar
Figure 17: weather radar image at 13:20
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Meteorological conditions summary
The crash site was located between EBCI and EBLG airports. As an
interpolation of the EBCI and EBLG METAR’s, the wind speed on the ground
at the crash site was around 10 kt coming from 180°/190°.
The data of the general forecasted wind at altitude were extrapolated based
on the comparison between the wind values mentioned on the EBCI and
EBLG METAR’S at 13:20 and 13:50 . Based on this, it can be assumed the
wind at FL50 was approximately 25 kt coming from 210°.
Observation reports from EBCI and EBLG show the ceiling and visibility were
excellent for VFR flights. A few clouds were reported in the EBCI METAR at
13:50 (CAVOK - no cloud below 5000 feet above aerodrome level) and no
gust. Additionally, no witnesses standing in the vicinity of the crash site
reported any abnormal meteorological conditions.
1.8 Aids to navigation.
The EBNM airfield being located below the EBCI TMA One (located between
FL55 and 2500 ft AMSL), all aircraft taking off from the EBNM airfield and
operating above 2500 ft are subject to the EBCI Air Traffic Control. When
climbing to the transition altitude (4500 ft AMSL), aircraft are transferred from
Charleroi APP (call sign ‘Charleroi Approach’) to Brussels ACC (call sign
‘Brussels Control’).
However, a special procedure has been agreed upon between the various air
traffic control services involved together with the pilots of the parachute
dropping flights. Each parachute dropping aircraft transferred from Charleroi
APP to Brussels ACC must stay in contact with Charleroi APP on the second
frequency of the radio. The reason for this procedure is to ensure that both
ATC units concerned (Brussels ACC and Charleroi APP) are consulted for
the authorization of the parachutists drop for their respective airspaces.
When the aeroplane reaches the altitude for the parachute dropping, it
contacts Brussels ACC to get an authorization for the zone FL245-FL55. The
aeroplane is further required to contact Charleroi APP to get a similar
authorization for the zone FL55-2500 ft AMSL.
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The flight path of the aeroplane could be reconstructed based on radar data.
The Pilatus appeared on the radar screens around 13:28:10 passing 1300 ft.
Shortly after, at 13:28:55 the pilot contacted ‘Charleroi Approach’ and
requested to climb to FL135. The controller instructed the pilot to fly
eastwards at low altitude because of inbound traffic approaching EBNM,
passing at 4400 ft at 3 NM to the south of the Pilatus. The position of the
Pilatus was 1 NM southwest of EBNM.
Figure 18: extract of low air chart showing the approximate flight path
At 13:30:35, the aeroplane was over “Bois de Neverlée” - Mode C indicating

1800 ft. At 13:30:50, when crossing the road N904, still on an easterly
heading, the pilot was instructed to climb to FL50.
When the aeroplane crossed the highway E411 in the vicinity of Champion
(Time: 13.32.32), the pilot asked ‘Charleroi’, any chance for left turn to the
target?” (the target = the dropping area), but this was refused by the
controller.
At 13:33:30, the aeroplane was cleared by the EBCI controller to resume own
navigation to the target. The EBCI controller also instructed the pilot to
contact ‘Brussels Control’ on 128.2 (radio frequency in MHz) to climb higher
and also to report back to EBCI before the drop.
At 13:33:42, the aeroplane was flying at 4500 ft close to the crossing of roads
N992 and N80 (= Top right-hand corner of the EBCI-TMA3B). The pilot read
back the last instructions from the controller and the aeroplane initiated a left
turn and climbed to FL51 (5000 ft). The pilot did not contact ‘Brussels
Control’ on 128.2.
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Figure 19: last 2 minutes flight path

Figure 20: last minute flight path
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As seen on the preceding graphs, the aeroplane performed a left turn of

approximately 120° from 13:33:36 to 13:34:16 while climbing from 4500 ft to
FL 51 (5000 ft). Afterwards, the radar data show the aeroplane in a straight
and level flight for 12 seconds (13:34:16 to 13:34:28).
At 13:34:30, the radar track shows a sudden change of direction. The

aeroplane reverses course to the right. Between 13:34:28 and 13:34:32, no
altitude is recorded and from that time, the radar shows:
• 3 last echoes of the secondary radar (with altitude data) originating from
the transponder of the aeroplane at 13:34:36, 13:34:40 and 13:34:44.
• Few primary radar echoes northeast of the flight path (not represented on
the graphs) without altitude data, obviously originating from parts
separating from the aeroplane.
1.9 Communication.
A normal radio communication was established for the take-off with “Namur
Radio” Aerodrome Flight Information Service (AFIS). Conversations held on
this frequency are not recorded, nor is it required.
After the take-off the pilot contacted Charleroi APP prior to entering the EBCI
TMA Sector 1 (2500 ft AMSL – FL55). All the communications established
between the aeroplane, Charleroi APP and finally Brussels ACC are
recorded.
Last flight (N°15) communication transcript:
Time Charleroi APP Brussels ACC Pilatus Flight

altitude
13:28:52 ‘Charleroi’, (call sign)
on 2000, request one
three five
(call sign), track to the
east, call you back
shortly for further
climb
Roger, (call sign)
13:30:50 (call sign), climb to 1800 ft
flight level five zero
Ok, (call sign)
13:32:32 ‘Charleroi’, (call sign), 3300 ft
request left turn back
to the target
(call sign), continue to
the east, call you
back shortly to
resume
Ok, (call sign)
13:33:30 (call sign), cleared to 4200 ft
resume navigation
over the target
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Right, navigation over

the target, (call sign)
13:33:38 (call sign), for higher
‘Brussels Control’,
one two eight decimal
two. Report before
the drop
13:33:42 (call sign) 4500 ft
13:34:27 Radio emission:
silence
silence 4 seconds
silence 4 seconds
13:34:45 "Aah"
The pilot switched the radio frequency to Brussels ACC at or after 13:33:42
but did not check in with Brussels ACC. He continued climbing up to FL51
(5000 ft), ending in a straight level flight for more than 10 seconds.
Between 13:34:27 & 13:34:45, several transmissions with only background

noise (like gusty wind) were transmitted on the Brussels ACC frequency.
During the last transmission, what seems to be a short cry was heard.
Flight N°14 communication transcript:

During the previous flight (N°14), it took only 24 seconds for the pilot to
contact Brussels ACC after having received the instruction from EBCI APP to
get the authorization for climbing higher than FL50. The airplane was flying at
3000 ft at the time.
Time Charleroi Tower Brussels (128.2) Pilatus

13:07:23 ‘Charleroi Tower’, (call
sign), one three five
(call sign), Climb to
flight level five zero
13:08:45 (call sign), for higher
‘Brussels Control’, one
two eight two, report
before the drop

One two eight two,
report before the drop,
(call sign)
13:09:09 ‘Brussels Control’, (call
sign), passing 3000 ft
request one three five
(call sign)climb to flight
level one three five
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1.10 Aerodrome information.
EBNM – Namur Suarlée airfield
The crash occurred at a distance of about 12,5 kilometres east-northeast of

the EBNM airfield.
EBNM Namur airfield is located 7 km west-northwest of Namur. Geographical
coordinates are 50°29’17” N – 4°46’08” E and elevation is 594 ft (181 m).
The airfield is equipped with two grass 24/06 bi-directional runways. The
dimensions of runway 06L/24R (gliders) is 630 m x 50 m while 06R/24L
(used for motorized aircraft) has the following dimensions 695 m x 31 m.
Both runway with orientation 24 has a right hand circuit. However, a special
opposite circuit (LH for runway 24 and RH for runway 06) is applicable for the
parachute dropping aeroplanes based at the airfield.
Prior permission is required (PPR) from the operator for the use of the
airfield.
A mix of aircraft (aeroplanes, helicopters and gliders) are operating from the
airfield and parachuting activities in VMC are authorized. Overflight of the
airfield must be avoided during parachuting activities.
Aerodrome Flight Information Service (AFIS) is provided on 118.000 MHz
and radio equipment is mandatory in each aircraft.
The technical and operational conditions applicable to airfield without ATC
are prescribed by BCAA Circular GDF-04.
An extract of Circular GDF-04 about the responsibilities of the airfield’s
commander when observing violations:
6.4 Verantwoordelijkheden van de 6.4 Responsabilités du

vliegveldoverste commandant d’aérodrome
6.4.2 De vliegveldoverste of zijn 6.4.2 Le commandant

plaatsvervanger: d'aérodrome ou son suppléant:
a) … a) … Final report FACTUAL INFORMATION.
b) is gehouden elke inbreuk op de b) est tenu de consigner et de
luchtvaartwetgeving en - communiquer sans délai à la
reglementering dat voorkomt op het DGTA toute infraction à la
vliegveld op te tekenen en zonder législation et la réglementation
uitstel mee te delen aan het DGLV aéronautique …
…
Translation :
6.4. Responsibilities of the airfield commander

6.4.2. The airfield commander or his replacement:
a) ...
b) records and communicates as soon as possible to BCAA every
violation of the aeronautical regulation and legislation etc.
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Brussels South Charleroi Airport
Brussels South Charleroi Airport (EBCI) is located 23 km west of

EBNM Namur airfield. Consequently, several Terminal Manoeuvring Areas
(TMA’s) are overlying EBNM airfield, located in class G airspace.
Consequently, a large part of the flight path of the aeroplane was performed
under the control of the EBCI Airport ATC. Amongst others, the following Air
Traffic Services (ATS) communication facilities are available at Charleroi
Airport: Charleroi TWR (121.300 MHz) and Charleroi APP (133.125MHz).
The crash occurred 35 km east of EBCI close to the intersection of EBCI

TMA ONE, TMA TWO A and TMA THREE B (FL55/3500 ft AMSL).
Figure 21: relative position of EBCI, EBNM and the crash site
Airspace view above EBNM
The following drawing shows the build-up of the different controlled and
uncontrolled areas above Namur airfield.
Namur area One is a circle of 2 NM radius centered on 50°29’17” N 4°46’26”

E and extending from the ground up to FL135. This area designates the
zone where parachuting activities are organized.
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Figure 22 : airspace above EBNM (not on scale)
1.11 Flight recorders.
The aeroplane was not equipped with a flight recorder, nor was it a
requirement.
Action cameras were carried by some parachutists. The cameras were

examined by the Police Laboratory, but no record of the last flight was found,
which is not abnormal as they would normally only be used during the jump.
All reserve parachutes were equipped with an Automatic Activation Device

(AAD).
The AAD devices sample the ambient air pressure to compute the altitude
and vertical speed 8 times per second. The AAD is switched on by the
parachutist upon climbing aboard the aeroplane to allow the system to
measure the ambient pressure on the ground, being the ground altitude of
the future drop zone.
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Figure 23 : Reserve parachute automatic activation device (AAD)
Taking into account that the QNH was 1009 hPa and the elevation of the
Namur airfield is around 600 ft, the QFE (atmospheric pressure at the airfield)
was 889 hPa4 when the AAD of the parachutists measured the atmospheric
pressure of the airfield. This explains why the height difference measured by
the AAD and the aeroplane encoder (set to 1013 hPa) was around 720 ft
(30*(1013-889) =720 ft).
During take-off, the AAD will go to an ‘active’ status and is ready to help the
parachutist in a critical situation. In the meantime, it also starts to measure
the ambient pressure 8 times per second. The AAD arms itself automatically
when a rapid pressure increase is observed, corresponding to a 35m/s fall
speed. This activation fall speed is close to a parachutist’s free fall speed of
about 50m/s.
The AAD will instantaneously activate the reserve parachute to deploy when
both the following conditions are satisfied:
• The free fall speed is reached and maintained.
• The altitude drops below the pre-set activation altitude, corresponding to
an approximate height of 300 m AGL.
The electronic system of the AAD also feature an internal memory that will
log the past data in memory from 7 seconds before the arming point
(actually, 7 seconds before the 35m/s fall speed is reached) and stops
recording 10 seconds after reaching the ground altitude. The data of all
seven AAD’s could be recovered with the support of the manufacturer (Vigil –
a Belgian brand).
It was determined that all AAD detected a fall speed of over 35 m/s and
armed simultaneously while the parachutists were still on board.
4
Below 10000 ft, the pressure lapse rate is about 1 hPa per 30 feet => 600ft/30ft=20 hPa
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Figure 24: last 27 seconds of one AAD’s record
The above AAD recording shows the last 27 seconds prior to the impact. The
Y-axis shows the height above the EBNM airfield ground level while the
X-axis represents the time in seconds.
Elevation of EBNM airfield is 594 ft (181 m) meaning that the first data of
altitude (left ordinate) on the graphs are around 5000 ft (±1520 m) AMSL.
Elevation of the crash site was quite similar to the EBNM elevation meaning
that the last seconds of horizontal flight were performed at 1330 meters
above ground level.
Figure 25: AAD record from 7 seconds before the detection of the 35m/s freefall speed
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1.12 Wreckage and impact information.
1.12.1 On-site examination of the wreckage

The aeroplane crashed in a ploughed field located north of the village of
Gelbressée. The propeller, the engine and the front section of the fuselage
impacted first the ground with the aeroplane attitude almost vertical. The
approximate direction of impact was west.
Figure 26: general view of the accident site
The propeller, the engine and the nose section of the fuselage were virtually
buried in the ground and had disappeared under the other remains of the
aeroplane.
Witnesses reported that the wreckage caught fire just a few tens of seconds
after impact, destroying most of the front and central section of the fuselage.
The inner quarter section of the left wing separated from the fuselage at
impact and was lying on the ground about 12 meters left of the fuselage. The
inboard section of the flap was still attached to this part of the wing. The
structural fuel tank built inside this section of the wing was fully open at its
outboard rib.
The outer three-quarters of the left wing was not found in the vicinity of the
main wreckage.
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The right wing structure was still attached to the fuselage and the wing strut.
The wing showed obvious impact damage on the leading edge, and the inner
part was destroyed by fire.
The horizontal stabilizer was lying on the ground in an upside down position
the upper surface being in contact with the ground and the leading edge
pointing approximately in direction of the front side of the fuselage. The right
side of the stabilizer was partially covered and hidden by the tail section of
the fuselage. The elevator was still attached to the stabilizer.
The tail section of the fuselage was found lying on its left side, meaning that
the remains of the vertical fin were in a horizontal position.
Figure 27: aerial view of the wreckage Final report FACTUAL INFORMATION.
The left wing integral fuel tank broke open when the wing failed and it
suffered additional damage during final impact, but it didn’t burn. The right
wing integral tank as well as the collector tank located inside the fuselage
broke open at the final impact and were largely destroyed by the post impact
fire.
Most of the instruments were severely damaged, beyond possible use.
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Figure 28: pattern of the in-flight separated parts
A search to locate the severed parts was initiated by the police. The parts
were numbered (W01, W02 …) in the order they were found.
The table below shows the distance between the main wreckage and the
different parts starting with the closest and ending with the parts found the
furthest from the main wreckage.
Reference Description Distance (meters)
W03 LH wing outboard aileron 900

W02 LH wing main spar upper cap 980

W01 Rudder counterweight 1020
W04 RH cargo sliding door 1190
W10 RH vertical stabilizer skin and antenna 1420
W05 LH wing (outer 3/4 section) 1460
W09 Fragment of LH wing tip 1600
W07 LH wing trailing edge fragment at rib 12 1700
W06 LH wing outboard flap 2100
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Figure 29: LH wing outboard aileron
Figure 30: Part of LH wing main spar upper cap
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Figure 31: Rudder counterweight.

Figure 32: RH sliding door.
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Figure 33: RH skin and RH antenna of vertical stabilizer
Figure 34: Outer three-quarters of the LH wing (View of the lower surface).
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Figure 35: Fragment of LH wing tip Figure 36: Small stringer
Figure 37: LH Wing trailing edge fragment at rib 12

Figure 38: LH wing outboard flap
1.12.2 Detailed examination of the wreckage

The wreckage was transported to the facility of the Belgian Defence Air
Safety Directorate (ASD), at EBBE for further examination.
A first detailed examination was performed on 24 October 2013 with the

support of an Accredited Representative (AccRep) of the Swiss Accident
Investigation Board (SAIB) and two safety investigators from Pilatus. Experts
from the Belgian Defence Air Component and from the Belgian CAA also
helped the AAIU(Be) investigators to carefully examine the wreckage.
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A few days later, the engine and the propeller were thoroughly examined with
the support of safety Investigators from Pratt and Whitney Canada and
Hartzell Propeller Inc.
The safety investigators from Pilatus, Pratt and Whitney Canada and Hartzell
Propeller were acting as advisors of the AccRep of respectively the Swiss
Accident Investigation Board (SAIB), the Transport Safety Board of Canada
(TSB) and the National Transportation Safety Board (NTSB) of the United
States. The BEA of France also delegated a safety investigator who
participated among other in the investigation on an accident of Pilatus PC-6
in France involving a structural failure.
Fuselage and right wing structure.

The fuselage front and central structure was almost totally destroyed by
impact and the subsequent fire. Only the rear section, from the bulkhead 6
(the cabin rear wall) to the tail remained almost intact.
The right wing was significantly crushed at impact along its entire length. A
part of the skin had been separated from the wing and came to rest 15
meters in front of the main wreckage. The first, inner, quarter of the wing
incorporating the structural fuel tank had almost disappeared under the effect
of the post-crash fire. Both half inboard and outboard flaps and ailerons were
still attached to the wing remains. The right wing strut was slightly bent and
showed burning damage. However it was still complete and attached to the
remains of both the fuselage and the wing.
Right ailerons
The inner and outer ailerons of the right wing were found at their normal
position, at the trailing edge of the wing. They were severely damaged by the
final impact with the ground.
Right wing flaps:

The inner and outer flap remains were retrieved at the trailing edge of the Final report FACTUAL INFORMATION.
wing. All damage was consistent with the final impact and the post-crash fire.
Left wing structure

The wing was reconstructed and showed that the wing main spar was broken
in several places. The skin and some ribs were cut to gain access to the
remains of the main spar.
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Figure 39: LH wing reconstruction
The wing main spar

reconstruction could
determine that the part
found at 980 meters from
the main wreckage was a
section of the LH wing
main spar upper cap
installed between ribs
N°5 and 8.
Figure 40: LH wing main spar upper cap installed between ribs N°5 and 8.
This section of the upper spar cap was bent and twisted. The curve shown by
the spar cap indicates the wing was bent downwards. The twist showed a
downward movement of the leading edge and an upward movement of the
trailing edge. This was evidence for the fact that the wing had been submitted
to negative g-forces causing an extraordinary downward aimed mechanical

load with respect to an aeroplane in normal flight attitude. In summary:
• The main spar upper caps failed in 3 places: at the wing attachment, at
wing rib No.5 and at rib No.8.
• The main spar lower caps also failed at 3 locations which are not the same
as those of the upper caps.
• The wing skin had been torn differently with respect to the spar cap
failures, at approximately the junction of the inner and the outer flap.
• Most broken lower and upper spar caps remained attached to their
respective skin sections and ribs with the exception of the upper main spar
caps between ribs 5 and 8 (Figure 40).
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Figure 41: sketch of LH wing main spar failures and wing strut failures.
Visual examination of all main spar cap fractures could not find any obvious
sign of fatigue crack. All fracture areas were isolated and sent for a thorough
fractographical analysis at the Belgian Royal Military Academy laboratory.
The laboratory examination concluded that no sign of metal fatigue,
corrosion, brittle behaviour or other material pathology could be identified
(The document showing the results of the laboratory examination are
enclosed at the end of this report).
Left Wing Strut

The left wing strut was broken
into 3 sections, the damage
being approximately located at
mid-point of the strut’s length.
One 1,25 meter section of the

strut remained attached to the

wing while another 1,50 meter
section remained attached to
the fuselage. A small central
section was retrieved near the
Figure 42 : LH wing strut failures. main wreckage remains.
Thorough visual examination of the wing strut showed it first distorted into a
Z-like shape under a heavy buckling load before breaking. The small piece of
strut that formed into a Z-shape showed some traces of blue colour indicating
the strut contacted the wing lower surface.
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Examination of the wing’s lower

surface in the vicinity of the strut-to-
wing attachment revealed that the
strut and the wing fittings were
undamaged. However, a collision had
occurred between the nut and the
wing lower surface caused by an
elastic deformation of its fittings.
Figure 43: Sketch of the wing to wing strut connection.
As with the visual examination of the wing main spar fractures, no obvious
signs of fatigue crack could be found on the strut and, in order to establish
factual information, it was decided to submit all interesting fragments to a
fractographic examination, along with the left wing parts.
The laboratory examination concluded that no sign of metal fatigue,

corrosion, brittle behaviour or other material pathology could be identified (A
summary and the conclusions of the fractographic examination are enclosed
at the end of this report).
Left wing tip

The wing tip was reconstructed, and showed its lower surface was free of
longitudinal scratches. There was no trace of a previous contact with the
ground.
Left wing ailerons

The inner aileron of the left wing was found still attached to the wing and
revealed that both the skin at the outer corner of the trailing edge and the
balance tab were missing.
The outer aileron, retrieved at 900 meters from the main wreckage, was
largely intact; no skin was missing and the counterweight and the balance tab
were still attached at the aileron5. Traces of friction were visible on the
counterweight tube including the red painted end of the counterweight. These
friction traces matched red paint traces found on the fuselage dorsal fin.
Traces of rivets torn out were visible at both lateral ends of the ribs. An old
skin repair correctly withstood a structural deformation of the aileron. The
axis of the structural deformation of the aileron was determined to be aligned
with a similar deformation of the lower skin of the wing.
5
An old skin repair properly withstood a structural deformation of the aileron.
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Friction
traces
Figure 44: LH wing outer aileron showing common deformation with the wing inner surface.
Left wing flaps:

The inboard flap remained attached to the inner quarter of the wing up to the
final ground impact. By contrast, the outboard flap found 2km away,
separated from the wing in flight. Examination could determine that the
separation of the flap was caused by the separation of the wing at the
junction of the inner and the outer flap.
Wing flap position

The position of both flap actuators was measured and showed different
lengths. This apparent inconsistency was not relevant because of the traction
produced on the flap control chain when the wing separated from the
aeroplane.
Flight controls:
The primary flight control installations consisted of an assembly of control
cables, bellcranks, pulleys and connecting rods.
Most flight control cables were broken, some of them showing local corrosion
consecutive to fire damage. All cable ends were found still attached to their
bellcranks or other attachments.
Some cables had been cut by the rescue services to gain access to the
victims or to facilitate the wreckage transportation.
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Examination of all ruptured areas of the cables showed obvious signs of

tensile overload failures, and no trace of abnormal wear;
- individual strands were found unwinded, showing the sudden release of
kinetic energy during impact (see Figure 46)
- the fracture surfaces of the broken strands were of the ‘cup-and-cone-type’
with necking
- cables were heavily deformed, also showing the sudden release of kinetic
energy during impact. (see Figure 45 and Figure 47)
The same is true for all the failed components, such as connecting rods, of
the different flight controls loops.
Figure 45: Remains of the elevator cables

Figure 46: Failed ends of an elevator cable
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Figure 47: Aileron control cables inside the LH wing
The lower bellcrank of the

aileron control system inside
the fuselage was broken
close to the LH aileron cable
attachment and at the rod
connecting both control sticks
together.
These damages had been Final report FACTUAL INFORMATION.

determined to be caused by
overload, likely at the final
impact.
Figure 48: Aileron bellcrank located inside the fuselage
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Vertical stabilizer
The vertical stabilizer
structure was largely
disintegrated showing the
main spar still attached to
the upper aft section of the
fuselage and some
fragments of the skins.
The vertical stabilizer was
equipped with antennas
installed symmetrically on
both upper sides.
Figure 49 : The structure of the vertical stabilizer

was largely disintegrated.
The right side antenna and

a significant part of the right
structure were found in a
cultivated field at 1420
meters from the main
wreckage. The metallic
leading edge of this
antenna was missing.
The left top side of the

structure, including the left
antenna, was found at the
crash site. Figure 50 : leading edge of the vertical stabilizer, showing
RH antenna leading edge metallic protection missing
The missing antenna leading edge was found lodged into the left wing lower
surface skin.
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Figure 51: View of RH antenna leading edge, retrieved inserted in left wing lower surface skin.
Rudder
The rudder was found on the main wreckage site, a few meters behind the
fuselage tail section.
The top side of the rudder is largely disintegrated and the rudder
counterweight is missing. This counterweight was found at a distance of 1020
meters from the main wreckage. The leading edge of the rudder was torn
open.
Figure 52: Rudder showing the top end largely disintegrated.
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Horizontal stabilizer
Figure 53: Horizontal stabilizer upside down Figure 54: Horizontal stabilizer in normal
flight position.
The horizontal stabilizer was found resting upside down on the ground with
its left side partially covered by the aft section of the fuselage. Both leading
edges showed impact damage. Left leading edge damage, contaminated by
soil, was the result of the final ground collision while the right leading edge,
less damaged, showed evidence of a possible impact by another aircraft
structure. Except the severed and broken articulation plates, the central
section of the stabilizer suffered less damage compared to the damage at
both leading edges.
Figure 55 shows the central

section of the stabilizer in a

normal flight position (upper
surface upward).
Examination of the rivets and
holes of both articulation plates
showed they failed by overload.
The rivets of the both
articulation plates were
sheared. The RH articulation
plate is slightly deformed.
Figure 55: Horizontal stabilizer forward centre section
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By contrast, the LH
articulation plate is
deformed and fractured.
Figure 56 shows the LH

articulation plate
repositioned to reflect the
position of the stabilizer at
the moment of its failure
(upward/rearward
movement of the RH
stabilizer).
Figure 56: Horizontal stabilizer LH articulation plate.
Elevator
The elevator remained attached to the stabilizer up to the final impact with
the ground. All damage was consistent with the final impact.
Pitch trim
The actuator was significantly
damaged, showing evidence of
impact with the ground. The
aluminium casing showed major
deformations obviously the
consequence of the actuator
being pressed into the ground.
A part of the broken connecting
fork from the stabilizer was found
attached to the rod end of the
actuator movable tube. The rod
end was slightly folded.
Figure 57: Horizontal stabilizer electrical actuator.

The bottom fixture of the actuator
on the bearing fork (called
‘stationary end’ in the Illustrated
Parts Catalog (IPC)) was
separated from the actuator and
also separated from the fork fitting
of the fuselage.
From the 4 fixing screws, 3 were
recovered inside the tail section of
the fuselage, sheared off at the
level of the actuator surface.
Figure 58: Stationary end (lower fixture) of
the actuator.
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The position of the pitch trim

movable tube was measured in
order to determine the position of
the stabilizer at impact. As seen
on the Figure 59, the movable
tube was found fully retracted (axis
of the rod end bearing extended
46 mm from the casing). This
position of the movable tube
corresponds to a full aircraft nose
down stabilizer position (+2°
Figure 59 : Movable tube and upper fixture of
stabilizer incidence)
the actuator
The opening in the top horizontal skin of the fuselage located below the
stabilizer as well as the left hand skin of the fuselage was found torn open
and folded towards the outside, causing the opening to be significantly larger.
This large opening was consistent with the ejection of the actuator from the
wreckage at final impact.
The stabilizer’s LH attachment plate

was recovered, buried in the ground
near the main wreckage. However, a
small part missing from the plate
remained attached to the stabilizer.
The vertical edge of the plate showed

impact traces corresponding to the
‘<’shaped tear of the side of the
fuselage.
Figure 60: Horizontal stabilizer LH articulation plate
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Area impacted by
the stationary end
of the actuator
Figure 61 : LH side of the aft fuselage torn open and folded outside
The horizontal stabilizer trim actuator was extensively examined and tested.
The results are enclosed at the end of this report.
Engine
The bottom section of the engine and accessory gearbox area showed
impact damage and were partially covered with soot and dirt.
The engine suffered severe compressive damage with distinctive twisting of
the gas generator and exhaust cases. The deformation resulted in the front
section of the engine (reduction gearbox) being displaced towards the 3
o’clock position, with regards to its original position, with the propeller shaft
pointing towards the bottom. Final report FACTUAL INFORMATION.
The engine was partially disassembled in order to examine the compressor

section, the accessory gearbox section, the combustion section, the turbine
section, the lubrication system and engine bearings, the fuel system, the
pneumatic lines, the engine shafting, the engine accessories and the
propeller reduction gearbox.
No pre-impact anomaly was found and the twisting of the gas generator and
exhaust cases shows the engine delivered power at impact.
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Figure 62: View of the engine and propeller ready to be inspected, after cleaning.
Propeller
All four propeller blades remained attached to the hub. The propeller had
relatively mild impact damage. The blades showed mild bending and little
rotational scoring due to impact with a muddy field. The cylinder was
fractured off the hub due to impact damage. A pre-impact blade angle
calculated from witness marks was approximately 38°. This is in the normal
operating range of low blade angle and is indicative of ‘power on’. There
were no discrepancies noted that would indicate abnormal operation. All
damage was consistent with impact damage.
Right sliding door

The sliding door showed damage limited to the upper roller wheels, guiding
the lateral opening movement of the door within a guide rail. The roller wheel
attachments were found partially torn, especially the front ones.
Left hinged doors

The left hinged doors were not used and remained closed. They were
retrieved in the fuselage wreckage.
Parachutist’s restraint system

Examination of the wreckage could determine that the aeroplane was
equipped with a restraint system for each parachutist seated on the
longitudinal bench and on the floor.
Most individual restraint systems were retrieved showing variable burning

damage of each strap.
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Except the discoloration caused by the

fire, most metallic components of the
restraint system were found
undamaged or slightly bent due to
impact.
Examination of the parachutists’

harnesses could not find any damage
related to a possible excessive force
applied at their connections between
the restraint system and the harness.
Figure 63: Remains of some restraint

systems
1.13 Medical and pathological information
The autopsy of all occupants showed that the impact forces were not
survivable. The autopsy of the pilot could determine that his hands sustained
serious injuries compatible with hands closed on the stick handgrip at impact.
It could also confirm the absence of alcohol or any trace of medicine, or any
other product susceptible to impair the pilot’s ability to fly. The autopsy could
not determine the presence or the absence of any pre-impact adverse
medical condition.
The pilot, aged 35, held a valid medical certificate Class 1 required to act as
pilot in command in commercial air transport. There is no indication in the
pilot’s medical file showing that he could have been subject to a possible
medical problem.
Stating that the pilot held a valid medical certificate (class 1) means that he
complied with the requirements of the aero-medical standards. This system
aims to maintain an acceptable annual medical incapacitation risk level.
The periodic medical assessment of commercial pilot has two main

purposes. The first is checking the licence holder’s physical ability to operate
in all routine and emergency situations and second is the assessment of the
risk of sudden incapacitation, such as a tendency towards heart attacks,
epilepsy or the presence of metabolic conditions such as diabetes, etc.
The medical certificate Class 1 standard is very high and means for pilots
engaged in public transport operations that they must show, through medical
examination, a risk of medical incapacitation lower than 1% in 1 year
(= 8760 hours), which is approx. 1 incapacitation in 106 hours. This “1% rule”
defines the content, depth and periodicity of the medical assessment of
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commercial pilots. This medical standard is applied in Belgium and the

system demonstrated its efficiency in meeting the target.
To illustrate the efficiency of the system, the incident database of Belgium for
commercial aviation was reviewed (19870 reports - period 2007-2014)
contains 45 reports on flight crew medical problem. The origin of the problem
was: food related (21 cases), fatigue (10 cases), oil smell (3 cases) and
others (10 cases). Most of the cases describe a flight crew becoming sick, or
having a reduced capacity. Only one report states that the individual involved
actually fainted but this occurred sometime after the first symptoms
appeared.
Out of the accident database, there are two recent events (period 2007-2014)
for which incapacitation was indeed a causal factor, but both events
concerned elderly private pilots with a known medical condition (ULM pilots
with class 3 medical certificate, not under the “1% rule”).
1.14 Fire
The wreckage caught fire shortly after the first witnesses arrived on the crash
site. The fire was concentrated on the central section of the fuselage and on
the first quarter of the right wing remains. The fuel tanks (RH wing and feeder
tanks) split open at impact releasing fuel in the direction of the engine
section. The fuel ignited when it came in contact with the engine heat and/or
sparks caused by short circuits.
Figure 64: Fuselage section destroyed by fire.
1.15 Survival aspects
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The violence of the final impact was not survivable for the occupants of the
aeroplane.
Because the parachutes did not have sufficient time to fully open, the same
as above applied for the parachutists exiting the aeroplane just before the
crash. The impact forces were not survivable.
Safety belts:
The aeroplane had 2 front seats equipped with safety belts, one for the pilot
(incorporating lap and shoulder harness) and the other one (lap only) for the
parachutist installed on the back to front co-pilot seat. A small seat located
back of the cabin, on the right side, was also equipped with a safety belt (lap
only).
For the other parachutists, sitting on a bench and on the floor, a restraint
system – single strap with a snap hook – allowed (imperfectly) to secure their
position during take-off and , when still on board, during landing. This
restraint system was required following the accident that occurred in 2002
with the same parachute club and the same type of aeroplane. The lack of
seats and restraint system for the passengers was identified as the cause of
the injuries to the passengers in the investigation report of that accident. .
Due to the accident in 2002, the following safety recommendation was made:
La réglementation belge n'est pas claire sur l'obligation du port de la

ceinture pour l'emport de parachutistes. La législation devrait être adaptée
en ce sens, toutefois afin d'éviter un effet contre-productif, un système
adapté à ce genre d'utilisation (paras) devrait être mis au point.
Translation:
The Belgian regulation does not clearly require the use of belts for the
transport of parachutists. The regulation needs to be modified to incorporate
such a requirement. However, a specific system (paras) needs to be
developed in order to prevent any counter-productive effect.
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BCAA accepted the

recommendation, by requiring the
installation of a restraint system for
each aeroplane used for sky diving.
However, the regulation was not
formally amended.
The aeroplane, upon its return to

Belgium in 2003 after the repair
carried out by the manufacturer,
was equipped with a locally made
restraint system.
A prototype of the restraint system,

shown on Figure 65 was
satisfactorily tested in the BCAA
laboratory with a static load of 1000
kg (rupture occurred at 1150 kg).
Figure 65: Prototype of restraint system.
The use of the restraint system had been rendered obligatory by a placard in
the cabin and in the flight manual (Figure 5).
This BCAA requirement, developed in 2002, is quite equivalent to the
standard described in the new EU 965/2012 regulation (not yet applicable at
the date of the accident).
SPO.IDE.A.160 Seats, seat safety belts and restraint systems

Aeroplanes shall be equipped with:
- a seat or station for each crew member or task specialist on
board;
- a seat belt on each seat, and restraint devices for each station;
For the purpose of the (EU) No 965/2012 regulation, a parachutist is

considered as a task specialist6, regardless of his actual function within the
organisation (instructor, qualified jumper, trainee, dual jumper, …).
SPO.SPEC.PAR.110 Seats
Notwithstanding SPO.IDE.A.160(a) and SPO.IDE.H.160(a)(1), the
floor of the aircraft may be used as a seat, provided means are
available for the task specialist to hold or strap on.
In spite of the BCAA requirement, interviews with key persons in the

parachute club indicate that the restraint system was rarely used.
6
‘Task specialist’ means a person assigned by the operator or a third party, or acting as an
undertaking, who performs tasks on the ground directly associated with a specialised task or
performs specialised tasks on board or from the aircraft.
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In flight, however, parachutists who had chosen to strap themselves removed

the restraint system when reaching a sufficient altitude of about 1500 ft AGL.
Strapped parachutists detached themselves from the restraint system, as it
would impede them of the possibility to jump from the aeroplane in the event
of an emergency.
Another factor is also that the restraint system needs to be stowed properly
so that parachutists would not stumble upon it when exiting the aeroplane, or
by distraction, trying to leave the aircraft while still attached to the floor
restraints.
For information, in 1998 the FAA performed a study called Evaluation of

Improved Restraints Systems for Sport Parachutists (DOT/FAA/AM-98/11).
Another publication Flying for skydive Operations – P-8740-62 provides a
summary of the FAA regulation and other information that affect Skydive
operations in the USA.
1.16 Tests and research.
1.16.1 The horizontal stabilizer trim actuator

The horizontal stabilizer trim actuator was thoroughly disassembled,
examined and tested. A full report of the horizontal stabilizer trim system is
enclosed in the appendices to this report.
1.16.2 Aircraft performance

The AFM doesn’t provide information about the roll rate of the aeroplane, nor
is it required. However, this information being interesting, Pilatus made a test
flight for the purpose of the investigation, with the following results:
• 6 separate manoeuvres were flown : 3 ‘left-to-right’ and 3 ‘right-to-left’

• Each double manoeuvre was flown in 3 separate configurations, 30°, 45°
and 60° angle of bank.
• Aircraft configuration was clean, with empty under wing tanks, main tanks
3/4 full, 2 pilots, 105 KIAS, engine max. cruise setting (1030 ft.-lbs.)
The following results were timed by the crew:

• 30 ° angle of bank both left to right and right to left swing-over in 2-3
seconds
• 45 ° angle of bank both left to right and right to left swing-over in 2.5-3.5
seconds
• 60 ° angle of bank both left to right and right to left swing-over in 3.5-4.5
seconds
Please note that the aircraft was equipped with underwing tanks which
reduce the rate of roll somewhat.
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For a 120° bank angle change (60° angle of bank swing over), the aircraft
needs therefore approximately 4 seconds.
1.16.3 Barrel roll in flight simulator Marchetti 260

In the early afternoon on the day of the accident, two witnesses, one standing
in the village near the airfield of Namur and the other standing on the airfield
itself reported their attention being drawn by an engine/propeller noise
change. They looked at the Pilatus and saw the aeroplane making a
manoeuvre at the end of the flight before proceeding to the airfield to land.
Both ground witness statements combined with the statements of 2
passengers flying in the aeroplane led the investigators to conclude that the
aeroplane performed a barrel roll while flying southwest of EBNM, at the end
of the descent when approaching the airfield.
An AAIU(Be) investigator had the opportunity to simulate a few barrel rolls

during a session with a Flight Training Device (FTD) belonging to the Belgian
Defence. This FTD is a flight simulator based on the SIA Marchetti providing
a fully simulated cockpit in a 3D spatial cockpit environment without motion
platform. This session was performed with the support of a flight instructor
and the only purpose was to familiarize with how to perform a barrel roll and
to assess the common mistakes made when performing this type of
manoeuvre. The specific performance with a Pilatus PC-6 could not be
simulated accurately with this session as an FTD for the Pilatus PC-6
currently does not exist.
First the speed was built up to 110 kt by making a dive in order to gain
enough energy. When levelling off, a reference point on the horizon from the
aircraft was chosen, situated left, at an angle of 45° from the flight path. The
exercise was initiated by pitching up and moving the stick to the left to get a
sufficient roll rate, while trying to keep the reference point in sight. Due to the
pitch up attitude when inverted, a significant loss of altitude and an increase
in airspeed sometimes occurred causing the reference point to disappear
below the aircraft’s nose. Failure to react adequately would bring the
aeroplane into a steep dive. This could be corrected by a release of the back
pressure and/or by applying a light adequate forward pressure on the stick.
However, a typical beginner’s error would be to overreact by exerting too
much forward pressure on the stick after having lost the reference point.
During the exercise on the flight simulator, when exerting a brutal forward
pressure on the stick to ‘correct’ this and to get the reference point back in
sight, a load factor of -3g could be observed on the g-meter. Further rolling
got the aircraft back to positive loads.
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1.17 Organizational and management information.
Parachuting activities require several distinct authorizations, approvals and

endorsements from the BCAA regarding the aeroplane specificities, the
operation of the aeroplane, the conditions required to operate a permanent
site for parachuting activities and the qualification of the pilots.
As for the parachuting sport itself, the parachute clubs are members of a
federation which regroups, regulates, monitors and supervises the different
clubs.
1.17.1 Operation of the aeroplane

Operation of an aeroplane for the purpose of parachute dropping is
considered as aerial work, requiring a specific authorization from the
authority (see Royal Decree on Air Navigation dated 15 March 1954, Article
50).
The Royal Decree doesn’t lay down the conditions of delivery of an

authorization to perform aerial work activities. The Royal Decree (Article 50
(2)) states that a Ministerial Decree should specify the condition of delivery,
suspension and withdrawal of the authorization. However, no Decree was
found on this particular topic.
An aerial work authorization was granted by BCAA (Operations Department)

to the operator Namur Air Promotion with a 2 year period validity on 16
November 2011. A copy of the authorization document is enclosed at the end
of this report.
Amongst others, Article 2 of this aerial work authorization N°564 stipulates

that the authorization is subject to the following conditions:
Translation: Original text:

a) The activities will be performed a) Les activités seront effectuées
on behalf and under the pour le compte et sous
authority, the direction and the l’autorité, la direction et la
survey of the operator. surveillance de l’exploitant.
b) The operator shall comply with, b) L’exploitant est tenu de
and shall ensure that the staff in respecter et de faire respecter
charge, observe the laws, par ses préposés, sans que leur
regulations and conventions responsabilité personnelle ne
governing national and soit dégagée pour autant, les
international air navigation, lois, règlements et conventions
without the staff’s personal régissant la navigation aérienne
liability being discharged. nationale et internationale.
c) … c) …
Figure 66: Extract of the aerial work authorization.
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Notwithstanding the above Article 2 a) and b), interviews with key persons
from the parachute club and the airfield and the operator itself show that the
operator authority, actions and initiatives to organize the operation of its
aeroplane was very limited. Also its presence on the field to monitor/survey
how the aeroplane was operated was very limited.
The main tasks performed by the operator were to assess and to accept the
new applicant pilots, mostly based on the insurance requirements (Licences,
experience, etc.) and to accept the CAMO/Maintenance organization
maintenance costs.
By contrast, the planning of the para dropping flights and the flight duty roster
of the pilots was held by the parachute club. The president of the Paraclub
Namur indicated that all pilots had to integrate themselves into a dedicated
flight duty roster page. Thereafter, before the week-end, the president
ensured a pilot was available and if not, contacted pilots to find a solution.
The most experienced pilot in the club was implicitly considered as the ‘chief’
pilot of the parachute club. However he didn’t have any decision-making
authority or official responsibility.
When several violations occurred in the vicinity or at the airfield, the airfield’s
commander systematically contacted the pilot in question and the president
of the Paraclub Namur to account for it. The chief pilot was sometimes
involved as well.
1.17.2 Operation authorization for a permanent site of parachuting activities

BCAA Circular GDF-05 titled Descentes en parachute – Valschermspringen
covers the conditions for the performance of parachute jumps. In particular,
• Chapter 5 covers the characteristics of the dropping and landing zones
of the parachutists.
• Chapter 7 covers the requirements for aircrafts and pilots. The licence
requirements applicable to pilots and the technical requirements for
aircraft are elaborately specified.
• Chapter 9 covers the flight procedures i.e. mainly the cooperation with
ATC to allow safe jumps in an airspace occupied by different users.
An authorization for parachuting activities was granted by BCAA (Airport

Department) to the Paraclub Namur on May 1999. This authorization was
further amended on 31 August 2011 by reference letter LA/A-
POR/BDC/dc/2011-1892 and was valid for 3 years.
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Extract of the authorization letter granted to Paraclub Namur:
Partial translation of section 3 “Operating Conditions”
3.1 The club should ensure strict compliance with the conditions of Circular
GDF-05 edition 3 dated 29/04/2004 (see Annex 1) or any subsequent
edition, including the prescriptions regarding:
3.2 The necessary dimensions of the site …
3.3 The conditions for a parachutist …
3.4 The aircraft and the designated pilots (section7).
3.5 The meteorological conditions …
3.6 The flight procedures (section 9)
3.7 Nobody is allowed to perform or to authorise a parachutist’s jump, if this
activity would represent a danger for the aircraft in flight, for the jumping
parachutists or for people and property on the ground.
3.8 The aeroplane must be equipped with a transponder …
3.9 The Belgian Civil Aviation Authority shall be informed each time that an
authorization or a licence, necessary to obtain the present authorization,
becomes due, or is replaced, or when a modification was performed that

could affect the validity of the present authorization.
Figure 67: Extract of the parachute club authorization.
The above authorization letter emphasizes the accountability of the Paraclub

Namur regarding the different requirements of the Circular GDF-05.
However, section 7 and section 9 of the Circular deal with the aircraft, the
designated pilot and the flight procedures which are also matters under the
responsibility of the operator, as prescribed in the aerial work authorization.
The pilots allowed to perform parachute dropping flights for the parachute
club were identified in the BCAA authorization letter; however the pilot
involved in the accident does not appear on this list.
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1.17.3 Special ratings for pilot performing parachute dropping flights

BCAA Circular FCL-27 titled Qualifications spéciales – Bijzondere
bevoegdverklaringen covers the conditions to be fulfilled by a pilot to obtain
and renew a special rating for parachute dropping flights. This rating is only
valid in Belgium and is shown by an endorsement in the pilot log book.
The pilot involved in the accident performed a skill test for parachute
dropping flight with an examiner on 21 September 2013. This test, valid for 2
years, was conducted with the aeroplane from the accident and an
endorsement in the pilot log book was made.
1.17.4 Insurance company requirements

The risk associated with the parachute drop activity seemed to have been
assessed by insurance companies that, in addition to the regulatory
requirements (see Circular FCL-27), defined a series of more stringent
specific requirements for the pilots engaged in this activity.
Namur Air Promotion indicated that the insurance company required:

• The pilot to be holder of a Commercial Pilot Licence (CPL(A))
• A Minimum total experience of 750 FH, from which 350 FH as PIC
• Minimum experience of 100 FH on turbine – powered aeroplanes
• Minimum experience on parachute dropping of 10 FH.
1.17.5 Paraclub Namur organization

Interviews with different key persons from the parachute club revealed that
the safety of the parachuting activity itself was adequately taken into account
within the parachute club. The organization seemed to be properly structured
and is working under the authority and the safety framework of the regional
federation of parachutists (Fédération Wallonne des Clubs de Parachutisme).
However parachute flights were an opportunity for the passengers to have

fun and they sometimes pushed the pilots to get special sensations. This
occurred mostly with members of the club and less with occasional
parachutists. These are the circumstances in which parabolic flights and

possible other aerobatics manoeuvres were performed.
The staff of the parachute club had complete trust in the pilots and therefore
did not appreciate the risks of such manoeuvres. Moreover, the staff and the
members of the parachute club did not seem to understand that trying to
push the pilot to perform special manoeuvres was not safe.
According to witness statements the aeroplane flew more than once close to
VNE speed during the dive after the drop. This was demonstrated in the
course of the investigation using calculations based upon radar records.
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1.18 Additional information.
1.18.1 About the management of a horizontal stabilizer trim runaway

The instructor who trained the pilot during his Pilatus PC-6 B2/H4 type
training conversion was interviewed in order to gather information about the
pilot’s ability to manage a pitch trim runaway. The instructor recalled that the
pilot was very quick to properly react when performing the trim runaway
exercises. The instructor recalled the pilot was a physically strong man able
to fly the aeroplane in level flight with the pitch trim set in both extreme
positions, using only one hand.
Additionally, an AAIU(Be) investigator took the control stick of a similar

aeroplane during an initiation flight made with an instructor and could verify
that the aeroplane remained controllable in level flight at 105 kt with the
horizontal stabilizer set in full nose down position.
As the pilot involved in the accident was an airline pilot regularly flying
BAe146 aeroplanes, there was some interest to investigate the procedure to
be applied in case of pitch trim runaway on this type of aeroplane. The
purpose was to evaluate the possibility of confusion between the procedure
of Pilatus PC-6 and the one applicable to BAe146. Comparison of both
procedures could conclude the actions to be applied were quite similar
leading to the conclusion that confusion between both aeroplane procedures,
in case of emergency, was very unlikely.
1.18.2 About parachuting aeroplanes’ accidents, period 1987-2014

The database of several Safety Investigation Authorities was searched for
the occurrence of accidents involving parachute dropping flights. For the
period 1987-2014, the search revealed 46 accidents, including 6 in Belgium
and involving multiple aeroplanes.
The data gathered showed 5 distinct flight phases:

• The take-off,
• The initial climb, following the take-off, up to a safe altitude for a jump
with a parachute.
• The transit flight, a climb up to the dropping altitude.
• The dropping, for which the aeroplane slows down, to allow the dropping
of parachutists.
• The descent, sometimes with parachutists and/or passengers on board,
up to the landing.
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Figure 68: proportion of accident related to flight phase.
The most critical flight phases are the take-off and the initial climb. The
identified causes of this type of accident included:
• Engine failure, in 41% of the cases.
• Inadequate flight preparation (45%), including
o Inadequate weight and/or balance (30%)
o Improper trim setting (12%)
o Inadequate engine preparation: Fuel starvation, carburettor icing
This is closely followed by the drop phase:

• When reaching the dropping altitude, the aeroplane has to slow down at
a speed close to the stall speed, in order to allow parachutists to jump. In
45% of the cases, the aeroplane actually stalled and entered into a spin,
making an escape of the parachutist difficult (however not impossible).
• The second cause of accident in this phase is the involuntary contact of
parachutists (or their parachutes) with the aeroplane’s tail.
The accidents during the transit flight – as in this case – are due to:
• Engine failure (62%), for which all parachutists jumped to safety.
• Mid-air collisions (38%), including one in Belgium. They account for all
the fatalities in this flight phase.
The accidents during descent are mostly due to mid-air collisions and one
particular case due to the automatic opening of the reserve parachute when
parachutists remained on board during descent.
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1.18.3 Pilatus PC-6 accidents showing similarities

AAIU(Be) deemed it interesting to identify few other Pilatus PC-6 accidents
showing similarities with the accident in Gelbressée, i.e. a structural failure
of a wing and/or a horizontal stabilizer trim event.
Date Place Type Event Cause
1/11/1997 Laon B2-H2 Loss of control and Loss of pitch control

France both wings caused by
separation. inadequate pitch
trim position
13/03/2000 Moorsele B2-H4 Loss of control Incorrect full nose
Belgium immediately after up setting of the
take-off horizontal stabilizer
trim actuator
9/06/2002 EBNM B2-H4 Loss of control Incorrect full nose
Belgium immediately after up setting of the
take-off horizontal stabilizer
trim actuator
15/05/2004 Agen B2-H2 Horizontal stabilizer Crack not detected
France trim actuator during periodical
attachment failure inspections.
30/05/2008 Lillo B2-H4 Left wing and Load in excess of
Spain horizontal stabilizer design load caused
separation in flight by entering in an
area with heavy
storm conditions.
• Accident in Laon (France) on 1st November 1997:

Aeroplane model B2-H2 incorporating a mechanical horizontal trim
actuator while the aeroplane involved in the Gebressée accident, model
B2-H4, is equipped with an electrical trim actuator.
• Accident in Moorsele (Belgium) on 13 March 2000:

The circumstances of the accident are similar to those of the accident in
Temploux on 9 June 2002.
• Accident in Temploux (Belgium) on 9 June 2002:

Aeroplane model B2-H4 equipped with a horizontal electrical trim
actuator. The probable cause of the accident was determined to be an
inadequate nose up trim setting for the take-off.
NB: All PC-6 B2-H4 have later been modified to incorporate a system
that warns the pilot visually and aurally about an incorrect trim setting
prior to take-off. Furthermore an operational procedure which requires a
check prior to take-off was implemented.
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• Incident in Agen (France) on 15 May 2004:

Aeroplane model B2-H2 equipped with a mechanical horizontal trim
actuator (while the accident aeroplane, model B2-H4 was equipped with
an electrical trim actuator). It has to be noted that the aeroplane landed
safely with a loose horizontal trim actuator.
• Accident in Lillo (Spain) on 30 May 2008:

Aeroplane model B2-H4 similar to this aeroplane, showing an in-flight
separation of the left wing. The investigation of this accident concluded
that the wing structure failed due to aerodynamic overload caused by
flying in adverse meteorological conditions (heavy storm).
1.19 Useful or effective investigation techniques

Not applicable.
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2 ANALYSIS.
2.1 Information from witnesses
During the last phase of the flight, the witnesses’ attention was drawn by a
change in the sound produced by the aeroplane in flight. Such changes,
described as the sound of the engine and propeller can originate from
variations in engine power and propeller pitch or from direction or attitude
changes of the aeroplane, or a combination of all the above
The aeroplane was flying 1330 m above ground level (AGL). This height
combined with the horizontal distance from the witnesses and the speed of
the sound made that the attention of the witnesses was drawn a few seconds
after the start of the event. No witness saw or was able to describe in detail
the entire event that led to the wing failure.
However from all the witnesses interviewed, two contained information vital
for the investigation:
• A witness standing at a horizontal distance of approximately 600 m from
the aeroplane described a change in sound accompanied by a few
significant up and down roll movements of the wings before the
aeroplane disappeared from the witness’s view.
• Another witness standing approximately 2.4 km away from the
aeroplane, heard a change in sound, looked at the aeroplane and saw it
in a steep dive, followed by a pull-up manoeuvre. At that point, he saw
one wing breaking off in an upward direction.
Interview with key persons from the parachute club, pilots and airfield
authority revealed that the pilot had been called several times to order by the
airfield authority. The pilot had been subjected to sanctions due to unruly
behaviour in the immediate proximity of the airfield, mostly at the end of the
last flight of the day.
Additionally, it was common knowledge that some parachute pilots made

some aerobatics manoeuvres from time to time such as parabolic flights with
or without passengers on board and flew the aeroplane during the dive, close
to VNE speed7. However, nobody seemed to realise the seriousness of the
problem related to this behaviour.
Final report ANALYSIS.
7
This was demonstrated in the course of the investigation using calculations based upon
radar records.
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2.2 Wreckage examination
As seen in section 1.12 ‘Wreckage and impact information’, thorough

examination of the wreckage did not reveal any pre-accident structural or
flight control deficiency.
However, the horizontal stabilizer trim actuator was found in full nose-down
position. A thorough examination of the actuator electrical system could not
determine any technical malfunction that could explain the full nose-down
position. The investigation could demonstrate that the trim actuator electrical
connections remained serviceable up to the final impact with the ground. The
radio recording showed that the pilot activated the push-to-talk button 4 times
for a total duration of 10 seconds during the plunge of the aeroplane, without
actually communicating with ATC. It is likely that the pilot also involuntary
activated the pitch trim switch by grasping the stick when trying to regain the
control of the aeroplane during the plunge. This hypothesis is supported by
the fact that the stabilizer trim toggle switch and the push-to-talk button are
both located on the hand grip of the stick. Moreover, the time (in all about 9
seconds) required to move the actuator from a mean flight level position to a
full pitch down position is compatible both with the duration of the plunge
(approx. 18 seconds) and the 10 seconds of activation of the push-to-talk
button.
This assumption is supported by the following:
• It is demonstrated that the pilot was properly trained to face an electrical
trim runaway.
• The design of the aeroplane and the procedure of the flight manual were
adequate to interrupt and correct a runaway trim.
• The instructor who trained the pilot indicated the pilot performed very
quickly the procedure to interrupt and correct a simulated runaway trim
during the PC-6 conversion training.
• The instructor who trained the pilot also indicated the pilot was physically
capable to keep the aeroplane level with a single hand during the trim
runaway exercises.
• It has been demonstrated during the certification test flights that the
Pilatus PC-6 B2H4 aeroplane remains controllable in level flight in case
of full nose down pitch trim. Manufacturer data show that the pull up force
to apply on the stick would be around 150 N in order to keep the
aeroplane in level flight with a 31% MAC CG position and 2800 kg total
weight.
• A test flight, performed with an AAIU(Be) investigator on board, could
verify that the pull-up force to apply on the stick is acceptable for a
person in a normal physical condition.
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• When the accident occurred, the pull-up force to be applied would have
been less than 150 N (15 kgf) taking into account that the aeroplane
centre of gravity was close or maybe slightly beyond the aft limit of the
balance envelope.
Examination of the wreckage could determine that the left wing failed as a
consequence of the aeroplane’s structure being submitted to excessively
high negative loads.
Study of V-n Diagram shows that the Pilatus can exceed the ultimate
negative load factor of -2.14 g from a speed of 115 kt and up. Therefore the
structure may not withstand a violent forward action on the stick at or above
this speed when submitted to negative loads. Considering that the speed
before the wing failure had been determined to be at least 118 kt means that
the aeroplane, in good condition and free of deficiencies can suffer a
catastrophic structural failure as a consequence of an inadequate violent
forward pressure on the column stick. This situation is not specific to the
Pilatus and is quite similar to all the aeroplanes certified in the normal
category.
The examination of the aeroplane’s structure, combined with the witnesses’

declarations, help to conclude that the overload failure of the wing was due to
a violent forward pressure on the column stick when the aeroplane was
inverted.
2.3 Communications
The communications of the preceding flight were compared with the

communications made during the last flight.
During flight 14, Charleroi APP instructed the Pilatus when flying at about
3000 ft to contact Brussels ACC for authorization to climb above FL50. The
Pilatus called Brussels ACC soon after (24 seconds later). The pilot
contacted Brussels ACC well in advance taking into account the time
necessary to climb 1900 ft higher, before reaching FL50 (4900 ft).
By contrast, during the last flight, Charleroi APP only instructed the Pilatus by
the time it was already flying at 4400 ft to contact ‘Brussels Control’ to climb
above FL50 (4900 ft). The pilot selected the frequency of Brussels ACC
(128.2), but did not contact them. Instead, the aeroplane climbed further to
FL50 (4900 ft) and levelled before the loss of control, without ever calling
Brussels ACC. Time between the last instruction from Charleroi APP and
loss of control was 46 seconds.
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In case of problems pilots normally prioritize their actions in the order: ‘aviate
- navigate – communicate’. This means that communication has the lowest
priority when struggling with the first two tasks. However, the pilot correctly
read back the instructions from Charleroi APP and also resumed navigation
to the airfield of Namur/Suarlée, as instructed, by turning westward while
climbing with a normal rate of climb. This indicates that the pilot still had the
aircraft under control when climbing to FL50 (4900 ft). Conversation records
analysis also show that the ‘Brussels Control’ frequency was not in overload
of communication during the last phase of the flight of the Pilatus.
Both facts mentioned above lead to the conclusion that there was no difficulty
for the pilot to communicate with ‘Brussels Control’.
The fact the pilot did not communicate with Brussels ACC could be
interpreted as a way to be free from both the control of Charleroi APP (no
longer focused on the aeroplane’s navigation) and Brussels ACC, not yet in
charge of the aeroplane’s navigation.
2.4 The sequence of the different structural failures
The impact traces on the wing’s lower surface left by the wing-to-strut
attachment nut and the blue colour found on the small piece of the strut
suggest that the strut failed first after a buckling deformation toward the wing,
followed by the wing’s main spar structural failure. The wing strut failed when
submitted to excessive compression forces as well as a bending moment,
caused by the friction at the strut-to-wing spar connection.
Left wing outer flap damage, limited to both end ribs and showing pulled-out
rivets, was determined to be consistent with both hinge supports being pulled
off during the wing separation, which occurred precisely at the junction of the
inner and the outer flap.
The outer aileron equipped with a counterweight and significantly heavier

than the inner one, was retrieved on the ground in the same area as the
rudder counterweight and a section of the left wing’s upper spar caps. All
these parts are high density elements with less ability to float in the air. This
allows the conclusion that these parts separated approximately
simultaneously and were therefore retrieved approximately below the area
where the structural failure occurred.
The reconstruction of the wing revealed common impact damage; the impact
damage on the outboard aileron’s lower surface matches with the damage on
the lower surface of the wing. This leads to the conclusion that the aileron
was still attached to the wing when struck.
Besides this, traces of friction were visible on the aileron’s counterweight

tube paint, including the red painted end of the counterweight for which
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corresponding red traces were observed on the fuselage dorsal fin. This
demonstrates that the outer three-quarter section of the left wing separated
first. Subsequently, the lower surfaces of the wing and the outer aileron
collided with the dorsal fin, causing the outer aileron separation.
Almost simultaneously, the wing’s leading edge collided with both the vertical
stabilizer and the right hand side horizontal stabilizer. This collision caused
the rupture of all three horizontal stabilizer’s supports; both the forward
articulation plates and the connection with the actuator at the fork fitting (rear
attachment of the stabilizer).
The minor damage to the central, attachment section of the horizontal

stabilizer combined with the facts that this stabilizer was lying inverted
underneath the fuselage’s tail section and that the tail fuselage skin was torn
open by elevator cables demonstrate that the stabilizer only remained
connected with the fuselage by the elevator cables up until the ground
impact. It can be concluded that the stabilizer/elevator assembly floated
during the plunge, likely positioned next to the left side of the aft fuselage.
This probably also induced violent shocks in the control column during the
plunge.
The examination of the right sliding door leads to the conclusion it ran off its
track as a consequence of the fuselage frame deformation when the
wing/strut structures failed. Fuselage deformation was more significant in the
area of the wing and strut attachments, which explains why the sliding door’s
front roller wheel attachments (positioned just aft of the wing) suffered more
damage than the rear ones.
All flight controls were checked and the remains proved to be complete. No
pre-impact anomalies were found. Control continuity was verified from the
cockpit to all flight control surfaces showing that all broken cables featured
typical overload-rupture characteristics.
Thorough examination of the damage to both the horizontal stabilizer trim

actuator and the fuselage tail structure concluded that the trim actuator
remained attached inside the tail section of the fuselage up to the final
impact, meaning that the actuator remained electrically connected to the
aeroplane until its ejection upon final impact.
2.5 Reconstruction of the last phase of the flight

The flight was reconstructed from the radar data and the AAD’s records.
Every 4 seconds the radar records the aeroplane’s position and the
aeroplane transponder transmits the altitude information. The AADs record
the ambient pressure every 1/8th of a second.
Combining the information from the radar, the radio communication and the
AAD, the investigation could determine that:
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• The pilot received the authorization to proceed to the drop zone and was
instructed to switch the radio frequency to ‘Brussels Control’.
• The pilot switched channel of the radio to ‘Brussels Control’ (exact time
unknown).
• The aeroplane stopped turning and continued a straight and level flight at
FL51 (5000 ft) for 12 to 16 seconds (point A on Figure 70).
• Suddenly, the aeroplane climbed rapidly for 1.5 seconds, immediately
followed by a descent (point B on Figure 70).
• The recordings show a steep dive and at point C of Figure 70, the
transponder of the aeroplane is not able to send information to the radar,
indicating the aeroplane is inverted (a transponder needs a line-of-sight
with the radar for the transmission).
• The AAD data show the readings of the different AADs are
diverging from that point on; this is relevant as the readings were rather
close to each other before this point. The cause of the divergence is
likely to be the detachment of the sliding door in flight; the ambient
pressure became different for each parachutist due to turbulences
affecting the cabin and depending on their position in the aeroplane.
• The detachment of the sliding door is determined by inspection to have
been caused by a disturbance in the aeroplane’s structure. This is the
point in time when the aeroplane lost its left wing.
• The aeroplane is further seen by the radar in a reverse track, opposite to
its initial flight direction (point C on Figure 70).
Figure 69: Radar and AAD data.
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Figure 70: Correspondence between AAD VIGIL data and radar data.
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Figure 71: Graph showing phases where the different AAD VIGIL’s are measuring similar and
diverging ambient pressures.
Figure 72: Graph showing closer AAD's pressure fluctuations
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Looking closer into the AAD records of Figure 72, it can be observed that
during the initial climb, the records show small fluctuations in 3 out of the 7
recordings. The climb would have caused small movements of the
parachutists inside the aeroplane, against the fuselage, or against each
other. The small shocks to the parachute packs would have caused an
overpressure in the pack, giving a false reading of the AAD as a
consequence (reading of a lower height).
The climb was followed by a dive of 40 ft (12 m) in 1 second. Such

movement caused an acceleration of (around) 24 m/s2 i.e more than twice
the gravitational acceleration. This movement is likely to have resulted in the
second group of pressure fluctuations recorded by the AADs. These
fluctuations are larger in amplitude and are observed in all individual records
of the AADs. After these fluctuations, the aeroplane’s flight path indicates a
steeper dive.
The data of the AAD’s were plotted in a graph whereupon trend lines were
added. Such a trend line predicts the height as function of time by means of a
polynomial (fifth order in this case) function. The coefficient of determination
(or R²) is a number between 0 and 1 and indicates how close the predicted
value is to the actual value. The closer to 1, the more reliable the value, ie
how accurate the trend line approximates the real value. By limiting the
considered time intervals, trend lines could be found with R² equal to 0.99. By
deriving the correspondent functions with respect to time, one was able to
find an approach for the vertical speed. By deriving twice with respect to time,
a function predicting the acceleration along the vertical axis was found.
These values were in each case in an order of 50-60 m/s² (5 to 6g) in the
region of the bend (red encircled) in Figure 71. It remains a very rough
approximation and the accuracy is difficult to determine because there are
other unknown factors such as the inertia of the pressure measurement
system. But nevertheless, the obtained speeds correspond to the speeds
calculated with the Vigil software and the values of the acceleration before
the dive are in the expected order of magnitude.
This method definitely shows that at the time of the bend upwards, the
aircraft was subject to exceptional high external g-forces.
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2.6 Possible manoeuvres
After the authorization of Charleroi APP to resume the flight as planned, the
pilot would have normally set course towards the Namur airfield and, after
contacting Brussels ACC, would have continued to climb with a normal climb
rate of around 1000 ft/min. The pilot did not call Brussels, but stopped
climbing and interrupted the turn toward the drop zone. Instead, a short steep
climb was initiated (2000 ft/min) after a few seconds of straight horizontal
flight, followed by a steep dive (2400 ft/min - up to the large pressure
variations recorded by AADs). The amplitude of these actions has been
determined to be within the capabilities of the Pilatus PC-6 aircraft.
The manoeuvre performed was either intentional or the result of a reflex, as

would be possible during an avoidance manoeuvre.
The following manoeuvres, or reason to perform it, were investigated:

• Possible medical incapacitation of the pilot
• In flight collision avoidance
• Bird strike avoidance
• Wake turbulence
• Wind turbine turbulences
• Meteorological related manoeuvres
• Intentional manoeuvres
o Pull up
o Parabolic flight
o Barrel Roll
2.6.1 Possible medical incapacitation

Although no factual element was found to indicate a sudden incapacitation of
the pilot, a possible loss of consciousness had been examined. Loss of
consciousness must be considered as unlikely considering the age of the
pilot, who was fit and in good health and the fact he was submitted to regular
class 1 medical examinations, demonstrating a risk of incapacitation lower
than 1 in 106 hours. There are elements however that would indicate the pilot
was active at the controls up to the final impact:
• The last radio communication with Charleroi APP was normal,
• Thereafter, the pilot selected the ‘Brussels Control’ radio frequency,
• The aeroplane was completing a wide left turn towards the dropping zone
followed by a straight and level flight at FL51 (5000 ft).
• In the last flight phase, before the wing separation, the aeroplane made
movements indicating two opposing pilot input (climb, dive).
• The radio switch on the stick was pushed four times during the final
plunge.
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• Additionally, significant injuries to both the pilot’s hands, suggest he was

firmly holding the control stick with both hands, up to the final impact in
an attempt to recover control over the aeroplane.
AAIU(Be) concludes that a possible incapacitation of the pilot cannot be ruled

out, but is highly improbable.
2.6.2 In-flight collision avoidance

The radar data were reviewed, and showed no other aeroplane in the direct
vicinity of the Pilatus PC-6. None of the witnesses reported seeing any other
aeroplanes flying in the vicinity of the Pilatus PC-6, nor did they report any
collision.
2.6.3 Bird Strike

There was no trace of birds found on the wreckage or in the vicinity (plumes,
bird remains, etc.), nor has any witness reported seeing a flock of birds in the
vicinity of the aeroplane. The risk of a bird strike was explored in the event
the pilot would have been forced to take evasive manoeuvers and, as a
consequence, lost control over the aircraft.
Finding birds at altitudes of 5000 ft AMSL or above, although rare, is not

uncommon. Ducks and larger birds such as geese and cranes can fly up to
altitudes of 10000 ft. This will usually occur during the migration season, in
the month between October-November and March-April, usually at night.
Around the time of the accident, the Bird Control Unit of Belgian Defence
reported a very low bird intensity in the area, and the radar detected no (large
scale) bird movements related to migration of birds neither at low nor high
altitude. No BIRDTAM8 was broadcasted. There were, however, migration
flights of Grey Cranes observed from the ground, that day, but in the east of
the country (Aywaille, Beuzet, Tilff,etc.), heading in the direction NE to SW.
During the day of the accident, with the meteorological conditions

considered, the average migration altitude would have been around 3000 ft.
At night migratory birds mostly fly individually. By contrast, during day,
migratory birds mostly fly in groups. Usually they fly concentrated together in
the early hours of the morning and in the evening.
The bird strike history (in civil aviation) shows that the vast majority of reports
for Belgium concern airports, or their immediate surroundings.
There are very few reports of bird strikes involving General Aviation aircraft
(16 out of a total of 2317 for the period 2005-2014), and none caused a loss
of control.
8
Birdtam: notice to airmen for notification of birds activity hazards.
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An evasive manoeuver of the aeroplane to avoid a bird strike is possible,

although unlikely. Moreover, the possibility that this manoeuver would evolve
in a loss of control is highly unlikely.
2.6.4 Wake vortex

Wake turbulence consists of vortices, which are rotating air flows. When
generated by heavy aeroplanes, it can induce rolling moments to aircraft
crossing the turbulence, exceeding the roll rate achievable by applying full
opposite aileron and finally causing that aircraft to be rolled over.
The last crossing traffic, almost 6 minutes before the loss of control, was a
Boeing 737 flying at 4000 ft (AMSL) when the Pilatus PC-6 was at 2000 ft.
Given the vertical separation between both aeroplanes, the altitude of the
Pilatus when the loss of control occurred (5000 ft AMSL) and the distance
already travelled by the vortices (flowing down and diminishing in intensity as
time goes by), the hypothesis that the aeroplane was destabilized by a wake
vortex can be excluded.
2.6.5 Wind turbine turbulences

Wind turbine turbulence can be excluded given the height (4370 ft AGL or
1330 m) of the aeroplane, above the underlying terrain, when the event
occurred. Wind turbine turbulences remain mostly at the same altitude.
2.6.6 Meteorological turbulence.

The ceiling and visibility were excellent. No gusts or turbulences were
reported. Contrary to wake turbulence, meteorological turbulence - in our
non-mountainous part of Europe - is more or less unidirectional and will not
cause an aircraft to roll upside down. Moreover, the structure of the Pilatus
PC-6 has been designed, as all aircraft, to withstand gust conditions of at
least 30 ft/s – - both up- and downward-, which can be classified as moderate
to strong turbulence. As such turbulence is the result of widespread adverse
weather conditions, the prevailing meteorological conditions can therefore be
excluded as a direct causal factor of the roll manoeuvre, and could not have
caused the rupture of the wing.
2.6.7 Intentional Manoeuvers

In contrast with the manoeuvers discussed here-above, the investigation
determined that the aeroplane had been occasionally used for intentional
manoeuvers with and without passengers on-board.

These manoeuvers can be qualified as aerobatic manoeuvers, as per ICAO
and EU Regulation definition.
The PC-6 is not certified to perform aerobatic manoeuvers. This is confirmed

in the Airplane Flight Manual (Section 1: Certification Limitations).
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The following possible aerobatics manoeuvres have been examined:

• Pull-up manoeuvre, followed by a stall
• Asymmetrical pull-up manoeuvre/one wing only stall
• Parabolic flight
• Barrel roll
2.6.7.1 Pull-up manoeuvre, followed by a stall

A sudden climb, if performed with an excessive angle of attack, could result
in a stall. If the angle of attack is excessive, both wings could stall
simultaneously, or only one, depending on the actual aircraft attitude.
However, there was, at first sight, no operational reason to brutally increase
the angle of attack in order to continue the climb.
The following graph shows the fall distance (=height) versus the time for:
• Typical parachutists in free fall as recorded several times by AADs prior
to the accident (blue curve)
• Theoretical frictionless free fall, as if the fall occurred with no atmosphere
(purple curve)
• The aeroplane’s fall data as recorded by the parachutists AADs during
the event beginning at the top of the AAD’s height curve (green curve).
Figure 73: Diagram showing the aeroplane's fall speed compared with other fall speed.
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Figure 74: Drawing of a typical high speed stall aeroplane's attitude.
If the aeroplane is set above the maximum angle of attack, in order to

achieve a steep climb, both wings will stall and the aeroplane will stop
climbing and start to descend.
The descent speed would be slower than in a free fall, as the engine still
provides an upward force.
The AAD data demonstrates objectively that the aeroplane is actually falling
faster than free fall. A high speed stall of both wings in a symmetrical
configuration can therefore be excluded.
2.6.7.2 Asymmetrical/one wing only stall:

In the event that the loading of both wings would not evenly be distributed,
one wing would stall before the other, causing this wing to drop violently
(“flicking”). The aeroplane would then brutally roll around its axis towards the
stalled wing and, depending on the reaction of the pilot, could be put into a
spin.
However, the initial drop of the stalled wing would have occurred at the top of
the climb causing a significant commotion in the cabin, parachutists being
moved around inside the aeroplane, by the violent roll.
As the AAD records show few pressure fluctuations at the top of the climb
(see Figure 72), but more intense fluctuations later, a high speed stall with
one wing drop, followed by a roll motion, can be considered as unlikely.
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Figure 75: Drawing showing a high speed stall followed by a flick roll.
2.6.7.3 Parabolic flight

The aircraft provides the people on board with the sensation of
weightlessness, by performing an approximately parabolic flight path relative
to the Earth’s surface. While performing this parabolic flight path, the aircraft
and its payload are in free fall along certain points of its flight path.
The manoeuvre intended by the pilot in this scenario, could have been a
“parabolic flight”, as was performed already several times in the past (and by
several pilots) with parachutists on board, which was confirmed by witnesses.
A violent diving motion (by pushing the stick forward violently), initiated when
the aeroplane was in a climbing attitude, would have thrown the unrestrained
parachutists from their floor seating position upward and caused them to
collide with the ceiling. A calculated negative acceleration of 24 m/s2 means
a resulting acceleration in the upward direction of 14.2 m/s2, which is about
1.5 g
The resulting movement of the parachutist colliding with the ceiling would
cause a change in the apparent weight carried by the aeroplane, causing the
centre of gravity to move forward and resulting in an increased pitch down
movement. This scenario would also have caused an important disturbance
in the cabin at the top of the manoeuvre (which was not recorded by AADs).
The resulting increase in pitch down of the aeroplane would increase the
diving rate (up to 12000 ft/min as seen on the graph) and could have caused
parachutists to move rearward.
In this configuration, the aeroplane would have been forced into an inverted
loop, reversing the aeroplane course and causing the wing to break.
However, the manoeuvre applied here seems to be too short in time and too
brutal to be a parabolic flight and, moreover, the AAD records show only
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disturbances at the beginning of the pull-up and at the end of the pull-down,
without disturbances at the top of the manoeuvre. Additionally, the pilot was
familiar with this parabolic flight manoeuvre and there is no obvious reason
why one would change the conditions of this manoeuvre.
A missed parabolic flight, although not excluded, is therefore considered

unlikely.
2.6.7.4 Barrel roll

A barrel roll is a flight manoeuvre during which an aircraft rolls about its
longitudinal axis, while following a spiral course in line with the direction of
flight.
A barrel roll manoeuvre would normally have resulted in positive g-forces,

due to the centrifugal forces keeping the parachutists tied to their floor
seating position, even when the aeroplane is in inverted position, and only
cause small displacements within the cabin.
However 3 different phases can be observed in the read-out of AAD’s

demonstrating fluctuations likely caused by the parachutists moving around
in the cabin (Figure 72: Graph showing closer AAD's pressure fluctuations):
• The first occurred at the beginning of the pull-up manoeuvre
• The second occurred 3 seconds later
• The third occurred 6 seconds after the beginning of the manoeuvre, this
sequence is coinciding with the structural failure of the aeroplane.
A barrel roll manoeuvre, clearly an aerobatic manoeuvre, if not adequately
performed, could lead to:
• Movement of the unrestrained parachutists through the cabin of the
aeroplane in case of unsufficient positive acceleration and/or
• A significant (uncontrolled) dive, when inverted, as experimented during
simulations using the Belgian Defence’s flight simulator.
One eye witness, standing about 600 m horizontally from the aeroplane,
reported having seen the wings of the aeroplane wiggling several times
before the final plunge began. The wiggle of the wings could have been a
barrel roll, taking into account the difficulties for the witness, with no specific
aviation knowledge, to see the details of a manoeuvre performed at a slant
distance (line of sight distance, not a distance across the ground) around
1500 m (600 m horizontal distance combined with a vertical distance 1330 m

AGL).
The steep climb, seen on the graph could have been the first part of a barrel
roll followed by an uncontrolled diving attitude, once the aeroplane was fully
inverted, and finally ending by an excessive forward pressure on the stick
and subsequent wing failure.
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Based on the AAD records, the time between the start of the pull-up, until the
occurrence of wing separation was determined to be around 5.5 seconds. On
the other hand, it can be assumed, from the roll rate tests performed by
Pilatus, that a 180° bank angle change (= aeroplane inverted) requires
around 6 seconds. The period of time (5.5 seconds) between the pull-up
manoeuvre until the moment the wing separated, is therefore compatible with
the Pilatus roll rate.
2.6.8 V-n Diagram analysis
Figure 76: V-n diagram showing the 110 kt fall speed was inside the yellow caution range.
The yellow speed range in the V-n diagram indicates that the aeroplane can
only be flown at this speed range, in smooth air and also that an abrupt
manoeuvre may not be exerted to avoid structural damage, or failure.
The airspeed when the failure occurred was at least 110 kt i.e. within the
limits of the (negative) yellow caution range, showing that any abrupt
manoeuvre when exposed to negative g loads may cause a structural failure.
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2.6.9 Conclusion of possible manoeuvres analysis

The aeroplane was put in an unusual attitude, ended by a negative G-load
manoeuvre exceeding the operating limitations of the aeroplane.
As seen above, an unintentional or avoiding manoeuvre conducted by the

pilot, whatever the reason were determined to be unlikely. On the other hand,
the investigation determined that aerobatic manoeuvres were performed in
the past by various pilots, none of which caused an accident.
As reported by witnesses, the pilot performed at least one barrel roll on the
day of the accident, at the end of one of the preceding flights.
This and other indications like for example witnesses’ statements, combined
with radar and AAD analysis suggest that the pilot tried to perform a barrel
roll that was improperly executed.
The determination of the exact manoeuvre, likely intended by the pilot, is not
possible with certainty and has no added value to the investigation.
Although a meticulously performed aerobatic manoeuvre will not induce any

excessive stresses on the structure of the aeroplane, a wrongly executed
manoeuvre will put the aeroplane in an unusual attitude causing the
unrestrained occupants to be moved within the aeroplane’s cabin causing an
unforeseeable location of the aeroplane’s centre of gravity and/or physical
interference between the pilot and the other occupants. Such a situation
would be almost impossible to recover from even for pilots having been
trained up to the required and adequate flying skills.
Finally, it is clear that the performance of aerobatic manoeuvres with

aeroplanes not certified in that category is an unsafe practice and even more
so with passengers on board, especially if not restrained.
2.7 Operator and parachute club organization
Unsafe practices during the aeroplane’s operation occurred repeatedly for

quite some time, without adequate reaction by the operator (Namur Air
Promotion) providing the aeroplane to the parachute club (Paraclub Namur).
The lack of oversight, reaction to events and written procedures by the

operator indicates that the pilots were not supported by an organization with
an adequate safety management structure and awareness.
The duty time limitations of the pilot performing parachute dropping activities
were not regulated by the operator, neither by the parachute club.
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On the day of the accident, the pilot had accumulated 13 flights for 4h and 30
minutes, and he had taken some rest for lunch. This is significantly less than
the maximum flight hours and rotations performed in the past; showing up to
34 dropping and 12 hours and 30 minutes on a single day, but this extreme
example did not concern the Paraclub Namur. This very intensive activity
(seemingly not limited to the individual pilot) is raising concerns with respect
to pilot fatigue.
The application of the last version of part-SPO9 regulation will bring a

possible solution to it. Additionally, EASA Rulemaking programme 2014-2017
incorporates the topic ‘Flight time limitation (FTL) requirements for
commercial operations other than commercial air transport’, completion
expected between 2016 and 2019.
The investigation showed that the operator was not fully involved in the
operations of its aeroplane. Moreover, the general impression to the
AAIU(Be) was that the operator simply made his aeroplane available for
customers, much more like a car rental firm than an aircraft operator.
The president of the Paraclub Namur, acting unofficially as the operator

(likely without realizing), was not a pilot and was not trained for such a
function. He was not qualified to monitor/survey the operation of the
aeroplane and he was convinced that all the pilots (being highly qualified
commercial pilots) were able to do self- and peer-assessment.
The logical objective of the parachute club was to allow the association to run
as smooth as possible. As a result, the aeroplane was considered to be no
more than a tool to realize the parachutists’ passion.
The investigation did not focus on the safety management of the parachute
dropping activities. However it was observed by AAIU(Be) that the Paraclub
Namur and its club members were adequately supported for the practice of
parachuting activities by a competent staff within the organization.
2.8 Weight and balance
The W&B evaluation composed during the investigation showed that the
assumed CG, located at 3.718 m from the reference line, was very close, or
even maybe beyond the aft limit of the balance envelope. The estimated
weight of the aeroplane, around 2480 kg, was within the limits.
9
Commission Regulation (EU) No 965/2012 of 05 October 2012 laying down technical
requirements and administrative procedures related to air operations pursuant to Regulation
(EC) No 216/2008 of the European Parliament and of the Council Initially amended by EU No.
800/2013, EU No. 71/2014, EU No. 83/2014 and EU No. 379/2014.
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The lack of accurate data regarding the exact distance between the
reference line and the different parachutists’ positions, as they installed
themselves inside the cabin makes an accurate W&B computation difficult.
The pilots of the aeroplane did not compute a W&B for each flight. They
estimated, based on earlier made computations, that the aeroplane loaded
with parachutists, could not be out of balance. The flight instructors in charge
of the PC-6 conversion training of the pilots flying the airplane involved in the
accident stated they made several W&B simulation exercises before reaching
that conclusion. The president of the Paraclub Namur indicated also that he
was convinced that the positioning of the parachutists on board the
aeroplane could be performed in any possible configuration safely.
Consequently, the parachutists were not instructed to take a position inside

the cabin of the aeroplane, according to their individual weight (logically the
heavier persons would be located closer to the aeroplane’s centre of gravity,
i.e. nearer to the cockpit).
Notwithstanding the above findings, there is no indication that the aft location
of the centre of gravity (CG) contributed to the loss of control over the
aeroplane. However it may have aggravated the outcome.
2.9 Use of restraint systems
Analysis of 46 accidents over the period between 1987and 2014, illustrates

the need for using a restraint system, during take-off and initial climb. The
restraints would prevent passenger movements in the cabin during take-off,
avoiding the aeroplane being set off-balance during these critical flight
phases. Furthermore, restraints would lead parachutists to take up correct
positions matching the theoretical positions for the CG computation.
The restraint system would also be useful, as would any restraint system,
during a crash landing, to withstand the deceleration and to avoid (or at least
mitigate) the crushing of passengers by other passengers falling on to them.
The restraint system of the aeroplane was designed for that purpose. Its use
was defined on a placard in the cabin of the aeroplane and in the AFM.
In addition to the fact that restraint systems can protect parachutists in case
of a forced landing, the restraint system also somewhat protects the pilot as it
would prevent parachutists’ body mass from hitting the pilot’s back.
The Belgian regulation applicable when the accident occurred did not clearly
define what restraint system should be used for parachutists, and when, for
which flight phase to use them.
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The (EU) n° 965/2012 Part SPO regulation, published after the accident,
states that restraint devices must be available for each station and must be
used during critical phases of flight10 or whenever deemed necessary by the
pilot-in-command.
The CS23 code specifies the technical requirements for restraint system
used in aeroplanes. It is supplemented by a “Special condition” document N°
SC-023-div-0111 published by EASA on 6 July 2009 to list the key points and
the requirements that are applicable to an aircraft for parachuting activities.
However, this document doesn’t apply to aeroplanes approved before 6 July

2009 for parachute dropping flights. Additionally, it doesn’t include any further
detail about the technical requirements for a restraint system.
For the dropping flight phase, the third most dangerous phase, restraint
systems must obviously be released.
In fact, the analysis of the 46 accidents for the period 1987-2014 does not
reveal any similar circumstances to the Pilatus accident. All the accidents
that occurred during the transit flight – as in the case of this accident – are
due to engine failure (62%), for which all parachutists jumped to safety and
mid-air collisions (38%), for which the chance to jump out of the aeroplane
had been demonstrated to be close to zero.
Examination of the remains of the restraint system shows that the

parachutists sitting on the bench and on the floor were not strapped in when
the wing structure failed. In the case of the accident, the unusual attitude
taken on by the aeroplane before the wing failure, could have forced chaotic
10
‘Critical phases of flight’ in the case of aeroplanes means the take-off run, the take-off flight
path, the final approach, the missed approach, the landing, including the landing roll, and any
other phases of flight as determined by the pilot-in-command or commander.
11
A special condition is prescribed by regulation (EU) N° 748/2012 chapter “21.A.16B Special
conditions”. The Special condition document N° SC-023-div-01 “Use of aeroplane for
parachuting activities” is enclosed in appendix.
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movements of passengers within the cabin, either forward, backwards, or

upwards. The use of the restraint system could have prevented a possible
shift of the parachutists within the cabin. This shift would cause a change in
the balance of the aeroplane and therefore a sudden change in the
aeroplane’s behaviour and manoeuvrability. However:
• The benefit of wearing a restraint system in case of an aeroplane being

put in an unusual attitude must be balanced with the disadvantage of
being strapped in case of necessity to jump out of the plane in an
emergency.
• Wearing a single strap with a snap hook restraint system when sitting on
the floor or on a bench does not put the parachutists in a completely fixed
position. This system cannot exclude the displacement of the
parachutists within the cabin, but would limit the amplitude of the
movement.
2.10 Use of oxygen system
The aeroplane flew regularly up to FL135 and even higher, although not
equipped with oxygen equipment.
The applicable regulation at the time of the accident (Royal decree 9 January
2005) required the use of oxygen equipment when flying above FL100.
Art. 22. Le pilote commandant de bord veille à ce que de l'oxygène soit mis
à la disposition de l'équipage et des passagers en quantité suffisante pour
tous les vols effectués à des altitudes-pressions supérieures à 3 000 m
(10 000 ft) ainsi qu'à des altitudes où le manque d'oxygène risque
d'amoindrir les facultés des membres de l'équipage ou d'être préjudiciable
aux passagers. Les membres de l'équipage de conduite exerçant des
fonctions indispensables à la sécurité du vol utilisent des inhalateurs
d'oxygène de manière continue lorsque l'altitude-pression régnant dans la
cabine est supérieure à 3 000 m (10 000 ft).
Art. 22. Voor alle vluchten uitgevoerd op een drukaltitude die hoger is dan 3
000 m (10 000 ft) alsook op altitudes waarop het gebrek aan zuurstof de
mogelijkheden van de bemanningsleden zou kunnen verminderen of
schadelijk zou kunnen zijn voor de passagiers, zorgt de boordcommandant
ervoor dat er een voldoende hoeveelheid zuurstof ter beschikking wordt

gesteld van de bemanning en van de passagiers. De leden van het
stuurpersoneel maken doorlopend gebruik van inhaleertoestellen voor
zuurstof in alle gevallen waar de drukaltitude in de cabine hoger is dan 3
000 m (10 000 ft) wanneer zij functies uitoefenen welke onontbeerlijk zijn
voor de veiligheid van de vlucht.
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The aim of the regulation is to avoid pilot’s physical and mental capability
reduction due to hypoxia. Additionally, flying at these heights will increase the
pilot’s fatigue.
The new EASA regulation Part SPO.OP.195 Use of supplemental oxygen is

less restrictive and states:
The operator shall ensure that task specialists and crew members use
supplemental oxygen continuously whenever the cabin altitude exceeds
10000 ft for a period of more than 30 minutes and whenever the cabin
altitude exceeds 13 000 ft, unless otherwise approved by the competent
authority and in accordance with SOPs.
The pilot’s log book showed he accumulated regularly more than 20 flights in
a single day up to and even exceeding FL135.
It is therefore considered unlikely that the accumulation of the previous 12

flights with short excursions up to FL135 would have caused a significant
fatigue. However, this may have induced insidious influence on his mental
state.
2.11 Pilot’s seat and pilot’s back protection
The unusual attitude taken by the aeroplane may have caused the
passengers to move inside the cabin.
• A sudden shift to the rear, of the parachutists, would move the
aeroplane’s CG aft outside the envelope, destabilizing the aeroplane.
• A forward shift of the passengers would normally concentrate the weight
in the normal range of the CG. However, this shift could cause
parachutists to fall onto the back of the pilot’s seat and possibly interfere
with his ability to control the aeroplane.
As seen on a picture of the aeroplane involved in the accident (Figure 4),

there was no separation between the cabin and the cockpit and the
aeroplane was equipped with a low back of the pilot’s seat that did not
provide any protection to the upper body and head of the pilot, from
parachutists thrown forward in the direction of the cockpit.
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Figure 77 shows a different seat model that

provides a better protection of the pilot’s
back. However, the pilot’s head remains
vulnerable to persons, or objects thrown
forward in the aeroplane.
Moreover, an aircraft’s seat is not designed,

nor certified to withstand an axial force
beyond the deceleration forces caused by
the pilot’s own weight. Figure 77 : Another seat with a
higher back.
Pilatus, when asked about the availability of a pilot’s back protection,

indicated this kind of equipment was not available.
There is no requirement or guidance material in the Special condition

document N° SC-023-div-01 to assess the need to install a pilot’s back
protection in aeroplanes conducting parachute dropping flights.
2.12 Maintenance manual

As outlined in chapter 1.6, a discrepancy in signing off maintenance tasks
was found. This was due to an ambiguous wording of the item 49 task
description.
The text found in the “Inspection” column of item 47 makes a distinction

between the maintenance of the trim actuator mechanical system and the
electrical system.
Figure 78: Item 47 of the 100h inspection schedule.
By contrast, the texts found in both columns “Inspection” and “Operation” of

item 49 are less clear and moreover don’t mention the word “electrical” while,
actually, the functional test “Ref. 27-40-00” on page 501 of the maintenance
manual requires a test of the horizontal stabilizer trim electrical system.
Figure 79: Item 49 of the 100h inspection schedule.
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In practice, most engineers using the manufacturer’s inspection schedule,

first read the inspection column to determine if the item is applicable or not. If
the item is deemed not applicable, they don’t read the “Operation” column
and then move on to the next line.
The text of item 49 “Inspection column” could be misleading, causing

engineers to omit the performance of the functional test.
A clearer definition of the tasks to be performed could be as follows:
2.13 Flight data recording
The aeroplane was not equipped with a flight data recorder (FDR) nor was it
required to carry one, by the applicable legislation.
However, when the parachute club restarted its activities in 2014, a leased
Pilatus PC-6 aeroplane equipped with a lightweight FDR was selected, that
records the basic parameters of the aircraft’s operation. This aeroplane was
equipped with such device on the proper initiative of the owner in order to be
able to monitor operations.
In recent years, a wide range of recording devices meeting the needs of non-
commercial aviation has been developed making different systems available
at reasonable prices. These systems feature mostly self-contained data
acquisition (GPS, image, audio, inertial measurement, etc.) and a data
storage system, including a crash resistant internal memory and a removable
memory.
A helicopter manufacturer installs such equipment as standard equipment in

all the helicopters produced since the last 2 or 3 years for the benefit of flight
monitoring by pilots or operators. Reportedly, such recording system may
also be used by pilots as a support to refuse performing unsafe manoeuvres
when pushed by passengers to do so.
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In addition to the possibilities offered by these new technologies to monitor

and improve the flight operations, such a FDR would also be helpful to
provide factual data for accident investigation.
A EUROCAE12 technical standard ED-155 was developed for the design of

lightweight flight data recorder. Additionally ICAO Annex 6 (Part II)
recommends the installation of a flight recorder on newly certified aeroplanes
(from 1 January 2016) used in general aviation. This is applicable for turbine
engine aeroplanes with MTOW less than 5700 kg with more than 5
passenger seats.
CIAIAC, the air accident investigation board of Spain recommended, in its

final report A-019/2008 of an accident showing similarities with the
Gelbressée accident, that ICAO would establish it as an essential
requirement for skydiving operations that the aircraft used for this activity,
would have an onboard flight data recorder capable of logging at least the
basic parameters of the aircraft’s operation. However, this recommendation,
to the best of our knowledge, has not yet been adopted by ICAO.
12
EUROCAE is the European organisation dedicated to the development of technical
standards in support of the aviation community.
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3 CONCLUSIONS.
3.1 Findings.
About the pilot

• The pilot was holder of a valid Belgian ATPL(A) licence incorporating
amongst others a rating for Pilatus PC-6 aeroplane.
• The pilot held a valid endorsement, filled in his logbook, to perform
parachute dropping flights as per Circular FCL-27.
• The pilot had a wide flying experience flying BAe146 and Pilatus PC-6
aeroplanes.
• The pilot was called to order several times by airfield authorities. This
was not reported to the BCAA, despite being required by the Circular
GDF-04.
About the aeroplane

• The aeroplane was registered in Belgium and had been owned and
operated by the same operator since its purchase in 2003.
• The aeroplane was exclusively made available to Paraclub Namur by the
operator.
• The airworthiness of the aeroplane was adequately managed by an
EASA approved Part M subpart G organization (CAMO) as well as the
maintenance being performed by the same organization, also approved
as EASA Part M subpart F organization.
• The aeroplane was covered by a valid Airworthiness Review Certificate.
• After another accident in 2001, the aeroplane had been repaired and
overhauled by Pilatus in 2003. It was at the same time equipped to
perform parachute dropping flights in accordance with the manufacturer’s
specifications (AFM Supplement report N°1824).
• The aeroplane was provided with locally manufactured single strap safety
belts (restraint system) for parachutists sitting on the floor and on the
longitudinal bench.
About the wreckage examination

• The aeroplane suffered a major structural failure, i.e. the separation of
the outer three-quarter section of the left wing.
Final report CONCLUSIONS.
• Examination of the wreckage showed that the left wing and the left wing
strut failed under excessive negative g overload.
• Fracture examination did not reveal any trace of pre-existing damage
(corrosion, fatigue cracks, dents, buckles,..) susceptible to weaken the
wing or the wing strut integrity. The material was tested and found
conforming to the manufacturer’s specifications.
• Examination of the wreckage did not reveal any anomaly susceptible to
have led to a non-commanded abrupt manoeuvre.
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• The pitch trim actuator was found set in A/C full nose down position at
final impact with the ground. Thorough examination of the pitch trim
system could not conclude that any anomaly occurred. Unlike it, the pitch
trim actuator could have been involuntarily activated by the pilot fighting
to recover control during the dive of the aeroplane.
About the Weight and Balance

• The weight of the aeroplane was within the limits.
• The lack of accurate data, or adequate guidance to determine the arm
between the reference line and the different parachutists’ positions, as
installed inside the cabin, makes an accurate W&B computation difficult
and error prone.
• The W&B evaluation performed during the investigation shows that the
centre of gravity was very close, or even maybe beyond, to the aft limit of
the balance envelope.
• The different pilots of this aeroplane were convinced that the aeroplane
could never be loaded by parachutists on such a way that the aeroplane
was out of balance. Consequently, the parachutists were not instructed to
take a place according to their weight.
• The W&B simulations performed during the investigation show that a
conservative loading of the aeroplane would mostly require installing the
heaviest passengers forwards. This practice, considered by most pilots
as common knowledge, was not applied on the accident flight.
About the regulation

• The Royal Decree on Air Navigation dated 15 March 1954 states that
aerial work shall be authorized by the aviation authority. However, the
regulation doesn’t lay down the conditions of delivery, suspension and
withdrawal of such an authorization.
• An aerial work authorization, as required by the Royal Decree was
prepared and delivered by BCAA based on a general assessment of the
application file. The authorization defines the responsibilities of the
applicant and other general standards.
• BCAA Circular GDF-05 covers the conditions to be fulfilled by parachute
clubs for the performance of parachute jumps. It includes, amongst
others, some requirements for the operation of the aeroplane and for the
pilot.
• An authorization, distinct from the aerial work authorization, was issued

by BCAA based on Circular GDF-05.
• BCAA Circular FCL-27 covers the conditions to be fulfilled by a pilot to
obtain and renew a special rating for parachute dropping flights.
• BCAA Circular GDF-04 covers the conditions to be fulfilled by
uncontrolled airfields.
• The Belgian regulation does not clearly define what restraint system to
use for parachutists, and when – for which flight phase – to use them.
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• The new (EU) n° 965/2012 Part SPO regulation, published after the
accident, states that restraint devices must be available for each station.
Nevertheless, the basic (CS-23) code does not specify the technical
requirements of the restraint system installed in parachuting aeroplanes.
The “Special condition” document N° SC-023-div-01 published by EASA
on 6 July 2009, while listing the key points and the requirements
applicable to an aircraft for parachuting activity, does not include any
further detail on this matter.
About the operator Namur air Promotion

• The last aerial work authorization was granted to the operator of the
aeroplane on 16 November 2011, valid for a 2 year period.
• As specified in the aerial work authorization, the operations shall be
performed under the authority, the direction and the survey of the
operator and the operator shall comply with, and shall ensure that the
staff in charge observe the laws, regulations and conventions governing
national and international air navigation (without the staff’s personal
liability being discharged).
• There are indications showing that the operator didn’t assume fully the
responsibilities as described in the BCAA aerial work authorization, in
particular regarding the oversight of the staff and the flights. These tasks
were in practice, and informally, transferred to the president of the
Paraclub Namur.
• The names of the different pilots authorized to fly for Namur Air
Promotion are only mentioned in the application file, where it is specified
that any pilot, not identified in the application file but duly qualified, can
be called upon.
About the Paraclub Namur

• The last authorization for the operation of a permanent site of
parachuting activities was granted to the Paraclub Namur on 31 August
2011, valid for a 3 year period.
• The authorization letter emphasizes the accountability of the Paraclub
Namur regarding the different requirements of the Circular GDF-05,
including for the aircraft, the designated pilot and the flight procedures. It
has to be noted that these matters are also under the responsibility of the
operator, as prescribed in the aerial work authorization.
• The names of the different pilots authorized to fly for the Paraclub Namur
are mentioned in the authorization letter. The name of the pilot involved
in the accident was not mentioned.
• n to the parachutist club.
• There is a partial overlap in the responsibilities attributed by the BCAA to
both different holders of authorization.
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3.2 Causes.
The cause of the accident is a structural failure of the left wing due to a
significant negative g aerodynamic overload, leading to an uncontrollable
aeroplane and subsequent crash.
The most probable cause of the wing failure is the result of a manoeuvre
intended by the pilot, not properly conducted and ending with an involuntary
negative g manoeuvre, exceeding the operating limitations of the aeroplane.
Contributing safety factors:
• The weakness of the monitoring of the aeroplane operations by the

operator.
• The lack of organizational structure between the operator and the
parachute club [safety issue].
Other safety factors identified during the investigation:
• The performance of aerobatics manoeuvre with an aircraft not certified to

perform such manoeuvres.
• The performance of aerobatics manoeuvre by a pilot not adequately
qualified and/or trained to perform such manoeuvres.
• Transportation of unrestrained passengers, not sitting on seat during
dangerous phase of the flight.
• The weakness of the legal framework and guidance for aerial work
[safety issue].
• The lack of effective oversight of aerial work operations by the BCAA
[safety issue].
• The lack of mandatory requirement to install devices recording flight data
on board aeroplane used for parachuting [safety issue].
• Insufficient back protection for the pilot [safety issue].
• No easy determination of the weight and balance of the aeroplane due to
the passengers not sitting in predetermined positions [safety issue].
• The issuing by BCAA of two distinct authorizations to the aeroplane
operator and the parachute club incorporating some overlaps, which
does not encourage the awareness of responsibility of the stakeholders
involved [safety issue].

• Possible erroneous interpretation of the maintenance manual [safety
issue].
• Violations and/or safety occurrences not reported as required by the
Circular GDF-04, preventing the BCAA from taking appropriate action.
• Peer pressure of parachutists sometimes encouraging pilots to perform
manoeuvres not approved for normal category aeroplanes.
• Flying at high altitude without oxygen breathing system although required
by regulation.
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4 SAFETY RECOMMENDATIONS
4.1 Safety issue: The weakness of legal framework and effective oversight.
Further to the investigation on the accident, AAIU(Be) undertook, when the

investigation was not yet completed, an assessment study on the danger of
parachuting activities. The investigators unveiled a general situation, not
having necessarily any bearing on the accident itself, requiring an urgent
need for improvement for the sake of aviation safety. The assessment study
focused on the volume of parachuting activity, the number of accidents with
parachute dropping aeroplanes and the risk of the parachuting activity itself
compared to the risk of accident during the transportation of the parachutists
in an aeroplane. AAIU(Be) found that aeroplane accidents come on top of
those linked to the parachute activity itself.
It was clear, during the investigation, that the risk associated with the
parachute activity itself was indeed recognized within the clubs. Through
procedures, training, re-training, supervision, etc., this risk seemed to be
adequately taken care of, while the associated aeroplane operations lacked
equal safety awareness.
AAIU(Be) concluded that an improvement of the organizational framework of
the flight operations involved in parachuting activities, as well as an
improvement of the monitoring and surveillance of these activities are
needed, both internally and by the competent oversight authority. Therefore
AAIU(be), considering the volume of the activity and the potential danger to
the occupants of the aircraft involved, made the following recommendation to
the BCAA on 24 January 2014:
Recommendation 2014-P-2:
It is recommended the BCAA reviews the regulatory requirements
pertaining to the activity of parachute droppings in order to increase
the safety of this activity to an acceptable level, as well as adapting
Final report SAFETY RECOMMENDATIONS
the level of oversight.
AAIU(Be) would suggest considering the following;
• Requirement for written procedures for the performance of the
parachute dropping flights.
• Requirement for a designated person in charge of the safety of the
flights.
• Requirements for a minimum experience for the pilots involved in
the activity.
The BCAA reacted positively to the recommendation in a response letter

dated 01 April 2014, stating that the decision was taken to apply the new
Part-SPO regulation in April 2015, 2 years before the final date for
implementation instead of upgrading the national regulation.
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The BCAA prepared a set of operating procedures, based on EASA Part

SPO Regulation, for the purpose of helping the parachute clubs to develop a
Procedure Manual. The purpose was to draft the framework of the
organization desired for such activities.
4.2 Safety issue: The lack of mandatory requirement to install devices

recording flight data on board aeroplane used for parachuting.
Simplified flight data recorders capable of logging at least the basic

parameters of the aircraft’s operation and meeting the needs of the non-
commercial aviation have been developed by industry, making these different
systems now available at a reasonable price. These recording devices could
be useful not only for the purpose of flight monitoring by pilots or operators
but also by avoiding pilots letting themselves be drawn into exceeding the
limits. In addition to the above mentioned possibilities offered by these new
technologies, such a simplified FDR would be also helpful during accident
investigation. Therefore,
Recommendation BE-2015-0001:
It is recommended that the EASA mandates the installation of a
lightweight recording system in aircraft used for parachuting
activities.
Note:
• A EUROCAE ED-155 standard has been developed to cover lightweight
recording systems.
• ICAO Annex 6: Part II International General Aviation — Aeroplanes
recommends the installation of a flight recorder on newly certified
aeroplanes used in general aviation from 1 January 2016 (for turbine
engine aeroplanes with MTOW less than 5700 kg with more than 5
passenger seats). However, this recommendation will not affect the

current fleet of aeroplane used for parachuting activities.
4.3 Safety issue: The weakness of framework regarding the technical

requirement of restraint systems for parachutists on board aircraft.
The last evolution of (EU) n° 965/2012 Part SPO Regulation, published after
the accident, provides that restraint devices must be available for each
station. However, the same regulation states that the floor of the aeroplane
may be used as a seat, provided means are available for the task specialist
to hold or strap on. These means are not further detailed and no other
regulation, standard or guidance material has been found to specify the
technical requirement for such an installation. Therefore:
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It is recommended that the EASA conducts research to determine the
most effective restraint systems for parachutists reflecting the various
aircraft and seating configurations used in parachute operations.
For the same reason as above:
It is recommended that the EASA, at the end of the research about
restraint systems for parachutists, clarifies the technical requirements
applicable to such restraint systems.
4.4 Safety issue: Insufficient back protection for the pilot.
The investigation highlighted that a parachuting aeroplane, being set in an

unusual attitude or subject to a loss of control, for whatever reason, can
potentially cause the unrestrained occupants to be thrown forward, hitting the
pilot’s back or the pilot’s head. Such a situation would make things worse,
possibly preventing the pilot from recovering from an already dangerous
situation. Study of other parachuting aeroplane accidents showed that the
parachutists’ jump phase of the flight, when the parachutists are
unrestrained, would be more subject to possible loss of control, due to the
combinations of the low airspeed and possible uncontrolled and/or
unforeseeable modifications of the weight and balance. Therefore:
It is recommended that the EASA carries out a study to assess the
need of a pilot’s back protection for all aeroplanes used in parachute
dropping activities. When assessed necessary, it is recommended that
EASA mandates the installation of such a system.
For the same reason as above:

It is recommended that Pilatus designs a pilot’s back protection to be
installed on PC-6 used for parachute dropping activities. Thereafter,
the installation of this pilot’s back protection should be proposed by
Pilatus in the AFM supplement 1824.
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4.5 Safety issue: No easy determination of the weight and balance of the
aeroplane due to the passengers not sitting in predetermined positions.
The investigation highlighted the difficulties encountered to determine

accurately the distance between the reference line and the different
parachutists, as installed both on the floor of the aeroplane and on the
longitudinal bench. The investigation observed also the existence of an
unproven determination that a PC-6 could never be loaded by parachutists in
such a way the aeroplane would be out of balance, having as a consequence
that the accident aeroplane was not loaded in a sensible manner. Therefore:
It is recommended that the BCAA makes sure that all operators of
aeroplanes used for parachuting activities use an adequate weight
and balance computing procedure, taking into account that the
passengers are installed on the floor in an unfixed position.
The lack of accurate data regarding the exact distance between the
reference line and the different parachutists’ positions, as installed inside the
cabin, makes an accurate W&B computation difficult. Therefore:
It is recommended that Pilatus incorporates a guideline in the AFM
supplement 1824 to help the operators of PC-6 aeroplane used for
parachuting activities to perform an easy and conservative evaluation
of the distance between the reference line and each parachutist on
board.
4.6 Safety issue: Granting overlapping authorisations by the BCAA.

AAIU(Be) detected a partial overlap in the responsibilities attributed by two

separate BCAA departments (Operation and Airport departments) to both the
parachute club and the aeroplane operator, which could introduce a
confusion of responsibility between the various stakeholders i.e. the operator,
the aeroplane owner, the parachute club and the airfield authorities.
Therefore:
It is recommended that the BCAA develops internally a system to
avoid granting authorizations with overlapping responsibilities to both
the parachute club and the aeroplane operator, or any other
stakeholder.
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The parachute club authorization was granted based on BCAA Circular GDF-
05. This circular covers the conditions to be fulfilled by an organization for the
performance of parachute jumps. Chapter 5 specifies the requirement to be
fulfilled regarding the use of the airfield and the characteristics of the
dropping and landing zones for parachutists. However other chapters cover
amongst others the requirements for aircraft, for pilots and also the flight
procedures to be applied i.e. mainly the cooperation with ATC. However,
these areas would logically fall within the area of competence of the operator.
Additionally, some parts of the BCAA Circular GDF-05 are now overridden by
the new (EU) n° 965/2012 Part SPO Regulation. Therefore:
It is recommended that the BCAA updates the Circular GDF-05
Descentes en Parachute – Valschermspringen.
4.7 Safety issue: Possible erroneous interpretation of the maintenance

manual.
In the inspection schedule found in chapter 05-22-01 of the maintenance

manual, the text of item 49 “Inspection column” could be misleading, causing
engineers to omit the performance of the functional test of the horizontal
stabilizer trim electrical system during 100 hours/annual inspection.
Therefore:
It is recommended that Pilatus reworks the text of items 47 and 49 of
the inspection schedule. AAIU(Be) suggests separating in two
different boxes the maintenance actions to be done to the trim
mechanical system from those to be done to the trim electrical
system.
Pilatus already implemented this recommendation in the revision N°19 of
the aircraft maintenance manual dated 14 May 2014. The latest AMM
version shows:
AAIU(Be) considers the intent of the safety recommendation has been met
by this AMM revision. This Safety recommendation is therefore closed.
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4.8 Safety issue: Lack of organizational structure between the operator and
the parachute club.
This deficiency will automatically be eliminated as a result of the BCAA

decision to apply the last evolution of (EU) n° 965/2012 Part SPO regulation
in April 2015. For this reason no recommendation is made to tackle this
issue.
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5 APPENDICES
Appendix 1: Extract of BCAA delivered aerial work authorization
Final report APPENDICES
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Appendix 2: Extract of BCAA delivered “Authorization for the operation

of a permanent site for parachute jumps”.
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Appendix 3: Extracts of Part SPO Regulation regarding the parachute

operation and seats, seat safety belts and restraint systems
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Appendix 4: Special Condition document “Use of aeroplane for parachuting

activities.
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Appendix 5: Royal Military Academy fractographical analysis
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Appendix 6: Horizontal stabilizer trim analysis
Preamble
The stabilizer trim system was investigated in order to determine if a trim runaway
could have occurred, causing an extraordinary pitch up or pitch down movement of
the aeroplane, possibly leading to manoeuvres out of the flight envelope.
At first sight, the occurrence of a runaway trim could be suspected because the
stabilizer actuator was found fully retracted (A/C full nose down).
Description of horizontal stabilizer electrical system
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Actuator jack screw position
The position of the pitch trim movable tube

was measured in order to determine the
position of the stabilizer on impact.
A fully retracted movable tube is given by

Pilatus as having a rod end bearing at 46
mm. The full stroke of the actuator is
85.8mm.
As seen in the figure, the movable tube

was found as being fully retracted.
This position of the movable tube corresponds to a full nose down stabilizer
position (+2° stabilizer incidence) => pitch down (aircraft nose down).
Picture showing the movable tube and the remains of the (broken) upper
bracket of the stabilizer.
As seen above, the horizontal stabilizer trim position at impact was in full nose
down position which is abnormal for an aeroplane flying level flight or climbing.
However the position at impact did not necessarily imply that it was in the same
position when the structural failure occurred, nor that the aeroplane would be
uncontrollable.
Actuator history
The pitch trim electrical actuator “Electromec” EM483-3 PN: 978.73.18.103 SN:
173 had been replaced on 10 April 2009.
AMM n°01975 rev.17 (Ch. 04-00-00) “Airworthiness Limitations” prescribes that

this actuator has to be overhauled every 3500 hours.
The actuator time in service was within the manufacturer’s limits. The next
replacement was scheduled at 17645 hours ACTT.
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Trim actuator location in the aeroplane
The stabilizer is hinged at the main

spar location (25% MAC) allowing
the trailing edge to move up and
down under the action of trim
actuator.
The trim actuator is located in the

tail of the fuselage, beneath the
stabilizer.
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The movable tube of the trim actuator is attached to the rear underside of the
stabilizer by a rod end bearing and a fitting while the stationary end of the actuator
is attached to a fuselage frame by a fork fitting and a spherical bearing.
Visible damage to the actuator

The actuator was found significantly damaged showing evidence of ground impact.
The aluminium casing showed heavy deformations obviously the consequence of
the actuator being pressed into the ground.
Pieces of earth were pressed

inside the deformations and
cavities of the casing while no
obvious evidence of impact with
solid objects was visible. A part of
the broken connecting fork of the
stabilizer was found attached to
the rod end of the actuator
movable tube. The rod end was
slightly folded. The stabilizer fitting
fracture shows the typical
characteristic of an overload
fracture.
The bottom fixture of the

actuator on the fork
fitting, called stationary
end in the IPC, was no
longer attached to the
actuator.
The stationary end was
found near the main
wreckage.
The 4 screws fixing the
stationary end to the
actuator were cut at the
height of the actuator
contact surface.
Three from the 4 screws
were recovered inside

the tail section of the
fuselage.
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The fork fitting was

disassembled from the
aeroplane wreckage to
allow better examination of
the fractured areas.
No preexisting damage as
corrosion, scratches or
fatigue cracks were found.
The fractures of both

cheek plates of the fork
fitting show also the typical
characteristic of an
overload fracture.
Determination at which stage of the crash the pitch trim actuator separated from
the fuselage
Knowing that the stabilizer was severed from the fuselage in flight, when suffering
the impact of the loose LH wing and remained attached rear of the fuselage during
the dive, two possibilities did exist:
• First possibility: The actuator was severed from the fuselage at the stationary
end and remained attached to the stabilizer up to the final impact of the
stabilizer with the ground. This assumption implies that the electrical
connection was interrupted from the moment the wing impacted the stabilizer,
implying that the movable tube of the actuator could not move any more, or
• Second possibility: The actuator remained attached to the fuselage structure
and was only torn off and ejected when the last ground impact of the aeroplane
occurred. In this case, the electrical connection remained operational and the
possibility exists that the movable tube of the actuator shifted position during
the dive.
We looked further at the trajectory and possible impact traces of the actuator
leaving the tail of the fuselage at impact. As the actuator is a compact and heavy
device, it would have restituted a lot of energy on impact. Collision with solid parts
of the airframe structure would have caused visible damage.
The inside of the tail structure in front of the actuator normal position didn’t show
any damage resulting from an impact of the actuator thrown forward in the axis of
the fuselage.
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Missing The fuselage tail structure

articulation features an oval opening in
plate area
Impacted the top horizontal skin of the
area fuselage located below the
stabilizer.
This opening as well as the

left hand skin of the
fuselage was found cut and
folded towards the outside.
This large opening was
consistent with the ejection
of the actuator.
In addition to the cut and folded LH lateral skin, the side of the fuselage also
showed a “<” shaped tear from the back to the front ending at the level of the
stabilizer LH articulation plate area.
As seen on figure, the LH articulation plate riveted on the fuselage left side is
missing.
LH stabilizer
articulation plate as
found partially buried LH articulation plate of the stabilizer was
retrieved buried in the ground near the tail
near the RH elevator
of the fuselage and also near the RH
elevator.
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Missing area
of the plate, The largest part of the stabilizer LH
remained on articulation plate was recovered near the
the stabilizer main wreckage while the missing part of
the same plate was still attached to the
stabilizer bearing.
The vertical rear edge of the plate showed

impact traces located at the height of the
“<” shaped tear of the side of the fuselage
proving the plate was still attached to the
fuselage side when the impact occurred.
Impacted
area
The underside of the actuator shows 4

scraches originating from a friction with
the LH stabilizer articulation plate rivets.
The washer and the nut protruding at the

bottom end of the actuator jack screw
had suffered impact deformation.
Normally this washer and its nut are

covered by the stationary end of the
actuator. Detailled examination shows a
deformation of the thrust washer support
and also the edge of the thrust washer
located under the washer is broken.
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Both cheek plates of the fork attaching the

stationary end to the fuselage were still in
place and held by the assembly bolt.
The length of the recovered screws

matches the thickness of the stationary end.
All fractures show they were cut by a
shearing force.
Examination of the outer circumference of the stationary end showed one outer
trace of impact and 2 inner impacts, compatible with the direction of the outside
impact, were found inside the stationary end.
The stationary end of the actuator was

repositioned.
The analysis of the damage concluded that

the LH attachment plate of the stabilizer
was impacted by the stationary end of the
actuator causing both parts to separate
from their own support (separation of the
LH attachment plate from the fuselage and
the separation of the stationary end from
the actuator).
All the separated parts were found on the crash site proving that the actuator
separated from the fuselage at the final impact.
The sequence of separation of the different parts was as follows:
1. Left wing separation
2. The separated wing impacts both the vertical and horizontal stabilizers
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3. The horizontal stabilizer separates from its 3 attachment points (2 hinges and
at the fork fitting of the stabilizer) but remains attached to the aeroplane by the
elevator cables. The analysis shows that the separation between the stabilizer
and the actuator occurred at the stabilizer fitting (at the connection between the
stabilizer and the actuator).
4. At the final impact of the aeroplane with the ground, the fork fitting cheeks
failed under the significant weight of the actuator and the impact deceleration
causing the actuator to be thrown forward towards the left side of the fuselage.
5. When being thrown away, the stationary end of the actuator impacted the left
articulation plate of the stabilizer.
Finally, we can conclude that the actuator remained attached to the fuselage by
the lower attachment and remained electrically connected to the aeroplane up to
the final impact.
Electrical circuit examination
Inspection of the stab trim circuit breaker
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The above drawing shows a typical circuit breaker panel of a recent Pilatus PC-6.
On the aeroplane, no aileron and rudder electrical trim were installed as well as no
electrical flap motor fitted meaning that the stabilizer circuit breaker was isolated in
this area of the panel and therefore very easy to reach.
Before the crash, the stabilizer trim circuit breaker was protruding more than the
other breakers and was equipped with an orange ring to facilitate its identification
in case of emergency.
The head of the stabilizer trim circuit

breaker was found missing as well as
the rear side. Actually, both protruding
extremities had been severed at
impact and could not be retrieved.
However, the inner movable cylinder
of the breaker was found in its original
position. The remains of the circuit
breaker were removed from the panel
allowing pushing out of the inner
movable cylinder, in a configuration as
if the circuit breaker had tripped.
As seen on the above picture, , the white ring appeared after pushing out the inner
movable component proving that the circuit breaker was in normal position
(electrical circuit was closed) when both ends were severed at impact.
This normal position of the circuit breaker indicates that no short circuit occurred
and that the pilot did not pull out the breaker. Pulling out the circuit breaker is part
of the procedure in case of electrical trim runaway.
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Inspection of the trim interruption switch and the alternate trim stabilizer switch
Rear side of the switches were also

significantly damaged by fire.
The trim interrupt switch and the alternate trim

stab switches were recovered and were both
externally and internally examined.
They were damaged to such an extent that no
conclusion could be drawn and their position at
impact could not be determined.
Inspection of the trim actuator relays
After disassembly of the housings of

both relays, examination of the
internal parts shows similar small
plastic parts damaged inside both
relays. This damage was caused by
the violence of the impact.
Examination of all electrical contacts
did not reveal any abnormality. The
contacts were clean and no sign of
any previous arcing could be found.
Consequently, a malfunction of the
relay such as fusion welding of a
contact causing the relay to remain
stuck after de-energizing the coils is
excluded.
Pilot stick stabilizer trim switch

The co-pilot stick was not installed so that no malfunction can occur at the co-pilot
pitch trim switch.
Hereby a drawing of the pilot grip wiring. Wires number 5, 8 and 9 are related to
the pitch trim.
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AAIU-2013-21
The pitch trim switch continuity was tested from the toggle switch in neutral
position. This test showed there was no electrical contact between wires 9 and 5
and thereafter between wires 9 and 8.
Later, the same test was conducted

while pushing the toggle switch
towards the ‘up’ and ‘down’
positions.
This second test showed there was

a normal electrical contact inside the
switch in both positions (Continuity 9
=> 5 in ‘up’ and 9 => 8 in ‘down’.
No anomaly was found.
Switch history: The pitch trim switch was replaced by a new one on 8 March 2012.
This switch is life limited at 3500 hours / 10 years as per AMM n°01975 rev.17
(Ch. 05-10-10) ‘Overhaul and replacement schedule’.
The next replacement was due at 18894 hours ACTT or 8 March 2022. Note: the
co-pilot switch was not installed.
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AAIU-2013-21
Trim actuator disassembly and inspection
Knowing that no anomaly could be found to the airframe pitch trim electrical
system, the last possible trim runaway could only originate from the actuator itself.
However, this hypothesis was considered as very unlikely taking into account the
precise fully retracted position of the movable tube. The pitch trim movable tube
(rod end bearing at 46 mm) stopped at the exact position determined by the limit
switch for the full nose down position. A mechanical trim runaway caused by
external forces acting on the tube would not be influenced by the electrical system,
and the tube could move beyond the position of the limit switch.
The following possible causes of a mechanical trim runaway have been identified:
• A mechanical failure of the reduction gear/differential system
• A mechanical failure of the jack screw and/or the associated gear nut
• A failure of (at least) one electrical motor to perform its normal brake function
Above, the trim actuator, as found near the

main wreckage. On the right, the actuator
after removal of the housing.
After the removal of the black housing of the actuator, made of a thin light alloy
skin, a first inspection showed that the housing of the moveable tube was
significantly deformed by the impact forces. The other internal parts did not show
obvious damage.
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AAIU-2013-21
During a normal trim

operation, the primary
motor is energized and
runs the reduction gear
train to make the
jackscrew turn while the
secondary motor works as
a brake system blocking
the nut gear. The design of
the jackscrew system
excludes any axial
translation displacement of
the jackscrew while the
moveable tube, fixed in
rotation is designed to
move only in translation.
Each motor is equipped with a brake, playing its role when no electrical power is
applied. Should the primary motor fail, then the pilot can use the secondary motor.
The secondary motor can run the nut gear. However, running the nut gear would
be useful only under the condition the (failed) primary motor works as a brake
system, blocking the jackscrew. This allows the moveable tube to displace axially,
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AAIU-2013-21
in translation.
In summary:
• No trim action of the pilot implies that neither the primary nor the secondary
motor is energized causing the brake of each motor to remain in braking
position.
• Action of the pilot on the hand grip trim switch feeds the primary motor, causing
the primary motor brake to release and the jack screw to turn. The secondary
motor is not energized implying its internal brake holds it in position, blocking
the gear nut.
• Action of the pilot on the alternate trim switch feeds the secondary motor,
causing the motor brake to release and the gear nut to turn. The primary motor
is not energized implying its internal brake holds it in position, blocking the
jackscrew.
The inspection of the

moveable tube, including the
gear nut and the jackscrew
did not show any mechanical
anomaly. However, several
axial pressures on the
jackscrew showed that the
jackscrew system was
sometimes reversible
meaning that it could turn and
move axially only under the
action of an axial force.
Therefore the braking action of both electrical motors was supposed to be
necessary to prevent any back-driving of the actuator under external forces,
avoiding a possible mechanical trim runaway.
We tested both motors as per

the Overhaul Manual
OHM483-3 Chapter 2-12.1
and found the brakes were
released around 8 volts
(indicated either by sound or
by armature starting to turn),
which was normal.
However, this test could not

exclude any doubt about the
working of the brake system.
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AAIU-2013-21
The best way would be to measure the brake torque for which the trim actuator
manufacturer indicated the holding torque was typically 1.4 in-lbs in both
directions.
We found first that the rotor shaft (armature) of both electrical motors could not be
turned by hand, likely under the working of the brake. The brake torque of both the
primary and secondary motors was measured using a lever and a weight. The
weight was progressively moved outboard until the engine brake could no longer
hold the applied moment. The brake torque, measured in both directions, showed
the brake of both motors was in accordance (and above) the manufacturer
specification (1.4 in-lbs). Brake values in both directions are for the Primary motor
around 2.5 in-lbs and around 4 in-lbs for the secondary motor.
Electrical circuit
The above electric diagram represents the horizontal trim actuator primary system
(secondary system not shown) with both the pilot and co-pilot sticks installed. In
the above example, the pitch trim switch provides a ground to the ‘down’ relay
(blue wire) that triggers the relay, allowing the relay to provide a + (red wire) to the
“Retract connection A” of the motor. This internally causes the feeding of both the
electromagnet of the internal brake (brake release) and the feeding of the motor
itself. The same principle applies when the pilot electrically closes the ‘up’ pitch
switch.
The horizontal trim actuator secondary system is simpler since it does not
incorporate any relay. Feeding of the secondary motor is directly supplied from the
battery through a specific circuit breaker and the alternate trim toggle switch.
However, electrical supply can be interrupted by the trim actuator interrupt switch,
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AAIU-2013-21
which disconnects simultaneously both the primary system and the secondary
system.
The procedure found in the AFM in

case of electrical trim runaway
prescribes to immediately open the
“Stab trim interrupt Switch” causing
the interruption of the (positive)
supply to the system, including the
secondary system.
Interruption of electrical feed
immediately stops the actuator
motor(s) and lets the electromagnet
brake return towards the braking
position. This safety system, if
correctly used in case of electrical
trim runaway would not cause any
problem.
An electrical trim runaway could occur because:

• Pilot or co-pilot hand grips pitch trim toggle switch remaining stuck at the end of
a trim action initiated by the pilot. This situation could be excluded in the
accident aeroplane because the inspection of the pilot switch proved the switch
was in good condition and no stick (and no switch) was installed on the co-pilot
side.
• An accidental chafing and subsequent aeroplane structure contact of a ground
wire of both the ‘down’ or ‘up’ relays (damaged insulation, etc.). This situation
had been considered as very unlikely taking into account the quality of the
Pilatus electrical system combined with the fact that damaged wire insulation
would first normally result in small, time-limited, poor electrical grounding,
having limited effects.
• A relay of the primary system remaining stuck when electrical feeding is
interrupted. This situation had been considered as very unlikely taking into
account the inspection of the relays showing no sign of anomaly.
As seen above, the hypothesis that a mechanical trim runaway had occurred could
be excluded because the moving tube was found set in a position corresponding
to the stop position of the internal limit switch. This demonstrates that the
movement and the final stoppage of the movable tube were electrically controlled,
therefore not erratic as it would have been in case of mechanical runaway.
The motors are series wound DC motors with two parallel, opposite wound field
windings. Depending on the desired direction of rotation, one or the other field
winding is powered. The motor brake is wired in series with the field-and motor-
windings and opens as soon as power is applied. During normal operation, only
one field winding is powered at any time and the motor turns in the desired
direction. As soon as power is removed, the motor stops and the brake engages.
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AAIU-2013-21
However, study of the primary electrical circuit shows that opposite trimming, in
case of (undesired) trim electrical runaway, could energize at the same time the
opposite wound field windings of the motor. The tests performed using the motors
of the aeroplane’s actuator showed that the motor stops turning and the brake
remains released when both Extend and Retract windings are energized at the
same time. This situation could only happen if an electrical trim runaway is
combined with a pilot’s involuntary reflex to trim in the opposite direction instead of
activating the interrupt switch.
Finally, in order to clarify the issue, a traction test using an actuator in good
condition was performed by AAIU. The traction tests with opposite wound field
windings of the primary motor energized at the same time have not led to a
mechanical runaway of the actuator. The same test was performed energizing the
secondary motors, with the same results. Additionally, Pilatus performed more
complete tests with tensile and compressive loads up to 10000 N, using a
hydraulic test bench. The actuator was subjected to loads in steps of 500/1000N,
during which the actuator never changed its position when the primary motor
brake was released.
A mechanical trim runaway would therefore be very unlikely in case of failure of

electrical motor internal brake.
Conclusion of the horizontal stabilizer trim analysis.
• The trim actuator moveable tube was found in full electrical (aeroplane) nose
down position.
• The full nose down position of the moveable tube of the actuator,
corresponding to the position of the internal limit switch, can exclude that a
mechanical trim runaway occurred.
• No anomaly was found that could have caused an electrical runaway, however
the wreckage was damaged to such an extent that we cannot totally exclude
that an electrical trim runaway occurred.
• However the circuit breaker was found in a normal position. In case of a trim
runaway the circuit breaker should have been manually pulled out. This
procedure was well known to the pilot.
• The AFM procedure to apply in case of electrical runaway has been reviewed
and found adequate.
• It has been demonstrated, during certification flights and during a flight made
with an investigator on board, that the PC-6 B2H4 aeroplane remains
controllable in straight horizontal flight in the range of airspeed of the accident
with a full nose down trim actuator.
• When the accident occurred, the centre of gravity of the aeroplane was close
or maybe beyond the aft limit. This CG position would have made the
aeroplane more controllable in case of horizontal stabilizer trim actuator set in
full nose down position.
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AAIU-2013-21
Pitch trim settings versus stick force
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AAIU-2013-21
AFM horizontal stabilizer trim runaway procedure

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AAIU-2013-21
THIS PAGE IS INTENTIONALLY

LEFT BLANK
Final report
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AAIU-2013-21
Recommendation 2011-…….-…….. to …………………….
AAIU(be) recommends …………………………………………:

• …………………………………
• ……………………………………
• ……………………………………
Air Accident Investigation Unit - (Belgium)

City Atrium
Rue du Progrès 56
1210 Brussels
Phone: +32 2 277 44 33

Fax: +32 2 277 42 60
air-acc-investigation@mobilit.fgov.be
www.mobilit.Belgium.be
Final report
148

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What were the injuries sustained in the accident?

What were the injuries sustained in the accident?

What damage was caused to the aircraft?

What damage was caused to the aircraft?

Air Accident Investigation Unit (Belgium)

Safety Investigation Report

THIS PAGE IS INTENTIONALLY

1.18 ADDITIONAL INFORMATION. ................................................................................ 73

2.6 POSSIBLE MANOEUVRES .................................................................................... 86

OPERATOR AND THE PARACHUTE CLUB. ............................................................ 112

5 APPENDICES ............................................................................................... 113

In accordance with Annex 13 of the Convention on International Civil Aviation and

In particular, Article 17-3 of the EU regulation EU 996/2010 stipulates that the

expressed in terms of flight levels. To indicate altitudes, the local barometric

SYMBOLS AND ABBREVIATIONS

CAS Calibrated airspeed

Final report SYMBOLS AND ABBREVIATIONS

QNH Pressure setting to indicate elevation above mean sea level

VMC Visual Meteorological Conditions

TERMINOLOGY USED IN THIS REPORT

Other safety factor: a safety factor identified during an occurrence investigation

Safety issue: a safety factor that

Safety action: the steps taken or proposed to be taken by a person, organisation

Final report TERMINOLOGY USED IN THIS REPORT

Safety message: An awareness which brings under attention the existence of a

Date and time of the accident: 19 October 2013 at 13:35

Aircraft: Pilatus PC-6/B2-H4, MSN 710

Accident location: 50°31’0.5’’ N - 4°57’1.0’’ E

Aircraft owner: Namur Air Promotion S.A.

Type of flight: Aerial Work - Parachute dropping

Contributing safety factors:

• The weakness of the monitoring of the aeroplane operations by the operator.

Other safety factors identified during the investigation:

• The performance of aerobatic2 manoeuvres with an aircraft not certified to

1.1 History of flight.

Flight # Time of take-off Time of drop Pilot # of passengers

Figure 1: last flight approximate flight path

Another witness standing approximately at an horizontal distance of 600 m

The aeroplane crashed on a field in the territory of Gelbressée, killing all

1.2 Injuries to persons.

Injuries Pilot Passengers Others Total

1.3 Damage to aircraft.

The aeroplane was entirely destroyed.

1.4 Other damage.

1.5 Personnel information.

Pilatus PC-6, valid until 30 September 2015

Pilatus PC-6 experience:

Previous week flight activities: 08:22 FH (BAe146)

PC-6 flights over the last 6 months:

Pilot history at EBNM airfield:

1.6 Aircraft information.

Max Structural cruising (VC): 220 km/h (119 kt)

Figure 2: Pilatus PC-6 B2H4

Total Time: 16159:20 FH

This type of propeller is a 4-blade, hydraulically operated constant speed

Propeller control - Beta propeller pitch in flight

Para dropping equipment

Figure 3: location of the restraint system

Pilot’s seat and pilot’s back protection