Crash of an Embraer EMB-505 Phenom 300 in Blackbushe: 4 killed

Date & Time: Jul 31, 2015 at 1508 LT
Type of aircraft:
Registration:
HZ-IBN
Flight Type:
Survivors:
No
Schedule:
Milan - Blackbushe
MSN:
505-00040
YOM:
2010
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11000
Captain / Total hours on type:
1180.00
Aircraft flight hours:
2409
Aircraft flight cycles:
1377
Circumstances:
The aircraft had positioned to Milan earlier in the day, flown by the same pilot, and was returning to Blackbushe with the pilot and three passengers on board. After descending through the London Terminal Manoeuvring Area (TMA) it was handed over from London Control to Farnborough Approach. Its descent continued towards Blackbushe and, having reported that he had the airfield in sight, the pilot was instructed to descend at his own discretion. When the aircraft was approximately four miles south of its destination, he was instructed to contact Blackbushe Information. The weather at Blackbushe was fine with light and variable winds, visibility in excess of ten kilometres, and no low cloud. HZ-IBN entered the left-hand circuit for Runway 25 via the crosswind leg. Towards the end of the downwind leg, it overtook an Ikarus C42 microlight aircraft, climbing to pass ahead of and above that aircraft. As the climb began, at approximately 1,000 ft aal, the TCAS of HZ-IBN generated a ‘descend’ RA alert to resolve a conflict with the microlight. The TCAS RA changed to ‘maintain vertical speed’ and then ‘adjust vertical speed’, possibly to resolve a second conflict with a light aircraft which was above HZ-IBN and to the east of the aerodrome. Neither the microlight nor the light aircraft was equipped with TCAS. Following this climb, HZ-IBN then flew a curving base leg, descending at up to 3,000 feet per minute towards the threshold of Runway 25. The aircraft’s TCAS annunciated ‘clear of conflict’ when HZ-IBN was 1.1 nm from the runway threshold, at 1,200 ft aal, and at a speed of 146 KIAS, with the landing gear down and flap 3 selected. The aircraft continued its approach at approximately 150 KIAS. Between 1,200 and 500 ft aal the rate of descent averaged approximately 3,000 fpm, and at 500 ft aal the descent rate was 2,500 fpm. The aircraft’s TAWS generated six ‘pull up’ warnings on final approach. The aircraft crossed the Runway 25 threshold at approximately 50 ft aal at 151 KIAS. The aircraft manufacturer calculated that the appropriate target threshold speed for the aircraft’s mass and configuration was 108 KIAS. The AFISO initiated a full emergency as the aircraft touched down, because “it was clear at this time that the aircraft was not going to stop”. Tyre marks made by the aircraft at touchdown indicated that it landed 710 m beyond the Runway 25 threshold. The Runway 25 declared Landing Distance Available (LDA) was 1,059 m; therefore the aircraft touched down 349 m before the end of the declared LDA. The paved runway surface extended 89 m beyond the end of the LDA. The aircraft continued along the runway, decelerating, but departed the end of the paved surface at a groundspeed of 83 kt (84 KIAS airspeed) and struck an earth bank, which caused the aircraft to become airborne again. It then struck cars in a car park, part of a large commercial site adjacent to the aerodrome. The wing separated from the fuselage, and the fuselage rolled left through 350° before coming to rest on top of the detached wing, on a heading of 064°(M), 30° right side down and in an approximately level pitch attitude. A fire broke out in the underside of the aft fuselage and burned with increasing intensity. The aerodrome’s RFFS responded to the crash alarm but their path to the accident site was blocked by a locked gate between the aerodrome and commercial site. The first two RFFS vehicles arrived at the gate 1 minute and 34 seconds after the aircraft left the runway end. The third RFFS vehicle, which carried a key for the gate, arrived approximately one minute later, and the three RFFS vehicles proceeded through the gate 2 minutes and 46 seconds after the aircraft left the runway. As the aircraft was located in an area of the car park surrounded by a 2.4 m tall wire mesh fence, the RFFS vehicles had to drive approximately 400 m to gain access to the accident site. Despite applying all their available media, the RFFS was unable to bring the fire under control. The intensity of the fire meant that it was not possible to approach the aircraft to save life. All four occupants of the aircraft survived the impact and subsequently died from the effects of fire. Subsequently, local authority fire appliances arrived and the fire was extinguished.
Probable cause:
The pilot was appropriately licensed and experienced, and had operated into Blackbushe Aerodrome on 15 previous occasions. He was reported to be physically and mentally well. The aircraft was certified for single-pilot operations and the pilot was qualified to conduct them. The engineering investigation of the accident aircraft did not find evidence of any pre‑existing technical defect that caused or contributed to the accident. The meteorological conditions were suitable for the approach and landing and, at the actual landing weight and appropriate speed, a successful landing at Blackbushe was possible. HZ-IBN joined the circuit at a speed and height which would have been consistent with the pilot’s stated plan to extend downwind in order that the microlight could land first. The subsequent positioning of HZ-IBN and the microlight involved HZ-IBN manoeuvring across the microlight’s path, in the course of which the first of several TCAS warnings was generated. After manoeuvring to cross the microlight’s path, HZ-IBN arrived on the final approach significantly above the normal profile but appropriately configured for landing. In the ensuing steep descent, the pilot selected the speed brakes out but they remained stowed because they are inhibited when the flaps are deployed. The aircraft’s speed increased and it crossed the threshold at the appropriate height, but 43 KIAS above the applicable target threshold speed. The excessive speed contributed to a touchdown 710 m beyond the threshold, with only 438 m of paved surface remaining. From touchdown, at 134 KIAS, it was no longer possible for the aircraft to stop within the remaining runway length. The brakes were applied almost immediately after touchdown and the aircraft’s subsequent deceleration slightly exceeded the value used in the aircraft manufacturer’s landing performance model. The aircraft departed the paved surface at the end of Runway 25 at a groundspeed of 83 kt. The aircraft collided with an earth bank and cars in a car park beyond it, causing the wing to separate and a fire to start. Although the aircraft occupants survived these impacts, they died from the effects of fire. Towards the end of the flight, a number of factors came together to create a very high workload situation for the pilot, to the extent that his mental capacity could have become saturated. His ability to take on new and critical information, and adapt his situational awareness, would have been impeded. In conjunction with audio overload and the mental stressors this can invoke, this may have lead him to become fixated on continuing the approach towards a short runway.
Final Report:

Crash of a Raytheon 390 Premier I in Blackbushe

Date & Time: Apr 7, 2004 at 0932 LT
Type of aircraft:
Registration:
N200PR
Flight Type:
Survivors:
Yes
Schedule:
Farnborough - Blackbushe
MSN:
RB-79
YOM:
2001
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4511
Captain / Total hours on type:
413.00
Circumstances:
After takeoff the pilot was unable to raise the landing gear and was presented with failure indications affecting both the lift dump and anti skid systems. Following a successful landing at Farnborough, and discussions with the aircraft's maintenance organisation, the aircraft was flown to Blackbushe for further technical investigation. After landing on Runway 26 the aircraft left the runway, struck a series of obstructions and was destroyed: there was no fire and the pilot was uninjured. The support bracket for the right main landing gear weight-on-wheels switch was found to have sustained a pre-impact failure which accounted for the indications reported by the pilot. Five recommendations have been made as a result of this investigation.
Probable cause:
The support bracket for the right main landing gear weight-on-wheels switch was found to have sustained a pre-impact failure which accounted for the indications reported by the pilot.
Final Report:

Crash of a Beechcraft B200 Super King Air in Blackbushe: 5 killed

Date & Time: Dec 23, 2000 at 1351 LT
Operator:
Registration:
VP-BBK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Blackbush - Palma de Mallorca
MSN:
BB-1519
YOM:
1995
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2664
Captain / Total hours on type:
1243.00
Circumstances:
The aircraft, with the pilot and four passengers on board, departed Blackbushe from Runway 08 in fog with a visibility of less than 500 metres. As the aircraft reached the upwind end of the runway it was seen to bank to the left before disappearing from view. It crashed 13 seconds later into a factory complex where a major fire ensued. All on board were fatally injured. A substantial amount of the aircraft structure was consumed by fire. Engineering examination of that which remained showed that there was no malfunction found within the engines, propellers or controls that would have affected the flight. Analysis of the cockpit voice recorder however showed a reduction in one of the propellers rpm as the aircraft rotated that would have led to thrust asymmetry. Through a combination of lack of visual reference, confusion as to the cause of the power reduction and possible disorientation the pilot lost control of the aircraft and although he may have realised the situation seconds before impact with the ground there was insufficient height available to effect a safe recovery.
Probable cause:
Whilst the CVR does not provide any comments by the pilot as to the problems he was experiencing, spectral analysis of the CVR recording indicates that a significant difference in propeller rpm occurred at rotation when the pilot would normally have removed his right hand from the power levers. There was no evidence of a malfunction in either engine or the propeller control systems thus it is probable that migration of a power lever(s) occurred due to insufficient friction being set on the power lever friction control. The fiction control had been slackened during recent maintenance and it was possible that it was not adjusted sufficiently by the pilot during his checks prior to takeoff. His simulator training had included engine failures but as far as could be established, the pilot had not encountered or been trained for the situation of power lever(s) migration during takeoff. With his level of experience the pilot should have controlled the resultant asymmetric thrust and in reasonable conditions continued the takeoff to a safe height where analysis of the problem could have been carried out. In the event the takeoff was carried out in extremely low visibility conditions leading to the pilot's total loss of any ground references within seconds of lift off. Having controlled the aircraft initially the lack of visual reference with the ground, possible confusion with attitude instrument bank angle display, physical disorientation brought about by cockpit activity and confusion as to the exact nature of the problem led the pilot to lose control of the aircraft at a low altitude. The unusual attitude developed by the aircraft and the reason for the power asymmetry may have been recognised by the pilot several seconds before impact however there was insufficient height available for him to effect a safe recovery. The transition from visual to instrument flight in the low visibility conditions existing at the time of departure was considered to be a major contributory factor in this accident.
Final Report:

Crash of a Cessna 441 Conquest II in Blackbushe: 1 killed

Date & Time: Apr 26, 1987 at 1145 LT
Type of aircraft:
Operator:
Registration:
G-MOXY
Flight Type:
Survivors:
No
Schedule:
Leeds - Blackbushe
MSN:
441-0154
YOM:
1980
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
5135
Circumstances:
The accident occurred at Blackbushe airfield following a go-around from an approach to land on runway 26. The aircraft appeared to begin the go-around normally but was then seen to bank to the left and start turning left. The turn continued through 135° of heading, at a low height, with the bank angle increasing progressively, until the aircraft crashed into trees, semi-inverted, approximately 550 meters from the runway 26 threshold. The reason for the initiation of the go-around was an unsafe main landing gear indication caused by a defective microswitch. The reasons for the subsequent loss of control could not be determined.
Probable cause:
The effectiveness of the investigations was considerably reduced by the lack of flight recorders. There was no evidence of pilot incapacitation. Extensive examination of the wreckage revealed no flap or flying control malfunction, neither was there any evidence of failure of either engine or propeller control mechanism. The curved flight path of the aircraft from go-around to impact and progressive increase in bank angle suggest that an asymmetric thrust condition was most probable.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Blackbushe: 1 killed

Date & Time: Oct 19, 1975 at 0811 LT
Operator:
Registration:
G-BBPV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Blackbushe - Stansted
MSN:
31-7305097
YOM:
1973
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5391
Captain / Total hours on type:
122.00
Aircraft flight hours:
771
Circumstances:
The aircraft was en route from Blackbushe to Stansted when about three minutes after takeoff it descended to aerodrome level and flew into some trees which were obscured by fog and low cloud. The aircraft caught fire and the pilot, the sole occupant, was killed.
Probable cause:
The accident was caused by the aircraft descending into fog covered ground. No reason for this loss of height could be positively established but there is a strong possibility that the pilot's ability to fly the aircraft became impaired by the onset of symptoms associated with coronary artery disease.
Final Report:

Crash of a Vickers 610 Viking 1B in Blackbushe: 34 killed

Date & Time: May 1, 1957 at 2220 LT
Type of aircraft:
Operator:
Registration:
G-AJBO
Survivors:
Yes
Schedule:
Blackbushe – Tripoli
MSN:
241
YOM:
1947
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
30
Pax fatalities:
Other fatalities:
Total fatalities:
34
Captain / Total flying hours:
6800
Captain / Total hours on type:
4800.00
Circumstances:
The aircraft was on a trooping flight from Blackbushe Airport to Idris in Tripoli and was carrying a crew of four, one supernumerary crew as passenger and thirty passengers. A few seconds after 2214LT the aircraft was observed to make its run and to take off. At 2216, it called the control tower and passed the following message, "I have got a port engine failure I am making a left-hand circuit to come in again". Having completed the downwind and base legs of this circuit, the aircraft crashed in a wood just as, or just after, it had turned onto the final approach and at a distance of about 1 200 yards from the threshold of the runway. Thirty-four of the thirty-five persons on board lost their lives.
Probable cause:
The accident was caused by the failure of the captain to maintain height and a safe flying speed when approaching to land on one engine after the failure (or suspected failure) of the port engine for reasons unknown.
Final Report:

Crash of a Handley Page H.P.81 Hermes IV/A in Blackbushe: 7 killed

Date & Time: Nov 5, 1956 at 2352 LT
Type of aircraft:
Operator:
Registration:
G-ALDJ
Survivors:
Yes
Schedule:
Tripoli – Blackbushe
MSN:
81/11
YOM:
1950
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
74
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The aircraft was flying under charter to the Air Ministry and had flown from Idris Airport, Tripoli with a crew of 6 and 74 passengers, nearly all members of servicemen's families. Shortly before midnight, on landing at Blackbushe in poor visibility, the aircraft undershot the runway, hit a beech tree 3,617 feet short of the threshold, swung sharply to port, came down among pine trees about 3,000 feet from the beech tree and caught fire. Three crew members were killed by the impact and four children lost their lives due to fire.
Probable cause:
The most probable cause of the accident is that in difficult conditions and while suffering from a degree of fatigue above the normal, the captain, relying on his vision of the airport lights to assess his height, judged his height to be higher than it actually was.
Final Report:

Crash of a Vickers 701 Viscount in Blackbushe

Date & Time: Jan 20, 1956 at 0850 LT
Type of aircraft:
Operator:
Registration:
G-AMOM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Blackbushe - Blackbushe
MSN:
26
YOM:
1953
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft took off from London Airport at 0755LT on a training flight, which was part of a routine base check being carried out by a training captain on a line captain. Having completed the first part of the check the aircraft landed at Blackbushe. At approximately 0850LT a takeoff was commenced from this airport for another exercise. On reaching the takeoff safety speed the training captain simulated a starboard outer engine failure. At this point the aircraft was just leaving the ground and as it did so the starboard inner propeller was seen to be stopping and the aircraft began turning to the right with an increasing amount of bank. It rose to about 30 feet and then descended and hit the ground at a point 250 yards from the runway in a steeply banked, nose-down attitude. It cartwheeled, slid along the ground backwards for 200 yards and came to rest just inside the northwest boundary of the aerodrome. The aircraft sustained major impact damage and fire broke out which almost completely destroyed it. The five occupants escaped with only slight injuries.
Probable cause:
The accident was due to an error by the training captain who operated No. 3 high pressure cock lever instead of No. 4 when simulating a failure of No. 4 engine during take-off. This resulted in the loss of all power from both starboard engines at a critical point of the take-off.
Final Report:

Crash of an Avro 652 Anson C.19 off Calshot

Date & Time: Aug 6, 1955
Type of aircraft:
Registration:
G-AHIG
Flight Phase:
Survivors:
Yes
Schedule:
Jersey – Blackbushe
MSN:
1322
YOM:
1946
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While overflying the Isle of Wight, enroute from Jersey to Blackbushe, the pilot encountered technical problems with both engines that lost power. He reduced his altitude and ditched the aircraft on the Solent, off Calshot. While the aircraft sank and was lost, all 11 occupants were quickly rescued by the crew of a yacht and then transferred to shore.
Probable cause:
It was determined that both engines failed in-flight due to fuel exhaustion. It is believed that the pilot failed to prepare his flight properly and did not refuel at Jersey (Saint Peter) Airport.
Final Report:

Crash of a Vickers 627 Viking 1B in Blackbushe

Date & Time: Aug 15, 1954 at 1000 LT
Type of aircraft:
Operator:
Registration:
G-AIXS
Survivors:
Yes
Schedule:
Blackbushe – Nice
MSN:
234
YOM:
1946
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Ten minutes after takeoff from Blackbushe, at an altitude of 6,000 feet, an oil leak occurred on the right engine that was shot down and its propeller feathered. The crew received the permission to return to Blackbushe. On final approach, at a speed of 100 knots, the aircraft stalled and crashed in flames in a field located 135 yards short of runway 26 threshold. All 37 occupants evacuated the cabin and four of them were injured, two seriously. The aircraft was destroyed by fire.
Probable cause:
The accident was the result of the captain allowing the aircraft to stall when making a single engine approach to land. A contributory factor was distraction of the captain's attention by the flickering of the undercarriage red indicator lights during a critical stage of the approach. The starboard engine was also damaged by fire and was removed for detailed examination by the Engine Division of the Bristol Aeroplane Company Ltd. Their report stated that the rear of the crankcase had been almost consumed by fire and that a number of cylinder barrels were severely burned. A detailed strip examination did not disclose any mechanical defect and no reason for the failure was established.
Final Report: