Crash of a Piper PA-46-310P Malibu off Guernsey: 2 killed

Date & Time: Jan 21, 2019 at 2016 LT
Operator:
Registration:
N264DB
Flight Phase:
Survivors:
No
Schedule:
Nantes - Cardiff
MSN:
46-8408037
YOM:
1984
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
30.00
Aircraft flight hours:
6636
Circumstances:
The pilot of N264DB flew the aircraft and the passenger from Cardiff Airport to Nantes Airport on 19 January 2019 with a return flight scheduled for 21 January 2019. The pilot arrived at the airport in Nantes at 1246 hrs on 21 January to refuel and prepare the aircraft for the flight. At 1836 hrs the passenger arrived at airport security, and the aircraft taxied out for departure at 1906 hrs with the passenger sitting in one of the rear, forward-facing passenger seats. Figure 1 shows the aircraft on the ground before departure. The pilot’s planned route would take the aircraft on an almost direct track from Nantes to Cardiff, flying overhead Guernsey en route (Figure 2). The Visual Flight Rules (VFR) flight plan indicated a planned cruise altitude of 6,000 ft amsl and distance of 265 nm. The aircraft took off from Runway 03 at Nantes Airport at 1915 hrs, and the pilot asked Air Traffic Control (ATC) for clearance to climb to 5,500 ft. The climb was approved by Nantes Approach Control and the flight plan was activated. The aircraft flew on its planned route towards Cardiff until it was approximately 13 nm south of Guernsey when the pilot requested and was given a descent clearance to remain in Visual Meteorological Conditions (VMC). Figure 3 shows the aircraft’s subsequent track. The last radio contact with the aircraft was with Jersey ATC at 2012 hrs, when the pilot asked for a further descent. The aircraft’s last recorded secondary radar point was at 2016:34 hrs, although two further primary returns were recorded after this. The pilot made no distress call that was recorded by ATC. On February 4, 2019, the wreckage (relatively intact) was found at a depth of 63 meters few km north of the island of Guernsey. On February 6, a dead body was found in the cabin and recovered. It was later confirmed this was the Argentine footballer Emiliano Sala. The pilot's body was not recovered.
Probable cause:
Causal factors
1. The pilot lost control of the aircraft during a manually-flown turn, which was probably initiated to remain in or regain VMC.
2. The aircraft subsequently suffered an in-flight break-up while manoeuvring at an airspeed significantly in excess of its design manoeuvring speed.
3. The pilot was probably affected by CO poisoning.
Contributory factors
1. A loss of control was made more likely because the flight was not conducted in accordance with safety standards applicable to commercial operations. This manifested itself in the flight being operated under VFR at night in poor weather conditions despite the pilot having no training in night flying and a lack of recent practice in instrument flying.
2. In-service inspections of exhaust systems do not eliminate the risk of CO poisoning.
3. There was no CO detector with an active warning in the aircraft which might have alerted the pilot to the presence of CO in time for him to take mitigating action.
Final Report:

Crash of a Boeing 757-204 in Gerona: 1 killed

Date & Time: Sep 14, 1999 at 2347 LT
Type of aircraft:
Operator:
Registration:
G-BYAG
Survivors:
Yes
Schedule:
Cardiff - Gerona
MSN:
26965
YOM:
1993
Flight number:
BAL226A
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
236
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16700
Captain / Total hours on type:
3562.00
Copilot / Total flying hours:
1494
Copilot / Total hours on type:
1145
Aircraft flight hours:
26429
Aircraft flight cycles:
9816
Circumstances:
Flight BY226A took off from Cardiff at 20:40 local time for a charter flight to Gerona. The crew contacted Gerona ATC at 23:14 hours. With a thunderstorm in the area, flight conditions were turbulent. ATC offered the option of a runway 20 ILS approach, but the crew decided to fly a VOR/DME procedure to runway 02 considering the prevailing conditions of wet runway, downslope and tailwind. At 23:33, in full landing configuration and just after passing 10 DME, the crew were advised of a change of wind to 200 degrees at 12 knots. Upon becoming visual the aircraft was not adequately aligned with the runway and the change in wind direction now favored the reciprocal runway so a missed approach was carried out. The aircraft was now positioned for an ILS approach to runway 20. During the approach the crew noted that the company minimum amount of fuel for a diversion to Barcelona (2,800 kg) had been reached. At 23:46:58 hrs, at 250 feet above ground level (agl) and on the correct glidepath, the captain disconnected the autopilot and autothrottle. The aircraft began to deviate above the glidepath. Twelve seconds later, at 110 feet agl, the captain briefly pushed the control column almost fully forward before returning it to an approximately neutral position. The aircraft pitched down to -4.5° nose down attitude and then back up to -2.5° nose down attitude. During this period the captain lost his visual reference with the runway because all runway lights had suddenly failed. The GPWS then warned of the excessive sink rate and the thrust levers being retarded to idle. At 21:47:17 the aircraft touched down in a 2° nose down attitude and a recorded peak normal (vertical) acceleration of 3.11 g. The aircraft bounced, the nose pitched up to +3.3°, a roll to the right commenced, both the thrust levers advanced and the power on both engines increased to 1.18 EPR. Full nose down elevator was applied and held until a second touchdown, resulting in a rapid pitch down. The aircraft made the second touchdown 1.9 seconds after the first at -0.5° pitch attitude (nose down), with a pitch rate of 7°/sec nose down and 4.2° of right roll. After a run of approximately 343 meters across flat grassland beside the runway, the aircraft ran diagonally over a substantial earth mound adjacent to the airport boundary, becoming semi-airborne as a result. At the far side of the mound a number of medium sized trees were struck and severed, predominantly by the right wing, and the right engine nacelle struck the boundary fence. The aircraft, yawed considerably to the right of its direction of travel, then passed through the fence, re-landed in a field and both main landing gears collapsed. It came to rest after a 244 meter slide across the field, with the fuselage almost structurally severed at two points.
Probable cause:
It is considered that the most probable cause of the accident was the destabilization of the approach below decision height with loss of external visual references and automatic height callouts immediately before landing, resulting in touchdown with excessive descent rate in a nose down attitude. The resulting displacement of the nose landing gear support structure caused disruption to aircraft systems that led to uncommanded forward thrust increase and other effects that severely aggravated the consequences of the initial event.
Contributory factors were:
- Impairment of the runway visual environment as a result of darkness and torrential rain and the extinguishing of runway lights immediately before landing;
- Suppression of some automatic height callouts by the GPWS 'SINK RATE' audio caution;
- The effect of shock or mental incapacitation on the PF at the failure of the runway lights which may have inhibited him from making a decision to go-around;
- The absence of specific flight crew training in flight simulators to initiate a go-around when below landing decision height;
- Insufficient evaluation of the weather conditions, particularly the movement and severity of the storm affecting the destination airport.
Final Report:

Crash of a Saab 340B in Amsterdam: 3 killed

Date & Time: Apr 4, 1994 at 1446 LT
Type of aircraft:
Operator:
Registration:
PH-KSH
Survivors:
Yes
Schedule:
Amsterdam - Cardiff
MSN:
195
YOM:
1990
Flight number:
KL433
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2605
Captain / Total hours on type:
1214.00
Copilot / Total flying hours:
1718
Copilot / Total hours on type:
1334
Aircraft flight hours:
6558
Circumstances:
After take off from runway 24, the aircraft followed a VALKO departure as cleared by Air Traffic Control (ATC) . During climb, passing flight level 165 (FL165), the Master Warning was triggered by the right engine oil pressure Central Warning Panel (CWP) light. The Captain slowly retarded the right hand power lever to flight idle and called for the emergency checklist. After completion of the emergency checklist procedure, the right hand engine oil pressure CWP light was still on and the Captain decided to return to Amsterdam . The right hand engine remained in flight idle during the remainder of the flight. While returning to Amsterdam, the flight was radar vectored by ATC for an Instrument Landing System (ILS) approach on runway 06 . After passing approximately 200 feet height, the aircraft became displaced to the right of the runway and a go around was initiated. During the go around, control of the aircraft was lost and, at 12 :46 UTC, the aircraft hit the ground, in a slight nose low attitude with approximately 80° bank to the right, approximately 560 meters right from the runway 06 centerline, just outside the airport. Two passengers and the Captain died in the accident; eight passengers and the First Officer (FO) were seriously injured.
Probable cause:
Inadequate use of the flight controls during an asymmetric go around resulting in loss of control.
The following contributing factors were reported:
- Insufficient understanding of the flight crew of the SAAB 340B engine oil system,
- Lack of awareness of the consequences of an aircraft configuration with one engine in flight idle,
- Poor Crew Resource Management.
Final Report:

Crash of a Piper PA-31-310 Navajo at RAF Brize Norton

Date & Time: Jun 11, 1986 at 1145 LT
Type of aircraft:
Operator:
Registration:
G-BFON
Survivors:
Yes
Schedule:
Oxford – Cardiff
MSN:
31-405
YOM:
1968
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
150.00
Circumstances:
The aircraft departed Kidlington at 1133 hrs, the takeoff and initial climb to 1,500 feet being uneventful. Radio contact was made with Brize Norton Controller who requested the aircraft to climb to 2,000 feet on the Brize Norton QFE of 1005 millibars. This was complied with, and at 1140 hrs the aircraft experienced surging of one, then both engines culminating in a complete loss of power at a position 5 nautical miles north north west of Brize Norton. The commander advised the controlled that an engine problem had developed and that he was turning southwards towards the airfield. He subsequently declared a Mayday after opening the crossfeed and switching on the two electric fuel pumps to no avail. The commander stated that up until that time he had been on straight feed, ie right inboard tank feeding the right engine and left inboard tank feeding the left engine, with the crossfeed OFF. The commander also stated that during the unsuccessful attempts to restart the engines, the tank selectors remained as selected as he was aware of the physical presence of fuel in both inboard tanks prior to the departure from Cardiff, and uncertain of the contents of the outboards. The company pilot seated behind the front seats recalled the right fuel gauge was still reading over FULL, and that the left gauge was indicating empty. The commander decided that a forced landing short of the airfield was inevitable, and lowered the gear. The passengers were also warned to tighten their seat belts. At approximately 250 feet above ground level, the mixture levers were pulled back to idle cut off, and the magneto switches thought to have been selected to OFF. The aircraft landed in a field of standing barley and the nose gear detaches causing the nose and the right wing to strike the ground, the aircraft rotate approximately 180° to the right, and the main gear to collapse. On impact, the right engine caught fire immediately followed by the cabin, with fire spreading rearwards along the aisle. The two front seat occupants left by the left main door, the rear passenger by the right overwing exit. Minor injuries were suffered, the commander being detained in hospital for 24 hours with burns. The aircraft was destroyed by a severe fire.
Probable cause:
Double engine failure caused by a fuel exhaustion.
Final Report:

Crash of a Partenavia P.68B off Guernsey: 5 killed

Date & Time: Oct 3, 1981 at 0213 LT
Type of aircraft:
Registration:
EC-DHE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cardiff - Alicante
MSN:
184
YOM:
1979
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
While on a night IFR flight from Cardiff to Alicante, the airplane went out of control and crashed into the sea off Guernsey Island. SAR operations were initiated but eventually suspended after few days as no trace of the aircraft nor the five occupants was found.
Probable cause:
Due to lack of evidences, the exact cause of the accident could not be determined. However, it is believed that the loss of control was the consequence of an engine failure.

Crash of a Cessna 500 Citation I in Jersey: 1 killed

Date & Time: Oct 1, 1980 at 1902 LT
Type of aircraft:
Registration:
G-BPCP
Flight Type:
Survivors:
No
Schedule:
Cardiff - Jersey
MSN:
500-0403
YOM:
1980
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1787
Captain / Total hours on type:
132.00
Aircraft flight hours:
138
Circumstances:
The pilot had completed three flights previous to the accident flight on the same day. He left Jersey at 0729 hrs to fly to Coventry via Cardiff for a day of business meetings in the Midlands and to return, again via Cardiff, to Jersey in the evening. Before leaving Coventry at 1729 hrs he had filed Air Traffic Control (ATC) Flight Plans for the sectors to Cardiff and to Jersey, he also checked the weather conditions at Jersey. The conditions shown in the forecast were of poor weather with low cloud and visibility intermittently falling to 400 metres in drizzle with 7 oktas of cloud below 100 feet. The 1650 hrs weather report for Jersey was noted on the top of his copy of the flight plan, this showed: surface wind 2900 at 11 knots, visibility 6000 metres, cloud 4 oktas at 100 feet, 7 oktas at 200 feet, intermittently becoming 3000 metres visibility in drizzle with 6 oktas cloud at 100 feet. Sufficient fuel for a return flight from Jersey was on-loaded at Cardiff, the pilot remarked, to the Customs Officer, that he might have to return because of the weather at Jersey. The aircraft departed Cardiff for Jersey at 1821 hrs. It could not be established whether the pilot obtained the latest weather reports for Jersey, issued at 1720 hrs and 1750 hrs whilst at Cardiff; or if he availed himself of the in-flight weather broadcast service by London Volmet South, which transmitted the 1820 hrs Jersey weather report whilst en route. Had he done so, he would have been aware of deteriorating landing conditions because the 1820 hrs report for Jersey showed: visibility 300 metres, runway visual range (RVR) 800 metres in drizzle and 8 oktas of cloud below 200 feet. By 1842 hrs the aircraft was descending towards Jersey. The pilot was in radio contact with 'Jersey Zone' ATC, he had received his inbound clearance and had been advised of the latest weather conditions at Jersey. Radar guidance was provided by Jersey Zone, then later, by Jersey Approach Control who also advised that the RVR had fallen to 850 metres and, later, to 650 metres. On receipt of this information the pilot asked for the Guernsey weather. He was informed that the weather at Guernsey had improved to 1800 metres visibility although the cloud base was still below 100 feet. At 1857 hrs, when at 7 miles on the approach to runway 27 at Jersey, the pilot reported that he was established on the Instrument Landing System (lLS). He then contacted Jersey Tower controller who cleared G-BPCP to land. During the final stages of the approach, about 45 seconds before the crash, the Tower controller advised that the RVR had improved to 850 metres. This message was not acknowledged. The approach controller continued to observe the progress of the aircraft towards the runway on his radar screen until it was about one mile from the threshold, at which point it appeared to be on the extended centre line of the runway. The approach controller then left the radar screen and went to the window to watch for the aircraft landing. When the aircraft was half a mile from the runway, it was observed by an eyewitness to be on a normal approach path for runway 27. It was lost to view as it passed behind an adjacent house and almost immediately afterwards there was an increase in engine power. This increase was also heard by a professional pilot who was on the aerodrome, about 500 metres from the end of the runway; he said that the "engines started to spool-up as for an overshoot" and shortly afterwards he saw a flash and heard an explosion. The aircraft struck the roof of a house situated 190 metres to the north of the runway threshold centre line. The house caught fire, the tail of the aircraft lodged in the blazing roof whilst the remaining structure fell into a courtyard where it was destroyed by fire. The four persons occupying the house at the time were able to escape with minor injuries although one, a young girl, was detained in hospital with serious bums. The pilot was killed.
Probable cause:
The accident was caused by the commander failing to execute correctly a missed approach 'go-around' manoeuvre in conditions of poor visibility and low cloud at night. He failed to fly an accurate procedure and allowed the aircraft to continue to descend and turn to the right. It is probable that this resulted from incorrect instrument flying technique but partial physical incapacitation cannot be ruled out. It is also probable that spatial disorientation was a causal factor to the accident.
Final Report:

Crash of a De Havilland DH.104 Dove 2A in Cardiff: 4 killed

Date & Time: May 6, 1959
Type of aircraft:
Operator:
Registration:
G-ALEC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cardiff - Cardiff
MSN:
04402
YOM:
1958
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The aircraft was taking part to an airshow at Cardiff Airport, carrying a crew of two and two passengers. While flying in the vicinity of the airfield, the airplane went out of control and crashed in unclear circumstances, killing all four occupants.
Probable cause:
It is believed the accident was the consequence of a pilot error.

Crash of a De Havilland DH.104 Dove 1B in Fritham: 1 killed

Date & Time: Jul 23, 1955 at 0952 LT
Type of aircraft:
Operator:
Registration:
G-AKSK
Flight Phase:
Survivors:
Yes
Schedule:
Cardiff – Southampton – Paris
MSN:
04116
YOM:
1948
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Before leaving Cardiff (Rhoose) Airport the pilot filed a Visual Flight Rules flight plan giving an elapsed time of 35 minutes for the flight to Eastleigh Airport, Southampton at a cruising altitude of 5,500 feet and then on to Paris. The aircraft took off at 0925LT carrying the pilot and 6 passengers. At approximately 0950LT he called London, asked for clearance to Southampton Zone and was told to call Southampton Zone. He then acknowledged this request. Shortly after 0950 the engines became unsynchronized and the aircraft vibrated. The port propeller stopped rotating and the aircraft lost height. On reaching 200 feet the port engine was restarted and the aircraft flew very low over a line of high tension cables. It continued to fly at 200 feet at low speed with increased vibration over undulating country and after climbing slightly to clear a ridge it descended into a densely wooded area. When near the tree tops it banked to the left and the port wing tip struck a tree. The aircraft then traveled 400 yards further, struck the tops of several trees and crashed, killing the pilot and seriously injuring 4 passengers.
Probable cause:
The accident was the result of the pilot mistakenly shutting down the port engine instead of the starboard engine in which a serious mechanical fault had developed. This led to a rapid loss of height and although the pilot re- started the port engine the starboard engine was not shut down. The starboard engine had sustained considerable impact damage. When dismantled it was found that the crankshaft had broken at n° 3 crankpin. This failure had occurred before the crash as a result of a fatigue crack which developed at a plugged hole in the rear web of the n°3 crankpin. Heavy scoring on the faces of the crankcase web and cap of n°1 main bearing showed that n° 1 & 2 cylinders continued working after the crankshaft had failed. The crankshaft had run for a total of 1,205 hours since manufacture including 619 hours since the last overhaul when a modification designed to prevent failures of this nature was embodied.
Final Report: