AAIB Bulletin 12/2023

TO REPORT AN ACCIDENT OR INCIDENT

PLEASE CALL OUR 24 HOUR REPORTING LINE
01252 512299
 Air Accidents Investigation Branch
Farnborough House AAIB Bulletin: 12/2023
Berkshire Copse Road
Aldershot GLOSSARY OF ABBREVIATIONS
Hants GU11 2HH
aal above airfield level kt knot(s)
ACAS Airborne Collision Avoidance System lb pound(s)
ACARS Automatic Communications And Reporting System LP low pressure
Tel: 01252 510300
ADF Automatic Direction Finding equipment LAA Light Aircraft Association
Fax: 01252 376999 AFIS(O) Aerodrome Flight Information Service (Officer) LDA Landing Distance Available
Press enquiries: 0207 944 3118/4292 agl above ground level LPC Licence Proficiency Check
http://www.aaib.gov.uk AIC Aeronautical Information Circular m metre(s)
amsl above mean sea level mb millibar(s)
AOM Aerodrome Operating Minima MDA Minimum Descent Altitude
APU Auxiliary Power Unit METAR a timed aerodrome meteorological report
ASI airspeed indicator min minutes
ATC(C)(O) Air Traffic Control (Centre)( Officer) mm millimetre(s)
ATIS Automatic Terminal Information Service mph miles per hour
ATPL Airline Transport Pilot’s Licence MTWA Maximum Total Weight Authorised
AAIB investigations are conducted in accordance with BMAA British Microlight Aircraft Association N Newtons
BGA British Gliding Association NR Main rotor rotation speed (rotorcraft)
Annex 13 to the ICAO Convention on International Civil Aviation, BBAC British Balloon and Airship Club Ng Gas generator rotation speed (rotorcraft)
EU Regulation No 996/2010 (as amended) and The Civil Aviation BHPA British Hang Gliding & Paragliding Association N1 engine fan or LP compressor speed
CAA Civil Aviation Authority NDB Non-Directional radio Beacon
(Investigation of Air Accidents and Incidents) Regulations 2018. CAVOK Ceiling And Visibility OK (for VFR flight) nm nautical mile(s)
CAS calibrated airspeed NOTAM Notice to Airmen
cc cubic centimetres OAT Outside Air Temperature
The sole objective of the investigation of an accident or incident under these CG Centre of Gravity OPC Operator Proficiency Check
Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PAPI Precision Approach Path Indicator
CPL Commercial Pilot’s Licence PF Pilot Flying
purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true PIC Pilot in Command
CVR Cockpit Voice Recorder PM Pilot Monitoring
DME Distance Measuring Equipment POH Pilot’s Operating Handbook
Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed PPL Private Pilot’s Licence
or blame or determine liability, since neither the investigation nor the reporting EASA European Union Aviation Safety Agency psi pounds per square inch
ECAM Electronic Centralised Aircraft Monitoring QFE altimeter pressure setting to indicate height above
process has been undertaken for that purpose. EGPWS Enhanced GPWS aerodrome
EGT Exhaust Gas Temperature QNH altimeter pressure setting to indicate elevation amsl
EICAS Engine Indication and Crew Alerting System RA Resolution Advisory
EPR Engine Pressure Ratio RFFS Rescue and Fire Fighting Service
ETA Estimated Time of Arrival rpm revolutions per minute
ETD Estimated Time of Departure RTF radiotelephony
FAA Federal Aviation Administration (USA) RVR Runway Visual Range
FDR Flight Data Recorder SAR Search and Rescue
FIR Flight Information Region SB Service Bulletin
FL Flight Level SSR Secondary Surveillance Radar
ft feet TA Traffic Advisory
AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAF Terminal Aerodrome Forecast
http://www.aaib.gov.uk g acceleration due to Earth’s gravity TAS true airspeed
GNSS Global Navigation Satellite System TAWS Terrain Awareness and Warning System
GPS Global Positioning System TCAS Traffic Collision Avoidance System
GPWS Ground Proximity Warning System TODA Takeoff Distance Available
hrs hours (clock time as in 1200 hrs) UA Unmanned Aircraft
HP high pressure UAS Unmanned Aircraft System
hPa hectopascal (equivalent unit to mb) USG US gallons
IAS indicated airspeed UTC Co-ordinated Universal Time (GMT)
This bulletin contains facts which have been determined up to the time of compilation. IFR Instrument Flight Rules V Volt(s)
ILS Instrument Landing System V1 Takeoff decision speed
Extracts may be published without specific permission providing that the source is duly acknowledged, the material is
IMC Instrument Meteorological Conditions V2 Takeoff safety speed
reproduced accurately and it is not used in a derogatory manner or in a misleading context.
IP Intermediate Pressure VR Rotation speed
IR Instrument Rating VREF Reference airspeed (approach)
Published 14 December 2023. Cover picture courtesy of Marcus Cook
ISA International Standard Atmosphere VNE Never Exceed airspeed
© Crown copyright 2023 ISSN 0309-4278 kg kilogram(s) VASI Visual Approach Slope Indicator
KCAS knots calibrated airspeed VFR Visual Flight Rules
Published by the Air Accidents Investigation Branch, Department for Transport KIAS knots indicated airspeed VHF Very High Frequency
Printed in the UK on paper containing at least 75% recycled fibre KTAS knots true airspeed VMC Visual Meteorological Conditions
km kilometre(s) VOR VHF Omnidirectional radio Range
AAIB Bulletin: 12/2023

CONTENTS

SPECIAL BULLETINS / INTERIM REPORTS

S2/2023: Airbus A321-253NX G-OATW 4-Oct-23 3

SUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTS

None

AAIB FIELD INVESTIGATIONS

COMMERCIAL AIR TRANSPORT

FIXED WING
None
ROTORCRAFT
None

GENERAL AVIATION
FIXED WING
None
ROTORCRAFT
None

SPORT AVIATION / BALLOONS

None

UNMANNED AIRCRAFT SYSTEMS

None

AAIB CORRESPONDENCE INVESTIGATIONS

COMMERCIAL AIR TRANSPORT

Bombardier Challenger 350 LN-JHH 30-May-23 15

GENERAL AVIATION
Piper PA-28-180 G-AVSC 1-Aug-23 20
Reims Cessna F152 G-BLJO 2-Jan-23 21
Scintex CP301-C1 G-CKCF 31-Oct-22 28
Vans RV-7 G-RVDB 29-Aug-22 34

SPORT AVIATION / BALLOONS

None

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AAIB Bulletin: 12/2023

CONTENTS Cont
AAIB CORRESPONDENCE INVESTIGATIONS Cont

UNMANNED AIRCRAFT SYSTEMS

DJI Mavic 2 Pro n/a 27-Mar-23 43

RECORD-ONLY INVESTIGATIONS

Record-Only Investigations reviewed September / October 2023 49

MISCELLANEOUS

ADDENDA and CORRECTIONS

None

List of recent aircraft accident reports issued by the AAIB 55

(ALL TIMES IN THIS BULLETIN ARE UTC)

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AAIB Bulletin: 12/2023

AAIB Special Bulletins / Interim Reports

AAIB Special Bulletins and Interim Reports

This section contains Special Bulletins and

Interim Reports that have been published
since the last AAIB monthly bulletin.

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Farnborough House
Berkshire Copse Road
Aldershot, Hants GU11 2HH

Tel:01252 510300
www.aaib.gov.uk

AAIB Bulletin S2/2023

SPECIAL
Accident

Aircraft Type and Registration: Airbus A321-253NX, G-OATW

No & Type of Engines: 2 CFM International SA LEAP-1A33 turbofan

engines

Year of Manufacture: 2020 (Serial no: 10238)

Date & Time (UTC): 4 October 2023 at 1151 hrs

Location: London Stansted Airport

Type of Flight: Commercial Air Transport (Passenger)

Persons on Board: Crew - 11 Passengers - 9

Injuries: Crew - None Passengers - None

Nature of Damage: Damage to several cabin windows and impact

damage to the left horizontal stabiliser

Commander’s Licence: Airline Transport Pilot’s Licence

Commander’s Age: 54 years

Commander’s Flying Experience: 4,905 hours (of which 2,300 were on type)
Last 90 days - 128 hours
Last 28 days - 27 hours

Information Source: AAIB Field Investigation

Introduction

This Special Bulletin is published to raise awareness of a recent occurrence in which several
cabin windows on an Airbus A321 were damaged by high power lights used during a filming
event. The damage was discovered after takeoff on the aircraft’s next flight. Work is ongoing
with the aircraft manufacturer and operator to fully understand the properties of the lights used
and how this risk can be managed in future.

This Special Bulletin contains facts which have been determined up to the time of issue. It is published to inform the
aviation industry and the public of the general circumstances of accidents and serious incidents and should be regarded as
tentative and subject to alteration or correction if additional evidence becomes available.
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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

Aircraft owners and operators should consider the hazard posed by such activities to
minimise the risk of aircraft damage.

History of the flight

The aircraft was scheduled to embark on a multi-day charter away from base with a flight
crew consisting of three pilots, an engineer, a load master and six cabin crew. The first
sector was a positioning flight from London Stansted Airport to Orlando International Airport,
Florida. In addition to the 11 crew there were nine passengers on board who were all
employees of the tour operator or aircraft operating company. The passengers sat together
in the middle of the aircraft just ahead of the overwing exits.

The aircraft departed a few minutes ahead of schedule and took off from Runway 22. Several
passengers recalled that after takeoff the aircraft cabin seemed noisier and colder than they
were used to. As the aircraft climbed through FL100 and the seatbelt signs were switched
off, the loadmaster, who had been seated just in front of the other passengers, walked
towards the back of the aircraft. He noticed the increased cabin noise as he approached
the overwing exits and his attention was drawn to a cabin window on the left side of the
aircraft. He observed that the window seal was flapping in the airflow and the windowpane
appeared to have slipped down1. He described the cabin noise as ‘loud enough to damage
your hearing’. Figure 1 shows the window in flight.

The loadmaster told the cabin crew and then went to the flight deck to inform the commander.
At this stage the aircraft was climbing past FL130, there were no abnormal indications on
the flight deck and the aircraft pressurisation system was operating normally. The flight
crew stopped the climb at FL140 and reduced airspeed whilst the engineer and then the
third pilot went to look at the window. Having inspected the window, it was agreed the
aircraft should return to Stansted. The cabin crew told the passengers to remain seated
and keep their seatbelts fastened, and reminded them about the use of oxygen masks if
that became necessary.

The cabin was quickly secured and the flight crew initiated a descent, first to FL100 and
then to FL90. They established the aircraft in a hold whilst they completed the overweight
landing checklist, confirmed landing performance and briefed for the return to Stansted.
The approach and landing on Runway 22 were uneventful. Landing at 1151 hrs, the total
flight time was 36 minutes. With the airport RFFS in attendance the aircraft taxied to the
apron, where the passengers disembarked normally.

Having parked and shut down, the crew inspected the aircraft from the outside and saw
that two cabin windowpanes were missing and a third was dislodged. During the flight the
crew had only been aware of an issue with a single windowpane. The cabin had remained
pressurised normally throughout the flight.

Footnote
1
The crew were not aware if this was only the outer pane or both panes.

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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

Figure 1
View of the left side cabin window aft of the overwing exit

Previous activity

The day before the occurrence flight the aircraft had been used for filming on the ground,
during which external lights had been shone through the cabin windows to give the illusion
of a sunrise. The lights were first shone on the right side of the aircraft for approximately
five and a half hours, with the light focused on the cabin windows just aft of the overwing
exits. The lights were then moved to the left side of the aircraft where they illuminated a
similar area on the left side for approximately four hours. Photographs taken during filming
showed six sets of flood lights on both sides of the aircraft. Figure 2 shows the lights
positioned on the left of the aircraft.

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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

Figure 2
Flood lighting on the left side of the aircraft

Recorded information

The aircraft was fitted with an FDR and CVR which were removed and successfully
downloaded at the AAIB. The flight was captured on both recorders and the CVR confirmed
reports from the flight crew interviews.

The aircraft took off from Stansted at 1115 hrs, climbing progressively to a maximum of
14,504 ft2 at 1123 hrs (Figure 3). The cabin altitude increased during this time, reaching a

Footnote
2
Pressure altitude is recorded to a reference pressure of 1013 mb.

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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

recorded maximum of 1,536 ft. The aircraft then descended to 10,000 ft initially, followed by
a further descent to 9,000 ft while circling to the north-west of the airport. No pressurisation
warnings were recorded during the flight, which landed back at Stansted Airport at 1151 hrs.

Figure 3
G-OATW FDR data

Aircraft examination

Cabin windows

Two window assemblies3 were missing, and the inner pane and seal from a third window
were displaced but partially retained in the airframe (Figure 4). A shattered outer pane was
recovered from the entrance to a rapid-exit taxiway during a routine runway inspection after
the aircraft landed.

Footnote
3
A window assembly consists of the inner and outer panes, and a rubber seal.

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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

Figure 4
Displaced and missing windowpanes on the left side of the aircraft

A fourth window protruded from the left side of the fuselage (Figure 5). The four affected
windows were adjacent to each other, just aft of the left overwing exit.

Figure 5
Protruding window on the left side of the aircraft

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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

Removal of the cabin lining inside the passenger cabin revealed that the window retainers
were in good condition and correctly installed. The foam ring material on the back of the
cabin liners was found to be melted in the areas adjacent to the windows that were damaged
or missing (Figure 6).

Figure 6
Foam ring material affected by elevated temperatures

Visual examination of the damaged windowpanes revealed that they were deformed and shrunk
(Figure 7). The deformed panes no longer formed an effective interface with the rubber seals.

Figure 7
Inner pane showing plastic deformation around the entire perimeter

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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

With the AAIB in attendance, the operator removed several cabin liners from the right side
of the passenger cabin. This revealed additional thermal damage and window deformation
in the area around the overwing emergency exit, but to a lesser extent than the left side of
the aircraft.

Horizontal stabiliser

The underside of the left horizontal stabiliser leading edge panel was punctured. Small
pieces of acrylic were found in the stabiliser when the panel was removed.

Cabin windows description

The outer surface of the cabin windows is flush with the outer surface of the fuselage. The
windows consist of an inner pane, an outer pane and a seal. The panes are made from
stretched acrylic. A vent hole through the inner pane lets cabin pressure into the space
between the inner and outer panes.

The cabin windows are attached to the window frames using retainers, eyebolts and nuts
(Figure 8).

Nut (total 6)

Retainer

Windowpanes
and seal missing

Figure 8
Correct installation of the retainer but the window assembly is missing

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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

External lighting

Photographs of the filming showed that the lights were between approximately 6 and 9 m
from the window areas where damage was apparent (Figure 9).

Image for illustration only – not to scale

7.1 8.0
6.7 6.9
8.2
9.1

8.7
7.6
6.6 6.1 7.2
6.1

Figure 9
Approximate distance of the flood lights from the fuselage during the filming activity

The aircraft operator identified the flood lights as Maxibrute 12. An online datasheet4 for
these lights included the data at Table 1. The investigation has not yet established the
reason for the specified minimum distance from the object to be illuminated.

Parameter Value

Lighting capacity 12,000 Watts

Minimum distance from object to be illuminated 10 m

Minimum distance from a flammable object 1.5 m

Maximum surface temperature 200°C

Table 1
Data extracted from the flood light datasheet
Footnote
4
Maxibrute_12 (filmgear.net) [Last accessed 13 October 2023]

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AAIB Bulletin: S2/2022 G-OATW AAIB-29637

Observations

The windows appear to have sustained thermal damage and distortion because of elevated
temperatures while illuminated for approximately four to five and a half hours during filming
activity the day before the flight. It is likely that the flood lights were positioned closer than
10 m. Whereas in this case the damage became apparent at around FL100 and the flight
was concluded uneventfully, a different level of damage by the same means might have
resulted in more serious consequences, especially if window integrity was lost at higher
differential pressure.

Further investigation

The AAIB investigation continues with the support of the BEA5, the aircraft manufacturer,
and the aircraft operator to understand how a similar occurrence can be prevented from
occurring again.

Published: 3 November 2023.

Footnote
5
Bureau d’enquêtes et d’analyses pour la sécurité de l’aviation civile, the French aviation safety
investigation authority.

AAIB investigations are conducted in accordance with Annex 13 to the ICAO Convention on International Civil Aviation,
retained EU Regulation No 996/2010 (as amended) and The Civil Aviation (Investigation of Air Accidents and
Incidents) Regulations 2018.
The sole objective of the investigation of an accident or incident under these Regulations is the prevention of future
accidents and incidents. It is not the purpose of such an investigation to apportion blame or liability.
Accordingly, it is inappropriate that AAIB reports should be used to assign fault or blame or determine liability, since
neither the investigation nor the reporting process has been undertaken for that purpose.
Extracts may be published without specific permission providing that the source is duly acknowledged, the material
is reproduced accurately and is not used in a derogatory manner or in a misleading context.

© Crown copyright 2023 12 All times are UTC

AAIB Bulletin: 12/2023

AAIB Correspondence Reports

These are reports on accidents and incidents which
were not subject to a Field Investigation.

They are wholly, or largely, based on information

provided by the aircraft commander in an
Aircraft Accident Report Form (AARF)
and in some cases additional information
from other sources.

The accuracy of the information provided cannot be assured.

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AAIB Bulletin: 12/2023 LN-JHH AAIB-29201

ACCIDENT

Aircraft Type and Registration: Bombardier Challenger 350, LN-JHH

No & Type of Engines: 2 Honeywell HTF7350 turbofan engines

Year of Manufacture: 2017 (Serial no: 20702)

Date & Time (UTC): 30 May 2023 at 0850 hrs

Location: Dundee Airport

Type of Flight: Commercial Air Transport (Passenger)

Persons on Board: Crew - 3 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Damage to left winglet

Commander’s Licence: Airline Transport Pilot’s Licence

Commander’s Age: 55 years

Commander’s Flying Experience: 8,100 hours (of which 700 were on type)
Last 90 days - 51 hours
Last 28 days - 39 hours

Information Source: Aircraft Accident Report Form submitted by the

commander and further enquiries by the AAIB

Synopsis

Whilst being marshalled on the main apron the left wingtip of the aircraft collided with a
lamppost. Neither the flight crew nor the marshaller were aware how close the wingtip was
to the lamppost. Wing spotters positioned to mitigate this risk saw the impending collision
and attempted to signal the aircraft to stop but neither the flight crew nor the marshaller saw
the signals.

The airport operator intends to enhance its guidance to ground crew. The aircraft operator
issued a notice to its pilots reminding them about standard marshalling signals.

History of the flight

The aircraft landed on Runway 27 at Dundee Airport at 0847 hrs and was instructed to
vacate via Taxiway B and park nose to the south on Stand 1B with the marshaller. It was
daytime and CAVOK.

A marshaller was positioned at the head of the stand and two ‘wing spotters’ were positioned
on the end of the apron (Figure 1). Another aircraft was already parked on the adjacent
stand (Stand 1A).

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AAIB Bulletin: 12/2023 LN-JHH AAIB-29201

N
Lamppost struck

Approximate position of
the wing spotters

Stand 2B Stand 2A Stand 1B Stand 1A

Approximate position of
the marshaller

Figure 1
Apron at Dundee Airport showing approximate path of the aircraft
and position of the marshaller and wing spotters

The marshaller started marshalling the aircraft as it approached the apron, and the flight
crew followed the instructions. As the aircraft approached the edge of the apron both wing
spotters could see that a collision was imminent and attempted to signal to the marshaller
and the flight crew to stop the aircraft. However, the marshaller was looking at the aircraft
and the flight crew were looking at the marshaller so neither saw the signals from the wing
spotters. The winglet on the left wingtip collided with a lamppost on the edge of the apron
and the aircraft came to an abrupt halt.

Figures 2 and 3 show the aircraft after the collision.

CCTV evidence showed the wing spotters started to signal the aircraft to stop 4 seconds
before the collision.

Figure 2
Aircraft after the collision

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AAIB Bulletin: 12/2023 LN-JHH AAIB-29201

Figure 3
Damage to the left winglet and lamppost

Recorded information

The occurrence was captured on CCTV. Figure 4 shows the sequence of events. The
marshaller is out of shot on the left of the images.

Organisational information

Following the airport operator’s investigation into this occurrence it commented that the
white hatched area at the top of the apron is intended as a safety buffer zone. No part of
the aircraft should enter this area whilst manoeuvring. It intends to instruct wing spotters to
stand on the outer edge of the buffer zone rather than inline with the lampposts, to ensure
the buffer is maintained. It also intends to:

● Conduct a review of its marshalling training package.

● Consider the introduction of direct headset communications between

marshaller and wing spotters.

● Consider a two-stage marshalling process with two marshallers for

circumstances similar to the accident.

The aircraft operator issued an Operational Order to all its pilots reminding them about
standard marshalling signals.

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AAIB Bulletin: 12/2023 LN-JHH AAIB-29201

Figure 4
CCTV footage of the occurrence (time stamps are local time)

Analysis

Whilst marshalling the aircraft onto the apron the marshaller directed the aircraft too close to
the edge of the apron. From his position at the head of the stand it would be difficult to judge
how close the wingtip on the far side of the aircraft was from the lampposts. They did not
notice the wing spotters signalling for the aircraft to stop as they were looking at the aircraft.
The wing spotter nearest the struck lamppost would have been obscured by the aircraft so
could not be seen by the marshaller.

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AAIB Bulletin: 12/2023 LN-JHH AAIB-29201

The flight crew did not notice that the left wingtip was too close to the lamppost. The
commander commented that it is difficult to judge the wingtip clearance due to the wing
sweep. They also did not see the wing spotter signalling for the aircraft to stop as their
attention was on the marshaller.

Conclusion

A collision occurred because neither the flight crew nor the marshaller noticed the aircraft
was too close to the lamppost. The wing spotters positioned to mitigate this risk were
unable to prevent the collision.

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AAIB Bulletin: 12/2023 G-AVSC AAIB-29438

ACCIDENT

Aircraft Type and Registration: Piper PA-28-180, G-AVSC

No & Type of Engines: 1 Lycoming O-360-A4A piston engine

Year of Manufacture: 1967 (Serial no: 28-4193)

Date & Time (UTC): 1 August 2023 at 1254 hrs

Location: Near Seaton, Devon

Type of Flight: Private

Persons on Board: Crew - 2 Passengers - None

Injuries: Crew - 1 (Minor) Passengers - N/A

Nature of Damage: Damage to propeller and nose gear leg

Commander’s Licence: Airline Transport Pilot’s Licence

Commander’s Age: 73 years

Commander’s Flying Experience: 7,600 hours (of which 250 were on type)
Last 90 days - 35 hours
Last 28 days - 22 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot

The flight departed from Dunkeswell Aerodrome with the purpose of revalidating the aircraft
owner’s PPL. The instructor was demonstrating the procedure for an engine failure at
2,200 ft and a target airspeed of 80 kt. He reported that as he applied nose-up pitch, there
was a loud bang and the aircraft immediately pitched down with severe buffeting.

After recovering control, the instructor elected to make a forced landing and, considering
it to be the only safe option, he chose to land in a nearby field. On landing he was unable
to stop the aircraft before entering a river at around 30 kt, with the aircraft finally coming to
rest after striking the opposite bank. Neither of the occupants were injured. The instructor
subsequently found that the baggage compartment door was open, and the canvas aircraft
cover was missing. He attributed the accident to the compartment door opening in flight
releasing the aircraft’s cover, which temporarily affected the airflow over the elevator,
resulting in the uncommanded pitch change.

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AAIB Bulletin: 12/2023 G-BLJO AAIB-28901

ACCIDENT

Aircraft Type and Registration: Reims Cessna F152, G-BLJO

No & Type of Engines: 1 Lycoming O-235-L2C piston engine

Year of Manufacture: 1979 (Serial no: 1627)

Date & Time (UTC): 2 January 2023 at 1230 hrs

Location: Field about 1.5 nm north-east of Shoreham

Airport, West Sussex

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - None

Injuries: Crew - None Passengers - N/A

Nature of Damage: Nose landing gear leg collapsed and damage to

bulkhead
Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 28 years

Commander’s Flying Experience: 89 hours (of which 17 were on type)

Last 90 days - 13 hours
Last 28 days - 5 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot and further enquiries by the AAIB

Synopsis

While on late downwind the engine started coughing and losing power. The pilot carried
out some checks, but the engine subsequently lost all power. He picked a field and glided
to it but touched down nosewheel first causing the nose landing gear leg to collapse. The
pilot had recently practised forced landings with an instructor and this likely contributed to
the safe outcome. An aircraft examination did not reveal any faults, and the conditions were
conducive to serious carburettor icing at any power, but the cause of the loss of power could
not be determined.

History of the flight

The pilot was carrying out circuit practice at Shoreham Airport using Runway 20. He had
carried out four uneventful circuits with ‘touch-and-go’ landings, and then while late downwind
on his fifth circuit, at about 1,100 ft aal, he reported that the engine started coughing and
losing power. He pumped the throttle, checked the magnetos were on and that the mixture
was rich. He could not recall if the carburettor heat was on or if he selected it on.

The engine subsequently lost all power. He made a MAYDAY call and looked for potential
landing sites as he did not think he could make it back to the runway. He found a field to
the north-east and headed towards it. He set two stages of flap, and once closer he set
full flap, but he did not recall doing any shutdown checks. The aircraft touched down “fairly

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AAIB Bulletin: 12/2023 G-BLJO AAIB-28901

flat” but nosewheel first, causing the aircraft to bounce and the nose landing gear leg to
collapse. The aircraft came to rest on its nose (Figure 1). The pilot exited the aircraft and
was not injured.

The pilot stated that he did not know what had caused the power loss and that he had
done the same thing on each of the previous four circuits, such as his downwind checks
which included checking that the mixture was rich and selecting the carburettor heat on for
10 seconds. He said he had practised forced landings with an instructor the week before,
and this enabled him to go into “autopilot mode” with picking a field and setting up an
approach. He thinks he flared a bit too early with the downhill slope which contributed to
the nosewheel-first touchdown.

The pilot stated that since the accident he has practised more forced landings.

Figure 1
Accident site

Aircraft examination

The maintenance organisation carried out an initial examination at the accident site the day
after the accident. They stated that there was nearly full fuel onboard. The spark plugs
looked normal, and the crankshaft could be rotated with the plugs removed. There was no
evidence of oil leaks. The fuel hose was disconnected from the carburettor and fuel flowed
freely. Fuel tank drain checks revealed a few droplets of water from the left tank and no
water from the right tank. Both magnetos were secure with no evidence of slippage.

After the aircraft was recovered from the field the maintenance organisation removed the
air intake assembly and carburettor. The carburettor heat valve operated normally and
actuating the throttle mechanism caused fuel to be ejected from the fuel jet. The carburettor
was then installed on another engine and the engine ran normally.

At the time of writing the engine core has been removed from service and will be sent for
overhaul at some stage.

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AAIB Bulletin: 12/2023 G-BLJO AAIB-28901

During the aircraft’s last annual maintenance check in September 2022, about 100 flying
hours before the accident, the engine had a top overhaul. The engine had accumulated
over 2,500 hours since its last complete overhaul when the engine manufacturer’s
recommended time between overhaul (TBO) is 2,400 hours. The operator was operating
the engine beyond the TBO by using an engine extension programme as defined in their
risk assessment RA47 which involved more detailed checks and inspections; this had been
approved by the CAA as part of their approved maintenance programme.

Meteorology

Ten minutes before the accident, the METAR at Shoreham Airport stated that the wind was
from 250° at 9 kt, the visibility was more than 10 km, the clouds were few at 1,500 feet and
scattered at 1,900 feet, with a temperature of 9°C and a dewpoint of 6°C; this meant the
relative humidity at the airport was 81%. At the circuit height of 1,100 ft aal the temperature
would have been about 2°C colder1, so the relative humidity would have been closer to
about 93%.

According to the CAA’s risk of carburettor icing chart, in the Safety Sense Leaflet on Piston
Engine Icing2, the temperature and dewpoint spread at the airport elevation indicated that
there was a serious risk of carburettor icing at any power setting (Figure 2).

Figure 2
Temperature and dewpoint, at Shoreham Airport near the time of the accident,
marked with a white cross on the CAA’s risk of carburettor icing chart

Footnote
1
The standard lapse rate in the International Standard Atmosphere (ISA) is 2°C/1,000 ft. The actual lapse
rate on the day could have been different.
2
CAA Safety Sense Leaflet on Piston Engine Icing, June 2023, [accessed October 2023].

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AAIB Bulletin: 12/2023 G-BLJO AAIB-28901

Pilot’s training history

The pilot had learnt to fly in California and after 54 hours of training in a Piper PA-28, during
July and August 2018, he passed his skills test and obtained his Private Pilot’s Licence with
an SEP rating that was valid for two years until 31 August 2020.

After flying once in the UK in 2019, he flew on 15 occasions in 2020 and 2021 from Redhill
Aerodrome in both a Piper PA-28 and a Cessna 152. He then did not fly for over a year
before starting to fly at Shoreham on 18 November 2022. He needed five flights with an
instructor, one in the Cessna 152 and four in a PA-28, before he was cleared to fly solo. The
instructor reported that he flew well but had issues with his checks and would sometimes
forget to turn the carburettor heat on when on downwind. He reported that after the training
flights his checks were good, so he signed him off.

The instructor’s understanding was that he had cleared the pilot to fly the PA-28, but the
pilot understood that he was cleared to fly the PA-28 and the Cessna 152. The paperwork
the instructor had signed stated ‘ready to fly solo’ without specifying a type.

Neither the flying school nor the instructor had checked the pilot’s licence which showed
that his SEP rating had expired on 31 August 2020. The pilot reported that he was unaware
that his rating had expired. There is no CAA system for reminding pilots when their ratings
are due to expire3. In the year leading up to 31 August 2020 the pilot had flown more
than 12 hours and had flown more than one hour with an instructor, so he had met the
requirements for rating revalidation but had not obtained the required signature in his
licence. The pilot subsequently obtained a new SEP rating on 18 January 2023.

The pilot flew a PA-28 solo from Shoreham on 16 and 20 December 2022, and then a
PA‑28 with an instructor at Redhill. On the day of the accident the pilot had booked to fly
the Cessna 152 solo from Shoreham. The flying school’s booking system allowed the pilot
to book this aircraft despite the flying school being of the view that he was not cleared to fly
the Cessna 152 solo.

The flying school has updated its electronic booking system to show in red any pilot who is
out of currency or not checked out when they try to book an aircraft. Pilots’ licence and rating
validities are now checked by admin staff and daily checks are carried out by a flight instructor.

Aircraft flight manual

The flight manual4 for the aircraft states the following procedure for an engine failure during
flight:

‘1. Glide Speed – 111 km/h – 60 kts – 69 MPH IAS.

2. Carburetor Heat – “ON”.

Footnote
3
Unlike with driving where the UK’s Driver and Vehicle Licensing Agency (DVLA) reminds drivers when their
driving licence is about to expire.
4
Aircraft Flight Manual Reims/Cessna F152, D1170-13GB, serial number F15201429 and up.

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AAIB Bulletin: 12/2023 G-BLJO AAIB-28901

3. Primer – IN and LOCKED.

4. Fuel Shutoff Valve – “ON”.

5. Mixture – RICH.

6. Ignition Switch – “BOTH” (or “START” if propeller stopped).’

It also contains a procedure for ‘Rough Engine Operation or Loss of Power’; this states that
a gradual loss of engine rpm and engine roughness may result from carburettor ice and
that to clear the ice full throttle should be applied and the carburettor heat knob pulled fully
out. It states that engine roughness can also be caused by spark plug fouling or a magneto
issue, and the magneto switch should be momentarily moved to the left and right position
to help diagnosis.

Use of carburettor heat in the circuit

The flight manual’s ‘Before Landing’ checklist states ‘Carburetor Heat – “ON” (apply full
heat before reducing power).’ The ‘Balked Landing’ checklist starts with: ‘1. Throttle – FULL
OPEN, 2. Carburetor Heat – COLD.’

When flying a circuit, the ‘Before Landing’ checklist is carried out on the downwind leg;
therefore, following the flight manual’s checklist would involve selecting the carburettor
heat on when on downwind and then leaving it on until landing, unless a ‘balked landing’
(goaround) is performed.

The pilot’s instructor at Shoreham had taught the pilot to use the same carburettor
heat technique on both the PA-28 and the Cessna 152. The flight manual for the
Piper PA‑28‑1615 states in the ‘Descent’ checklist ‘Carburetor heat…ON if required’. It
does not have a checklist for a balked landing or go-around.

The instructor had taught the pilot to select carburettor heat on for 10 seconds on downwind,
to check for the presence of carburettor ice, and then to turn it off if no ice is present. The
presence of ice is established by noting any increase in engine rpm which can result after
the ice has melted although some rough running can also occur when heat is first applied
and ice is present. The instructor taught the pilot to turn carburettor heat on again prior to
reducing power on the base leg, and then to turn it off when cleared to land on final - that is
four actuations of the carburettor heat knob during each circuit. He said that some of their
instructors teach to land the Cessna 152 with the carburettor heat on and then to turn it off
during a touch-and-go, because their belief is that the power loss from the carburettor heat
in the Cessna 152 is less than on the PA-28.

Other instructors are known to teach students to turn the carburettor heat on while on
downwind and then to leave it on until final or until doing a go-around or touch-and-go.

Footnote
5
Pilot’s Operating Handbook, Piper Cherokee Warrior II, PA-28-161. VB-880. Revision 25 April 2005.

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The CAA’s Safety Sense Leaflet on Piston Engine Icing states the following:

‘Landing

When conducting ‘downwind’ or ‘joining’ checks prior to landing, select the

carburettor heat on to remove any ice that may be present. It should be
selected to hot before power is reduced on base leg or final approach. In
many aircraft it is recommended to select the carburettor heat to cold again
at around 300 ft, to give improved power in the event of a go-around or touch
and go. The carburettor heat should be selected cold after landing if this was
not already done on final.

Go-around or touch and go

If the carburettor heat is still in the hot position, ideally it should be moved to
cold, prior to the application of take-off or go-around power. Check after applying
power that you have remembered to do so. This is to ensure the engine is
developing full power for the manoeuvre.’

The safety sense leaflet includes the following caveat: ‘The Aircraft Flight Manual (AFM) or
Pilot’s Operating Handbook is the primary source of information for individual aircraft. In the
case of a conflict between the guidance in this SSL and the applicable AFM, the latter shall
take precedence’.

The PA-28 types the pilot had been flying and the Cessna 152 use a carburetted Lycoming
engine. The engine manufacturer has published a Service Instruction concerning ‘Use
of Carburettor Heat Control’6. It states that ‘Full Heat’ should be applied during landing
approach if icing conditions are suspected. It also states that: ‘In the case that full power
needs to be applied under these conditions, as for an aborted landing, return the carburetor
to “Full Cold” after full power application.’ This is different to what is recommended in the
CAA’s safety sense leaflet which states to move it to ‘cold’ before power application.

Analysis

The relatively low-hours pilot experienced a complete loss of engine power at about
1,100 ft aal in the circuit but was able to select a field, maintain control and land. The
aircraft suffered some damage, but the pilot was uninjured. The pilot had recently practised
forced landings with an instructor and this likely contributed to the safe outcome.

The maintenance organisation’s examinations did not reveal any faults with the engine
or fuel systems and there was sufficient fuel onboard. A few droplets of water were
recovered from the left fuel tank, but this was a day after the accident so could have been
the result of condensation. Water in the fuel tanks usually affects engine performance
shortly after takeoff, but in this event the pilot had completed four circuits, so it is unlikely
that water was a factor.

Footnote
6
Lycoming Service Instruction No. 1148C, published 12 October 2007.

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According to the CAA’s chart on the risk of carburettor icing, the conditions on the ground
were conducive to carburettor icing at any power setting. There was a cloud layer 400 feet
above circuit height so the relative humidity would have been higher at circuit height than
at ground level. It is possible that the pilot forgot to select carburettor heat on downwind
or did not set it for long enough. This could have led to carburettor ice formation and the
coughing symptoms reported. The flight manual’s ‘rough engine operation’ checklist calls
for full carburettor heat to be selected. The pilot could not recall if it was still set or if he
set it. He recalled pumping the throttle which is not a procedure in the flight manual for
‘rough engine operation’ or for an engine failure. Pulling the throttle back to idle, during
pumping, could exacerbate a carburettor icing condition. The flight manual calls for full
power to be set. It also states to check each magneto, which the pilot did not attempt, but
he was at a very low height where the priority is to select a safe place to land and maintain
control of the aircraft.

The pilot had been taught to select carburettor heat on while on downwind, then off after
10 seconds, then on again on base, and then off again on final once cleared to land. That
is four selections of the carburettor heat knob which could increase the opportunity for one
of these selections to be missed. The flight manual does not include a pre-landing check
that involves selecting carburettor heat on for 10 seconds; it states to select carburettor heat
on, and then leave it on until landing or a ‘balked landing’. Flying a downwind leg with the
carburettor heat off could contribute to carburettor ice formation.

Carburettor icing is a possible cause of the loss of power experienced, but it is also possible
that the pilot made an incorrect fuel system or engine control selection because this was
only his second flight in a Cessna 152 in over a year. The flying school stated that the pilot
had not been approved to fly the Cessna 152 solo, but this was not clear to the pilot and
the booking system did not prevent him booking that aircraft type. The booking system has
been modified to prevent this in future.

The engine core has not yet been examined so an engine fault cannot be entirely ruled out.

Conclusion

The engine lost power late downwind in the circuit. The maintenance organisation’s
engine and fuel system examinations did not reveal any faults, although the engine core
had yet to be examined. The conditions were conducive to carburettor icing at any power,
so this was a possible cause, but no conclusive cause could be determined. The pilot had
recently practised forced landings with an instructor and this likely contributed to the safe
outcome.

Safety actions

The flying school has updated its electronic booking system to show in red any
pilot who is out of currency or not checked out when they try to book an aircraft.
Pilots’ licence and rating validities are now checked by admin staff and daily
checks are carried out by a flight instructor.

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AAIB Bulletin: 12/2023 G-CKCF AAIB-28767

ACCIDENT

Aircraft Type and Registration: Scintex CP301-C1, G-CKCF

No & Type of Engines: 1 Continental Motors Corp C90-14F piston

engine

Year of Manufacture: 1960 (Serial no: 557)

Date & Time (UTC): 31 October 2022 at 1058 hrs

Location: Blue Bell Hill, Kent

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - None

Nature of Damage: Aircraft destroyed

Commander’s Licence: Airline Transport Pilot’s Licence

Commander’s Age: 65 years

Commander’s Flying Experience: 5,425 hours (of which 16 were on type)

Last 90 days - 88 hours
Last 28 days - 25 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot

Synopsis

The aircraft settled into trees shortly after takeoff. The pilot reported that he took action to
remain in control of the aircraft until impact and the occupants were rescued uninjured. The
pilot suspected that the engine had suffered from carburettor icing and reported that the
aircraft encountered turbulence sufficient to cause a loss of control. The aircraft probably
exceeded its maximum takeoff weight.

History of the flight

The occupants intended to fly from Rochester to Goodwood. The pilot reported that there
was no pressure to undertake the flight.

After the pre-flight ground inspection and start-up, the aircraft remained on the apron for the
engine oil to warm up, then taxied on the Eastern Taxiway to the threshold of Runway 20R.
An engine check was conducted at the threshold, during which the magnetos performed
normally, and the application of carburettor heat was accompanied by a 100 rpm drop.
Carburettor heat remained on until the aircraft was lined up and ready for takeoff, with one
stage of flap set, and during this interval the engine ran smoothly and without any signs of
carburettor icing.

The pilot reported that the takeoff and initial climb were normal, and flap was raised as
usual.

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AAIB Bulletin: 12/2023 G-CKCF AAIB-28767

Approaching a wooded ridge south of the aerodrome, the pilot perceived that the aircraft
was lower than usual and the passenger, who was also a pilot, noticed that engine speed
had reduced. The pilot recalled that the indicated airspeed was 55 kt and that the aircraft
then encountered turbulence which resulted in an incipient spin. He immediately applied
opposite rudder and nose-down elevator, and regained wings level flight shortly before the
aircraft settled into trees, impacting with sufficient force for both occupants’ headphones
and glasses to come off, but not to cause injury. Their four-point harnesses and the cabin
remained intact, and there was no apparent fuel leak.

The pilot switched off the fuel and magnetos, and used the radio to call for assistance.
Rescue from the tree canopy was complex and took several hours, involving machinery for
working at height.

Aircraft information

The Scintex CP301-C1 is a light two seat taildragger of mostly wood and fabric construction
with a maximum takeoff weight of 650 kg. G-CKCF was fitted with two fuel tanks in the
fuselage with a total capacity of 120 litres. The propeller, a Hoffman 7H-14-RZ of 178 cm
diameter and 120 cm pitch, was refurbished in April 2022.

A witness familiar with the aircraft reported that the engine was equipped with a carburettor
heat system that, when selected on, directed warm air into the carburettor air intake. Such
a system can reduce or prevent ice build-up in the intake and throttle body and may reduce
ice that has already accumulated.

No pre-existing mechanical defects were reported.

Weight and balance

The aircraft had a basic weight of 427 kg when checked in June 2019. Its maximum takeoff
weight was 650 kg. Both fuel tanks were full before the flight.

The pilot calculated that the aircraft’s weight on this takeoff was 648.5 kg, stating that he
assumed a fuel weight of 73.5 kg. He had understood that the capacity of the tanks was
approximately 100 litres, and he used a specific gravity of 0.7 kg per litre to calculate the
weight of the fuel.

At standard pressure and temperature, the specific gravity of 100LL (Avgas) fuel is 0.72 kg
per litre, and full fuel (120 litres) in both tanks would weigh approximately 86 kg. There was
no evidence of activity before takeoff that would have significantly reduced the weight of fuel.

At the time of the accident the pilot estimated that he and his passenger together weighed
148 kg, making the aircraft approximately 11 kg overweight without any additional load.

The pilot stated that the aircraft also carried two headsets, a quart of oil, a fuel strainer and
dipstick, some cloths and a bag. He estimated that together these weighed no more than
10 kg. Therefore, the aircraft probably weighed approximately 671 kg, 3.2% above the
stated maximum.

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Meteorology

An unofficial report of conditions at Rochester at 1058 hrs indicated wind from 140° at 12 kt,
visibility more than 10 km, cloud scattered with a base at 2,000 ft and surface temperature
12°C. At 1050 hrs weather information obtained from Biggin Hill, 18 nm west of Rochester,
indicated similar conditions, with wind from 150° at 9 kt, temperature 14°C, dewpoint 12°C
and QNH 1014. At Southend, 15 nm to the north-east, the wind was from 160° at 12 kt,
temperature 16°, dewpoint 13° and QNH 1014.

Wind speed and direction remained largely constant in the hour before and after the
occurrence, and there were no reports of significant gusts. There had been light rain at
Rochester approximately 24 hours before the takeoff.

Aerodrome information

Rochester Airport has an elevation of 426 ft and two parallel grass runways.
Runway 02L/20R has a TODA of 830 m and Runway 02R/20L a TODA of 684 m. The
average slope from north to south is approximately 1% up.

The pilot recalled that the surface was dry and firm during the takeoff. Other reports
indicated that it was wet or very wet, with soft ground in places. Photographs taken shortly
after the accident showed wet grass and some standing water in the vicinity.

The area of wood into which the aircraft descended rises to the same elevation as the
aerodrome approximately 400 m to the south of the upwind runway threshold, then rises
steadily to 130 ft above the aerodrome elevation at the accident site, a further 1,000 m to
the south-south-west. The relative locations are shown in Figure 1. The average gradient
from the runway end to the accident site is therefore approximately 3%.

A note on the aerodrome’s website stated, ‘The proximity of large buildings and topography
may cause turbulence and windsheer [sic] in some wind conditions.’1

Aircraft performance

Demonstrated performance

The aircraft manual shown to the AAIB did not contain takeoff performance information.
Other sources indicate that at the maximum takeoff weight of 650 kg, a typical takeoff
ground roll from a hard runway would be approximately 280 m, and the takeoff distance to
clear a 15 m obstacle approximately 500 m.2

During an assessment reported to the LAA in 2021 the aircraft achieved a climb rate of
approximately 600 fpm at full throttle and 58 KIAS, between 1,500 and 4,460 ft. The aircraft
was found to exhibit a pre-stall buffet at 40 KIAS with flaps up. Insufficient information was
recorded to determine the density altitudes at which the assessment was conducted.

Footnote
1
Aerodrome website accessed October 2023.
2
At sea level, 15°C and QNH 1013 HPa.

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Upwind
threshold of
Runway 20R

Final
position of
G-CKCF

Figure 1
The relative locations of the upwind threshold of Runway 20R
and the final position of G-CKCF

During a Permit revalidation check flight in May 2022, the aircraft achieved a climb from
1,000 ft to 2,000 ft in 110 seconds at 61 KIAS, 2,200 rpm. This equates to a climb rate of
545 fpm and a climb gradient of 8.8% in still air. The departure aerodrome for the check
flight had an elevation of 565 ft, at which the surface temperature was 14°C and the QNH
1010 HPa.

Factors affecting takeoff performance

Safety Sense Leaflet 7 – ‘Aeroplane performance’, published by the CAA, includes

guidance on assessing takeoff performance and summarises information provided in
Aeronautical Information Circular (AIC) 127/2006. These documents include factors that
may be applied to basic performance data to determine the likely effect of runway and
atmospheric conditions. AIC 127/2006 cautions that for surface and slope factors the
increases shown are to the takeoff distance to a height of 50 ft, but that since these factors
do not influence the airborne part of the takeoff, the effect on ground run is proportionally
greater. As surface and slope have no effect once the aircraft is airborne, it is possible to
estimate the effect of these factors on the ground run if data is provided for both takeoff
run and takeoff distance.

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Applying the factors for wet grass, upslope and soft ground yields a ground run of 700 m or
more. Applying the recommended safety factor of 1.33 indicates that the takeoff ground run
required may have been 930 m or more, exceeding the takeoff run available.

Lifting off before an adequate climb speed has been achieved results in less than optimum
climb performance. The best angle of climb is achieved at the airspeed where excess thrust
(the amount of thrust available above thrust required) is greatest. Below this speed, the
thrust required to overcome total aircraft drag increases and excess thrust reduces.

Other information

A witness reported that as the aircraft passed the upwind end of the runway it was flying
slower than expected, in a steep nose-up attitude.

The pilot stated that his normal technique was to apply carburettor heat until setting power
for takeoff, and then to take off with full power and one stage of flap set. He reported that
he considered the sustained drop in rpm when carburettor heat was selected on during the
power check, and the absence of rough running indicated that icing was not present. He
commented that the performance of the aircraft was normally “ok but not sparkling”.

The pilot recalled that on the accident takeoff he checked that the rpm at full power was
correct at about 2,450-2,500 rpm. An engine speed of 2,350 rpm was achieved during a full
power takeoff when assessed in 2021.

The pilot reported that the takeoff and initial climb were normal but that the flight path
seemed low over the trees. When the trees could not be avoided he resisted the temptation
to raise the nose, keeping the wings level and maintaining flying speed until impact.

Safety Sense Leaflet 14 – ‘Piston engine icing’, includes a chart indicating that the prevailing
temperature and dewpoint were within the range conducive to the formation of severe icing
at any power setting. 3

The pilot commented that he could have applied carburettor heat if he had suspected
carburettor icing sooner, but that the situation developed so quickly he doubted it would have
helped. It is possible for ice to defeat a carburettor heating system if it has accumulated
before the system is selected on.

A pilot who had flown G-CKCF from Rochester reported that with one person on board and
full fuel the performance was “barely sufficient” to clear obstacles in the takeoff flight path,
and that in 30 hours of operating the aircraft he had not encountered carburettor icing on
takeoff.

Another pilot reported that he would not fly the aircraft from Rochester with full fuel and a
passenger.

Footnote
3
Accessed August 2023.

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Analysis

There was no report of pre-existing mechanical defects. The aircraft weight probably
exceeded its maximum for takeoff of 650 kg.

It was not possible to determine if carburettor icing had reduced the available engine power.
The pilot’s statements indicate he had determined no carburettor icing was present before
the aircraft was ready for takeoff. However, the temperature and dewpoint were within the
range conducive to the formation of severe icing at any power setting.

The investigation did not determine at what point on the runway the aircraft became
airborne, nor its initial climb speed. The takeoff ground roll would have been influenced
by the aircraft weight, aerodrome elevation, surface condition, and upslope. Applying the
factors suggested in relevant CAA guidance indicates that the takeoff run required may
have exceeded the available runway length. The low speed and steep attitude observed by
one witness, if representative, are consistent with an attempt to continue the takeoff without
having achieved sufficient speed for adequate climb performance.

The full-throttle climb performance at maximum takeoff weight demonstrated in 2021 and
2022 exceeded the gradient from the runway end to the point of impact. Not achieving
this performance in the prevailing conditions, which were not significantly different, is
consistent with additional weight, reduced power, takeoff and climb with insufficient speed,
or a combination of these.

Information published by the aerodrome indicated that windshear was possible in some
circumstances. There were no indications of meteorological conditions conducive to
significant windshear.

The aircraft settled into trees upright and largely wings level. The pilot reported having
resisted the temptation to raise the nose, maintaining a speed of approximately 50 kt until
impact. Maintaining controlled flight until touchdown or impact increases the probability of
a survivable outcome.

Conclusion

The aircraft had insufficient performance to clear obstacles in the takeoff path. Its weight
probably exceeded the maximum permitted for takeoff, and its performance may have been
diminished by a reduction in power due to carburettor icing.

Safety information

CAA Safety Sense Leaflet 07 – ‘Aeroplane performance’, Safety Sense Leaflet 14 – Piston
engine icing’ provide relevant guidance. The Skyway Code also provides advice and
guidance relating to aircraft mass, balance and performance.4

Footnote
4
Accessed October 2023.

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

SERIOUS INCIDENT

Aircraft Type and Registration: Vans RV-7, G-RVDB

No & Type of Engines: 1 Superior XP-IO-360-B1HC2 piston engine

Year of Manufacture: 2018 (Serial no: PFA 323-14526)

Date & Time (UTC): 29 August 2022 at 0753 hrs

Location: Ronaldsway Airport, Isle of Man

Type of Flight: Private

Persons on Board: Crew - 1 Passengers - 1

Injuries: Crew - None Passengers - None

Nature of Damage: None

Commander’s Licence: Private Pilot’s Licence

Commander’s Age: 71 years

Commander’s Flying Experience: 1,874 hours (of which 1,769 were on type)
Last 90 days - 23 hours
Last 28 days - 9 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot and other AAIB enquiries

Synopsis

After attending to an uneasy passenger while orbiting over the sea, the pilot inadvertently
approached and landed on Runway 03 instead of the active Runway 08. The ATCO, who
was attending to ground activities, did not observe the aircraft during its final approach.

The report considers the importance of recovering situation awareness and adopting sterile
cockpit procedures before commencing with an approach. It discusses vigilance in ATC
and the importance of teamwork in detecting possible misperceptions.

The air traffic services unit is taking safety action relating to the monitoring of aircraft, and
team resource management training.

History of the flight

The aircraft was cleared on Ronaldsway’s radar frequency to enter the control zone under
VFR, and advised to expect joining right hand downwind for landing on Runway 08, which
was in use. When around 3.5 nm south-east of the airport at 2,800 ft amsl, the aircraft was
transferred to the tower frequency. The ATCO reported a surface wind from 080° at 9 kt,
offering the pilot a choice of Runways 08 or 03.

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

The pilot requested Runway 08 before being instructed to ‘report ready for right base
runway zero eight.’ The aircraft appeared to turn downwind for Runway 08 although its
position was also consistent with right base for Runway 03 (Figure 1)1,2.

Figure 1
G-RVDB’s position after pilot requested Runway 08

From there, the pilot reported ready for right base (Figure 2). He was instructed to orbit left
to accommodate an ATR 76 on a commercial air transport flight that was joining final for
Runway 08 at 8 nm.

Figure 2
G-RVDB’s position when the pilot reported ready for right base Runway 08

The pilot was unable to see the ATR during its approach so the ATCO advised him when it
landed, and the pilot reported ready to leave the orbit (Figure 3).

Footnote
1
Figures 1-4 are screenshots of the Air Traffic Monitor from the ATS unit’s investigation report on the incident.
2
The ATM screen is orientated south up, because of the control tower’s orientation.

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

Figure 3
G-RVDB leaving orbit

The pilot reported that he aligned the aircraft with a “large runway slightly off to [his] right”,
calling ‘final zero eight’ on the radio frequency, and was cleared to land on Runway 08
(Figure 4). However, he inadvertently performed an approach and landing on Runway 03
instead.

Figure 4
G-RVDB reports turning final Runway 08

The aircraft stopped its landing roll around the intersection of the two runways (Figure 5).
Confusion over taxi instructions, which the ATCO issued as though the aircraft had landed
on Runway 08, led the pilot to re-orientate the airfield against the chart he was using.

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

Figure 5
Ground situation after the ATR had landed

Meteorological information

Ronaldsway’s visibility was reported at 0750 hrs as 10 km or more, with few clouds at
1,500 ft.

Additional information from the pilot

The pilot reported he had focussed attention on reassuring the passenger who expressed
unease while orbiting over the sea. The absence of fixed ground references made orientating
himself during the turning manoeuvre more difficult. He noticed a crosswind after joining
final approach but did not check the compass. Having been given a choice of runways, he
believes he experienced confirmation bias3 during the approach by mis-reading the runway
designation numbers ‘03’ as ‘08’, while he was thinking about his landing technique.

Information from the air traffic services unit (ATSU)

The ATC tower

Both the ATCO and air traffic services assistant (ATSA) said it had been a quiet morning.
Glare from the morning sun and sea made it difficult to see aircraft from the south-facing
control tower, with the sunblinds themselves presenting a “margin” across the window and
additional glare from their “shiny” surface (Figure 6).

Footnote
3
Confirmation bias – tendency to seek out and prefer information that supports an existing belief, even in light
of contradictory information.

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

Figure 6
View of Runway 03 approach with similar glare and sunblind position as the incident4

The ATSA

The ATSA indicated that around the time G-RVDB reported ready for right base, he told
the ATCO that from the air traffic monitor (ATM) he believed the aircraft was not aligning
correctly with the runway but that the ATCO did not respond. The ATCO asked the aircraft
to orbit, which the ATSA felt corrected the situation to the extent the pilot would need to re-
orientate himself. He could see the aircraft while it orbited.

While the ATR was on ‘short final’ for Runway 08, the ATSA took an operational phone call.
He returned looking for G-RVDB on Runway 08’s final approach but noticed it had already
landed. Sensing it had arrived sooner than he expected, he asked the ATCO if it had landed
on Runway 03. The ATCO indicated he believed it had landed on Runway 08.

The ATCO

The ATCO indicated that because of the outside glare he had observed G-RVDB on the ATM
while it was orbiting. He recalled wondering why the pilot could not see the ATR during its
approach and felt confident from the pilots readbacks that he would align with Runway 08.
He did not visually acquire the aircraft during its final approach because he was checking
that the ATR’s parking stand was clear. Similar to the ATSA, he said he returned to looking
for G-RVDB on ‘short final’ for Runway 08 to find it had landed. He said he discovered it
had landed on Runway 03 during the subsequent couple of days.

The ATCO reflected on the importance of monitoring general aviation aircraft, especially
those unfamiliar with Ronaldsway, and responding to colleagues’ input. He said he

Footnote

4
Photograph from the ATS unit’s investigation report on the incident.

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

previously worked in a control tower with no ATM and as a result of this incident intends to
monitor the ATM more often.

The ATSU’s investigation report

The ATSU’s investigation report on the incident listed ‘Preventative actions’5, including:

‘1. A reminder of the obligations to monitor all stages of final approach, in

order to recognise when an aircraft might be incorrectly or dangerously
positioned on approach should be included in the next safety digest.

2. A programme of TRM [team resource management] training should be

put in place. All members of the ATS section, including managers should
undergo TRM training. This should be done as a matter of urgency…

3. The sunblinds within the [visual control room] VCR are commonly
acknowledged within the section to cause significant visibility issues.’ An
‘action’ was opened to research an ‘alternative solution… or replacement
blinds…’

The Isle of Man’s Head of air traffic services reported the first item had been completed, and
confirmed their intent to undertake items two and three as safety actions in an appropriate
time frame.

Regulatory information

The CAA’s ‘Civil Aviation Publication (CAP) 493 Manual of air traffic services – Part 1’6
included the following:

‘Aerodrome controllers shall maintain as far as practicable, a continuous

watch by visual observation on all flight operations on and in the vicinity of an
aerodrome as well as vehicles and personnel on the manoeuvring area. Visual
observation shall be achieved through direct out-of-the-window observation,
or through indirect observation utilising a visual surveillance system[7] which is
specifically approved for the purpose by the CAA…

A landing aircraft, which is considered by a controller to be dangerously

positioned on final approach, shall be instructed to carry out a missed approach.
An aircraft can be considered as dangerously positioned when it is poorly placed
either laterally or vertically for the landing runway.’

Footnote
5
Listed as ‘Preventative actions’ in the report - these have been confirmed as safety actions by the Isle of Man
Head of air traffic services.
6
Formally adopted by the Isle of Man CAA (IOMCAA).
7
The IOMCAA stated no such visual surveillance system is approved at Isle of Man.

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

Human performance guidance

Situation awareness

The Civil aviation authority of New Zealand’s ‘Situation awareness’ guidance document
states8:

‘We have limited ability to divide attention amongst tasks and generally, have
to switch attention back and forth between tasks. This leaves us vulnerable to
losing track of the status of one task when our attention is drawn away from the
task at hand, or while engaged in another task.’

The UK CAA’s ‘Civil Aviation Publication 737’ (CAP 737) suggests pilots can update their
situation awareness using a systematic process, for example, ‘Rotate attention from plane
to path to people (aviate, navigate, communicate)…’; and ‘Monitor and evaluate current
status relative to your plan… Focus on details and scan the bigger picture…’9,10

Skybrary’s ‘Situational Awareness Quick Reference & Reminder’11 states:

‘Manage workload… Manage attention… Validate your data… Use multiple

sources… Check Your Understanding… Check for contradictory elements…
Think ahead…’

Its advice on recovering situation awareness includes:

‘Go to the nearest SAFE, SIMPLE and STABLE solution… Communicate –

Asking for help is not a weakness… Take time to think… Be willing to delay
flight progress.’

Sterile cockpit procedures

The European Aviation Safety Agency (EASA) describes ‘sterile’ cockpit procedures as time
when pilots ‘shall not be disturbed… except for matters critical to the safe operation of the
aircraft and/or the safety of the occupants.’

The CAA’s Safety Sense Leaflet 31 – ‘Distraction’12 provides guidance on ‘Distraction and
interruption in general aviation’. It states, ‘Research suggests that the disruptive effects of
distractions and interruptions can be reduced by making us aware of our vulnerability to
them’.

Footnote

8
Situational awareness guidance (aviation.govt.nz) [accessed 5 May 2023]
9
Referenced under ‘Tips for good SA management (Bovier, 1997)’.
10
CAP737 Flight-crew human factors handbook (caa.co.uk) [accessed 5 May 2023]
11
PowerPoint Presentation (skybrary.aero) [accessed 5 May 2023]
12
Safety Sense Leaflet - Distraction (caa.co.uk) [accessed 11 October 2023]

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

Vigilance

SKYbrary describes vigilance13 as:

‘…paying close and continuous attention to a field of stimulation for a period of

time, watchful for any particular changing circumstances.

...changes may be quite small, but their potential effect may be considerable.
The speed and accuracy with which we detect these changes (assuming we
detect them at all) determines the timeliness of our decisions and actions.
Vigilance is greatly affected by our level of alertness, and this is why we can be
affected not only by being overloaded but also by being ‘under-loaded’.

Perception and vigilance are closely related and affect the accuracy and
currency of our mental model of the air traffic situation. The vigilant ATCO can
detect situations where a misperception is likely and will therefore be more likely
to detect whether their perception is correct than a non vigilant ATCO…

Vigilance is not a skill… [It] is a result of a number of circumstances over which

the individual does not always have sufficient influence. It is also very difficult
for the individual to detect changes in their vigilance… Often, reduced vigilance
is revealed by unwanted outcomes of decisions and actions. That is why it is
very important that colleagues keep an eye on each other. It is usually easier
for somebody else to notice when things start to deteriorate then it is for us. We
can, however, take a number of measures that will help us to remain vigilant for
a longer period of time. By making sure we are physically fit, well rested, well
trained and informed, we enhance our capacity to stay vigilant longer.’

Analysis

The aircraft

It may have been disorientating and distracting to orbit without a fixed ground reference while
looking for inbound traffic and reassuring the passenger. Pilots can maximise their situation
awareness by managing potential distractions and taking time to focus systematically on
the aircraft, its flight path, and necessary communications – sometimes summarised as
‘plane, path, people’. Seeking help from ATC and taking time to observe the aerodrome
environment can avoid errors like confirmation bias.

ATC

The radio calls between the ATCO and the pilot were consistent with an aircraft performing an
approach to Runway 08, but neither seemed aware G-RVDB was approaching Runway 03
until after it landed. It is apparent the ATSA may have detected that the pilot was making an
approach to the wrong runway.

Footnote
13
Vigilance in ATM | SKYbrary Aviation Safety [accessed 12 July 2023]

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AAIB Bulletin: 12/2023 G-RVDB AAIB-28620

The ATSA could see G-RVDB while it orbited. The ATCO referred to the ATM because of
sun glare, which was known to impede direct visual observation of aircraft at Ronaldsway.
While the ATSU considers sun glare to be inherent to Ronaldsway’s south-facing control
tower, it intends to explore alternatives to the existing sun blinds.

The ATCO stopped monitoring G-RVDB to check on ground activities, feeling assured the
pilot knew which runway to use. The quiet morning may have reduced his vigilance. Being
alert to small changes or anomalies, and the possibility for unexpected events, helps ATCOs
to maintain their situation awareness and detect possible misperceptions – in themselves
or others.

In this case the outcome of G-RVDB landing on the wrong runway was benign. However,
Figure 5 illustrates the potential for conflict with other aircraft using the active runway or
taxiways.

Conclusion

The runway incursion occurred because the pilot mistook Runway 03 for Runway 08,
having been reassuring an uneasy passenger while orbiting over the sea. The ATCO did
not monitor the aircraft during its final approach.

Safety actions

The ATSU has published a reminder to controllers to monitor all stages of an

aircraft’s final approach to recognise when an aircraft might be incorrectly or
dangerously positioned. It intends to provide TRM training for all members of
the ATS section and to replace the VCR sun blinds if a better solution can be
found.

© Crown copyright 2023 42 All times are UTC

AAIB Bulletin: 12/2023 DJI Mavic 2 Pro AAIB-29098

ACCIDENT

Aircraft Type and Registration: DJI Mavic 2 Pro

No & Type of Engines: 4 DJI electric engines

Year of Manufacture: Unknown (Serial no: 163CJ1JR0A780V)

Date & Time (UTC): 27 March 2023 at 1000 hrs

Location: Liverpool

Type of Flight: Private

Persons on Board: Crew - None Passengers - None

Injuries: Crew - N/A Passengers - N/A

Nature of Damage: Front left, rear left and rear right arm modules
damaged and damage to the camera gimbal
module
Commander’s Licence: None

Commander’s Age: 28 years

Commander’s Flying Experience: 0 hours (of which 0 were on type)

Last 90 days - 0 hours
Last 28 days - 0 hours

Information Source: Aircraft Accident Report Form submitted by the

pilot and further enquiries by the AAIB

Synopsis

During a short flight the unmanned aircraft collided with a building. The pilot reported he
inadvertently pressed the wrong control lever. He did not hold the necessary qualification to
operate the aircraft. The operator has implemented new procedures to prevent recurrence.

History of the flight

The unmanned aircraft (UA) had been purchased by the university to assist with research.
The university had registered as an ‘operator’ with the CAA.

On the day of the accident the aircraft was being flown by a research student. It was his
first flight of any UA and he had not undertaken any training. He was intending to evaluate
how the aircraft could be used to assist his research. He decided to fly it from the window
of his living quarters on the third floor of the building, having confirmed there were no people
in the vicinity. After approximately 3 minutes of flight, whilst the aircraft was maintaining 10
meters above the ground, the pilot attempted to increase its height. However, he believes
he inadvertently pressed the forward/backward stick instead of the up/down stick. The
aircraft moved towards the building, collided with the wall and fell to the ground. No one
was injured but the aircraft was extensively damaged.

The pilot did not know what mode the UA was operating in when the accident occurred.

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AAIB Bulletin: 12/2023 DJI Mavic 2 Pro AAIB-29098

Aircraft examination

The aircraft and the flight logs were sent to the manufacturer for analysis. The manufacturer
confirmed the aircraft was behaving normally until the moment of the accident and there
was no evidence of any malfunction. It confirmed the aircraft was in ‘positioning mode’
when the accident occurred1.

Aircraft information

The DJI Mavic 2 Pro is a quadcopter with a takeoff mass of 907 g. It is fitted with a gimbal
mounted camera.

The UA has a vision system to detect obstacles and prevent collisions. However, it can
only see obstacles within its detection range and the system requires sufficient lighting and
sufficiently marked or textured obstacles. The vision system is not available in all flight
modes.

Drone regulation

UK Regulation (EU) 2019/947 and its associated acceptable means of compliance and
guidance material provides the regulation and policy in relation to the operation of UAS.
CAA CAP 722 ‘Unmanned Aircraft System Operations in UK Airspace’2 provides guidance
to assist in compliance with the applicable regulatory requirements.

If the accident flight was operated in compliance with the regulation it would have come
under the A2 subcategory. To operate in this category the pilot is required to obtain a
Flyer ID and hold an A2 Certificate of Competency (A2 CofC). To obtain this certificate a
pilot is required to undertake a theory course, pass an exam and certify they can safely fly
specified manoeuvres.

Details of the requirements for UA pilots and operators can be found via the CAA’s Drone
and Model Aircraft Registration and Education Scheme found at https://register-drones.caa.
co.uk/

Organisational information

Following the accident the university has reviewed its procedures for operating UAs and
introduced the following guidelines:

● All UAs (irrespective of the category they are flown in) must be logged with
the Safety Adviser’s office. No flying is allowed if the UA is not logged.

● All UAs will have a nominated responsible person assigned to them.

Footnote
1
The UA has three selectable modes (positioning, sport and tripod) plus a fourth mode (ATTI) which it can
switch to automatically in certain circumstances. In positioning mode the UA utilises GPS and its vision
system to locate itself, stabilise and navigate.
2
CAA CAP 722 ‘Unmanned Aircraft System Operations in UK Airspace’ available at https://publicapps.caa.
co.uk/docs/33/CAP722_Edition_9.1%20(1).pdf (accessed 19 July 2023)

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AAIB Bulletin: 12/2023 DJI Mavic 2 Pro AAIB-29098

● All areas will need to introduce secure arrangements for the storage and
access to the UAs.

● All pilots will complete the A2 CofC course.

● All pilots will attend the Safety Adviser’s Office drones training session.

Conclusion

During flight the pilot inadvertently pressed the forward/backward lever causing the UA
to collide with a building. The investigation did not determine why the UA’s vision system
did not detect the obstacle. The pilot had not undertaken any training and did not hold the
required qualification to operate the aircraft.

The university has implemented procedures to ensure appropriate control of UAs and to
ensure all pilots have completed the appropriate training, registration, and qualifications.

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AAIB Bulletin: 12/2023

AAIB Record-Only Investigations

This section provides details of accidents and incidents which
were not subject to a Field or full Correspondence Investigation.

They are wholly, or largely, based on information

provided by the aircraft commander at the time of reporting
and in some cases additional information
from other sources.

The accuracy of the information provided cannot be assured.

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AAIB Bulletin: 12/2023 Record-only investigations reviewed: September - October 2023

Record-only investigations reviewed: September - October 2023

4 Mar 2023 Piper PA-38-112 G-OFFS Hawarden Airport, Flintshire

The student pilot reported that while the aircraft was at the refuelling point,
its flaps and engine were affected by downdraft from a helicopter hover
taxiing on an adjacent taxiway. A subsequent engineering inspection found
no damage to the aircraft, which was returned to service.

28 May 2023 Cessna 175B G-ARMN Near Aldermaston, Berkshire

(modified)
Having successfully completed power checks, the aircraft took off and at
approximately 250 ft there was a loud bang. The engine lost power and
the pilot made a forced landing in a muddy field. After a ground roll of
about 30 m the nosewheel dug in and became detached. The engine
was 21 years old and maintained on-condition having gone beyond the
manufacturer’s 12 years service life check. The failure was subsequently
attributed to a failure of one of the cylinder head spark plug threads which
caused the spark plug and heli-coil to be ejected from the engine, and on
further inspection one of the remaining cylinders was found to have low
compression.

31 May 2023 Piper PA-28-181 G-BPXA Netherthorpe Airfield, Nottinghamshire

During approach to grass Runway 06 at Netherthorpe, a change in wind

resulted in the aircraft’s wheels touching a hedge near the threshold.
The wheel spats, nose landing gear, flaps, propeller and tailplane were
damaged but the pilot was able to taxi the aircraft.

4 July 2023 Piper PA-23-250 N15YP Clayton J Lloyd International Airport,

Anguilla
During the normal procedure to lower the landing gear for landing, the nose
gear did not extend. After several attempts to extend it and flying by the
control tower to obtain confirmation, the pilot observed three green lights
and proceeded to land. The nose landing gear collapsed on landing. The
cause was not established.

16 July 2023 Rotorsport UK G-CEYR Eaglescott Airfield, Devon

MT-03
The student pilot had just touched the gyroplane down after some solo
circuits; the wind was reported as 12 kt on the runway heading but varying
slightly from left to right. After touchdown, the pilot moved the stick
forward and slightly left (into wind) while the rotors were still turning but the
gyroplane “felt out of control” and rolled over onto its side. The pilot stated
that the accident would have been avoided if the stick had been held back
until the rotors had stopped and then pushed forward.

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AAIB Bulletin: 12/2023 Record-only investigations reviewed: September - October 2023

Record-only investigations reviewed: September - October 2023 cont

19 July 2023 Team Minimax 91 G-BYFV Hughley Airfield, Shropshire

The Single Seat De-Regulated (SSDR) aircraft suffered an engine failure
shortly after takeoff. During the forced landing, the wingtip struck a tree
and the aircraft landed heavily. The pilot escaped unaided but sustained
minor injuries; the aircraft was destroyed by the post-accident fire. Later
examination by the owner revealed the engine’s rear crankshaft bearing
had failed. The pilot suggested that pilots practise rapid evacuation from
the cockpit and consider wearing fireproof clothing.

20 July 2023 Casa 1-131E G-BHPL Henstridge Airfield, Somerset

Series 1000
Jungmann
On takeoff from Runway 24 at Henstridge the engine ‘coughed’ at about
100 ft then stopped, and the pilot considered options for a forced landing.
The aircraft hit trees at the edge of the airfield and came to rest inverted with
substantial damage. The pilot was not injured. The pilot did not identify a
cause of the engine failure.

10 Aug 2023 Fournier RF6B-100 G-BKIF Near Gloucester

The aircraft was approaching Gloucestershire Airport and descending at
low power with the carburettor heat set to OFF. The engine began to run
roughly and the pilot selected carburettor heat ON, but the engine then
stopped. The pilot manoeuvred the aircraft to glide toward the airfield but,
on short final and concerned the aircraft would not clear trees short of the
runway, the pilot made a right turn and landed on the central reservation
of the A40 dual carriageway. The cause of the engine failure was not
positively determined. There was significant damage to the aircraft.

3 Sept 2023 Vans RV-6A G-RUSL Westonzoyland Airfield, Somerset

The aircraft touched down heavily, then bounced which possibly damaged
the nosewheel. As the aircraft rolled out, the nosewheel dug into the grass
runway causing the aircraft to pitch onto its nose and become inverted.

4 Sept 2023 Piper PA-28-161 G-XENA Alderney Airport, Guernsey

On departure, a pilot from another aircraft reported that one of the red
threshold light units had fallen over. It was later established that the
previous aircraft, G-XENA, approached very low and hit the light. The
pilot of G-XENA commented that the aircraft descended unexpectedly on
short final.

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AAIB Bulletin: 12/2023 Record-only investigations reviewed: September - October 2023

Record-only investigations reviewed: September - October 2023 cont

6 Sept 2023 Piper PA-28-161 G-BFDK Compton Abbas Airfield, Dorset

Whilst taxiing to park after landing, the left wing struck a fence causing
damage to its tip and leading edge. The pilot was concentrating on
manoeuvring past a line of parked aircraft to the right, and insufficient
attention was given to avoiding the fence to the left.

6 Sept 2023 Piper PA-28-181 G-BGWM Solent Airport Daedalus, Hampshire

The aircraft was taxiing from a grass parking area for departure and its
left wingtip collided with the propeller of a parked aircraft. The plastic
wingtip of the taxiing aircraft was destroyed and the parked aircraft
required inspection before further flight. The pilot attributed the collision to
‘a momentary lapse of concentration’.

9 Sept 2023 Vans RV-4 G-INTS London Ashford Airport, Lydd, Kent
After landing, the right main landing gear collapsed. The aircraft had
ground-looped on its previous landing and it was possible that this
damaged the landing gear making it more likely that it would collapse.

13 Sept 2023 Piper PA-28-161 G-BMKR Leeds East Airport

The aircraft touched down normally but, as the student pilot applied the
brakes, it veered off the runway and onto the grass. As the aircraft came
to a halt, the nose landing gear collapsed.

14 Sept 2023 Cessna A152 G-BOSO Redhill Aerodrome, Surrey

The pilot made a normal approach but the sun was in his eyes, impairing
his vision, and the aircraft bounced on touchdown. He initially pulled back
on the control column but then pitched the aircraft nose down to improve
his view, and the aircraft struck the ground and turned over. The pilot
vacated the aircraft without assistance and sustained only minor injuries.
He subsequently observed that a go-around would have been a better
response to the initial bounce.

18 Sept 2023 Rotorsport UK G-GRYN Kiltinney Airfield, County Londonderry

Calidus
During takeoff from a narrow runway with a crosswind the aircraft departed
the runway. The pilot aborted the takeoff, the right mainwheel settled in
boggy ground and the aircraft toppled over onto its right side.

25 Sept 2023 Piper PA-28-140 G-OFTI St Athan Airfield, Vale of Glamorgan

The aircraft landed heavily, the nose landing leg failed and the propellers
struck the runway surface.

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AAIB Bulletin: 12/2023 Record-only investigations reviewed: September - October 2023

Record-only investigations reviewed: September - October 2023 cont

30 Sept 2023 Piper PA-15 G-ASHU Popham Airfield, Hampshire

(modified)
The aircraft’s engine lost power after lift-off following a touch-and-go
landing. The pilot lowered the nose to land ahead on the remaining
runway, but the aircraft suffered a hard touchdown and ran off the side of
the runway, and the landing gear collapsed.

9 Oct 2023 Cessna 170B N2366D Duxford Airfield, Cambridgeshire

During the rollout after landing, the aircraft hit a bump and started to drift
to the right. The left gear and spat dug into soft ground and the aircraft
ground looped. A subsequent inspection revealed that the airframe
structure had slight deformation.

15 Oct 2023 Aeroprakt A22 G-CHAD Park Hall Airfield, Derbyshire

Foxbat
The aircraft landed heavily in gusty conditions which resulted in a bent
nose landing gear leg.

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AAIB Bulletin: 12/2023

Miscellaneous
This section contains Addenda, Corrections
and a list of the ten most recent
Aircraft Accident (‘Formal’) Reports published
by the AAIB.

The complete reports can be downloaded from

the AAIB website (www.aaib.gov.uk).

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 AAIB Bulletin: 12/2023

TEN MOST RECENTLY PUBLISHED

FORMAL REPORTS
ISSUED BY THE AIR ACCIDENTS INVESTIGATION BRANCH

3/2015 Eurocopter (Deutschland) 2/2018 Boeing 737-86J, C-FWGH

EC135 T2+, G-SPAO Belfast International Airport
Glasgow City Centre, Scotland on 21 July 2017.
on 29 November 2013. Published November 2018.
Published October 2015.
1/2020 Piper PA-46-310P Malibu, N264DB
1/2016 AS332 L2 Super Puma, G-WNSB 22 nm north-north-west of Guernsey
on approach to Sumburgh Airport on 21 January 2019.
on 23 August 2013. Published March 2020.
Published March 2016.
1/2021 Airbus A321-211, G-POWN
2/2016 Saab 2000, G-LGNO London Gatwick Airport
approximately 7 nm east of on 26 February 2020.
Sumburgh Airport, Shetland Published May 2021.
on 15 December 2014.
Published September 2016. 1/2023 Leonardo AW169, G-VSKP
King Power Stadium, Leicester
1/2017 Hawker Hunter T7, G-BXFI on 27 October 2018.
near Shoreham Airport Published September 2023.
on 22 August 2015.
Published March 2017. 2/2023 Sikorsky S-92A, G-MCGY
Derriford Hospital, Plymouth,
Devon
1/2018 Sikorsky S-92A, G-WNSR
on 4 March 2022.
West Franklin wellhead platform,
North Sea Published November 2023.
on 28 December 2016.
Published March 2018.

Unabridged versions of all AAIB Formal Reports, published back to and including 1971,
are available in full on the AAIB Website
http://www.aaib.gov.uk

© Crown copyright 2023 55 All times are UTC

 Air Accidents Investigation Branch
Farnborough House AAIB Bulletin: 12/2023
Berkshire Copse Road
Aldershot GLOSSARY OF ABBREVIATIONS
Hants GU11 2HH
aal above airfield level kt knot(s)
ACAS Airborne Collision Avoidance System lb pound(s)
ACARS Automatic Communications And Reporting System LP low pressure
Tel: 01252 510300
ADF Automatic Direction Finding equipment LAA Light Aircraft Association
Fax: 01252 376999 AFIS(O) Aerodrome Flight Information Service (Officer) LDA Landing Distance Available
Press enquiries: 0207 944 3118/4292 agl above ground level LPC Licence Proficiency Check
http://www.aaib.gov.uk AIC Aeronautical Information Circular m metre(s)
amsl above mean sea level mb millibar(s)
AOM Aerodrome Operating Minima MDA Minimum Descent Altitude
APU Auxiliary Power Unit METAR a timed aerodrome meteorological report
ASI airspeed indicator min minutes
ATC(C)(O) Air Traffic Control (Centre)( Officer) mm millimetre(s)
ATIS Automatic Terminal Information Service mph miles per hour
ATPL Airline Transport Pilot’s Licence MTWA Maximum Total Weight Authorised
AAIB investigations are conducted in accordance with BMAA British Microlight Aircraft Association N Newtons
BGA British Gliding Association NR Main rotor rotation speed (rotorcraft)
Annex 13 to the ICAO Convention on International Civil Aviation, BBAC British Balloon and Airship Club Ng Gas generator rotation speed (rotorcraft)
EU Regulation No 996/2010 (as amended) and The Civil Aviation BHPA British Hang Gliding & Paragliding Association N1 engine fan or LP compressor speed
CAA Civil Aviation Authority NDB Non-Directional radio Beacon
(Investigation of Air Accidents and Incidents) Regulations 2018. CAVOK Ceiling And Visibility OK (for VFR flight) nm nautical mile(s)
CAS calibrated airspeed NOTAM Notice to Airmen
cc cubic centimetres OAT Outside Air Temperature
The sole objective of the investigation of an accident or incident under these CG Centre of Gravity OPC Operator Proficiency Check
Regulations is the prevention of future accidents and incidents. It is not the cm centimetre(s) PAPI Precision Approach Path Indicator
CPL Commercial Pilot’s Licence PF Pilot Flying
purpose of such an investigation to apportion blame or liability. °C,F,M,T Celsius, Fahrenheit, magnetic, true PIC Pilot in Command
CVR Cockpit Voice Recorder PM Pilot Monitoring
DME Distance Measuring Equipment POH Pilot’s Operating Handbook
Accordingly, it is inappropriate that AAIB reports should be used to assign fault EAS equivalent airspeed PPL Private Pilot’s Licence
or blame or determine liability, since neither the investigation nor the reporting EASA European Union Aviation Safety Agency psi pounds per square inch
ECAM Electronic Centralised Aircraft Monitoring QFE altimeter pressure setting to indicate height above
process has been undertaken for that purpose. EGPWS Enhanced GPWS aerodrome
EGT Exhaust Gas Temperature QNH altimeter pressure setting to indicate elevation amsl
EICAS Engine Indication and Crew Alerting System RA Resolution Advisory
EPR Engine Pressure Ratio RFFS Rescue and Fire Fighting Service
ETA Estimated Time of Arrival rpm revolutions per minute
ETD Estimated Time of Departure RTF radiotelephony
FAA Federal Aviation Administration (USA) RVR Runway Visual Range
FDR Flight Data Recorder SAR Search and Rescue
FIR Flight Information Region SB Service Bulletin
FL Flight Level SSR Secondary Surveillance Radar
ft feet TA Traffic Advisory
AAIB Bulletins and Reports are available on the Internet ft/min feet per minute TAF Terminal Aerodrome Forecast
http://www.aaib.gov.uk g acceleration due to Earth’s gravity TAS true airspeed
GNSS Global Navigation Satellite System TAWS Terrain Awareness and Warning System
GPS Global Positioning System TCAS Traffic Collision Avoidance System
GPWS Ground Proximity Warning System TODA Takeoff Distance Available
hrs hours (clock time as in 1200 hrs) UA Unmanned Aircraft
HP high pressure UAS Unmanned Aircraft System
hPa hectopascal (equivalent unit to mb) USG US gallons
IAS indicated airspeed UTC Co-ordinated Universal Time (GMT)
This bulletin contains facts which have been determined up to the time of compilation. IFR Instrument Flight Rules V Volt(s)
ILS Instrument Landing System V1 Takeoff decision speed
Extracts may be published without specific permission providing that the source is duly acknowledged, the material is
IMC Instrument Meteorological Conditions V2 Takeoff safety speed
reproduced accurately and it is not used in a derogatory manner or in a misleading context.
IP Intermediate Pressure VR Rotation speed
IR Instrument Rating VREF Reference airspeed (approach)
Published 14 December 2023. Cover picture courtesy of Marcus Cook
ISA International Standard Atmosphere VNE Never Exceed airspeed
© Crown copyright 2023 ISSN 0309-4278 kg kilogram(s) VASI Visual Approach Slope Indicator
KCAS knots calibrated airspeed VFR Visual Flight Rules
Published by the Air Accidents Investigation Branch, Department for Transport KIAS knots indicated airspeed VHF Very High Frequency
Printed in the UK on paper containing at least 75% recycled fibre KTAS knots true airspeed VMC Visual Meteorological Conditions
km kilometre(s) VOR VHF Omnidirectional radio Range
AAIB Bulletin 12/2023

AAIB Bulletin 12/2023

AAIB Bulletin 12/2023

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