Annual Safety Review 2019: Air Accidents Investigation Branch

AAIB
Air Accidents Investigation Branch
Annual Safety Review

2019
Annual Safety Review 2019 AAIB
© Crown Copyright 2020
All rights reserved. Copies of this publication may be reproduced for personal use, or for
use within a company or organisation, but may not otherwise be reproduced for publication.
Extracts may be published without specific permission providing that the source is duly
acknowledged, the material is reproduced accurately and it is not used in a derogatory
manner or in a misleading context.
Published 6 July 2020
Enquiries regarding the content of this publication should be addressed to:

Farnborough House
Berkshire Copse Road
Aldershot
Hampshire
GU11 2HH.
enquiries@aaib.gov.uk
This document is also available in electronic (pdf) format at www.aaib.gov.uk

AAIB
Annual Safety Review 2019 Air Accidents Investigation Branch
Foreword
I am pleased to introduce this Annual Safety Review

which includes information on occurrences and the safety
and Contents
Foreword
action taken or planned in response to AAIB investigations
concluded in 2019. It may seem strange that we are
publishing this review in the midst of a pandemic that has
had such a profound effect on aviation in 2020. However,
last year’s events are no less significant because of what
has followed. As attention focuses on restart and recovery,
the key safety messages are as a relevant as ever.
Investigations
The AAIB received 826 occurrence notifications in 2019
and opened 37 field investigations, eight of which were
into fatal accidents in the UK resulting in 10 deaths. A further 124 investigations were
opened by correspondence. In addition, the AAIB appointed an accredited representative
to 96 overseas investigations, including 45 involving UK registered aircraft.
The AAIB deployed on investigations to Belgium, USA, Ethiopia, Chile, UAE, Italy, Portugal,
Montserrat and Kazakhstan. Globally, the most prominent event was the loss of a second
Boeing 737 Max in Ethiopia which led to the grounding of the fleet and a fundamental review
of certification regimes and other systemic issues.
Closer to home, the loss of a Piper Malibu a few miles north of Guernsey, led to a complex
and high-profile investigation that drew attention to two significant safety issues – the risks
associated with unlicensed charter operations, and the need for carbon monoxide detectors
with an active warning. This was one of two AAIB investigations conducted in 2019 which
involved operations to locate and gather evidence from aircraft wreckage on the seabed.
An article on how we set about these operations is included in this Annual Safety Review.
In 2019 all the fatal accidents that we investigated in the UK involved general aviation aircraft
or gliders with the most common factor being loss of control in flight. The most common
factor in commercial air transport accidents and serious incidents was system/component
failure or malfunction. The AAIB published two Special Bulletins, 29 Field Investigation
Reports and made 12 Safety Recommendations. Details of them all are in the pages that
follow, together with updates on the status of responses received and the action being
taken. Also included are details of 153 significant safety actions taken by manufacturers,
operators and regulators to address safety issues identified during AAIB investigations.
I am pleased to report that some progress has been made by the industry and regulators
towards the introduction of takeoff acceleration monitoring systems following safety
recommendations of global concern raised by the AAIB and others in 2018. However, the
AAIB investigated five more takeoff performance serious incidents in 2019, showing why
these systems are urgently needed.
© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

+44 (0)1252 512299 @aaibgovuk
iii
AAIB
Developments
Within the Branch, major projects last year included the development of a sophisticated
case management system that exploits modern digital collaborative tools to manage
investigations from notification to closure. It will allow us to meet all legal requirements,
including evidence and wreckage management, and provide a rich source of safety data for
future exploitation.
Other changes included the introduction of a ‘record only’ option for some less serious
occurrences allowing us to focus AAIB expertise and investigation resources where the
safety benefit is greatest. And by publishing our field investigation reports on-line as soon
as they are ready, rather than wait for up to six weeks for the next monthly bulletin, we have
reduced overall timescales to publication.
Collaboration between the Air, Marine and Rail Accident Investigation Branches has
been further strengthened with the Accident Investigation Chiefs’ Council driving forward
workstreams to maximise the synergy between the three modal branches and form common
positions on areas of joint interest. Joint memoranda of understanding have been developed
between the branches and other authorities to facilitate cooperation while protecting the
AIB’s independence.
Engagement
I am very grateful to all those who contributed to our Stakeholder Survey; we greatly valued
the feedback. In this Review there is an article to explain how we are using the insights
to develop our external communications to reach a wider audience and influence key
stakeholders with the important safety messages from our investigations.
In 2019 the AAIB established a global outreach framework. We engaged directly with
many safety investigation authorities around the world and participated actively in several
international forums. These connections enable us to share experiences and ideas,
develop specialist capabilities and train together. This is important as the investigation of
civil aviation accidents is an inherently international activity. A short article on our overseas
deployments and some of our engagement activities in 2019 is provided in this Review.
Future challenges
2020 is already proving to be an extraordinary year as the UK adjusts to life outside the
EU and the world sets about recovering from the impact of the Coronavirus. The AAIB
is investigating more and more unmanned air system accidents as the regulatory and
technological boundaries are being pushed to the limits. Soon the regulations will be in
place for commercial spaceflight from the UK and that may bring a whole new dimension
to our work.
In the meantime, I invite you to peruse this 2019 Annual Safety Review which I trust you will
find interesting and useful.
Crispin Orr
Chief Inspector of Air Accidents
+44 (0)1252 512299 @aaibgovuk
iv
AAIB
Contents
Foreword ...........................................................................................................................iii
AAIB stakeholder research...............................................................................................3
and Contents
Foreword
AAIB underwater wreckage operations...........................................................................7
The AAIB worldwide........................................................................................................17
CICTT factors on investigations by the AAIB in 2019..................................................19
Field investigations.................................................................................................. 20
Correspondence investigations............................................................................... 21
Fatal investigations ................................................................................................. 22
Statistics for 2019............................................................................................................23
Category definition .................................................................................................. 24
Notifications 2019.................................................................................................... 25
Notifications 2018.................................................................................................... 26
Notifications 2017.................................................................................................... 27
Safety Recommendations in 2019 ................................................................................ 29
Safety Recommendations issued in 2019............................................................... 33
Safety Actions from investigations reported on in 2019 .............................................49
Field investigations.................................................................................................. 49
Correspondence investigations............................................................................... 63
Index of Safety Actions............................................................................................ 86
Appendix 1 - CICITT occurrence categories .................................................................88

+44 (0)1252 512299 @aaibgovuk
1
AAIB

+44 (0)1252 512299 @aaibgovuk
2
AAIB
AAIB stakeholder research
Avid followers of our work will know that air accident investigations
started in the UK more than 100 years ago. Bound by the need to
comply with regulations and international standards, one could be
forgiven for assuming that the AAIB would not be overly concerned
about people’s views on its work. However, while regulations give
us and our Inspectors the powers needed to secure valuable
evidence to conduct an investigation, our effectiveness in
improving aviation safety depends on our collaboration with
those we investigate and those with the means to effect changes
that we call for in our Safety Recommendations.
For this reason, we recently commissioned research specialists
Stakeholder Research
ComRes to undertake research with a wide range of our
stakeholders. We had three objectives for the research:
AAIB
● To understand overall stakeholder perceptions of the Branch and the
contribution it makes to improving aviation safety.
● To benchmark stakeholder opinions about the performance and processes

of the Branch.
● To understand stakeholder views on the Branch’s engagement with

stakeholders.
119 stakeholders were surveyed online and ten 30-minute telephone interviews were
conducted. The stakeholder types included Government/Regulators, Manufacturers,
Operators, Academia, Sporting Associations and Unions.
ComRes research report summary
Overall perceptions
Stakeholders have a good understanding of the AAIB’s remit, and the organisation is seen
extremely positively. Four in five would speak highly of the AAIB, and the organisation is
seen as professional, knowledgeable, trustworthy and impartial. The AAIB’s work is seen as
highly valuable to the aviation industry worldwide.
Performance
The AAIB’s work is seen very positively. The AAIB is seen to be independent and expert,
and very capable at making safety recommendations and avoiding apportioning blame.
While ratings are lowest for being compassionate, this derives from a lack of knowledge.
Those who have relevant experience are very positive about the compassion of inspectors.
AAIB is seen as good at investigating incidents involving well established factors such
as technical and maintenance issues. While ratings are high for human and operational
factors, stakeholders would like to see an increased focus on these, and welcome the
+44 (0)1252 512299 @aaibgovuk
3
AAIB
AAIB’s appointment of its first Inspector of Air Accidents (Human Factors). Stakeholders
are uncertain about the AAIB’s ability to investigate incidents involving Unmanned Air
Systems, and think it is crucial the organisation is able to cope with the rise of new
technologies.
Communications
Stakeholders access reports through a range of channels; primarily the website, but also hard
copies, the press and word of mouth. Around half have read guidance documents and the
same for the Annual Safety Review. Both are seen as useful by those who have read them,
while those who have not read the annual review usually were unaware of its publication.
Some stakeholders would like the AAIB to explore new methods of communication.
AAIB
What we are doing?
This is a sample of some of the actions we are taking following the research.
Unmanned air systems
Since the survey, we have published many correspondence investigations on unmanned air
systems (UAS) as part of our monthly bulletins. In January 2020 we published our first Field
Investigation involving a UAS, which was an accident to a DJI Matrice 210. In last year’s
Annual Safety Review we included an article on how we investigate UAS accidents and our
‘decision tree’ for initiating an investigation. We are now preparing a dedicated section for
our website so it will be easier to find out which UAS accidents we investigate and how, and
it will bring together those on which we have published a report.

+44 (0)1252 512299 @aaibgovuk
4
AAIB
Communication
Since the survey, we have been publishing Field Investigations individually. This means
that we can communicate the safety messages from our reports faster, removing the delay
that was sometimes caused if reports were finalised just after the monthly bulletin had
been produced. In October, we started a new format for less serious incidents. Introducing
this ‘record only’ category is freeing up Inspectors’ time to focus on those Field and
Correspondence Investigations which will provide the greatest safety benefit, and over the
year we expect this initiative to help further reduce the time it takes to publish some of our
reports.
We have also started to produce short videos for investigations where we feel there is a
public interest or a widely applicable safety message. One of these videos has had more
than 140,000 views, so communicating this way is reaching a much wider audience.
Sporting associations
We have improved the frequency and consistency of our engagement with sporting aviation
AAIB
clubs and associations making best use of our established single points of contacts. So the
sporting associations, such as the British Gliding Association and Light Aircraft Association,
have regular contact with the appointed individual Inspector.
We know there is more to do and over this year we look forward to more exciting
developments in the way we communicate and engage with our stakeholders.

+44 (0)1252 512299 @aaibgovuk
5
AAIB

+44 (0)1252 512299 @aaibgovuk
6
AAIB
AAIB underwater wreckage operations
Wreckage Operations
AAIB Underwater
Introduction
Every aircraft accident brings its own challenges in finding and examining the wreckage.
However, when an aircraft accident occurs over water the challenges can become more
extreme and require the AAIB to make significant and difficult decisions.
In recent years the AAIB has conducted a number of investigations of accidents where
the aircraft wreckage has come to rest under water. The approach in conducting these
investigations has been developed over many years and is documented in internal processes
and agreements with partner organisations. We continue to develop these processes and
techniques through applying lessons learnt after each investigation.
This article will provide some insight into the factors we consider when investigating an
accident where the aircraft wreckage is in water.
Who investigates?
The AAIB is responsible for investigating all accidents within the UK, its Crown
Dependencies and its Overseas Territories, that occur on land and within their territorial
waters. We are also responsible for investigating accidents involving UK registered
aircraft (or those registered in UK’s Crown Dependencies or Overseas Territories) that
occur in international waters. Other States may also delegate their investigations to us.
A recent example is our investigation into the accident involving the US registered Piper
PA-46 (Malibu), N264DB, which occurred in international waters in the English Channel.

+44 (0)1252 512299 @aaibgovuk
7
AAIB
Wreckage Operations
The tail section of N264DB at a depth of 68 m

AAIB Underwater
Where the safety investigation is led by another accident investigation authority, the AAIB
may also participate in the search, survey and recovery operation as either an Accredited
Representative, Expert or Observer. An example was the accident to the Air France
Airbus A330, F-GZCP, in the Atlantic on 1 June 2009. The investigation was led by the
French accident investigation authority (BEA) who invited the AAIB to participate in the
underwater survey as an observer.
BEA image of wreckage from F-GZCP taken at a depth of 3,980 m
Recovery of wreckage
As with all investigations, our initial objective is to recover and preserve evidence that is
considered essential in establishing the cause of the accident. In doing so our priority is the
safety of individuals involved in the operation and ensuring that the AAIB’s resources are
used in the most effective manner possible.

+44 (0)1252 512299 @aaibgovuk
8
AAIB
In general terms, the decision to search and recover wreckage from water, either floating or
submerged, is made after considering the following questions:
1. Is it safe to do so?
2. Is it necessary to establish the cause of an accident and identify safety

issues?
3. Is the cost of the operation proportionate to the expected safety benefit?
If it is possible to establish the cause of the accident and make Safety Recommendations
without recovering the wreckage, then we may not recover it. However, we will always
consider the feasibility of recovering the wreckage against the three questions above so
that an informed decision can be made. The AAIB is not responsible for the recovery of
victims from aircraft accidents either on the land or in the water but will always work with and
Wreckage Operations
AAIB Underwater
support the relevant authorities.
How the AAIB conducts this type of operation
As diving operations are heavily regulated, and the AAIB are not experts in chartering
and operating vessels, we normally work with the MoD Salvage and Maritime Operations
Project Team (SALMO) who act as the Government Competent Authority on the recovery
and surveying of aircraft wreckage in water. As such, SALMO are the Project Team in any
maritime or diving contracts and we act as their adviser. A Memorandum of Arrangement
between AAIB and SALMO defines the roles and responsibilities of each organisation.
SALMO are always available to advise the AAIB, identify options and manage risk for
finding and recovering wreckage in water. Subject to their available resources at the time,
we can ask SALMO to carry out the following tasks:
● Work with AAIB personnel in the preservation of evidence.
● Assist with the development and execution of the search, survey and
recovery plan.
● Carry out a full onsite risk assessment with regard to the safety of AAIB
personnel working in the maritime environment.
● Contract vessels and marine contractors (including survey / diving /

Remotely Operated Vehicle (ROV)) to meet the AAIB requirements.
● When required, provide and operate their underwater location / survey and
recovery equipment.
● Provide guidance and advice on the training needs for AAIB personnel
undertaking maritime operations.

+44 (0)1252 512299 @aaibgovuk
9
AAIB
The AAIB will help to identify the likely location of the aircraft by analysing the radar
recordings, considering the aircraft performance and by using our equipment to detect the
underwater locator beacon. We will also identify the evidence to be recovered and take
action to preserve it once it has been recovered to the vessel.
We also have a key role in the safety of the divers, personnel on the recovery vessels and
the ROV by providing information on the aircraft and associated hazards. This requires
AAIB Inspectors to deploy on the vessels so they need to maintain their qualifications and
competencies for working at sea.
Categories of water operation
We categorise the type of water in which an aircraft has crashed to enable us to respond
appropriately. These categories are Inland, Coastal and Offshore. It should be noted that
Wreckage Operations
these categories are different to the normal maritime definitions.

AAIB Underwater
Categories of water depth when considering aircraft search and recovery
Inland
Inland water can take many forms, including rivers, lakes, lochs and canals. Inland water is
defined as ‘away from the coast and more than knee deep, or fast moving of any depth’. The
factors to consider are varied and may often bring unique challenges.
A shallow waterway or lake, with partially submerged wreckage may require specialist lifting
equipment that can reach the wreckage, whereas a deep open expanse of water will first
require suitable equipment to find the wreckage and then undertake a survey to determine
its condition. Only then can the feasibility of recovering the wreckage be considered. By
definition, inland water is away from the coast and can be difficult to access with specialist
lifting equipment, which may need to be floated close to the wreckage.
An example of a challenging recovery involved an accident to an AS350 in Loch Scadavay in

the Western Isles of Scotland. The helicopter was partially submerged in the remote loch and
was lifted using floatation devices. It was then towed ashore and recovered using a shore
based mobile crane.
+44 (0)1252 512299 @aaibgovuk
10
AAIB
G-PLMH partially submerged in Loch Scadavay prior to recovery
Wreckage Operations
AAIB Underwater
Coastal
Coastal waters are defined as being ‘not inland and with the aircraft partially visible at some
stage of the tide’. The wreckage will therefore be in relatively shallow water and may be within
the tidal range on a beach, at the foot of a cliff or in an estuary. Consequently, the wreckage
may be submerged at high tide and above the waterline at low tide. Wave action and strong
tidal flows can cause the wreckage, which may have some buoyancy, to move or be buried by
sand, silt or mud.
Wreckage close to the coast can be difficult to recover and it might only be accessible at
certain stages of the tide. The wreckage may be further damaged if the recovery is delayed,
especially if the sea is rough and the wreckage is washed against the shore or cliffs.
We would normally expect to recover wreckage in coastal waters. An example is an

accident involving an Augusta Bell 206B Jet Ranger II helicopter (G-SUEX) next to cliffs
near Flamborough Head, Yorkshire. The wreckage came to rest on a shale beach in a small
inlet at the foot of the cliffs. Although the wreckage could be accessed by sea, we were
unable to recover it by boat and so was lifted it using a cliff top winch.
Recovery of G-SUEX, Flamborough Head, Yorkshire in 2014

+44 (0)1252 512299 @aaibgovuk
11
AAIB
Offshore
The third type of operation, and normally the most complex and expensive, is finding and
recovering wreckage from offshore, which is defined by the AAIB as ‘not coastal and in water
deep enough to cover the aircraft if it sank’.
Following an aircraft accident at sea, a search and rescue operation, involving a number of
different organisations, would be initiated and carried out in accordance with international
protocols laid down in Annex 12 to the convention on international civil aviation Search
and Rescue and the International Aeronautical and Maritime Search and Rescue Manual
published by the IMO and ICAO. Although the AAIB would not actively participate in the
search and rescue phase, we would work with and provide support to the appropriate
authorities. At the same time, we would start preparation for the investigation phase, which
would commence once the search and rescue phase had been concluded.
Wreckage Operations
AAIB Underwater
An early priority is to find the wreckage. Although the last position of the aircraft in flight
might be known, being able to determine the location of wreckage on the seabed requires an
understanding of where the aircraft entered the water and the tidal conditions. This requires an
understanding of the aircraft dynamics including the direction, speed and distance travelled.
Once the area in which the aircraft entered the water has been identified, an estimation of the
tidal drift and sink rate is applied to determine the most likely location on the seabed. This
defines the search area. The next step is to conduct the search.
We often use side scan sonar (SSS) to carry out the initial underwater search. This is achieved
by “flying” a towed SSS transmitter/receiver close to the seabed that emits a series of sonar
pulses that are reflected off the seabed and any underwater objects. The reflected pulses are
captured and processed on the vessel to produce an image of the seabed and objects. The
SSS operator and the AAIB inspectors then assess the image to identify any potential targets.
SSS was used in the search of a Piper PA-28 (G-CDER) which ditched off the East Sussex
coast and came to rest upside down on the seabed. Other surveying techinques, such as
multibeam sonar, which use a surface based sonar transmitter/receiver are also used to
locate wreckage.
Side scan sonar survey results from search of G-CDER

+44 (0)1252 512299 @aaibgovuk
12
AAIB
Commercial aircraft are normally equipped with cockpit voice and flight data recorders that
are fitted with an acoustic beacon which is activated when it is submerged in water. The AAIB
has its own handheld detectors that can be held over the side of a small boat and a more
capable ‘towed fish’ that can be deployed from a suitable vessel and can be used to detect
a beacon at depths of up to 1,000 m. The AAIB does not just use its equipment to locate
missing aircraft; we also deployed to the Red Sea to search for the El Salam Boccaccio 98, a
ferry which sank on 2 February 2006, 80 km (50 miles) from Duba, Saudi Arabia.
Wreckage Operations
AAIB Underwater
The towed fish being recovered from the water during sea trials
Once a potential target has been identified we need to visually determine if it is wreckage
from the aircraft. We do this by using an remotely operated vehicle (ROV) equipped with
cameras and if conditions allow this is followed up by divers equipped with handheld
cameras. A full survey of the aircraft and wreckage field is always carried out to capture
evidence and to allow an assessment to be made as to what items should be recovered and
the best way in which to do so.
The survey will also enable us, by assessing the aircraft damage and whether the whole
aircraft is there, to establish:
● the attitude and speed of the aircraft when it struck the water,
● whether the aircraft is complete or there has been an inflight break up,
● if the engine(s) had been operating,
● evidence of fire.
Offshore activities require significant planning and early engagement with SALMO to
identify suitable vessels and weather windows. It is often necessary to plan the operation
over three phases sometimes using different vessels for each phase.

+44 (0)1252 512299 @aaibgovuk
13
AAIB
The phases are:
● Phase 1. Finding the wreckage by using vessels either towing SSS or by

using hull mounted multi beam sonar equipment.
● Phase 2. Surveying the wreckage with ROVs.
● Phase 3. Recovering the wreckage which may require a dynamically
positioned vessel equipped with a stabilised crane, ROV, divers
and a decompression chamber.
When planning the search, the depth of water, seabed topography, tidal flows, sea state
and weather will all be factored in to determine the most appropriate vessel and survey
technique to be used. For shallow waters it may be easier to deploy surface-based divers
or a small ROV, which is a relatively cheap way of surveying the wreckage. As the water
Wreckage Operations
depth increases the complexity and costs also increase. Critically, as the depth increases
AAIB Underwater
it is necessary to change from surface-based divers to saturation divers which require the
use of vessels that can remain dynamically positioned and specialised diving equipment
with decompression facilities.
If the decision is made to recover all or part of the wreckage, then a plan must be made
to ensure the correct assets are in place to ensure the safety of all those involved in the
operation and to minimise injury to those undertaking the recovery or destroying evidence.
Wreckage may be recovered by attaching lifting straps to move it into cages or bags
positioned on the seabed by divers or an ROV, or by lifting it directly to the surface. Air bags
can also be attached which are then inflated and float the wreckage to the surface. It might
also be necessary to cut the wreckage into manageable pieces before it is moved. The
vessel must be large enough to secure the wreckage onboard and to allow AAIB Inspectors
to undertake anti-deterioration measures, which is essential to delay the onset of corrosion
when the aircraft is removed from saltwater.
Recovering the wreckage of helicopter G-BLUM onto the deck of the vessel
in the early hours of the morning. (Irish Sea)
+44 (0)1252 512299 @aaibgovuk
14
AAIB
Conclusion
Following an aircraft accident where the wreckage enters the water, the AAIB is prepared
and has the necessary support on standby to enable an investigation tto be carried out
to determine the cause of the accident. The complexities and difficulties associated with
finding, surveying and recovering wreckage make the activity challenging. We will weigh
the benefits in surveying and recovering the wreckage against the risk to individuals, and
vessels, involved in the operation. Although the cost effectiveness of underwater activities
is a consideration, we will attempt to survey and recover wreckage when it is practical to do
so and is considered necessary to determine the cause of the accident.
Wreckage Operations
AAIB Underwater

+44 (0)1252 512299 @aaibgovuk
15
AAIB

+44 (0)1252 512299 @aaibgovuk
16
AAIB
The AAIB worldwide
The AAIB is the UK’s designated Accident Investigation Authority for the purposes of
Annex 13 to the Convention on International Civil Aviation (Air Accident and Incident
Investigation). The global nature of commercial and non-commercial aviation, and the
aerospace industries, means that we contribute to investigations and related activities
around the world.
We are proud that we continue to be held in high esteem by the international investigation
community. We are involved with many international aviation safety bodies and are invited
to lead or participate in many seminars, forums and training exercises. We have been
welcomed as participants in investigations where there is a UK interest and as observers
to those that provide training benefit to our Inspectors.
In 2019 we established a global outreach framework to engage directly with accident
AAIB Worldwide
investigation authorities around the world.
The map on the next page shows some of the overseas activities conducted by the AAIB in
2019 and illustrates our global reach.
As an example an accident to Britten-Norman Islander registration VP-MNI,

at John A Osborne Airport, Montserrat on 23 September 2019

+44 (0)1252 512299 @aaibgovuk
17
AAIB
Colour key
Places visited for accident and serious incident investigations

Belgium, Channel Islands, Chile, UAE, Ethiopia, France, Italy, Kazakhstan,
Montserrat, Norway, Portugal, USA
Places where the AAIB has either provided or received training

Bermuda, Canada, Cayman Islands, Falkland Islands, Hong Kong, Ireland,
Netherlands, Taiwan, USA
Places where the AAIB has sent representatives to participate in international

organisation meetings
International Civil Aviation Organisation (ICAO) Canada
European Union Aviation Safety Agency (EASA) Germany
European Civil Aviation Conference (ECAC) Hungary, Ukraine
European Network of Safety Investigation Authorities (ENCASIA) Belgium, Latvia,
Poland, Switzerland
International Society of Air Safety Investigators (ISASI) Netherlands, USA
Places where the AAIB has participated in international conferences, forums or

exercises
Austria, Australia, Canada, Japan, Portugal, Singapore, USA
Places visited by the AAIB for liaison and outreach

Argentina, France, Hong Kong, Netherlands, Taiwan, USA

+44 (0)1252 512299 @aaibgovuk
18
AAIB
CICTT factors on investigations by the AAIB in 2019
Every occurrence in the UK is recorded on the European Central Repository (ECCAIRS) and
is coded using the occurrence taxonomy defined by the CAST/ICAO Common Taxonomy
Team (CICTT). This is a worldwide standard taxonomy to permit analysis of data in support
of safety initiatives. In the UK the coding of occurrences is carried out by the CAA. It should
be noted that they are recorded as multiple factors, for example turbulence (TURB) leading
to loss of control in flight (LOC-I). Similarly, other (OTHR) is also used and may include
aspects that do not have specific classifications.
CICTT Factors on Investigations

AMAN UNK
ICE FUEL
EVAC RI 4 4 ADRM
RAMP 4
by the AAIB in 2019

BIRD ATM
5
UIMC
NAV
USOS LOC-G 6
SCF-NP
61
C... 67
C...
L... MAC
6
F-POST
6
SCF-PP WSTRW
7
46
ARC OTHR MED

87 8
91
F-IN
10
LOC-I
41 TURB
11
GCOL
32 CTOL
RE 23
37
See Appendix 1 for

category descriptions
Factors for all investigations reported on by AAIB in 2019

+44 (0)1252 512299 @aaibgovuk
19
AAIB
Field investigations
ARC USOS
4 LOC-I 1
5
UIMC
1
ATM
3
RI
1
by the AAIB in 2019
OTHR SCF-NP
8 7 RE
1
SCF-PP
3
MED
CTOL 1
1
FUEL EVAC LALT
2 1 1
MAC
2
See Appendix 1 for

Factors for field investigations reported on by AAIB in 2019
In 2019 the AAIB published 29 field investigation reports, 12 of which were investigations
into fatal accidents and 17 were into non-fatal accidents or serious incidents.
The 17 investigation reports published during 2019 into non-fatal events were balanced
between commercial air transport (CAT) and general aviation (GA) aircraft and were
attributed to OTHR.

+44 (0)1252 512299 @aaibgovuk
20
AAIB
Correspondence investigations
UN.. FU..
F-P... RI AMAN
C...
AT.. 3 3
U... EVA.. RAMP
BIR.. 4
MAC
4
SCF-NP
57 LOC-G ICE
61 4
ADRM
4 NAV

5
WSTRW
by the AAIB in 2019

SCF-PP
7
41
ARC MED
OTHR
86 7
74
F-IN
RE 10
36
TURB
11
LOC-I CTOL
GCOL 28 21
31
See Appendix 1 for

Factors for correspondence investigations reported on by AAIB in 2019
Correspondence investigations are usually conducted into non-fatal accidents on

GA aircraft and to some serious incidents on CAT aircraft. The factors most predominant
in these occurrences were classified as abnormal runway contact (ARC), commonly the
result of a hard or bounced landing or cross wind conditions.

+44 (0)1252 512299 @aaibgovuk
21
AAIB
Fatal investigations
SCF-NP
3
F-POST
4
SCF-PP
2
by the AAIB in 2019
UNK LOC-I OTHR

2 8 5
ARC
1
NAV UIMC
GCOL 1
CFIT 1 1
1 CTOL
1
See Appendix 1 for
Factors for fatal investigations reported on by AAIB in 2019
The predominant cause of fatal accidents in general aviation, in common with previous
years, was loss of control in flight (LOC-I) such as a stall near to the ground. However, other
factors identified during our investigations included physiological events.

+44 (0)1252 512299 @aaibgovuk
22
AAIB
Statistics for 2019
An overview of what we were involved with during 2019 can be seen below:
153
Number
of Safety
Actions
noted 2
173 Number 29
Number of
n/a
of Special Number of
Correspondence Number Bulletins Field Reports
Investigation of Formal published published
Reports published Reports
(incl UAS)
(incl UAS and published
Rec-only)
37
UK Field
Investigations
4.88 opened
n/a 11.97
Average months (incl UAS)
to publication for a Average months Average months
Correspondence to publication to publication
Investigation for a Formal for a Field
Investigation 8 Investigation
UK Fatal
23 Accidents
Number of UAS 124 12
Correspondence Total number of
Investigations Correspondence Number of
opened (AARF)
10 Safety
Investigation
Investigations Number of Recommendations
Statistics
opened Deaths
14
Number of UAS
48 826 115
Correspondence Record-only
Investigations Referred Total Number
Investigations
published to Sporting of Notifications opened
Associations received by the 28
AAIB
Record-only
0 Investigations
Military published
13 (AAIB
392 Overseas assistance)
No further (no AAIB
AAIB action involvement)
(Civil) 0
51 45 1 Joint Military
Foreign UK Military & Civil
Registered Registered (no AAIB Aircraft
Overseas Overseas involvement)
© Crown copyright 2020 Aircraft Accident Reporting - Telephone number www.aaib.gov.uk

+44 (0)1252 512299 @aaibgovuk
23
AAIB
Introduction
The following pages provide the statistics for 2019, 2018 and 2017 for accidents and
serious incidents notified to the Air Accidents Investigation Branch.
An explanation of the categories is as follows:
Category definition
UK Aircraft overseas Investigations involving UK registered aircraft, or aircraft

registered in one of the UK Overseas Territories or Crown
Dependencies, occurring in a Foreign State where the AAIB
has participated in the capacity of Accredited Representative
in accordance with ICAO Annex 13.
Foreign Aircraft overseas Accidents and serious incident investigations to Foreign
registered aircraft occurring in a Foreign State where the AAIB
has participated in the capacity of Accredited Representative
or Expert in accordance with ICAO Annex 13.
UK Field Investigations Investigations involving the deployment of a ‘Field’ team within
the UK or to one of the UK Overseas Territories or Crown
Dependencies and those investigations where a team has
not deployed but Safety Recommendations are made. Also
includes investigations which have been delegated to the
AAIB by another State.
Unnmanned Aircraft Accidents and serious incident investigations to UAS where
Systems (UAS) they are operated under a CAA permission, or are privately
operated with mass greater than 20 kg.
Investigation
Military with AAIB Where an MoD aircraft accident, serious incident Service
Statistics
Assistance / Observer Inquiry may be convened, an AAIB Inspector is appointed to

assist or observe.
AARF Investigations Investigations conducted by correspondence only using an
Aircraft Accident Report Form (AARF) completed by the
aircraft commander.
Overseas (no AAIB Notifications to the AAIB of an overseas event which has no
involvement) AAIB involvement.
Referrals to Sporting Investigations referred to the relevant UK Sporting
Associations Associations.
No further AAIB action Occurrences notified to the AAIB involving civil registered
(Civil) aircraft which do not satisfy the criteria of an accident or
serious incident in accordance with the Regulations.
Military (no AAIB Notifications to the AAIB concerning Military aircraft with no
involvement) AAIB involvement.
Record-Only An occurrence that if investigated fully has little likelihood of
Investigations identifying new safety lessons that will advance aviation safety.

+44 (0)1252 512299 @aaibgovuk
24
AAIB
Notifications 2019
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
UK Registered
3 1 5 1 8 6 8 6 4 2 0 1 45
Overseas
Foreign Reg Overseas 3 1 5 4 7 4 5 6 1 6 4 5 51
UK Field Investigations 2 3 2 3 3 4 4 4 4 2 2 4 37
Military (AAIB
0 0 0 0 0 0 0 0 0 0 0 0 0
Assistance)
Total no of
Correspondence 11 20 11 14 11 10 14 13 6 6 5 3 124
Investigations (AARF)
Correspondence
Investigations (AARF) 3 3 3 2 0 2 1 0 4 2 2 1 23*
involving UAS
Overseas (no AAIB
2 0 2 1 1 1 0 1 2 2 0 1 13
involvement)
Referred to the
appropriate Aviation 3 1 3 5 6 5 8 7 6 1 2 1 48
Sporting Association
Record Only
1 1 1 7 11 15 22 16 14 7 6 14 115
Investigations
Total no further AAIB
22 23 26 26 23 45 49 33 44 40 36 25 392
action (civil)
0 0 0 0 0 0 0 0 1 2 1 7 11*
action (civil) inv UAS
Military (no AAIB
0 0 1 0 0 0 0 0 0 0 0 0 1
involvement)
Investigation
Total 47 50 56 61 70 90 110 86 81 66 55 54 826
Statistics
UK Fatal accidents 1 1 0 0 1 0 2 1 0 0 1 1 8
Number of deaths 2 1 0 0 1 0 2 2 0 0 1 1 10
* Included in the total
UK Registered Overseas numbers of AARF
No further AAIB action
(Military) 0.12% 5.45% and non-reportable
investigations.
Foreign Reg Overseas
No further AAIB action 6.17%
(Civil) 47.46%
UK Field investigations
4.48%
Military (AAIB assist)

0.00%
Correspondence
investigation (AARF)
15.01%
Overseas (no AAIB)

Record Only 1.57%
investigations 13.92%
Referred to the appropriate
Aviation Sporting Association
5.81%

+44 (0)1252 512299 @aaibgovuk
25
AAIB
Notifications 2018
UK Registered
2 1 1 2 4 4 3 0 2 4 0 0 23
Overseas
Foreign Reg Overseas 5 6 3 1 2 5 4 5 1 3 4 2 41
UK Field Investigations 2 4 0 3 2 3 4 2 0 5 1 0 26
Military (AAIB
0 0 1 0 0 1 1 0 0 0 0 0 3
Assistance)
Total no of
Correspondence 7 14 9 16 28 29 34 24 20 20 12 8 221
Correspondence
Investigations (AARF) 1 1 0 0 1 1 1 0 2 3 0 1 11*
involving UAS
Overseas (no AAIB
1 1 1 0 2 0 1 0 1 0 2 0 9
involvement)
Referred to the
15 22 29 22 28 44 37 50 28 33 23 10 341
action (civil)
0 0 2 0 1 1 3 2 0 1 1 1 12*
action (civil) inv UAS
Military (no AAIB
0 1 0 0 0 0 0 0 1 0 0 0 2
involvement)
Total 33 53 44 47 74 93 90 87 53 68 42 22 706
Investigation
Statistics
Number of deaths 2 0 0 2 1 3 1 0 0 7 0 0 16
UK Registered Overseas Foreign Reg Overseas

Non-reportable (Military) 3%
0% 6%
UK Field Investigation
4%

1%
Non-reportable (Civil)
48%
Correspondence
Investigation (AARF)
31%
* Included in the
Overseas (no AAIB total numbers
Referred to the appropriate involvement) of AARF and
Aviation Sporting Association 1% non-reportable
6% investigations.

+44 (0)1252 512299 @aaibgovuk
26
AAIB
Notifications 2017
UK Registered
5 4 3 4 5 4 6 2 5 4 2 0 44
Overseas
Foreign Reg
3 3 4 9 6 7 8 4 5 2 3 7 61
Overseas
UK Field
2 3 4 2 6 3 2 4 5 1 2 4 38
Investigations
Military (AAIB
0 0 0 0 0 1 0 0 0 0 0 0 1
Assistance)
Correspondence
9 7 15 15 36 29 24 25 17 11 10 6 204
Overseas (no AAIB
2 1 0 1 0 0 1 1 1 1 0 1 9
involvement)
Referred to the
No further AAIB
15 19 24 22 22 29 33 27 32 34 18 23 298
action (civil)
Military (no AAIB
0 1 0 0 0 0 0 0 0 0 0 0 1
involvement)
Total 40 40 51 58 84 82 78 72 69 55 37 43 708
Number of deaths 1 0 5 1 4 2 2 2 4 0 4 3 28
Investigation
Statistics
Non‐reportable (Military) UK Registered Overseas Foreign Reg Overseas
0% 6% 9%
UK Field Investigation
Non‐reportable (Civil) 6%
42%
0%
Correspondence Investigation
(AARF)
29%
Referred to the appropriate Aviation

Sporting Association Overseas (no AAIB involvement)
7% 1%

+44 (0)1252 512299 @aaibgovuk
27
AAIB

+44 (0)1252 512299 @aaibgovuk
28
AAIB
Safety Recommendations in 2019
In 2019 the AAIB issued 12 Safety Recommendations from 5 investigations.
160
150
140 146
139
120 128
114
109 109
100
103
98
95 95
80
82 82
76 76
68 69
60 66
58 58 57 57
55
40 47
42
38 40 39 39 37 39
32 32
28 29
20 26 26
23
17 19 20 17
13 15 12
9 10
0
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Recommendation numbers made in previous years
Each addressee to a Safety Recommendation has to respond within 90 days in

accordance with European Regulation EU 996/2010 Article 18, and detail what actions
have been taken or are under consideration and the time expected to be taken for their
completion. If no actions are being considered by the addressee they have to provide
their reasoning for the decision.
Monitoring of Safety Recommendations
From 1 January 2019 the AAIB took responsibility for monitoring not only the responses
but also the action taken by the addressees to Safety Recommendations. This is in
accordance with the amendment that was made to ICAO Annex 13 in November 2018.
The specific Paragraph 6.12 requires that; ‘A State that receives a safety recommendation
shall implement procedures to monitor the progress of the action taken in response to that
and Safety Action Overview
safety recommendation’.
Safety Recommednation
The AAIB carries out this function on behalf of the State Safety Board (SSB) for the UK,
its Overseas Territories and Crown Dependencies.
It is important to note that the AAIB monitors the progress of actions taken in response to
a Safety Recommendation. The AAIB is not a regulator and cannot require action to be
taken. The AAIB reports the progress to the SSB which then considers whether further
regulatory intervention is required.

+44 (0)1252 512299 @aaibgovuk
29
AAIB
This monitoring of actions is not only for Safety Recommendations issued by the AAIB
but also those that have been issued to addressees in the UK from other State Accident
Investigation Authorities.
When the AAIB receives a response to a recommendation from the addressee it is

assessed as to its adequacy under the requirements of Article 18 of Regulation
(EU) 996/2010. The AAIB applies the following assessment criteria to the Safety
Recommendation responses:
● Adequate means that the response fully meets the intent of the Safety
Recommendation and the action is expected to address the safety issue.
● Partially Adequate means the response goes someway to meeting the

intent of the Safety Recommendation and the action will address the safety
issue to a certain extent, but further action would be required to fully address
the issue identified.
● Not Adequate means that the response does not address the intent of the
Safety Recommendation nor does it address the safety issue concerned.
The AAIB will apply an open or closed status depending on the expectation
of whether the addressee will reassess their response.
○ Not Adequate - Open The status of ‘open’ implies that AAIB still has
concerns regarding the identified safety deficiency and that there is an
expectation that the addressee will provide further responses.
○ Not Adequate - Closed The status ‘closed’ implies that there is a low
likelihood that the addressee will act on the recommendation or provide
any further responses.
● Superseded means the Safety Recommendation has been ‘Superseded’

either by a ‘newer’ and more comprehensive Safety Recommendation
or actions have subsequently been taken by the addressee that have
superseded the recommendation.
Safety Recommendation

+44 (0)1252 512299 @aaibgovuk
30
AAIB
Actions taken on a Safety Recommendation are reported as meeting one of the following:
ACTION STATUS Meaning Status

● Planned actions
All planned actions are completed. Closed
complete
Some of the planned actions have been

● Planned actions
completed and the addressee is not Closed
partially completed
intending on taking any further action.
The planned actions have not been

● Planned actions not
completed and the addressee now has no Closed
completed
intention of taking any further action.
● Planned actions
Actions are still on-going and a new date for
ongoing update due Open
completion has been submitted
(XX/XX/XXXX)
● Not enough The update is not detailed enough to assess.

Open
information A request will be made for a further update.
Refer to Not
● No planned actions There are no planned actions
Adequate
A Safety Recommendation issued after 1 January 2019 will therefore remain Open until
such time as the addressee has completed its activity in relation to that recommendation.
It is therefore possible for the response to a Safety Recommendation to be assessed as
Adequate but it will remain Open until the planned actions are completed.
Of the 12 Safety Recommendations issued in 2019, as of the of 15 June 2020, responses

have been received for 11 Safety Recommendations. The AAIB response assessment has
classified those responses as follows:
● Four are Adequate, with planned actions completed, and are Closed.
● One is Adequate, with planned actions ongoing, and remains Open.

● Two are Partially Adequate with planned actions ongoing, and remain
Open.
● Two are Partially Adequate with not enough information on the planned
actions, and remain Open.
● Two are Not Adequate and are Closed.
● One is awaiting a response from the addressee.

+44 (0)1252 512299 @aaibgovuk
31
AAIB
Summary table
Response
Number Action Status Status
Assessment
2019-001 Partially Adequate Planned actions ongoing update due 28 February 2020 Open
2019-002 Not Adequate No planned actions Closed
2019-003 Adequate Planned actions ongoing update due 1 June 2020 Open
2019-004 Adequate Planned actions complete Closed
2019-005 Partially Adequate Not enough information Open
2019-007 Partially Adequate Not enough information Open
2019-010 Awaiting Response Open
2019-011 Not Adequate No planned actions Closed
2019-012 Partially Adequate Planned actions ongoing update due 31 July 2020 Open
Each Safety Recommendation is also defined as to whether it is a Safety Recommendation of

European Union Wide Relevance (SRUR) or a Safety Recommendation of Global Concern
(SRGC). Of those issued in 2019, nine were SRUR and three were SRGC. The AAIB, as
well as all EU Member States, is required to record on the European Central Repository
Safety Recommendation Information System (SRIS) all recommendations it raises and the
response that are received. Data from SRIS is available to view publicly at:
http://eccairsportal.jrc.ec.europa.eu/index.php?id=114&no_cache=1
Safety Recommendation Topics

0 1 2 3
Aircraft / Equipment / Facilities - Aircraft documentation
Aircraft / Equipment / Facilities – Maintenance manuals
Procedures / Regulations - Aircraft maintenance/inspection

Aircraft / Equipment / Facilities - Aircraft equipment -
Recorded data systems
Procedures / Regulations - Aircraft flight manual
Procedures / Regulations - Aircraft operations
Procedures / Regulations - Oversight/Auditing
Procedures / Regulations - Recorded data systems
Procedures / Regulations – Safety management systems
The chart above shows the recommendation topics using the ENCASIA taxonomy.
Note - a recommendation can include several topics within the classification system.

+44 (0)1252 512299 @aaibgovuk
32
AAIB
Safety Recommendations issued in 2019
Notes: Safety Recommendation classification correct at time of publication.

Safety Recommendations can also be made through AAIB Special Bulletins and
are then also reflected in the final report.
Reflects the situation with Safety Recommendations at 15 June 2020.
British Aerospace BAe ATP, SE-MHF, on 3 May 2018
Synopsis
The aircraft experienced a loss of DC electrical power during the cruise whilst operating a
cargo flight from East Midlands Airport to Stansted Airport, resulting in the loss of a significant
number of flight deck instruments and systems. The crew decided to return to East Midlands
Airport where they made a normal landing, following which DC electrical power was restored
without crew action. The loss of electrical power was consistent with a failure of the No 1
Transformer Rectifier Unit (TRU) or its contactor, followed by a subsequent failure of the DC
essential busbar couple function. Subsequent testing of the aircraft’s electrical system did
not identify the cause of either failure.
The investigation identified that the aircraft’s FDR was recording intermittently due to
corrosion caused by moisture ingress. Two Safety Recommendations are made, relating
to the prevention of moisture entering the FDR on BAe ATP aircraft with the Large Freight
Door (LFD) modification and for the replacement of flight recorders using magnetic tape.
Intermittent fault within the FDR system
The PV1584 FDR fitted to SE-MHF had an intermittent fault that caused nine hours of data
not to be overwritten and the loss of data during several other flights. Inspection of the
FDR found evidence of moisture within the electronics module. This most likely caused
the intermittent operation of the magnetic-tape recording function. The moisture may have
also prevented the correct operation of the BITE as no fault was noticed during the period
of incorrect operation.
Records showed that between 2010 and 2018,

35% of the PV1584 FDRs removed from BAe

ATP aircraft contained evidence of moisture

within the unit’s electronic module. The
majority of these units required replacement of
damaged connectors, with 22 FDRs confirmed
as having failed due to moisture damage.
The majority of FDRs found with moisture

ingress were those that had been fitted to BAe
ATP aircraft with the LFD. Discussions with
engineers, and inspection of SE-MHF, indicate
+44 (0)1252 512299 @aaibgovuk
33
AAIB
that rainwater can enter the cargo bay area during loading, which may then find its way
into the rear equipment bay and the FDR. There was also some evidence that rainwater
had dripped onto the FDR. Over time this will increase the probability of moisture entering
the FDR and cause it to fail as corrosive products develop. Although tested for resistance
to moisture ingress at certification, the PV1584 is not hermetically sealed and therefore
moisture and liquids can easily enter the unit. Unlike later generation solid-state recorders,
the unit was not required to be tested for its waterproofness or the potential effects of
dripping water.
Therefore, to minimise the effects of moisture ingress on the performance of the FDR fitted
to the ATP, the following Safety Recommendation is made:
Safety Recommendation 2019-001 made on 18 April 2019
It is recommended that the European Union Aviation Safety Agency (EASA)

require BAE SYSTEMS to protect the flight data recorder fitted to those ATP
aircraft equipped with large freight doors from the effects of rainwater and other
liquids.
Addressee response
Received 3 July 2019
The European Union Aviation Safety Agency (EASA) has contacted BAE SYSTEMS to
discuss the protection of the flight data recorder fitted to those ATP aircraft equipped with
large freight doors from the effects of rainwater and other liquids.
Response Assessment Partially adequate
Action Status Planned actions ongoing, update due

28 February 2020
Safety Recommendation Status Open
Magnetic tape obsolescence
In response to an ICAO recommendation to discontinue the use of magnetic-tape FDR

and CVR technology, EASA required the replacement of all magnetic-tape CVRs with a
solid-state CVR by 1 January 2019. However, although EASA acknowledged that magnetic
tape is unreliable, obsolete and ‘have an insufficient recording quality’, they did not require
the replacement of magnetic tape FDRs.
In addition to the operator of SE-MHF, which has indicated that it intends operating their
BAe ATP fleet for several more years, there are also a small number of UK-operated aircraft
that are equipped with a magnetic-tape FDR. Discussions with UK based MROs indicate
that long-term support for this obsolete technology is declining. However, it may still be
several years before aircraft operating in Europe with magnetic-tape FDRs are finally retired
from service, or a lack of spares require an operator to install an alternative solid-state FDR.
+44 (0)1252 512299 @aaibgovuk
34
AAIB
It is important that FDR systems are reliable and ensure high quality data is available to
accident investigation authorities. Therefore, the following Safety Recommendation is
made:
Safety Recommendation 2019-002 made on 18 April 2019
It is recommended that the European Union Aviation Safety Agency (EASA) set
an end date to prohibit the use of flight data recorders that use magnetic tape as
a recording medium, to ensure compliance with ICAO Annex 6 from that date.
Addressee response
Received 3 July 2019
Prohibiting the use of flight data recorders (FDRs) that use magnetic tape as a recording
medium was considered under European Union Aviation Safety Agency (EASA) rulemaking
tasks RMT.0400 & RMT.0401 ‘Amendment of requirements for flight recorders and
underwater locating devices’.
The results of the related regulatory impact assessment (RIA) are contained in the associated
notice of proposed amendment NPA 2013- 26, which was published on 20 December 2013.
As described in the RIA, a conservative assumption was that, on 1 January 2013, 20% of
FDRs installed on aeroplanes operated for commercial air transport by EASA Member State
operators were using magnetic tape technology. The proportion of magnetic tape FDRs was
assumed to decrease at a rate corresponding to the renewal rate of the fleets of aeroplanes
of EASA Member State operators. Assuming an economic life cycle of 30 years for an
aeroplane, the proportion of magnetic tape FDRs on board aeroplanes was expected to
decrease by 10% every 3 years. With this assumption, by 1 January 2019 the proportion
of aeroplanes fitted with a magnetic tape FDR was estimated to be close to 0%. Therefore,
requiring the replacement of magnetic tape FDRs for a few residual inservice aeroplanes
was considered not to be justified.
Furthermore, prohibiting the use beyond 01 January 2019, of FDRs that use magnetic
tape as a recording medium would need to be considered through a new rulemaking task
which would be allocated a priority according to EASA’s established rulemaking planning
process. The FDR is not needed for safe flight and landing, it does not directly improve the
survivability of aircraft accidents, and the number of aeroplanes of EASA Member State
operators potentially impacted by phasing out of magnetic tape FDRs is minimal, so that
such a rulemaking task would most probably be allocated a low priority.
Response Assessment Not adequate
Action Status No planned actions
Safety Recommendation Status Closed

+44 (0)1252 512299 @aaibgovuk
35
AAIB
Airbus A320, EI-CVB, on 3 February 2018

Synopsis
A vehicle carrying out a runway inspection was cleared onto the active runway ahead of
an aircraft decelerating after landing. The investigation identified shortcomings in runway
inspection procedures and the management of the internal review conducted after the
incident.
Runway inspections
The importance of effective runway inspection is borne out by the number of foreign objects
found over a relatively short period at Gatwick Airport and the potential safety risk these
pose to aircraft. Whilst this problem is not unique to Gatwick Airport, in its drive to maximise
the use of its single runway, the airport has created an intensity of operations that makes
the task of runway inspection more difficult to achieve.
It is apparent from the investigation that both ATC and the airside operations teams were
striving to carry out runway inspections under the prevailing working environment. There
was, however, evidence of a lack of understanding of how each discipline’s work impacted
on others operating at the airport and had potentially normalised procedures that would
otherwise have been considered undesirable, or at worst unacceptable. The ATC and
airport investigations were triggered by the pilot declaring his intention to file a safety report.
The ATC report, subsequently adopted by the airport operations department, saw nothing
wrong in what happened. This was reinforced by subsequent interviews with ATC staff
and was in direct contrast to the opinion of the airline operator involved and of other airline
operators, when asked.
The ATC report justified the actions of the

controller and operations staff as it considered
the aircraft was committed to vacating at RET
Foxtrot Romeo. This was based on the radio
transmissions during the landing roll and ground
radar recordings showing the aircraft moving off
the centreline towards the exit as the operations
vehicle entered the runway. The report, however,
gave no consideration to the fact the aircraft

appeared to be still on the centreline at the time

the instructions were issued to the operations
vehicle, the speed of the aircraft, the wet state of
the runway and the implications had the aircraft,
for whatever reason, needed to continue on the
runway past RET Foxtrot Romeo. There was
also no apparent understanding of the potential
distraction caused by asking the crew questions
at a time of high workload.

+44 (0)1252 512299 @aaibgovuk
36
AAIB
These conclusions were inconsistent with the comments of the ATC manager who justified
the actions based on the aircraft having been re-cleared, after it touched down, to vacate at
RET Foxtrot Romeo: in effect an instruction during the landing to stop short of a particular
position on the runway. It is not clear that this is in accordance with any recognised ATC
procedure.
In confirming the procedure to be adopted, SI 021 made no reference to re-clearing

aircraft, but specified the need to ensure an aircraft ‘must clearly be established in the
turn off the runway-centreline into the runway exit’ before a vehicle can be cleared onto
the runway ahead of it. This statement leaves the risk, as already outlined, of an aircraft
subsequently turning again to continue along the runway past the exit. In addition, SI 021
contains no information on the direction runway inspections should be performed.
The guidance available to the controllers both in SI 021 and MATS Part 2 lacks relevant
information published in the airport’s runway inspection SOP, such as communication
procedures and actions in the event of a vehicle breakdown on the runway. There was
also a lack of consistency between the existing guidance in MATS Part 2 and SI 021 on
the desirability of conducting the runway inspection in one run.
Safety Recommendation 2019-003 made on 15 August 2019
It is recommended that Air Navigation Solutions Ltd amend the wording

of the Gatwick Airport Manual of Air Traffic Services Part 2, Chapter 10 and
Supplementary Instruction 021 to specify how an aircraft is determined to have
fully committed to vacating the runway, and ensure a vehicle cannot be cleared
onto the runway ahead of an aircraft until the aircraft has done so.
Addressee response
Received 11 November 2019
● The ANSP and the airport company have introduced a new regime for
runway inspections including the introduction of planned (rather than ad-
hoc) delivery of inspections and requirements to only accept inspections
in blocks meaning urgent on/off access (as in the incident being reported
upon) is no longer required and not used.
● The appendix to this letter contains the original text and the new text that
has been submitted to the CAA to address the recommendation. The
process to introduce this as an instruction included a review with the local
examiners and an assessment of the effect that this change may have
on workload and/or complexity. The instruction is now with the CAA for
review and approval. Upon receipt of the CAA approval this instruction will
be published.
● A follow-on review of safety performance regarding runway inspections

in light of this incident and subsequent to the changes to the procedures
+44 (0)1252 512299 @aaibgovuk
37
AAIB
implemented. The review revealed no incidents or reported events and

standards reporting showed the introduction has been delivered safely.
Response Assessment Adequate
Action Status Planned actions ongoing, update due

1 June 2020
Boeing 737 4Q8, G-JMCR, on 12 October 2018
Synopsis
The aircraft was operating a night flight to East Midlands Airport, with the left engine
generator disconnected, and had just commenced its descent when the crew faced an
unusual array of electrical failures on the flight deck. Despite the loss and degradation of a
number of systems, the aircraft landed safely at East Midlands.
The electrical failures were caused by the right engine Generator Control Unit (GCU)
which had been incorrectly secured in its mounting tray and had disconnected in flight. The
investigation also uncovered a number of contributory factors including: the management of
defects and Acceptable Deferred Defects (ADD), recording of maintenance, and a number
of weaknesses in the operator’s Safety Management System with regards to managing risk.
Use of the minimum equipment list
The operator did not appear to use the MEL in the spirit of EASA’s Acceptable Means of
Compliance or its own procedures. Rather than using the MEL to allow the aircraft to return
to its main operating base where the faults could be rectified, it appears to have been used
to enable the aircraft to meet operational commitments. Fault finding, and rectification was
frequently stopped before the root cause had been identified and on a number of occasions
the aircraft was dispatched from a location where the work could have been carried out.
The burnt pins on the feeder cable was

a known fault. On 10 October 2018, an
engineer correctly identified that there
was a FF on Gen 1 and inspected the

connector between the engine and

pylon but ran out of time to check the
connector between the pylon and wing
where the burnt pin was located.
The Rectification Interval Extensions (RIE) for the defect on Gen 1 should only have been
granted in exceptional circumstances. However, while resources were available to identify
and fix the fault within the specified time, the RIE was approved to enable the operator to
meet operational commitments.

+44 (0)1252 512299 @aaibgovuk
38
AAIB
There also seemed to be confusion with operations and engineering staff within the LMC
and the Part M organisation as to what constituted a main operating base. It was commonly
believed that a number of locations across their operating network that had Part 145
organisations could be considered as a main operating base and that it was acceptable for
aircraft to be dispatched from East Midlands with an ADD operating in accordance with the
limitations in the MEL. This was, however, contrary to the operator’s Operation Manual.
The confusion as to what constituted a main operating base and the routine deviation from
the operator’s procedures on the use of the MEL and RIE might have partly been due to the
operator’s policy and procedures not being suitable for its routine operations. Therefore,
the following Safety Recommendation is made:
It is recommended that West Atlantic UK revises its policy and procedures

for approving and clearing Minimum Equipment List entries and Rectification
Interval Extensions to ensure that it conforms with the guidance contained within
the European Union Aviation Safety Agency Acceptable Means of Compliance.
Addressee response
Received 17 December 2019
Signatories for RIE have received additional training in RIE approval, including detailed
analysis of FSR to ensure application is within the regulatory requirements.
MEL Revision 14, May 2019 updated to include: Changes to section 9.3.8 defining
“maintenance bases” and “transit station” within a night program. Changes to section 9.5.3
giving the commander detail on the risk assessment of multiple defect within the context of
the operation they expect. This guidance is meant as the last action before aircraft operation
and supports the risk analysis process adopted by Part M within the LMC. The processes
have been developed in conjunction with each other.
All RIE’s have an accompanying SMS report filed which is investigated by Part M.
A policy/organisational change has been implemented introducing a dedicated team of

engineers tasked with monitoring on daily bases all deferred and repetitive defects (MEL).
The defect control process started in May 2019 and was fully effective as from October 1, 2019.
The defect control team is part of the Line Maintenance Control process and reports to the
NPCA via the LMC Manager.
For this purpose, a Defect Control application was introduced called Chronic’X. In addition,
all aircraft defects are recorded in the FSR with actions taken, risk assessment and recovery
plan in place.
Daily meeting at 08:45, 7 days a week assess all open defects using the data in the FSR
and Chronic’X.
+44 (0)1252 512299 @aaibgovuk
39
AAIB
Defect control team arrange parts, manpower and rectification plan to ensure rectification is
completed expeditiously or before the open defect (MEL) expiry date.
This system gives full control on approving and clearing of MEL entries. Weekly meeting the
NPCA is briefed to ensure MEL oversight.
The process is described in the LMC Company operating Procedure CoP 4.0 chapter 12- A
follow-on review of safety performance regarding runway inspections in light of this incident
and subsequent to the changes to the procedures implemented. The review revealed no
incidents or reported events and standards reporting showed the introduction has been
delivered safely.
Action Status Planned actions complete
Operational management of defects
The operator recognised that the management of defects and rectification across their fleet
was challenging due to the nature of their operations. The aircraft were rarely in the same
place on consecutive days and there were frequently changes to the flying programme, which
made the provision of spares, specialist engineers and equipment difficult. The operator’s
staff were also conscious of the tight turnaround times that their customers expected and
whilst there was no evidence of external pressure having been applied to any individuals,
there may have been an element of self pressure to ensure that aircraft were not delayed.
Fault finding was frequently stopped part way through and on three separate occasions
the GCU were swapped without the aircraft documentation having been completed in
accordance with Commission Regulation (EU) No 1321/2014, (continuing airworthiness).
The following Safety Recommendation is made:
It is recommended that West Atlantic UK ensures that all work undertaken on its
aircraft is documented in accordance with the requirements of Regulation (EU)
No 1321/2014 (regarding continuing airworthiness).

Addressee response
The work undertaken on the aircraft are either covered by an SRP (Sector Record Page)
entry with action taken and action reference of via a dedicated Work Order (WO)
For Deferred Defects and or repetitive defects (MEL’s) dedicated Work Orders are raised
by LMC for defect trouble shooting as required to either give trouble shooting advise and or
have spare parts available.
+44 (0)1252 512299 @aaibgovuk
40
AAIB
The procedure for issuing WO is laid down in CoP 4.0 chapter 12 in order to ensure work is
properly documented and traceable in case of repetition.
The FSR Fleet status listing log and Chronic’X and LMC shift handover application are
put in place to monitoring and control that the correct MEL references and Airworthiness
documentation is applied.
Response Assessment Partially adequate
Action Status Not enough information
Management of defects policy
The management of defects was primarily carried out by staff in the LMC. These individuals
may be required to manage a number of issues on separate aircraft during their shift. Their
main aim is to ensure that the company meets its operational commitments during their
period of duty. The main oversight was undertaken during the 0600 hrs morning conference
which involved representatives from LMC and the Part M organisation using the updates
provided on the operator’s messaging system. Despite numerous entries on FSR highlighting
concerns with the electrical system on G-JMCR, and the difficulty in completing the fault
finding during the tight turnaround times, there was no evidence of a plan to ensure that
the aircraft was given sufficient downtime to rectify the faults and clear the ADD. Instead,
the issue drifted on with an RIE approval and a number of engineers at different locations
repeating similar fault-finding tasks until eventually the GCU was incorrectly secured and
disconnected in flight.
The operator has addressed the situation by establishing the post of Defect Controller who
reports through the Part M organisation. However, this individual is not available outside
normal office hours or during periods of holiday or sickness. Moreover, the morning
conference calls only take place during the normal working week which means that
frequently only the operations supervisor and the LMC staff are in a position to undertake
a dynamic risk assessment of the ongoing airworthiness of individual aircraft. While these
individuals have the authority to prevent an aircraft flying if they believe it is unsafe to do so,
it might not be apparent to them that this dynamic oversight is a key part of their job. The
following Safety Recommendation is made:
It is recommended that West Atlantic UK revises its policy and procedures to

ensure effective management of defects, and the undertaking of dynamic risk
assessments of the airworthiness of aircraft during all hours of operation.

+44 (0)1252 512299 @aaibgovuk
41
AAIB
Addressee response
A new risk assessment application integrated into the FSR requires a risk assessment in the
event an aircraft develops multiple deferred defects.
The monitoring of deferred defect risk assessment is the responsibility of the LMC controller.
LMC controller will take appropriate actions to mitigate identified hazards.
The process is described in CoP 4.0 chapter 13 The process is described in CoP 4.0
chapter 1.
Communicating with other Part 145 organisations
The electrical fault that occurred during the landing at Amsterdam was unusual. Lights
and screens that can only be on or off were flashing which indicated that there was an
intermittent fault within the No 2 electrical system that eventually caused the circuit breaker
for GCU 2 to trip. The Part 145 engineers did not have access to the operators FSR and
would not have known the history of the electrical problems on the aircraft, which LMC
described to the commander as serious. While the commander gave a detailed explanation
to LMC as to the problems he had experienced, this was not relayed to the engineer who
was tasked with rectifying the problem with Gen 2 and resetting the system so that the
aircraft could return to East Midlands. No written tasking document, recent history of the
aircraft or the concerns from LMC that there was a serious electrical problem on the aircraft
were provided to the engineer. The engineer reset the system as requested and reported
back to LMC who did not ask him to undertake any further work. The total time from the
engineer being tasked to travelling to the aircraft and completing the work was 35 minutes.
In completing the trouble shooting as laid out in the Maintenance Manual, the engineer
had satisfactorily completed the task he was given, which was to investigate why the two
serviceable generators were inoperative. But the circuit breaker that was found to have
tripped could not have caused the intermittent electrical supply to the flight deck instruments.
Significantly, no one appeared to address the potential increase in risk to the safe operation
of the aircraft should the fault reoccur in flight while operating with one generator already
inoperative in accordance with MEL 21-1b.
The commander initially felt uneasy at the fault being cleared but was reassured when the
engineer discussed what he had done with LMC: the engineer felt that his conversation with
LMC was more to do with when the aircraft could be returned to service. In turn, the LMC
was reassured by the commander, who was new to the company, and the engineer that the
aircraft was now serviceable. However, the engineer in Amsterdam did not have knowledge
+44 (0)1252 512299 @aaibgovuk
42
AAIB
of the ongoing electrical problems on the aircraft and none of the three parties discussed
the impact of the fault on Gen Bus 2 reoccurring during the next flight. In summary, none
of the three individuals involved had the full picture on the condition of the aircraft and a
risk assessment was not carried out to determine if the aircraft was in a safe condition to
continue flying with one generator inoperative. The following Safety Recommendation is
made:
It is recommended that West Atlantic UK revises its policy and procedures for the
tasking of maintenance activities by Line Maintenance Control and the sharing
of relevant aircraft technical history to ensure that maintenance organisations
undertaking work have access to all appropriate information.
Addressee response
The technical log records all maintenance defects actioned against each airframe and is
transferred into RAL, our approved maintenance management system.
The WAcloud application “FSR” collects additional maintenance information on deferred

maintenance activities.
The Chronic’X system access data in both RAL and the FSR to provide a comprehensive
source of information and feedback on defect control to support line maintenance with
trouble shooting.
The station engineers have access to the FSR for consultation if so required.
Response Assessment Partially Adequate
Action Status Not enough information
Safety management system

This investigation identified safety issues across a number of areas that had not been identified
or addressed by the Operator’s SMS. Therefore, the following Safety Recommendations
are made:
It is recommended that West Atlantic UK revises its Safety Management System

to meet the requirements of the scale and nature of their operation.

+44 (0)1252 512299 @aaibgovuk
43
AAIB
Addressee response
1. To support the Head of Risk, Safety and Compliance a full-time Part M

Quality Engineer has been employed as of 1st November 2019. This will
provide a dedicated resource with direct responsibilities for ensuring the
policy of the Management System is effectively managed.
2. The Safety Management System has been modified to include additional

quality assurance and verification processes to monitor corrective and
preventative actions introduced to mitigate risks within the operation.
3. Four additional part-time auditors have been employed in support of the

Compliance Monitoring programme.
4. Additional training courses have been implemented and delivered;
a) Advanced Safety and Compliance Course for Managers.
b) Internal Auditors Course.
c) Investigators Course.
It is recommended that the Civil Aviation Authority assess West Atlantic UK’s
Safety Management System to ensure it meets the requirements of the scale
and nature of their operation.
Addressee response
Received 25 October 2019

The Civil Aviation Authority accepts this recommendation. The CAA has conducted an initial
assessment of West Atlantic UK’s Safety Management System and continues to monitor
compliance and effectiveness of this element of the organisation’s approval.
Further assessments, including effectiveness, are scheduled to be completed by no later

than February 2020.

+44 (0)1252 512299 @aaibgovuk
44
AAIB
DHC-8-402 Dash 8-Q400, G-JECR, 15 November 2018
Synopsis
Whilst climbing to FL190 en-route to Charles De Gaulle Airport, Paris the pilots received
an alt mismatch message and they elected to return to Exeter Airport. Following an
inspection after landing, a small white crystalline deposit was found covering three of
the four static pressure holes on the left primary pitot static probe. It is probable that
the use of a non-approved product, to improve the seal between a test adaptor and the
pitot static probe during maintenance immediately prior to this flight, may have resulted
in the blockage of the static holes and led to the alt mismatch message. Two Safety
Recommendations have been made; one to the air data accessory kit manufacturer and
one to the aircraft manufacturer to improve the instructions for the use of testing kits when
carrying out leak tests of the pitot/static system and to only use approved lubricants. The
maintenance organisation has taken Safety Action to introduce tighter controls on the test
kit equipment.
Instructions for use of air data accessory kits
The kit manufacturer stated that the

instructions for use of the air data
accessory kit should be described in
the relevant section of the AMM. The
work orders issued by the maintenance
organisation state that to accomplish a
task it is to be done in accordance with
the specific AMM task. However, the
AMM does not provide any details on how
to install the adaptors, which products
should be used, or any additional
information to aid the technicians to
achieve a good seal between the probe
and the adaptor.
Therefore, to improve the information with the air data accessory kits, which are used on
several different aircraft types, the following Safety Recommendation is made:
Safety Recommendation 2019-010 made on 24 October 2019
It is recommended that Nav-Aids Ltd amend the manual supplied with air data
accessory kits to include more specific installation instructions, and to include
warnings against using non-approved materials to aid sealing.

+44 (0)1252 512299 @aaibgovuk
45
AAIB
Addressee response
Awaited
Response Assessment Awaited
Action Status Awaited
AMM instructions
To improve the information in the AMM for the De Havilland Aircraft of Canada Ltd
DHC-8-402 the following Safety Recommendation is made:
It is recommended that De Havilland Aircraft of Canada Ltd amend the

instructions in the Aircraft Maintenance Manual for the DHC-8-402 for testing
pitot static probes to include more specific installation instructions, and to
include warnings against using non-approved materials to aid sealing.
Addressee response
Received 22 April 2020
De Havilland Aircraft of Canada Ltd appreciates the chance to respond to your proposed
Safety Recommendation.
While safety is of upmost concern in our industry, it is our belief that, in this particular
situation, any qualified technical staff should review and utilize the manual for any of the
required pieces of test equipment that are external to the basic airframe. The information
necessary to utilize the test equipment is specific to the each type of test equipment and
different again, depending on each supplier of the various types of test equipment.
Furthermore, these types of instructions are already available, as well as being authored by
those who manufacture the equipment.
One of the manufacturers has an on-line video available to aid use of a preferred lubricant
for installation of the adapter (http://navaidsltd.net/LF5050-Lubricating-Fluid.html)
Response Assessment Not adequate
Action Status No planned actions

+44 (0)1252 512299 @aaibgovuk
46
AAIB
Boeing 737-8AS, EI-GJT, 9 October 2018

Synopsis
Shortly after reaching cruise at FL360 the commander’s attitude indicator malfunctioned
affecting numerous aircraft systems, and the aircraft climbed 600 ft. After a significant time
delay an irs caution was displayed. The Quick Reference Handbook (QRH) was followed
by the crew and the left Air Data Inertial Reference Unit (ADIRU) was put into ATT mode.
The left Primary Flight Display (PFD) continued to display erroneous attitude information
to the pilot, and other systems were also affected. The aircraft was flown manually to
Edinburgh where it landed safely.
The left Inertial Reference System (IRS) suffered a transient fault in one of its accelerometers
which led to an erroneous calculation of position. False position information led to the
incorrect attitude information on the commander’s PFD, and the autopilot (AP) responded
by initiating a slow climb.
QRH guidance
There was a significant period between the first symptoms of faulty attitude information and
the appearance of the irs fault indication. Shortly after the attitude information failed, pitch
and roll comparator annunciations appeared on both PFDs. While these flags indicate a
failure, they do not decisively indicate where it lies. Pilots must use standby instruments
to determine where the failure is and, if necessary, recover to the correct attitude through
manual flight. Selecting a different source for the faulty PFD would remove the flags and
restore valid attitude information on both pilots’ PFDs, although it would lead to a reduction in
redundancy because all PFD attitude information would be from a single source. Information
is available in the FCOM to aid crew understanding, but because of the expressed philosophy
in the QRH discouraging troubleshooting, and the training discouraging the use of QRH
checklists except in response to relevant associated warnings, it is unlikely crews will act
unless specifically directed to do so by the QRH checklist.
In these events, the failure occurred in VMC and

straight and level flight and the outcome was
benign. However, the PFD is a primary instrument
which dominates a pilot’s display panel, and
a failed attitude display presents a powerful

disorientating stimulus to the relevant pilot. The

comparator annunciation appears simultaneously
in both PFDs and, if no action is taken, can remain
as a significant distraction for the remainder of the
flight. In manoeuvring flight it could be unclear where the failure lay, and the presence of
the failed display would continue to constitute a disorientating factor.
Boeing decided to amend the QRH checklist for irs fault but this would not address the
situation where there was faulty attitude information but no IRS caution message.

+44 (0)1252 512299 @aaibgovuk
47
AAIB
Therefore, the following Safety Recommendation is made:
It is recommended that Boeing Commercial Aircraft amend the Boeing 737

Quick Reference Handbook to include a non-normal checklist for situations
when pitch and roll comparator annunciations appear on the attitude display.
Addressee response
Received 24 April 2020
Boeing has reviewed the Quick Reference Handbook (QRH) procedures for the 737
and compared the handbook to other Boeing models. The current PITCH and ROLL
comparator annunciations are classified as flags in our certification documentation. Adding
corresponding non-normal procedures to the QRH would require reclassifying the flags as
alerts for certification purposes. Boeing is currently reviewing our certification documentation
to understand all the potential effects of making the proposed changes.
We will update the AAIB on the QRH change status by July 31, 2020. Boeing will also
provide the AAIB with a copy of any changes upon their release.
Response Partially adequate
Action Status Planned actions ongoing, update due by

31 July 2020


+44 (0)1252 512299 @aaibgovuk
48
AAIB
Safety Actions from investigations reported on in 2019
Early in an investigation the AAIB will engage with authorities and organisations which are
directly involved and have the ability to act upon any identified safety issues. The intention is
to prevent recurrence, and to encourage proactive action whilst the investigation is ongoing,
and not for those involved to wait for the issue of official Safety Recommendations.
When safety action is taken, it may mean there is no need to raise a Safety Recommendation
as the safety issue is likely to have been addressed. The published report details the safety
issues and the safety action that has taken place.
In 2019 there were 153 Safety Actions recorded directly as a result of 18 field and 36
correspondence investigations. There were 88 commercial air transport (CAT), 48 general
aviation (GA) and 17 unmanned air systems (UAS) Safety Actions undertaken in 2019.
FIELD INVESTIGATIONS
Auster AOP.9, G-BXON on 18 June 2017
The pilot was undertaking his second flight on the recently-restored vintage ex-military
aircraft. Shortly after taking off from Spanhoe Airfield, the aircraft was observed to bank left
into a steep descent and strike the ground to the left of the runway. The pilot was fatally
injured, and the passenger sustained serious injuries. The investigation determined that the
aircraft stalled at a low height, from which it did not recover before striking the ground. The
investigation also identified several issues relating to the aircraft and engine performance,
maintenance documentation, the Permit to Fly application process, and guidance for pilots
preparing for their first flight on a new type. The Light Aircraft Association (LAA) has taken
a number of safety actions.
Safety actions:
The Light Aircraft Association (LAA) has:
● Created a database of initial flight test performance results and introduced a

process to compare future aircraft against other examples of the same type prior
to permit issue. In the case of factory-built aircraft, scheduled performance figures,
when available, will also form part of this consideration.
● Clarified the wording of the stall requirement in the Flight Test Schedule which
relates to the speed at which stall warning will occur. The new wording emphasises
that this requirement relates only to aircraft with artificial stall warning devices and
reflects that some LAA aircraft may not be so equipped.
● Introduced a procedure whereby, when it issues a newly-constructed or

newly-rebuilt aircraft with a Permit to Fly, it will write to the owner with any safety
related observations on the submitted flight test results. The observations
will include highlighting the absence of any stall warning features, particularly
+44 (0)1252 512299 @aaibgovuk
49
AAIB
when the reported characteristics deviate markedly from that expected or from
published data for the type.
● Produced guidance for pilots preparing for their first flight on a new type: it has
published two magazine articles on the topic and has also produced a Technical
Leaflet, TL 2.30 ‘Converting to a new type’, for use as a preparation tool, similar
to the one provided for testing pilots. Subjects addressed include: researching a
new aircraft type (eg by reviewing its operating manual, operating limitations and
handling peculiarities); the planning and content of a first flight on type to become
familiar with the aircraft alongside a suitably experienced pilot; the importance
of beneficial weather conditions (eg consideration of density altitude); choice
of appropriate flying clothing; and consideration of the desirability of carrying
passengers both in terms of aircraft weight, and pilot recency and experience on
type.
● In October 2018, revised TL 2.21 ‘Rebuilding an aircraft under the LAA system’ to
include additional guidance on the completion of worksheets, the expected level of
detail to be recorded, and reiterated the respective responsibilities of owners and
inspectors for the quality and conformity of rebuild projects. Additional guidance
relating to the integrity of riveted joints in rebuilt aircraft was also included, as
was updated information to bring the LAA’s published guidance on minimum flight
testing hours into line with actual practice, and to describe the factors that LAA
Engineering considers when determining the initial flight test requirements for a
given aircraft.
● In January 2019, issued Airworthiness

Information Leaflet MOD/920/001‘AOP.9
Inspection of rivets securing the aileron
operating rod end fittings’ which
requires an inspection of the aileron
control rod rivets on all AOP.9s within its
fleet to identify the type and condition
of rivets installed, and appropriate
rectification according to the findings of
the inspection.
Piper PA-31, N250AC on 6 September 2017
Approximately 20 minutes after takeoff from a private airstrip in Cheshire the pilot
reported pitch control problems and stated his intention to divert to Caernarfon Airport.
Approximately 5 minutes later, the aircraft struck Runway 25 at Caernarfon Airport, with
landing gear and flaps retracted, at high speed, and with no noticeable flare manoeuvre.
The aircraft was destroyed. The elevator trim was found in a significantly nose-down
position, and whilst the reason for this could not be determined, it is likely it would have
caused the pilot considerable difficulty in maintaining control of the aircraft.

+44 (0)1252 512299 @aaibgovuk
50
AAIB
The extensive fire damage to the wreckage and the limited recorded information made it
difficult to determine the cause of this accident with a high level of confidence. A possible
scenario is a trim runaway, and both the CAA and the EASA are taking safety action to
promote awareness for trim runaways as a result of this accident.
Safety actions:
As a result of this investigation the EASA have

undertaken action to promote awareness of trim
runaways as part of its General Aviation safety
promotion plan. It also intends to include trim runaway
as part of a wider technical safety project, studying
various technical failure scenarios. Also, as a result
of this investigation the CAA plans to produce a
coordinated package of educational information on trim
runaway, including a video, Clued Up article and online
information which will be targeted at GA pilots.
Both authorities have indicated that they intend to work together on the subject for a
coordinated approach and to ensure a broad reach.
DHC-8-402 Dash 8 Q400, G-JEDU on 10 November 2017
The aircraft was carrying out the third sector of a four-sector day from Belfast City Airport
to Inverness Airport. After takeoff, the landing gear was selected up. Cockpit indications
indicated that the main landing gear (MLG) retracted normally but the nose landing
gear (NLG) did not. The crew carried out the actions in the relevant abnormal checklists
and were unable to lower the NLG. After burning off fuel, the aircraft was diverted to
Belfast International Airport where it landed with the NLG retracted. The crew initiated an
emergency evacuation.
It was determined that a damaged electrical

harness on one of the nose landing gear
proximity sensors caused an erroneous
signal, which resulted in the forward NLG
doors starting to close while the NLG was
still in transit to the up position. The nose

landing gear tyres contacted the forward

doors, causing the NLG to rotate off-centre.
Although the NLG subsequently retracted,
the forward doors remained open and the
tyres became jammed in the NLG bay.
This prevented the nose landing gear from
extending when subsequently commanded.

+44 (0)1252 512299 @aaibgovuk
51
AAIB
The damage to the harness resulted from a cyclically-driven fatigue failure mechanism,
which occurred because the harness had been secured with a non-flexible cable tie which
restricted it from flexing during normal nose landing gear operation.
Safety actions:
The aircraft manufacturer has:
● In October 2018, issued a Service Letter to inform operators of the Dash 8 Q400,
of the correct routing of the nose landing gear lock (NGLK) sensor harnesses.
● In November 2018, issued Service Bulletin 84-32-157 to inspect the NGLK sensors
for correct routing and signs of wear, abrasion or fretting.
● In January 2019, updated three AMM tasks in order to clarify the harness routing,
provide instructions for the location of the rubber lacing, to add cautions indicating
that harnesses should not be retained or restricted at locations other than the
specified p-clips and to correct a routing installation illustration.
The operator has:
● Throughout August and September 2018, the operator carried out an inspection of
the nose landing gear proximity sensor harness routing on its Dash 8 Q400 fleet
and undertook rectification of any anomalies noted.
EMB-145EP, G-CKAG on 22 December 2017
The flight crew were conducting an ILS

Category II1 approach and landing on
Runway 27 at Bristol Airport. On touchdown
they noticed that the aircraft de-rotated
sharply. The pilot flying (PF) was unable
to maintain directional control during the
landing roll and the aircraft ran off the
left side of the runway onto the grass. At
some point during the landing the throttles
were moved forward, reducing the rate of
deceleration. As the aircraft left the paved
surface the crew realised that the landing had been carried out with the Emergency/Parking
brake set. The aircraft may have remained on the runway surface but for the addition of
forward thrust during the landing roll.
Safety action:
The operator introduced a revision to the Landing Checklist in the Operations Manual
which requires the handling pilot to confirm the parking brake is off.
1
Decision height lower than 200 ft but not lower than 100 ft and RVR of not less than 350 m.

+44 (0)1252 512299 @aaibgovuk
52
AAIB
Agusta Westland AW189, G-MCGR on 17 February 2018
The helicopter was tasked to rescue three

climbers in the area of the Beinn Narnain
mountain. The flight was at night and
the crew made several attempts to reach
them from different directions but due to
low cloud were unable to do so. On the
fourth attempt, from another direction,
the visual references seen through each
pilot’s Night Vision Imaging System (NVIS) were lost and a turn back down the re-entrant
was attempted. Due to the proximity of the ground, the pilot climbed the helicopter but lost
airspeed after which the helicopter yawed to the right. The Pilot Flying (PF) attempted to
use the Automatic Flight Control System (AFCS) upper modes to assist him but decoupled
them because they caused the collective control lever to lower. The helicopter spot-turned
through some 370° before regaining VMC on top. Control was regained and the aircraft
subsequently landed. The crew liaised with the Mountain Rescue Team (MRT) who
recovered the climbers on foot.
Safety action:
Shortly after the incident, the operator introduced a scenario-based training exercise
for all pilots that reproduced the incident during six-monthly recurrent training and
testing. The training was continued with an emphasis on unusual attitude recovery.
EC135 P2+, G-POLA on 5 April 2018
During a maintenance flight to adjust engine speed, main rotor rpm varied between
its maximum and minimum continuous limits. A mechanical stop within the adjusting
potentiometer had failed in such a way that main rotor speed could not be controlled
accurately, putting the helicopter at a significant risk. The pilot had not been specially
trained to carry out the flight test but his actions in flight prevented rotor speed exceeding
its limits and a more serious outcome. The manufacturer and operator have taken safety
action regarding the conduct of airborne engine speed adjustments. and Safety Action Overview
Safety actions:
The manufacturer has:
● Issued an AMM amendment regarding

the N2 adjuster installation procedure
(76-11-00,8-4), a caution to install the
stop ring correctly / take care that the ring
is not forgotten.

+44 (0)1252 512299 @aaibgovuk
53
AAIB
● Issued an AMM amendment regarding N2 adjustment maintenance flights

(05-60-00, 6-4), to check, prior to flight while on ground without power, that the
N2 adjustment switch works properly (only three switch positions are possible -
decrease, neutral, increase). After successful check the switch must be turned
into the neutral position.
● Issued Safety Information Notice AH 3254-S-76: ‘Engine Controls – Engine

Power Turbine Speed (N2)’ to draw attention to this occurrence, remind operators
of the procedure, and to highlight the difference in N2 adjustment procedures
between the P2 and T2 Series EC135 helicopters.
● Has undertaken to inform operators of all its helicopter types of the circumstances
of the occurrence to G-POLA, reminding them of the importance of the specific
pilot skills required by all AMM post maintenance flying tasks.
The operator:
● Has categorised its flight test activities according to which of its pilots should
perform them. It has restricted the N2 adjustment flight procedure to the remit of
specially trained type rating instructor and examiner pilots.
● Intends to incorporate the incident scenario in to its newly established simulator

training package.
Cessna 152, G-UFCO on 19 April 2018
The purpose of the flight was to carry out aerial photography. During a manoeuvre at
low level the aircraft stalled and descended rapidly, passing through some trees, before
striking the ground. There was a post-crash fire and neither occupant survived.
Safety action:
Since the accident the flying club has issued instructions to their pilot members to
remind them of their responsibility to understand and comply with the privileges of their
licences and ratings. The club flying instructors have been reminded not to authorise
any rental flight where there may be any doubt as to its purpose. The club is also re-
drafting the flying order book and aircraft hire/rental agreements to make it clearer as
to what can and cannot be undertaken in a hired aircraft. Additionally, the club intends
to provide warning signage/posters to remind pilots and passengers of the restrictions

and implications of travelling for any kind of payment in light aircraft.

+44 (0)1252 512299 @aaibgovuk
54
AAIB
Cessna 172M Skyhawk II, N9085H on 30 April 2018
Shortly after takeoff the aircraft exhibited a tendency

to pitch nose down despite the application of nose
up trim. During the subsequent approach to land,
the forces required to maintain the approach path
increased to the point where the pilot could no
longer control the glidepath and the aircraft struck
the ground short of the runway. The investigation
found that the drive chain for the elevator trim
actuator had been fitted incorrectly, which resulted
in the elevator trim tab moving in the opposite
sense to the movement of the trim wheel.
The maintenance organisation has introduced procedures to ensure that duplicate

inspections of all flight critical systems are carried out following maintenance.
Safety action:
The Bermuda-based maintenance organisation has introduced procedures to ensure

that duplicate inspections of all flight critical systems are carried out, in line with its
BCAA-approved maintenance procedures, on any aircraft that they operate or maintain,
regardless of its State of Registration.
Guimbal Cabri G2, G-PERH on 8 June 2018
While conducting a Simulated Engine Failure from the Hover (SEFH) the helicopter yawed
rapidly to the left. Despite the actions of the pilots the helicopter continued to yaw rapidly,
and control was not recovered. The helicopter was seen to climb while spinning before
descending rapidly and contacting the ground, sustaining severe damage. Both occupants
suffered serious injuries.
Safety actions:
As a result of this, and other similar events, the manufacturer published in February 2019
two Service Letters to prevent reoccurrence. They are available on its customer support
portal.
● SL19-001 - Throttle management during simulated engine failure.
This service letter provides an explanation of the engine governor / correlator

system and the need to ensure the twist grip throttle is fully closed whilst practicing
certain manoeuvres. It proves advice to flight instructors on how to position the
hand on the throttle grip to enable the throttle to be closed in one movement and
therefore ensuring the engine throttle does not open when the collective is raised.

+44 (0)1252 512299 @aaibgovuk
55
AAIB
● SL19-002 - Controllability in yaw at low rotor speed.
This service letter proves advice on yaw control when operating with low rotor
speeds. It includes a list of scenarios where yaw control could be lost and
mitigating actions to prevent loss of control. One scenario is Simulated Engine
Failure from the Hover. When operating at low rotor speeds with full or almost full
right pedal applied it is recommended not to raise the collective but keep it as low
as possible and increase forward airspeed by cyclic input, and not to increase the
rotor speed by turning the twist grip.
Grob G109B, G-KHEH on 10 June 2018
The aircraft collided with a dead tree whilst 0957:02 – Descent
conducting a field landing exercise. It has

from 1,078 ft amsl
not been possible to determine conclusively

Accident site
whether the aircraft was suffering from an
engine problem, most likely carburettor icing, 0958:24 – aircraft on
approach heading,
during the descent, however, the engine 674 ft amsl
was under power at the point it collided with

the tree. Had it been necessary, the aircraft
should have been able to avoid the tree and
carry out a landing in the field beyond. It
was considered most likely that the pilots
did not see the tree until it was too late to
avoid it.
Safety action:
The BGA publication on 11 July 2018 in response to this and previous field landing
accidents sets out the main hazards and precautions required in conducting field landing
training.
AS350B2 Ecureuil, G-PLMH on 13 June 2018
Whilst the helicopter was performing an underslung load operation at Loch Scadavay the
boat it was carrying became unstable and flew upwards, causing the lifting line to strike the
helicopter’s tail rotor. The helicopter became uncontrollable and descended rapidly into the
loch, fatally injuring the pilot.
The physical characteristics of the boat and the method by which it was carried increased
the probability of it becoming unstable.
Safety actions:
As a result of this accident, the operator has taken a number of safety actions intended
to prevent similar accidents in the future.

+44 (0)1252 512299 @aaibgovuk
56
AAIB
These are as follows:
● Temporarily curtailed Helicopter Exernal

Sling Load Operation (HESLO) involving
the carriage of boats, caravans and
aeroplanes.
● Released a Safety Information notice

reminding pilots and Task Specialist
Air (TSA) that helmets must be worn
onboard, which must fit and be properly
secured at all times.
● Increased the length of the standard

lifting line for Identification of Unstable or
Potentially Unstable Loads (UoPULs) to
20 m, with an associated airspeed limit of 60 KIAS. Where shorter lifting lines are
required, the airspeed limit is 40 KIAS and, for some operations, 30 KIAS.
● Added a section on UoUPL to its HESLO 1 pilot training syllabus. This contains
sections on low-density loads and aerodynamic shape, and refers to load
orientation. It states that ‘any change in the status of a load in flight calls for an
immediate reduction of speed below 40 KIAS’.
● Significantly expanded its Specialist Operation (SPO) Manual and Ground

Handler’s Manual guidance on the preparation and acceptance of loads to
emphasise UoPULs. This includes information on low-density loads and
aerodynamic shape, and methods of rigging loads to increase their stability, eg
cargo nets, and amalgamation.
● Provided guidance in its Ground Handler’s Manual which explains that pilots and
Task Specialist Ground (TSG) should examine UoPULs together. Adequate time
must be allowed to assess and rig UoPULs, and to put adequate control measures
in place. Customer expectations should be managed accordingly.
● Added a section on flying techniques for UoPUL to its SPO Manual, which includes:
accelerate in 10 KIAS increments; continually observing the load in the mirror; if
the line goes slack, jettison the load; and states that ‘the company will support any
pilot who declines to carry [a UoPUL] on the grounds that he is not able to put in
place adequate control measures’.
● Undertaken to continue with its plan to extend its Crew Resource management
(CRM) training throughout the organisation and bring more of that training ‘in-
house’.
● Undertaken to produce written guidance on decision making. Furthermore, to

select and endorse a decision making aid company-wide and incorporate it in to
CRM training.

+44 (0)1252 512299 @aaibgovuk
57
AAIB
Rutan Long-Ez (Modified), G-BPWP on 7 July 2018
The pilot was operating his aircraft with a mixture of

automotive gasoline (Mogas) and aviation gasoline
(Avgas) 100LL in the left fuel tank and Avgas 100LL
in the right fuel tank. While on base leg to land on
Runway 04 at Dunkeswell Airfield the engine, which
was being supplied with fuel from the left fuel tank,
suddenly stopped. The pilot established a glide to land
in a field in the undershoot, but at a late stage in the
approach he spotted a fence running across his chosen
landing site. Whilst manoeuvring to avoid the fence the
aircraft touched down firmly, seriously injuring the pilot;
the passenger sustained minor injuries.
The likely cause of the engine stopping was either carburettor icing or a vapour lock in the
aircraft fuel supply to the engine.
Safety action:
The LAA have advised that they will use this accident to publicise the risk from vapour
lock when operating piston engines on Mogas.
Cessna 150M, N66778 on 18 July 2018
N66778 was taking off from Beef Island, in the British Virgin Islands (BVI), on the sixth
sector of a delivery trip from Florida to Argentina. After takeoff the aircraft was seen to fly
along the length of the runway at slow speed in a nose-high attitude. It then turned left
before entering a steep nose dive and hitting the sea.
The investigation concluded that the aircraft stalled during the left turn. No evidence of any
mechanical failure was found.
The aircraft was likely to have been operating slightly above the Maximum Takeoff Weight
and with the centre of gravity aft of the approved limit. Several items were not secured in
the cabin which could have shifted aft during the takeoff roll moving the centre of gravity
further aft. It is possible that this aft centre of gravity caused control difficulties resulting in
the stall. Improvements in emergency communications on BVI have been made following
the accident.
Safety action:
As a result of this accident the BVI Airports Authority (BVIAA) has taken action to
ensure that Virgin Island Search and Rescue (VISAR) can now be contacted directly
by ATC if they cannot be alerted via the 911 operator.

+44 (0)1252 512299 @aaibgovuk
58
AAIB
Boeing 737-800, EI-FJW and Airbus A320-214, OE-IVC on 13 August 2018
A landing Boeing 737 closed to within 875 m

of a departing Airbus A320 when landing
at Edinburgh Airport. The airport air traffic
control service provider defined this as a EI-FJW OE-IVC
runway incursion as the 737 was over the

runway surface when the A320 was still on its
takeoff roll.
A combination of factors, including brief

delays to the departure of the A320 and the
speed of the Boeing 737 being higher than normal, led to the reduction in separation
before the controllers became aware of the closeness of the aircraft. The trainee controller
lacked the experience to resolve the situation in a timely manner and the supervising
OnTheJob Training Instructor judged it safer to let the 737 land than to initiate a goaround
in proximity to the departing aircraft.
The Air Navigation Service Provider (ANSP) has conducted a review of High Intensity
Runway Operations at Edinburgh and taken a number of safety actions to improve
procedures and on-the-job training for trainees.
Safety actions:
The ANSP at Edinburgh has taken the following safety actions in response to this
incident:
● Published procedures in the Edinburgh MATS Part 2 regarding what events must
be entered as Manditory Occurrence Reporting (MOR) on the TOKAI2 system.
● Conducted a review of High Intensity Runway Operations at Edinburgh.
● Conducted a review of On the Job Training Instructor (OJTI) competency and

introduced refresher training for all OJTIs as an outcome of the review.
● Has introduced additional higher OJTI chairs to provide OJTIs with a better view
of the trainee, the screens and the trainee interactions with the equipment.
● Has reminded OJTIs of the requirement in the Unit Training Plan which mandates
the requirements for a pre-training briefing between the OJTI and the trainee
controller prior to every training session or at least every training day.
● Has incorporated a one-sheet overview of trainee ATCO’s experience in their

training file covering what key conditions and procedures they have experienced
(eg fog, wind, go-arounds, significant slot delays, weather avoiding, snow etc).
2
TOKAI - web-based application for air traffic management that enables users to report, investigate and take
corrective action following incidents and accidents.

+44 (0)1252 512299 @aaibgovuk
59
AAIB
Czech Sport Aircraft Sportcruiser, G-CGEO on 7 October 2018
The aircraft’s right main landing gear

(MLG) leg was damaged following a
normal landing at Fowlmere Aerodrome.
Investigation of the failed MLG leg revealed
a manufacturing defect that caused the
progressive delamination of the leg during
service.
Safety action:
The aircraft manufacturer is currently certifying a reinforced MLG leg, part

number SG0160L/P, intended to increase the durability of the legs in service. This new
MLG will be available for retrofit to all models of Sportcruiser and PS-28 Cruiser aircraft.
In addition to slightly enlarging the MLG leg cross-section, the inflatable tubes and stretch
film material used during leg manufacture are now surrounded by a woven glass fibre
‘sock’, to prevent radial migration of the stretch film into the leg’s composite structure.
Boeing 737-8AS, EI-GJT on 9 October 2018
Shortly after reaching cruise at FL360 the commander’s attitude indicator malfunctioned
affecting numerous aircraft systems, and the aircraft climbed 600 ft. After a significant time
delay an irs caution was displayed. The Quick Reference Handbook (QRH) was followed
by the crew and the left Air Data Inertial Reference Unit (ADIRU) was put into ATT mode.
The left Primary Flight Display (PFD) continued to display erroneous attitude information
to the pilot, and other systems were also affected. The aircraft was flown manually to
Edinburgh where it landed safely.
The left Inertial Reference System (IRS) suffered a transient fault in one of its accelerometers
which led to an erroneous calculation of position. False position information led to the
incorrect attitude information on the commander’s PFD, and the autopilot (AP) responded
by initiating a slow climb.
One Safety Recommendation is made concerning the Boeing 737 QRH.

Safety action:
Following this incident, Boeing decided to amend the QRH checklist for irs fault. The
reference to ATT mode would be removed and the checklist would direct crews to use
the IRS Transfer Switch to supply relevant aircraft systems from the serviceable side.

+44 (0)1252 512299 @aaibgovuk
60
AAIB
Boeing 737-4Q8, G-JMCR on 12 October 2018
The aircraft was operating a night flight to East Midlands Airport, with the left engine
generator disconnected, and had just commenced its descent when the crew faced an
unusual array of electrical failures on the flight deck. Despite the loss and degradation of a
number of systems, the aircraft landed safely at East Midlands.
The electrical failures were caused by the right engine Generator

Control Unit (GCU) which had been incorrectly secured in its
mounting tray and had disconnected in flight. The investigation
also uncovered a number of contributory factors including: the
management of defects and Acceptable Deferred Defects (ADD),
recording of maintenance, and a number of weaknesses in the
operator’s Safety Management System (SMS) with regards to
managing risk.
Safety actions:
As a result of this serious incident, and the findings of the AAIB, the operator has stated
that they will take the following safety actions:
● Redefine the criteria of a maintenance base with each aircraft allocated to a specific
maintenance base dependent on the route flown.
● All ADDs will be monitored daily and best endeavours made to rectify them within
48 hours. Where this time limit is not achieved an occurrence report will be
raised to enable an investigation to be carried out to establish why this was not
possible.
● A Safety Report will be raised via the SMS for all RIE applications.
● Monitor in real-time the management of ADD and RIE applications using a number
of Performance Indicators over a 12-month rolling period.
● Line Maintenance Control (LMC) will be informed of all intended deferred defects
before actual deferral.
● Prior to deferral of a defect, a risk assessment based on the source of the fault
and subsequent impact on the aircraft systems and operational limitations will
be carried out by an engineer in consultation with the crew. LMC will provide
historical defect information relevant to the unserviceable system in question and
knowledge of the aircraft’s historical airworthiness generally.
● An additional status header of ‘Risk Assessment’ has been added to the Flight
Safety Reporting (FSR). A summary of the risk assessment will be documented in
the FSR against the deferred defect highlighting significant risks that are associated
with the aircraft’s airworthiness status.
● A review of persons authorised to ground a serviceable aircraft without reason and

with good reason following a risk assessment has been carried out.
+44 (0)1252 512299 @aaibgovuk
61
AAIB
● Procedural deficiencies were identified in the following processes. A compliance

review of these areas had been planned for completion by 31 July 2019 with
corrective and preventative actions identified implemented by 30 September 2019.
○ Risk management of deferred defects.
○ Rectification management of deferred defects.
○ Interface between LMC and remote Part 145 organisations.
○ Standardisation of policy across all departments concerning deferred defect

control.
DHC-8-402 Dash 8 Q400, G-JECR on 15 November 2018
Whilst climbing to FL190 en-route to Charles De Gaulle Airport, Paris the pilots received
an alt mismatch message and they elected to return to Exeter Airport. Following an
inspection after landing, a small white crystalline deposit was found covering three of the
four static pressure holes on the left primary pitot static probe. It is probable that the use
of a non-approved product, to improve the seal between a test adaptor and the pitot static
probe during maintenance immediately prior to this flight, may have resulted in the blockage
of the static holes and led to the alt mismatch message. Two Safety Recommendations
have been made; one to the air data accessory kit manufacturer and one to the aircraft
manufacturer to improve the instructions for the use of testing kits when carrying out leak
tests of the pitot/static system and to only use approved lubricants. The maintenance
organisation has taken Safety Action to introduce tighter controls on the test kit equipment.
The air data accessory kit manufacturer Outboard

recommends the use of LF5050 to aid installation Forward
and the avionics technicians stated that it is often
missing from the kit box due to kit control issues. It
is possible therefore that to ‘get the job done’ the
technicians may resort to other more easily available
products with the unintended consequence, in this
case, of residual grease blocking some of the static
holes. As a result of this investigation the following
safety action has been taken:
Safety action:
The maintenance organisation has purchased new air data accessory kits and
implemented tighter tool control of the kits to ensure all the components are always
available.

+44 (0)1252 512299 @aaibgovuk
62
AAIB
CORRESPONDENCE INVESTIGATIONS
Aeryon Skyranger R60, (UAS) SR9112798 on 18 January 2018
After takeoff the unmanned aircraft (UA) experienced winds exceeding the manufacturer’s
stated limitations and was unable to hold its position position. A culmination of the
subsequent position warning and automatic attempt to return “home” and land triggered
a software error, commanding the UA to land while not over its home position. As the UA
descended there was a loss of link with the ground control unit and the UA collided with a
tree. The loss of signal was probably caused by the loss of radio line of sight between the
UA and ground control unit when it drifted in the high wind over a five-storey building.
Safety actions:
As a result of the accident, the operator carried out a comprehensive review of their
procedures as well as liaising with the manufacturer on the technical aspects of the
accident. As a result, the operator has introduced a number of safety actions. These
include:
● Ensuring software checks and updates are integrated into the maintenance
procedures.
● Ensuring at least one member of the operating team is experienced in operating the
system and introducing a mentoring scheme to provide opportunities to increase
experience levels with appropriate oversight.
● Providing information on the most appropriate sources of weather information to be

used in planning and operating flights and ensuring these take into account actual,
as well as forecast, weather conditions.
● Providing pilots and observers with training on weather effects experienced in a

built-up environment, especially related to wind.
● Introducing reduced wind limits on the operation of UAS to allow a safety factor,
mitigating the risk of exceeding the limits. These will also be varied to take account
of each pilot’s experience.
● Revised training on the assessment of ground station transmitter siting to minimise

the likelihood of signal loss.
● Review of incident and accident reporting procedures.
MBB-BK 117 D-2 EC145, G-RMAA on 3 May 2018
The pilot of the Helicopter Emergency Medical Service (HEMS) helicopter took off from a
car park in variable wind conditions. Once airborne the helicopter yawed to the left and the
pilot attempted to correct by applying opposite anti-torque pedal, but it continued to rotate.
He lowered the collective and as the helicopter landed, its fenestron contacted a low wall
on the perimeter of the car park. Most of the pilot’s experience had been on another type

+44 (0)1252 512299 @aaibgovuk
63
AAIB
of helicopter and he had made inputs consistent

with controlling that aircraft, which were insufficient
in this instance. The operator has reviewed the
circumstances of the accident and has taken two
safety actions as a result.
Safety actions:
As a result of this event the operator has

re-briefed all of its pilots on the possible
consequences of remaining light on the skids
when lifting into the hover.
The operator has also updated their Operations Department Communication (ODC) to
reflect the most recent EASA Acceptable Means of Compliance and refer to dimensions
of both the EC135 and the EC145.
Cameron A-300 hot air balloon, G-VBAD on 18 May 2018
A passenger fell off the basket onto the ground whilst

attempting to board before flight and was seriously
injured.
Safety action:
The operator has stated that it now briefs passengers

to take extra care when climbing in or out of the
basket and suggests to some passengers that
preloading might be a better option for them than
climbing in after the envelope has been inflated.
Just Super STOL XL, G-SSXL on 10 June 2018

The aircraft was on a test flight prior to being issued with a Permit to Fly. Shortly after
takeoff the engine failed. During the subsequent forced landing the aircraft landed firmly,
sustaining severe damage. One of the two pilots suffered serious injuries.
It is believed that the engine failure was caused by fuel vaporisation as a result of high
engine compartment temperatures.
Safety actions:
In consultation with the engine manufacturer, the owner stated he would have the
engine cowlings redesigned to increase the intake airflow and modify the engine
+44 (0)1252 512299 @aaibgovuk
64
AAIB
layout by relocating the fuel pumps and cooling fuel returning to the header tank.
These changes are intended to reduce the possibility of a fuel vapour lock recurring.
● LAA Technical Leaflet TL 2.263 highlights the procedures for using unleaded Mogas
in piston engines. Due to the greater risk of vapour lock the LAA has stated that
when using Mogas the temperature of fuel in the tank must not exceeding 20°C
and the aircraft must fly below 6,000 ft.
● The LAA plans further flight tests over a range of weights to gain more accurate
approach speed data for this aircraft type.
● The LAA has stated that it will review how it manages the testing of new engine
types and engine installations. One option being considered is the download of
the ECU’s data as part of the engine’s initial testing, so that all available measured
parameters can be checked against the manufacturer’s stated limitations.
Britten-Norman BN-2B-21 Islander, VP-AEJ on 4 July 2018
During a short flight between the islands of Saint Eustatius Drive mechanism
and Saint Kitts, in the Caribbean, the pilot noticed that the
ailerons felt “sluggish” but the aircraft landed successfully at
Saint Kitts. It was found that a drive rod for the right aileron
had broken and a spherical bearing, fitted to one end of the
rod, had corroded heavily and was seized. Several safety
actions have been taken to reduce the maintenance interval
for control rods due to an increased risk of corrosion from
the environmental factors where the aircraft operated. This
investigation was delegated by the Dutch Safety Board
to the AAIB in accordance with paragraph 5.1 of ICAO
Aileron attachment
Annex 13.
Safety actions:
The following safety actions have been taken by:
The aircraft manufacturer and Safety Action Overview
● Service Letter SL127 published to remind operators of the greasing requirements

and to provide relevant feedback.
Maintenance organisation
● A reduction in the lubrication task interval from 1,000 hours to 100 hours for the
aileron drive rod bearings.
● A fleet-wide corrosion inspection of all drive rod/bearing assembles.
3
LAA leaflet TL 2.26 can be found here: https://www.lightaircraftassociation.co.uk/engineering/
TechnicalLeaflets/Operating%20An%20Aircraft/TL%202.26%20Procedure%20for%20using%20E5%20
Unleaded%20Mogas.pdf [accessed April 2019]

+44 (0)1252 512299 @aaibgovuk
65
AAIB
Boeing 787-9 Dreamliner, G-TUIM on 6 July 2018
The aircraft was on approach to Runway 26L at London Gatwick Airport and was being
configured to land. After flaps 1 was selected, there was a progressive deterioration in
normal flight controls, landing gear lowering and nosewheel steering capabilities. The crew
performed a go-around and actioned the relevant checklists. The aircraft landed safely with
flaps 20 set but with the nosewheel steering inoperative.
The cause of the system degradation was a failure of the Nose Landing Gear Isolation
Valve (NLGIV). Following this event, the manufacturer changed its procedures in relation
to the manufacturing and testing of the NLGIV.
Safety actions:
Following this incident, the aircraft manufacturer:
● Introduced changes to the component Acceptance Test Procedure for the NLGIV
● Made changes to the manufacturing procedures of the NLGIV to prevent brinelling.
● Made amendments to the Fault Isolation Manual (FIM) and Aircraft Maintenance
Manual (AMM) to add operational tests of the NLGIV.
Airbus Helicopters EC175B, G-EMEA on 10 July 2018
The helicopter was returning to Aberdeen after a routine passenger flight. During a normal
approach to land the landing gear appeared to deploy normally but at touchdown the nose
landing gear collapsed due to the failure of the A-frame pintle pin. Owing to a low fuel state
the passengers were disembarked whilst the helicopter was in a low hover. The aircraft
was then landed safely, using sandbags to support the fuselage.
During the subsequent

investigation, the operator Nose landing gear actuator
identified that a bush, which
should have supported the pintle
pin, had not been fitted into the
A-Frame
A-frame when it was installed
50 flying hours before the

incident flight. The investigation

Pintle Pin
identified several human factors Pintle Pin Bushing
issues which contributed to the

accident, including shift staffing
levels, lack of experience and fatigue. The helicopter manufacturer subsequently
published Service Information Notice 3259-S-32 notifying operators of this failure mode
and an Alert Service Bulletin (ASB) 32A003, requiring an inspection to ensure the correct
installation of the pintle pin bushing. The ASB was subsequently mandated by EASA
Airworthiness Directive 20180190.

+44 (0)1252 512299 @aaibgovuk
66
AAIB
Safety actions:
Following this incident to G-EMEA, the operator revised its procedures regarding work
time monitoring and reminded staff of their responsibilities to follow company fatigue
management procedures. The operator introduced a ‘complex task’ job card for the
H175 nose landing gear leg replacement task. Additionally, the operator reviewed the
engineering manpower, supervision and experience levels needed for base maintenance
inputs.
On 13 July 2018, the helicopter manufacturer published Safety Information Notice (SIN)
No 3259-S-32 which notified other operators of this, and previous, nose landing gear
pintle pin failures. The SIN highlighted the need to remove and reinstall the pintle pin
bushing during A-frame replacement.
As a result of another operator identifying an incorrectly fitted pintle pin bushing, the
helicopter manufacturer published Emergency Alert Service Bulletin (ASB) 32A003 in
August 2018. This required a one-off inspection of the EC175 nose landing gear pintle
pin bushing. In addition, operators were required to review helicopter maintenance
records to identify any occasions where bushings had been misinstalled or found not
fitted. ASB 32A003 was subsequently mandated by the EASA with the publication of
Airworthiness Directive 2018-0190 on 31 August 2018.
Flight Design CTSW, G-KUPP on 19 July 2018
An electrical fire in the instrument console developed

shortly after takeoff and the pilot returned to land on
the active runway. An electrical short circuit with the
composite instrument console, resulting in a resin fire,
was traced to a damaged wire. The wiring had been
previously modified and a Service Bulletin has been
released to reduce the risk of electrical and fuel fires.
Safety action:
The UK type approval organisation has issued a

Service Bulletin No 150 to modify Flight Design
CTSL, CTSW and CT2K aircraft, to reduce the risk
of electrical and fuel fires.

+44 (0)1252 512299 @aaibgovuk
67
AAIB
Piper J5A Cub Cruiser, G-BSXT on 20 July 2018
During a check flight, a newly repaired Piper J5A Cub Cruiser overran the runway and
struck a gate at Felthorpe Airfield near Norwich. This was because the aircraft was
travelling too fast in the final stage of the landing. It floated a long distance and landed a
long way down the runway. The pilot had no time on type and the aircraft had heel brake
controls that he found difficult to use.
The LAA did not have the opportunity to assess the suitability of the check pilot, in part due
to a misunderstanding between the LAA and one of its Inspectors about what airworthiness
process to follow. In response to this accident, the importance of clear and unambiguous
communications with members has been reinforced at LAA HQ. The LAA has also
informed inspectors of the circumstances of this event and issued a decisionmaking flow
chart to help them determine what process should be followed.
Safety actions:
In response to this accident, the LAA has re-emphasised to its staff the importance of
clear and unambiguous conversations between LAA headquarters, aircraft owners and
LAA inspectors.
The LAA has also produced a communication for LAA inspectors that describes this
event and provides advice regarding inspector responsibilities in this type of case. It
has also produced a decision-making flow chart to assist inspectors to determine what
process should be followed.
As a safety action in response to the accident involving G-BXON, the LAA has published
Technical Leaflet 2.30 Converting to a new type4. This contains relevant guidance for
pilots transitioning between aircraft types.
Boeing 737-8Q8, YR-BMF on 28 July 2018
Prior to departure the aircraft’s takeoff

data was calculated on an electronic flight
bag (EFB) using its zero fuel weight (ZFW)
instead of its takeoff weight (TOW). The
pilots did not crosscheck or independently
calculate the data. During the takeoff the

aircraft suffered a tailstrike.
Despite ATC asking the pilots if they had

a tailstrike, the error subsequently being
noticed in the EFB and a member of
4
LAA (2018). Technical Leaflet 2.30. Converting to a new type. Issue 1. 19 December 2018. http://www.
lightaircraftassociation.co.uk/engineering/TechnicalLeaflets/Operating%20An%20Aircraft/TL%202.30%20
Converting%20to%20a%20New%20Type.pdf (accessed on 15/01/2019).

+44 (0)1252 512299 @aaibgovuk
68
AAIB
the cabin crew hearing a strange noise during the takeoff, the tailstrike checklist was
not actioned. The aircraft continued to its destination and, after landing, damage was
discovered on the underside of the aircraft.
Safety actions:
As a result of this event the operator issued Safety Information Bulletin No 7/2018 to its
pilots, highlighting the background to it and highlighted the following:
● ‘The flight crew members are advised to strictly follow the provisions of OMB 4.6
“AFTER COMPUTING INDEPENDENTLY, THE CREW SHALL PERFORM A
CROSSCHECK OF THE RESULTS”,
● When feeding the Flight Management Computor (FMC) with data that can affect
performance or carrying out a correction, a cross-check shall be initiated before
executing the task,
● To take into consideration the importance of the information provided by the cabin
crew and ATC,
● QRH shall be used any time a non-normal situation occurs (ie NNC Tail Strike).’
Skystar Kitfox Mk 7, G-FBCY on 5 August 2018
While returning to its home airstrip, the aircraft experienced a loss of engine thrust
coincident with an uncommanded increase in engine speed. The pilot made a forced
landing in a ploughed field during which the nosewheel collapsed, resulting in substantial
damage to the aircraft. Subsequent examination of the propeller hub revealed that the
threads on the lead screw within the propeller pitch-change mechanism had been stripped.
This had caused the propeller blades to move to a very fine pitch setting, leading to the
loss of thrust.
Safety actions:
Prior to this accident, the LAA had embarked on a long-term project to transfer aircraft,
engine and propeller information from SPARS5 to a web-based Type Acceptance Data
Sheets (TADS) system, in order to make this information, including Airworthiness
Information Leaflet (AIL), easily available to its
members. This activity is ongoing and the transfer

of aircraft-specific data is almost complete, and

it is planned that the transfer of engine and
propeller information will follow. It is envisaged
that the propeller TADS will include any relevant
limitations or modifications for each propeller
type and the LAA considers that this will provide
a useful reference for aircraft owners when
deciding what propellers to fit to their aircraft.
5
SPARS - LAA paper based Inspectors manual.

+44 (0)1252 512299 @aaibgovuk
69
AAIB
The LAA also intends to reissue the AIL originally issued in 2008 for the Arplast PV50
propeller and is currently identifying all LAA aircraft to which this propeller is fitted.
Owners of projects still under construction who may have this propeller but who have not
yet identified the propeller type to the LAA, will be identified when an application for an
initial permit to fly or modification is made.
The LAA published a ‘Safety Spot’ article in the November 2018 issue its ‘Light Aircraft’
magazine, to alert owners to the issues arising from this accident.
ERJ 170-200 STD, Embraer 175, G-FBJK on 11 August 2018
When advised that the takeoff runway had changed the pilots recalculated the takeoff
performance from an intersection. This produced a different flap setting, which they did not
notice, despite them cross-checking the information. The aircraft subsequently took off with
an incorrect flap setting for the calculated takeoff performance data.
Safety actions:
The operator has taken the following safety actions:
● Changed its SOPs on EFB performance calculation procedures, in OM Part A,

to align them with the current EASA regulation where both pilots independently
calculate the departure performance and cross-check the other pilots, before being
accepted for use.
● The operator has introduced the use of a takeoff and landing data card on their
Embraer 175 fleet. It believes the process of transferring data from the EFB to the
card could potentially act as an additional safety barrier.
The operator is considering the following safety action:
● Changing the format, font or colour of the calculated takeoff speeds and flap setting
on the EFB to make the calculated data stand out differently from the rest of the
inputted data.
CZAW Sportcruiser, G-CGJS on 18 August 2018
The aircraft suffered an engine failure while climbing

through 1,400 ft after takeoff, and a forced landing

was carried out into a ploughed field. The aircraft was

damaged but the occupants were not injured. The
flywheel had detached due to failure of its attachment
bolts which were found to have broken; fatigue was
evident on at least one bolt. There was a discrepancy
in the time intervals for replacement of the bolts in the
engine manufacturer’s documentation.

+44 (0)1252 512299 @aaibgovuk
70
AAIB
Safety actions:
By the engine manufacturer
● The engine manufacturer made a series of improvements to the configuration of

the flywheel attachment system on this engine type. The improvements included
the introduction of Nordloc washers, which the manufacturer stated ‘should be
implemented on existing engines whenever flywheel bolts are replaced’. The
various configurations that have been used, and the installation process for
Nordloc washers are detailed in Service Bulletin JSB 012.
● On 12 February 2019, the engine manufacturer issued Service Bulletin JSB 0143,
which aligned the maintenance requirement for ‘non-approved propellers’ to that
described in the Maintenance Manual.
By the LAA
● The LAA was proactive in highlighting the failures of flywheel attachment bolts after
first becoming aware of the problem.
Sikorsky S-92A, G-CKXL on 23 August 2018
The pilots were operating the S-92A helicopter on a multi-sector route between platforms
in the Brae field in the northern North Sea, approximately 150 nm north-east of Aberdeen.
On the third sector from the East Brae platform to the Brae Alpha platform, the pilots mis-
identified the Brae Bravo platform as the destination and made an approach to the hover
above the deck of the platform. The radio operator on the Brae Bravo platform told the
pilots that they had made an approach to the wrong deck; following clearance to depart,
the pilots continued the flight without further incident.
The operator stated that it would conduct additional training addressing the task management
requirements and complexity during shuttling6 to prevent a recurrence.
Safety actions:
The operator identified the following safety actions to be carried out:
● Training to highlight complex requirements of shuttling and need to concentrate on

all aspects of SOPs.

● Highlight of importance of following checklists at appropriate times.
● Review shuttle checks.
● Highlight task management during the brief for a shuttling line training flight.
6
Shuttling is the act of flying between installation helidecks which are less than 10 nm apart.

+44 (0)1252 512299 @aaibgovuk
71
AAIB
Airbus Helicopters AS 350, VP-CIH on 30 August 2018
The AS 350 helicopter suffered tail rotor control problems in flight due to a rupture of the
tail rotor gearbox (TGB) actuating rod. The pilot carried out a successful run-on landing.
On 20 March 2019 the EASA issued Airworthiness Directive 2019-0060, mandating an
inspection of TGB actuation rods to check for
cracks.
Safety action:
● As a result of these findings, on 20 March

2019 the EASA issued Airworthiness
Directive 2019-0060, mandating dye
penetrant crack checks of TGB actuating
rods on affected AS 350 and AS 355
helicopters.
DJI Matrice 210 (UAS, registration n/a) on 4 September 2018
After about six minutes into the flight, a battery low voltage condition was detected by the
UAS causing it to enter an automatic landing mode. Shortly afterwards, while the aircraft
was 20 m above the ground, it powered down and the electric motors stopped, causing
it to fall to the ground. An investigation of this and similar accidents was conducted by
the manufacturer which found that the batteries’ State of Charge (SOC) was indicating
an erroneously high level of charge remaining. Safety actions were taken by the CAA to
introduce operational restrictions while a fix was being found, and by the manufacturer to
develop and ‘push out’ firmware changes to the battery and aircraft.
Safety actions:
A number of safety actions have been made by the aircraft manufacturer and UK
regulator.
These are summarised as follows:
● Provided battery firmware updates to correct

the erroneously high SOC issue.

● Provided aircraft firmware updates to

perform a gross check of the batteries’ SOC
and trigger a RTH or Automatic Landing if a
difference of greater than 10% is detected at
specified trigger points.
● The DJI Pilot app has been updated to provide a clear warning when the battery
firmware is out of date. The manufacturer is also planning improvements to the
DJI Go 4 app.

+44 (0)1252 512299 @aaibgovuk
72
AAIB
● A planned update to the Matrice 200 series user manual will specify that the
DJI Pilot app is recommended and will specify that the batteries contain firmware
that must be individually updated.
● The CAA issued four safety notices and Skywise Alert SW2019/067 to raise
awareness of the battery issues and firmware updates to DJI Matrice 200 series
users, as well as introducing operational limits depending on the version of
firmware installed. These limitations have now been removed with the publication
of Skywise Alert SW2019/116 which also reminded operators to have appropriate
mitigations in place if flying over persons or property.
Cirrus SR20, G-GCDA on 19 October 2018
The aircraft owner was collecting his aircraft after its annual inspection. The pre-flight
checks and takeoff roll were normal. However, just as the aircraft lifted off, the pilot became
aware of smoke in the cockpit. He landed immediately and despite shutting down all the
electrical equipment, the smoke persisted. With the assistance of an engineer, the source
of the smoke and a small fire was identified and extinguished. It was caused by a ‘circuit
track’ in a switch panel, which had been electrically overloaded because of an unidentified
problem with a diode in the standby battery wiring harness. The aircraft manufacturer
has taken several safety actions to ensure the significance of the diode is understood
and have included an additional circuit protection device. The aircraft manuals and circuit
diagrams have also been amended to clarify the circuit maintenance information.
The aircraft manufacturer has examined the switch panel circuit and reviewed this
sequence of events. The position and unremarkable look of the diode was understood
by the manufacturer. In addition, they have also identified that there is a slight risk of
misassembly.
Safety actions:
The following safety actions are being carried out by the manufacturer:
● An update to the parts catalogue, wiring manual and electric CAPS service bulletins
have been released.
● The addition of a fuse to the harness assembly to prevent damage. The

engineering drawings for this are now released and will be used in new aircraft.
Issuing new CAPS kits is planned but not released yet. Adding the fused harness
will require another round of revisions for the service bulletins. The fused harness
is field retrofittable and can be installed in existing aircraft and listed as the field
spare.

+44 (0)1252 512299 @aaibgovuk
73
AAIB
Piper PA-34-220T Seneca V, G-OXFF on 2 November 2018
The aircraft was about to enter the runway for

takeoff when the instructor became concerned
about the feel of the left rudder pedal. He aborted
the flight and taxied the aircraft back to the hangar.
The subsequent engineering inspection found
the left rudder cable had parted, with evidence
that it had melted through due to chafing against
the standby battery cable. Safety actions have
been taken by the Civil Aviation Authority and the
manufacturer has issued a mandatory Service Bulletin (No 1337) to reroute the emergency
power wiring to give more clearance from the rudder cables.
Safety actions:
Safety actions taken by the regulator and manufacturer;
● This potentially serious risk to airworthiness was brought to the attention of the
manufacturer, the CAA, EASA and the FAA. The CAA took immediate steps to
inform owners and operators of similarly configured Piper Seneca V aircraft.
● The manufacturer has subsequently issued a mandatory Service Bulletin (No 1337)
which gives instructions to reroute a portion of the emergency power wiring to
improve the clearance from the rudder control cables.
Bell 429, M-YMCM on 25 November 2018
Whilst on short final to Edinburgh Airport, at approximately

100 kt, the helicopter suffered a bird strike to the left
windscreen. The windscreen shattered and debris
entered the cockpit, injuring the occupant in the left seat,
who required hospital treatment.
The Bell 429 windscreen is not designed to withstand bird

strikes and the design certification requirements do not
require it to do so. A recent study by the Rotorcraft Bird
Strike Working Group has recommended the introduction

of bird strike protection requirements for Normal category
rotorcraft to minimise the risk of damage or injury.

+44 (0)1252 512299 @aaibgovuk
74
AAIB
Safety actions:
By the European Union Aviation Safety Agency (EASA)
● In November 2018, the EASA published the European Plan for Aviation Safety
(EPAS) for 2019 – 20237. Rule Making Task 0726 is entitled ‘Rotorcraft occupant
safety in event of a bird strike’.
The document states:
○ ‘Since the 1980s there have been an increasing number of accidents

involving rotorcraft bird strikes where the rotorcraft was not certified in
accordance with the latest bird strike protection provisions. This has
resulted in a number of occurrences where rotorcraft bird impacts have
had an adverse effect on safety. The objective of this RMT is to improve
rotorcraft occupant safety in the event of a bird strike. This will be achieved
by considering the development of new CS27 provisions for bird strike
and also considering proportionate retrospective application of applicable
CS-27 and CS-29 to existing fleets and types that are not compliant with
the latest provisions.’
The document indicates that associated timescales are 2024.
By the Federal Aviation Administration (FAA)
● In a presentation at the 12th rotorcraft symposium8, the FAA indicated that their
Rotorcraft Standards Branch (RSB) is reviewing the Bird Strike Working Group
report. Further FAA study and evaluation will influence potential rulemaking and
indications are that the RSB will pursue rulemaking in fiscal year 2020. This
will be a multi-year process to achieve a final rule and they will ‘coordinate and
harmonize to maximum extent with EASA’.
● The FAA indicated that they consider pilots and operators to be the first line of
defence. They will consider how to address appropriate rotorcraft flight manual
procedures. These are not considered to be flight limitations but ‘best practices’.
They will continue discussion and studies with industry. Guidance material such
as Advisory Circulars will be issued where appropriate. and Safety Action Overview
7
European Plan for Aviation Safety 2019 – 2023 https://www.easa.europa.eu/document-library/general-publications/
european-plan-aviation-safety-2019-2023 [Accessed 28 February 2019]
8
Presentation number 28 Bird Strike Rotorcraft Protection https://www.easa.europa.eu/newsroom-and-events/
events/12th-rotorcraft-symposium#group-easa-downloads [Accessed 28 February 2019]

+44 (0)1252 512299 @aaibgovuk
75
AAIB
DHC-8-402 Dash 8, G-ECOC on 13 December 2018
During the climb to cruising altitude the flight

crew took the precautionary action of using the
fixed oxygen system following a pressurisation
event. The aircraft pressurisation system was
reset and functioned normally, however the
oxygen system failed to provide the pilots with
oxygen. The oxygen cylinder regulator was later
disassembled, and the crew oxygen supply port
was found blocked with a piece of debris. It is
suspected that the debris was the tip of a screw extraction tool, but no evidence could be
found to explain how it came to be in the regulator. The operator has changed the ‘first
flight’ checks to ensure the flight deck emergency oxygen system is functioning correctly.
Safety action:
The operator has taken the following safety action:
● The Operations Manual for the Flight Deck Fixed Oxygen Checks has been
updated to include a one-second flow of oxygen to ensure that system pressure is
maintained during the first flight check.
DJI Matrice M210 RTK, (UAS, registration n/a) on 14 January 2019
The unmanned aircraft system (UAS) was fitted

with a third-party lidar9 pod for its planned survey
mission which involved flights of around 8 minutes
duration. As it commenced its pre-programmed
route, it appeared to continue to climb above the
30 m height that had been set. The remote pilots
observed that is was too high and attempted
to land it immediately. The aircraft appeared
unresponsive to the remote pilot’s inputs and it
then commenced an uncontrolled descent, rapidly
increasing speed, until it struck the ground.
Safety actions:
The UAS operator is updating its procedures to include the following checks:
● Before any new aircraft / payload combination is flown, its actual weight will be
established and recorded, by weighing, to ensure it is within specified limits.
● Before any new app or software is flown, confirmation, in writing, of its compatibility
with other equipment by either the airframe manufacturer or the app developer
is required.
9
Lidar is a surveying device that uses laser light to measure distances.

+44 (0)1252 512299 @aaibgovuk
76
AAIB
Airbus A330-243, G-TCCF on 6 February 2019
Coffee was spilled onto the commander’s audio control panel (ACP). This resulted in
failure of his ACP and later, the ACP on the co-pilot’s side. During the failures, the ACPs
became very hot and produced an electrical burning smell
and smoke. The commander decided to divert to Shannon,
Republic of Ireland. The failure of two ACPs caused
significant communication difficulty for the flight crew. The
operator has taken safety action to reduce the chance of
spillage.
Safety action:
The operator changed their procedure to ensure

that cup lids are provided for flights on all routes and
reminded cabin crew of the requirement to use them.
The operator also issued a flight crew notice reminding
pilots to be careful with liquids. The operator raised an
action to source and supply appropriately sized cups
for the aircraft’s cup holders.
Evolve Dynamics Sky Mantis (UAS, registration n/a) on 7 February 2019
During a demonstration flight, the UAS dropped to the ground from a height of 50 m when
the electric motors stopped, despite the battery being fully charged. The UAS struck the
ground and was destroyed in the subsequent post-impact fire. The UAS manufacturer
determined that the loss of power was caused by the battery not being fully locked in
place.
Safety action:
The manufacturer has since updated the

Sky Mantis Operations Manual to include an
instruction to check that the battery is locked
in place and will include this requirement in
customer training. It also intends to install
sensors in the battery lock mechanism which
will prevent the aircraft from being able to fly if

the battery is not correctly locked in place.

+44 (0)1252 512299 @aaibgovuk
77
AAIB
Socata TB20 Trinidad, G-BMIX on 7 February 2019
The aircraft, whilst taxiing at night at Dundee

Airport, departed the right side of Taxiway E at
the point where the taxiway curves to the left
prior to joining the main apron. The aircraft’s
left main landing gear oleo was damaged
as it rolled over the paved edge of the main
apron. A contributory factor in the pilot’s loss
of situational awareness of his position on
Taxiway E may have been his loss of sight of
the taxiway edge lights against the brightly-lit
main apron. Excessive taxiing speed may
have also been a contributing factor.
Safety action:
Dundee Airport conducted an investigation into the event and plan to take two actions
resulting from their investigation. A taxi speed limit is to be inserted into the warnings
section of the textual data of the Aeronautical Infomation Publication (AIP) document
for Dundee Airport. The airport also plans to reduce the severity of the lip between the
grass and the main apron surface at the point where Taxiway E joins the main apron.
Airbus A320-214, G-EZOI on 25 February 2019
A louder than usual noise was observed from an avionics vent fan before flight. During
flight the noise increased and vibration became apparent. The crew then noticed a strong
burning smell so they donned their oxygen masks and diverted the flight. An Electronic
Centralised Aircraft Monitoring (ECAM) message, associated with an avionics ventilation
system fault, was generated and the crew performed the associated actions.
A subsequent investigation revealed the cause of the event to be worn bearings in the
avionics extract fan. The fan manufacturer and the aircraft manufacturer both took safety
action to prevent similar incidents in future.
Safety actions:
Fan manufacturer
● The fan manufacturer issued service bulletin 3454HC-21-101 on 18 April 2018,

which provided details of an optional modification which introduced a ball bearing
health monitoring (BBHM) function to continuously monitor the condition of the ball
bearings and preventively stop the fan before its failure.

+44 (0)1252 512299 @aaibgovuk
78
AAIB
Operator
● Following the fan manufacturer’s original service bulletin and information

letters between 2005 and 2013, the operator introduced a soft-life campaign to
incorporate the recommendations to reduce the inflight failure rate of these fans.
This commenced in 2016.
● In November 2018 the operator commenced a soft-life campaign to install the

BBHM function and at the date of this report 23 modified fans had been installed.
Airbus A300b4-622R(F), D-AEAD on 26 February 2019
The aircraft’s takeoff clearance was cancelled because a maintenance vehicle that had
been manoeuvring on an adjacent taxiway entered the runway. The vehicle driver had
become disorientated.
Safety actions:
The airport operator has carried out the following safety actions;
● A runway safety guide has been produced by Heathrow Airport Limited for issue
to contractors holding A Class driving permits but driving airside on manoeuvring
areas and runways.
● A Temporary Advice Notice (Airside_ASD_TAN_0119) has been published updating

procedures for setting up work sites adjacent to runways, including the requirement
to place Bolton barriers across runway access points prior to any work commencing.
● A Safety Alert (ASWorks_SA_017) has been issued to contactors at the airport

advising of the updated procedures.
Spitfire Mk.T IX (Modified), G-CTIX on 27 February 2019
The landing gear warning horn sounded during the

approach to land. The undercarriage had been
selected down and the green light indicating it was
safe was illuminated, but the right undercarriage leg
collapsed towards the end of the landing ground

roll. Neither occupant was injured. The operator

has provided additional information to its pilots
concerning the landing gear systems on each of its
aircraft and the aircraft will be modified to standardise
system functionality with its other Spitfires.
The right main undercarriage was not locked down and retracted under the weight of the
aircraft on landing.

+44 (0)1252 512299 @aaibgovuk
79
AAIB
It is likely the undercarriage was serviceable and capable of operating correctly, but
excessive air load or incomplete selection of the undercarriage lever to the down position
meant that the hydraulic system returned to idle before the undercarriage was locked down.
The undercarriage warning horn operated as intended but the right undercarriage down
switch was stuck closed, providing an incorrect indication that the undercarriage was safe.
The pilot’s previous experience and incomplete knowledge of the systems fitted to G-CTIX
led him to believe that the green down indication alone confirmed that the undercarriage
was safe.
Safety actions:
As part of the repairs and return to service, the Operator has taken the following safety
action to standardise the operation and functionality of its Spitfires:
● Individual switches for the undercarriage down position and the warning horn have
been replaced with a single switch for both purposes.
● A switch has been added to the throttle quadrant so that the undercarriage warning
horn will sound if the throttle is closed, flaps are down and the undercarriage
position switch is not closed.
● Having reviewed the circumstances of the accident, the operator held a safety
briefing for its pilots aimed in part at improving their awareness of the various
undercarriage operating and indication systems fitted to its aircraft.
● Recognising the differences between different marks of the same basic design,
and the fact that aircraft have been fitted with a variety of systems that are not
necessarily original, the operator intends to provide its pilots with handling notes
for each aircraft that correctly describe the systems currently fitted to it.
DHC-8-402 Dash 8, G-JECN on 2 March 2019
The aircraft had landed at Southampton and was being taxied to its allocated stand.
The No 1 engine had been shut down in accordance with the operator’s SOPs. As it
approached the stand, at walking pace, the commander applied the brakes, which had no
effect and the aircraft hit signage and the rotating No 2 (right) propeller struck a nearby
ground power unit (GPU). The accident was caused by the aircraft standby (hydraulic)
power unit (SPU) not being selected to on. This selection was normally made during the
approach checks. However, on this occasion, the approach checks were not completed
prior to landing. This meant that the aircraft mainwheel brakes did not work with the No 1
engine shut down. During the collision the aircraft sustained damage to the nose fuselage
behind the radome, a nose landing gear door and right propeller tips.
The Operator considers several safety barriers failed in the lead up and during the
accident. The approach checks and after landing checklist should have captured the
incorrect aircraft configuration. The use of the emergency brakes may have prevented
the outcome.

+44 (0)1252 512299 @aaibgovuk
80
AAIB
Safety actions:
Because of this event, the Operator has carried out a safety study looking into previous
occurrences. This has produced several additional observations to be considered,
regarding the approach checklist design and the single engine taxi risk assessment.
In addition, a Notice to Air Crew (NOTAC) has been raised implementing a No 1 hydraulic
system check during taxi.
Tecnam P2006T, G-SACL on 17 March 2019
During taxi the pilot manoeuvred the aircraft to the left to avoid a Piper PA-28 parked on the
right side of the taxiway. Whilst he was looking to the right to ensure sufficient clearance from
the PA-28, he was also looking ahead to identify the centreline, which he found difficult due
to road markings on the apron. The road markings were white and faded with older markings
visible. As he was attempting to regain the centreline the aircraft’s left wing tip struck a large
metal generator which was positioned close to the left apron edge. The pilot stated that the
colour of the generator blended with the hangar behind and he had not noticed it.
The aircraft slewed to the left and came to rest after the nose struck an articulated lorry
parked next to the generator.
Safety actions:
An aerodrome inspector from the CAA visited Redhill after the accident and inspected
the apron. The following changes were agreed with the airport operator: and Safety Action Overview
● The existing edge of white road marking will remain in front of the hangars.
● A yellow taxiway centreline marking will be placed 6 m from this edge.
● A red safety line (behind which aircraft will be parked) will be marked 6 m from the
other side of the yellow centreline.
● Instructions to aircraft operators will be issued to ensure that the main wheels of
parked aircraft are pushed back on to the edge of the grass.
● A warning will be added to the UK AIP10 to request that pilots unsure of wing tip
clearance request assistance.
10
Aeronautical Information Publication.

+44 (0)1252 512299 @aaibgovuk
81
AAIB
Airbus A320-232, HA-LPL on 23 March 2019
The aircraft was being pushed back from its stand by a ‘towbarless’ tug when the pilots
detected a “major shake” from the aircraft nose landing gear. On inspection, damage was
found on the torque link pivot of the nose landing gear and the aircraft had to be taken
out of service. The damage had been the result of incorrect alignment of the tug lifting
paddles. This was caused by the tug laser alignment system being lined up on the nose
gear main forging whilst the nosewheels were 10° to 15° off centre. Correct alignment
with the nosewheels is vital. Lining up on the nose gear leg, rather than the nosewheels,
potentially leads to misalignments of up to 250 mm. This can result in significant damage
to the components on the lower articulated part of the nose landing gear on this and many
other aircraft types.
Safety actions:
The handling company have taken four safety actions to prevent recurrence.
● The towbarless tug training was reviewed to confirm the correct procedures are
being taught. There is now a specific emphasis made on the requirement to
ensure the tug is always aligned with the nosewheels.
● Pushback crews have been briefed to be more aware of the importance of the
nosewheel position and have been asked to make the aircraft crew aware that, if
possible, the nosewheels should be straight.
● The handling company are consulting with the tug manufacturer to identify and if
possible, trial a system, that warns the tug operator of wheel misalignment.
● The A320 has been identified as the most potentially susceptible aircraft type
to sustain nose landing gear damage whilst using the TLD 200MT tug. When
possible on the A320 series of aircraft, the handling company will use either the
conventional tow bar and tug or the TLD 100E towbarless tug.
DJI Inspire 2 (UAS, registration n/a) on 25 March 2019
The DJI Inspire 2 UAS was returning from a surveillance flight when it unexpectedly yawed
and uncontrollably descended, contacting the ground. An object was seen to be released
from the aircraft prior to the loss of control which was thought to be a part of a propeller
blade. The operator has implemented safety action as a result of this investigation.
Safety actions:
During warm starts the operator has introduced physical checks, including an inspection
of the propellers, before the next flight.
The operator has also instructed its pilots not to overfly people.

+44 (0)1252 512299 @aaibgovuk
82
AAIB
Airbus A320-214, G-EZWC on 3 April 2019
While being pushed back from Stand 18

at Belfast International Airport, the aircraft
was stopped with the tug and tow bar
positioned at a significant angle to the
aircraft’s nose. The tow bar disconnected
from the nose landing gear, and the aircraft
rolled forward and struck the tug.
Safety actions:
Following this incident, the handling agent acted to prevent a reoccurrence of the incident:
● A Safety Alert was issued to all staff regarding the incident.
● A training awareness training module was developed covering the use of pushback
tugs and gear selection.
● Refresher training was instigated for headset procedures and action to be taken in
the event of a shear pin to bar head separation.
● A Safety App was developed that all managers and supervisory assessment staff
could use on pushback and/or headset evaluation.
● Bluetooth headsets would be issued to tug drivers to improve communication with

the flight deck.
Colomban MC-30 Luciole, G-CIBJ on 10 April 2019
After a local flight, the ground taxi route back

to the hangar involved several tight turns and
when full left rudder pedal was applied the
cockpit filled with smoke. The pilot exited
the aircraft without injury and the ensuing fire
consumed the aircraft. It is suspected that
the terminals of the starter solenoid were not
insulated, and the rudder pedal created an

electrical short circuit which damaged a fuel

pipe and ignited the fuel.
Safety action:
The LAA has recommended that all UK-registered Colomban Luciole aircraft be
modified to the higher heat-resistant fuel pipe specification.

+44 (0)1252 512299 @aaibgovuk
83
AAIB
Boeing 737-73S, EI-SEV and Boeing 737-33A, G-GDFB on 30 April 2019
EI-SEV was taxiing to park on Stand 22 (S22) at East Midlands Airport (EMA) and the
routing passed behind G-GDFB on Stand 24 (S24). As EI-SEV passed behind G-GDFB its
winglet struck the other aircraft’s right horizontal stabiliser.
Low Visibility Procedures (LVPs) were in force,

and controllers could not see the apron area
and were unaware that S24 was occupied.
Neither the UK Aeronautical Information
Publication (AIP) nor the pilots’ airfield charts
indicated that wingtip clearance could be
compromised when taxiing behind parked
aircraft in that location.
Safety actions:
Following this event:
● The airport operator closed Stand 22 pending a safety review and conducted
a survey of parking stands across the airport to identify any similar aircraft taxi
separation hazards.
● The operators of both aircraft alerted their EMA-based flight crew to the hazard of
reduced separation when using Stands 20 to 25.
● The operator of EI-SEV issued a Company NOTAM to alert its pilots to the reduced
separation hazard on Stands 20 to 25 at EMA.
Ace Aviation As-tec 13, G-CKUL on 15 May 2019
After an uneventful local flight the pilot was returning to Shotteswell Airfield at an altitude
of 2,100 ft when he noticed the engine speed suddenly increase. He observed that the
pusher propeller had detached from the aircraft and so he shut the engine down and
commenced a glide descent back to Shotteswell Airfield,
which was approximately 1 nm to the north. A successful
power-off landing was made.
The flex-wing aircraft’s single-cylinder engine rotates a

pusher propeller using a reduction drive belt, driven by a
pulley on the engine crankshaft. Drive belt tension may
be adjusted using an eccentrically-mounted bearing on the
propeller driveshaft. Inspection of the engine revealed that
the eccentric bearing assembly and propeller had detached
at the support bracket due to a fatigue failure of the bearing
support. The propeller was not located following the event.

+44 (0)1252 512299 @aaibgovuk
84
AAIB
Safety action:
Following this event, the engine manufacturer issued a safety notice11 to all owners and
operators of the Mini 3 engine, requiring the eccentric bearing support to be replaced
before the next flight.
Boeing 737-89P, SP-LWA on 20 May 2019
After an uneventful takeoff from London Heathrow the flight crew were informed that the
aircraft was 953 kg heavier than indicated on the load sheet. The flight crew corrected
the figures in the aircraft’s flight management computer and the flight continued without
incident.
The load sheet error occurred because a consignment of mail was initially recorded twice
in the operator’s computer load management system. A correction was applied by both
the dispatcher and by an electronic message from the cargo company, which resulted in
both entries being removed.
Safety actions:
The handling agent has taken safety action to remind all dispatchers of the importance
of checking that the load sheet reflects the actual loading of the aircraft. They have also
changed work patterns to ensure dispatchers will remain familiar with the IT systems
used by all the operators they service.
The operator has taken safety action by asking for all future occurrence for duplicate
cargo figure to be report to them so that they can determine the cause.

11
Simonini Racing SRL Security Campaign No. 1, 31 May 2019.

+44 (0)1252 512299 @aaibgovuk
85
AAIB
Index of Safety Actions (by aircraft weight)
Commercial Air Transport (Fixed Wing) Page

Boeing 787-9 Dreamliner, G-TUIM 66
Airbus A330-243, G-TCCF 77
Airbus A300b4-622R(F), D-AEAD 79
Boeing 737-89P, SP-LWA 85
Boeing 737-800, EI-FJW and Airbus A320-214, OE-IVC 59
Boeing 737-8AS, EI-GJT 60
Boeing 737-8Q8, YR-BMF 68
Airbus A320-214, G-EZOI 78
Airbus A320-214, G-EZWC 83
Boeing 737-4Q8, G-JMCR 61
Airbus A320-232, HA-LPL 82
Boeing 737-73S, EI-SEV and Boeing 737-33A, G-GDFB 84
ERJ 170-200 STD, Embraer 175, G-FBJK 70
DHC-8-402 Dash 8 Q400, G-JEDU 51
DHC-8-402 Dash 8 Q400, G-JECR 62
DHC-8-402 Dash 8, G-JECN 80
DHC-8-402 Dash 8, G-ECOC 76
EMB-145EP, G-CKAG 52
Britten-Norman BN-2B-21 Islander, VP-AEJ 65
Commercial Air Transport (Rotary Wing)

Sikorsky S-92A, G-CKXL 71
Agusta Westland AW189, G-MCGR 53
Airbus Helicopters EC175B, G-EMEA 66
MBB-BK 117 D-2 EC145, G-RMAA 63
EC135 P2+, G-POLA 53
AS350B2 Ecureuil, G-PLMH 56
Commercial Air Transport (Hot Air Balloon)

Cameron A-300 hot air balloon, G-VBAD 64
General Aviation (Fixed Wing)

Spitfire Mk.T IX (Modified), G-CTIX 79

Piper PA-31, N250AC 50

Piper PA-34-220T Seneca V, G-OXFF 74
Cirrus SR20, G-GCDA 73
Socata TB20 Trinidad, G-BMIX 78
Tecnam P2006T, G-SACL 81
Cessna 172M Skyhawk II, N9085H 55
Auster AOP.9, G-BXON 49
Grob G109B, G-KHEH 56
Cessna 152, G-UFCO 54

+44 (0)1252 512299 @aaibgovuk
86
AAIB
General Aviation (Fixed Wing) Cont Page

Rutan Long-Ez (Modified), G-BPWP 58
Cessna 150M, N66778 58
Czech Sport Aircraft Sportcruiser, G-CGEO 60
CZAW Sportcruiser, G-CGJS 70
Just Super STOL XL, G-SSXL 64
Piper J5A Cub Cruiser, G-BSXT 68
Skystar Kitfox Mk 7, G-FBCY 69
Colomban MC-30 Luciole, G-CIBJ 83
Flight Design CTSW, G-KUPP 67
Ace Aviation As-tec 13, G-CKUL 84
General Aviation (Rotary Wing)

Bell 429, M-YMCM 74
Airbus Helicopters AS 350, VP-CIH 72
Guimbal Cabri G2, G-PERH 55
Unmanned Air Systems

Evolve Dynamics Sky Mantis (UAS, registration n/a) 77
DJI Matrice 210 (UAS, registration n/a) 72
DJI Matrice M210 RTK, (UAS, registration n/a) 76
Aeryon Skyranger R60, (UAS) SR9112798 63
DJI Inspire 2 (UAS, registration n/a) 84


+44 (0)1252 512299 @aaibgovuk
87
AAIB
Appendix 1 - CICITT occurrence categories
CODE DESCRIPTION
ARC ABNORMAL RUNWAY CONTACT
AMAN ABRUPT MANEUVER
ADRM AERODROME
MAC AIRPROX/TCAS ALERT/LOSS OF SEPARATION/NEAR MIDAIR
COLLISIONS/MIDAIR COLLISIONS
ATM ATM/CNS
BIRD BIRD
CABIN CABIN SAFETY EVENTS
CTOL COLLISION WITH OBSTACLE(S) DURING TAKEOFF AND LANDING
CFIT CONTROLLED FLIGHT INTO OR TOWARD TERRAIN
EVAC EVACUATION
EXTL EXTERNAL LOAD RELATED OCCURRENCES
F–NI FIRE/SMOKE (NON-IMPACT)
F–POST FIRE/SMOKE (POST-IMPACT)
FUEL FUEL RELATED
GTOW GLIDER TOWING RELATED EVENTS
GCOL GROUND COLLISION
RAMP GROUND HANDLING
ICE ICING
LOC–G LOSS OF CONTROL–GROUND
LOC–I LOSS OF CONTROL–INFLIGHT
LOLI LOSS OF LIFTING CONDITIONS EN ROUTE
LALT LOW ALTITUDE OPERATIONS
MED MEDICAL
NAV NAVIGATION ERRORS
OTHR OTHER
RE RUNWAY EXCURSION
RI RUNWAY INCURSION
SEC SECURITY RELATED
SCF–NP SYSTEM/COMPONENT FAILURE OR MALFUNCTION (NON-POWERPLANT)
SCF–PP SYSTEM/COMPONENT FAILURE OR MALFUNCTION (POWERPLANT)
TURB TURBULENCE ENCOUNTER
USOS UNDERSHOOT/OVERSHOOT
UIMC UNINTENDED FLIGHT IN IMC
UNK UNKNOWN OR UNDETERMINED
WILD WILDLIFE
WSTRW WIND SHEAR OR THUNDERSTORM

+44 (0)1252 512299 @aaibgovuk
88
AAIB
GLOSSARY OF ABBREVIATIONS
aal above airfield level lb pound(s)
ACAS Airborne Collision Avoidance System LP low pressure
ACARS Automatic Communications And Reporting System LAA Light Aircraft Association
ADF Automatic Direction Finding equipment LDA Landing Distance Available
AFIS(O) Aerodrome Flight Information Service (Officer) LPC Licence Proficiency Check
agl above ground level m metre(s)
AIC Aeronautical Information Circular mb millibar(s)
amsl above mean sea level MDA Minimum Descent Altitude
AOM Aerodrome Operating Minima METAR a timed aerodrome meteorological report
APU Auxiliary Power Unit min minutes
ASI airspeed indicator mm millimetre(s)
ATC(C)(O) Air Traffic Control (Centre)( Officer) mph miles per hour
ATIS Automatic Terminal Information Service MTWA Maximum Total Weight Authorised
ATPL Airline Transport Pilot’s Licence N Newtons
BMAA British Microlight Aircraft Association NR Main rotor rotation speed (rotorcraft)
BGA British Gliding Association Ng Gas generator rotation speed (rotorcraft)
BBAC British Balloon and Airship Club N1 engine fan or LP compressor speed
BHPA British Hang Gliding & Paragliding Association NDB Non-Directional radio Beacon
CAA Civil Aviation Authority nm nautical mile(s)
CAVOK Ceiling And Visibility OK (for VFR flight) NOTAM Notice to Airmen
CAS calibrated airspeed OAT Outside Air Temperature
cc cubic centimetres OPC Operator Proficiency Check
CG Centre of Gravity PAPI Precision Approach Path Indicator
cm centimetre(s) PF Pilot Flying
CPL Commercial Pilot’s Licence PIC Pilot in Command
°C,F,M,T Celsius, Fahrenheit, magnetic, true PM Pilot Monitoring
CVR Cockpit Voice Recorder POH Pilot’s Operating Handbook
DFDR Digital Flight Data Recorder PPL Private Pilot’s Licence
DME Distance Measuring Equipment psi pounds per square inch
EAS equivalent airspeed QFE altimeter pressure setting to indicate height
EASA European Aviation Safety Agency above aerodrome
ECAM Electronic Centralised Aircraft Monitoring QNH altimeter pressure setting to indicate
EGPWS Enhanced GPWS elevation amsl
EGT Exhaust Gas Temperature RA Resolution Advisory
EICAS Engine Indication and Crew Alerting System RFFS Rescue and Fire Fighting Service
EPR Engine Pressure Ratio rpm revolutions per minute
ETA Estimated Time of Arrival RTF radiotelephony
ETD Estimated Time of Departure RVR Runway Visual Range
FAA Federal Aviation Administration (USA) SAR Search and Rescue
FIR Flight Information Region SB Service Bulletin
FL Flight Level SSR Secondary Surveillance Radar
ft feet TA Traffic Advisory
ft/min feet per minute TAF Terminal Aerodrome Forecast
g acceleration due to Earth’s gravity TAS true airspeed
GPS Global Positioning System TAWS Terrain Awareness and Warning System
GPWS Ground Proximity Warning System TCAS Traffic Collision Avoidance System
hrs hours (clock time as in 1200 hrs) TODA Takeoff Distance Available
HP high pressure UA Unmanned Aircraft
hPa hectopascal (equivalent unit to mb) UAS Unmanned Aircraft System
IAS indicated airspeed USG US gallons
IFR Instrument Flight Rules UTC Co-ordinated Universal Time (GMT)
ILS Instrument Landing System V Volt(s)
IMC Instrument Meteorological Conditions V1 Takeoff decision speed
IP Intermediate Pressure V2 Takeoff safety speed
IR Instrument Rating VR Rotation speed
ISA International Standard Atmosphere VREF Reference airspeed (approach)
kg kilogram(s) VNE Never Exceed airspeed
KCAS knots calibrated airspeed VASI Visual Approach Slope Indicator
KIAS knots indicated airspeed VFR Visual Flight Rules
KTAS knots true airspeed VHF Very High Frequency
km kilometre(s) VMC Visual Meteorological Conditions
kt knot(s) VOR VHF Omnidirectional radio Range
Annual Safety Review
2019

Annual Safety Review 2019: Air Accidents Investigation Branch

Uploaded by

Copyright:

Available Formats

Annual Safety Review 2019: Air Accidents Investigation Branch

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Annual Safety Review 2019: Air Accidents Investigation Branch

Uploaded by

Copyright:

Available Formats

AAIB

Air Accidents Investigation Branch

Annual Safety Review

© Crown Copyright 2020

Published 6 July 2020

Enquiries regarding the content of this publication should be addressed to:

Air Accidents Investigation Branch

This document is also available in electronic (pdf) format at www.aaib.gov.uk

I am pleased to introduce this Annual Safety Review

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

AAIB stakeholder research

For this reason, we recently commissioned research specialists

● To benchmark stakeholder opinions about the performance and processes

● To understand stakeholder views on the Branch’s engagement with

ComRes research report summary

What we are doing?

Unmanned air systems

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

AAIB underwater wreckage operations

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

The tail section of N264DB at a depth of 68 m

BEA image of wreckage from F-GZCP taken at a depth of 3,980 m

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

2. Is it necessary to establish the cause of an accident and identify safety

3. Is the cost of the operation proportionate to the expected safety benefit?

How the AAIB conducts this type of operation

● Work with AAIB personnel in the preservation of evidence.

● Contract vessels and marine contractors (including survey / diving /

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

Categories of water operation

these categories are different to the normal maritime definitions.

Categories of water depth when considering aircraft search and recovery

An example of a challenging recovery involved an accident to an AS350 in Loch Scadavay in

G-PLMH partially submerged in Loch Scadavay prior to recovery

We would normally expect to recover wreckage in coastal waters. An example is an

Recovery of G-SUEX, Flamborough Head, Yorkshire in 2014

Side scan sonar survey results from search of G-CDER

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

The phases are:

● Phase 1. Finding the wreckage by using vessels either towing SSS or by

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

The AAIB worldwide

In 2019 we established a global outreach framework to engage directly with accident

As an example an accident to Britten-Norman Islander registration VP-MNI,

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

Places visited for accident and serious incident investigations

Places where the AAIB has either provided or received training

Places where the AAIB has sent representatives to participate in international

Places where the AAIB has participated in international conferences, forums or

Places visited by the AAIB for liaison and outreach

© Crown copyright 2020 AAIB 24-hour Reporting - Telephone number www.aaib.gov.uk

CICTT factors on investigations by the AAIB in 2019

CICTT Factors on Investigations

by the AAIB in 2019