Crash of a Fokker F27 Friendship 600 in Saint Peter: 2 killed

Date & Time: Jan 12, 1999 at 1706 LT
Type of aircraft:
Operator:
Registration:
G-CHNL
Flight Type:
Survivors:
No
Schedule:
Luton - Saint Peter
MSN:
10508
YOM:
1975
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3930
Captain / Total hours on type:
750.00
Copilot / Total flying hours:
958
Copilot / Total hours on type:
317
Circumstances:
The Fokker F27 was operating on a cargo flight to Guernsey, carrying newspapers. The aircraft departed Luton at 16:14. and climbed to cruising altitude FL150/160). The descent was begun at about 60 miles from Guernsey Airport and the aircraft was vectored onto final approach by Jersey Radar. The approach checklist was actioned and the flaps were lowered to 16° just before the aircraft was turned to intercept the ILS localizer. With less than six miles to run to the threshold the commander told the first officer that he could see the runway and was content to continue the approach visually. The first officer informed ATC that they wished to continue the approach visually; they were given the appropriate clearance and control of the aircraft was then handed over to Guernsey Tower. Initially the aerodrome controller cleared the aircraft to continue the approach (there was departing traffic on the runway) and the commander called for flaps to 26° followed by the landing checklist. About one minute later the commander said "three whites" (meaning that he was aware that the aircraft was slightly high on the glide path indicated by the precision approach path indicator lights) which the first officer acknowledged. The commander then said "ok the decision is to land, speed below one four four, flaps forty". The first officer acknowledged the instruction to select flaps to 40° and announced "running". There followed a pause of about five seconds before the first officer said, "flaps forty gear and clearance you have - oops". The commander then said, in an anxious tone of voice "ok flaps twenty six" and the engines could be heard accelerating on the cockpit voice recording. There then followed a number of expletives from the commander interspersed with some loud clicks as controls or switches were operated and the sound of a warning horn which stopped before the end of the recording. On approach the aircraft had lost control, attaining a nose-high attitude. The plane stalled, clipped a house on Forest Road with its left wing and ploughed into a field short of the runway.
Probable cause:
The investigation identified the following causal factors:
(i) The aircraft was operated outside the load and balance limitations;
(ii) Loading distribution errors went undetected because the load sheet signatories did not reconcile the cargo distribution in the aircraft with the load and balance sheet;
(iii) The crew received insufficient formal training in load management.
Final Report:

Crash of a De Havilland DHC-7-102 (Dash-7) in Ashburton: 2 killed

Date & Time: Nov 28, 1998 at 0947 LT
Registration:
VP-CDY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saint Peter - Saint Peter
MSN:
84
YOM:
1982
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
17200
Copilot / Total hours on type:
1700
Circumstances:
Prior to the flight the commander had filed a flight plan which indicated that after take off the aircraft would transit from Guernsey to the Berry Head VOR at FL 100. It was then planned to manoeuvre in the Plymouth area whilst conducting a performance related test flight. The commander called for start clearance at 0902 hrs and, after a short taxi, the aircraft was cleared for take off at 0918 hrs. After take off Guernsey ATC handed the aircraft over to the London Air Traffic Control Centre (LATCC) at 0930 hrs. As the aircraft approached Berry Head at FL 100 the commander requested FL 60. The aircraft was cleared for this descent and then handed over to Exeter ATC at 0943 hrs. Exeter ATC confirmed the aircraft requirements for a block of airspace between FL 60 and FL 100 and offered a radar advisory service. The aircraft was then vectored onto a northerly heading to keep it clear of departures from Plymouth Airport. As the aircraft approached FL 60 the commander requested further descent to FL 50, which was approved. The air traffic controller at Exeter then noticed that the altitude readout from the aircraft radar transponder indicated FL 47. He called the aircraft to confirm the local sector safe level of 3,500 feet but received no reply; this call was timed at 0947 hrs. From FDR timings the crew would not have heard this call. At the same time the transponder information disappeared from the radar screen and the primary radar return was no longer visible. The controller made repeated calls to the aircraft but received no reply. He arranged for LATCC to inform the Distress and Diversion cell whilst he notified the local emergency services. A large number of eye witnesses saw the aircraft in its final descent before impacting the ground; twenty two of these witnesses were interviewed. All agreed that the sky was clear and bright with only a few of them describing small amounts of light cumulus clouds. No one saw any other aircraft in the area and all were certain that there was no smoke or fire issuing from the aircraft or its engines whilst it was in the air. Most witnesses described the aircraft in a spin or a spiral descent, generally to the left, although some described the motion as like a falling leaf. Four witnesses, who all had a clear view of the aircraft throughout, described the aircraft completing a two or three turn spin/spiral to the left. Those witnesses who were in a position to hear clearly the sound of the engines confirmed that the engines were making a loud noise as if at a high power setting. The impact with the ground was followed immediately by a post crash fire. Both pilots were killed.
Probable cause:
A sustained ground fire had largely destroyed the wreckage. However, it was established that the aircraft had been structurally complete. The No 1 propeller was feathered and the flaps were fully and symmetrically retracted. There was no evidence of any mechanical malfunction. The two pilots had flown together previously on many occasions. On this flight the commander occupied the right seat from and made all radio transmissions. It was his normal practise to direct the flight, set the required engine power and to record data. This then allowed the FO, who occupied the left seat, to concentrate on flying the aircraft. The commander initially asked ATC for a block of airspace from FL 60 to FL 100 and then requested a base of FL 50. This was entirely consistent with the intention to perform a 3-engine climb. It would be normal practice to configure the aircraft for the next test point during the descent to the planned base altitude, as had been done on the previous flight. On this occasion however, the flap was not selected to 25° but remained fully retracted. In accordance with the configuration requirements for the 3-engine climb the No 1 the propeller was feathered and the engine was shut down. With the autopilot engaged and the 3 operating engines at a low power setting the aircraft levelled at FL 50 and the speed reduced. During this speed reduction the crew should have noted the trim wheel rotating as progressive nose up trim was being applied by the autopilot. It is possible that the non-handling pilot may have interpreted this as a manual trim input by the handling pilot. There would also have been clear aural and tactile warnings, via the stick shaker, that the aircraft was approaching the stall. Although both pilots were familiar with the test schedule the aircraft was not correctly configured for this particular test. Furthermore, the autopilot was retained down to the point of the stall and there appears to have been no adequate response to the stick shaker. If the crew were unaware of the flap configuration error then the stall warning may have surprised them but for a crew of their experience to fail to react correctly to the compelling intervention of the stick shaker is most unusual. However, the possibility of some distraction cannot be discounted. The available evidence therefore suggests that normal crew operation and co-ordination was lacking during this phase of flight. In the absence of a working CVR it is not possible to state why this occurred. The aircraft stalled with the autopilot still engaged. Power was increased on the three operating engines and two seconds later the autopilot was deselected. The application of asymmetric power ultimately caused the aircraft to roll rapidly to the left and this motion was countered by the application of right rudder and right spoiler. The elevator was then moved to the full nose up demand position. With the exception of decreasing application of right spoiler the controls remained in these positions until just prior to impact when the engine power was reduced. The flight control inputs and the changes to engine power suggest that both pilots were involved in the aircraft operation throughout the descent to the ground. The progressive and sustained rudder inputs together with the constant application of full aft control column also suggest that the same pilot retained authority over these flight controls. However, some of the crew actions were unusual. The non-handling pilot would have been ready to apply take-off power on the three operating engines in order to initiate the climb but the application of asymmetric power at the stall inevitably led to autorotation and was therefore inappropriate. The application of opposite rudder by the handling pilot was a normal pilot response but the application of full aft control column following the stall is inexplicable, irrespective of whether the pilot subsequently believed that he was in a spin or a spiral dive. Analysis of the manufacturer's flight test data during prolonged stalls provided no evidence of any elevator overbalance due to aerodynamic loads on the lower surface of the elevator. Moreover, in this instance, following the application of asymmetric power the aircraft adopted large bank angles that would have further reduced any aerodynamic load on the lower elevator surface. It is therefore considered most probable that the control column was placed in the fully aft position by the pilot. The nose-up elevator trim, applied by the autopilot before its disconnection, would have produced unexpected control forces when positioning the control column for recovery such that the normal release of back pressure would have been ineffective. However, this does not explain the subsequent application of full aft control column. It is possible that the rapid autorotation that followed the application of asymmetric power at the stall caused the handling pilot to become disorientated. The high longitudinal control forces that had been generated by the application of full nose up trim by the autopilot prior to the stall may then have exacerbated his difficulties.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Jersey: 1 killed

Date & Time: Jun 12, 1998 at 1842 LT
Operator:
Registration:
CN-TFP
Flight Type:
Survivors:
No
Schedule:
Tangier - Saint Peter
MSN:
31-7552086
YOM:
1975
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9100
Aircraft flight hours:
5253
Circumstances:
The pilot, sole on board, departed Tangier on a delivery flight to Saint Peter-La Villiaze, Guernsey Island, where the aircraft should be taken over by another crew to be ferried to Iceland. While approaching the Channel Islands, the pilot informed ATC about technical problems and elected to divert to Jersey Airport. Shortly later, after both engines stopped due to a fuel exhaustion, the plane lost height and crashed in the sea about 3 nm northwest of Jersey Island. The aircraft was destroyed and the pilot was killed.
Probable cause:
The following causal factors were identified:
- The commander had not made an appropriate allowance for adverse headwind components before or during the flight.
- The aircraft was not carrying sufficient fuel for the intended flight.
- The commander apparently ignored pre-flight and in-flight indications that he should land and refuel in France.
- The commander's chances of survival were adversely affected by not adopting the optimum configuration and heading for ditching.
Final Report:

Crash of a Fokker F27 Friendship 500F in Saint Pierre

Date & Time: Dec 7, 1997 at 1818 LT
Type of aircraft:
Operator:
Registration:
G-BNCY
Survivors:
Yes
Schedule:
Southampton - Saint Pierre
MSN:
10558
YOM:
1977
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
2865.00
Copilot / Total flying hours:
2150
Copilot / Total hours on type:
320
Aircraft flight hours:
44877
Aircraft flight cycles:
53639
Circumstances:
During his pre-flight preparation the commander noted that the crosswind at Guernsey would need close monitoring throughout the day as it would be close to the aircraft's crosswind limits. The aircraft departed from Guernsey at 16:10 for the first sector to Southampton, with the first officer acting as pilot flying (PF). On departure the first officer stated that the aircraft was 'difficult to keep straight' on the runway and moderate turbulence were encountered after takeoff between 500 to 1,000 feet agl but the remainder of the flight was uneventful. The aircraft departed again from Southampton at 17:23, with 50 passengers and 2 kg of freight on board, with the commander as the PF and the first officer as the pilot not flying (PNF). During the cruise the first officer obtained the latest weather for Guernsey: surface wind as 170°/19 gusting to 32 kt, visibility 5 km in rain, cloud scattered at 600 feet, broken at 800 feet, temperature 11°C, dew point 9°C, QNH of 1004 mb with turbulence and windshear below 200 feet agl. The commander briefed the first officer that he intended to carryout a 'radar vectored' ILS approach to runway 27 using 26.5° of flap, instead of the usual 40°, for greater aileron control in the crosswind conditions during the landing. He also intended to add 10 kt to the target threshold speed (TTS). In the final stages of the approach the aircraft experienced a drift angle of 25° to 30° in turbulent conditions. The aircraft was slightly above the prescribed glide path, as it crossed the threshold and the commander stated that when over the runway it was obvious to him that the aircraft would touchdown beyond the normal landing area. He therefore decided to initiate a go-around. Full power was applied and, when established with a positive rate of climb, the landing gear was selected up and the flaps retracted to 16°. The aircraft climbed to 1,500 feet, the flaps were retracted and the crew were given radar vectors for a second ILS approach to runway 27. The commander described the second approach as being more stable and on the correct 3° glide path throughout. The drift angle this time was between 30° and 40° from the inbound track. The crew had correctly calculated the TTS as 96 kt with 40° of flap and 106 kt when using 26.5° of flap. The 40° flap TTS of 96 kt was displayed on the landing data card on the flight deck. The aircraft was cleared to land by ATC approximately three minutes before the actual touchdown. The surface wind was passed as '180°/18 kt with the runway surface wet'. Nineteen seconds before touchdown ATC transmitted the surface wind as '190°/20 kt". The first officer stated that the indicated airspeed (IAS) had been 120 kt 'down the slope' and 110 kt as the aircraft crossed the threshold. The commander stated that the aircraft crossed the threshold, with 26.5° of flap selected, at the correct height with the projected touchdown point in the normal position. Both pilots stated that during the flare, at a height estimated by the commander to be between 10 to 15 feet above the runway, the aircraft appeared to float. The commander reduced the engine torques to zero. The aircraft then continued to descend and touched down, according to the commander, 'a little beyond the normal point, left main wheel first followed by the right and then the nose wheel'. Several fireman however, who were on standby in their vehicles at the airport fire station, saw the aircraft touch down. They described the touchdown point as being opposite the runway fire access road, i.e. with 750 meters to 900 meters of runway remaining. After touchdown the commander selected ground fine pitch on both engines but neither the first officer, the No 1 cabin attendant, who was seated at the rear of the aircraft, nor several of the passengers were aware of the normal aerodynamic braking noise from the propellers. The first officer selected the flaps up and, with the commander having called 'your stick', applied full left (into wind) aileron. It is normal for the PNF to then call '5 lights (indicating that both propellers were in ground fine pitch), TGTs (turbine gas temperatures) stable and flaps traveling'. The first officer can recall seeing five lights but stated that he did not make the normal call. The commander applied full right rudder and braking; applying maximum braking on the right side to keep the aircraft straight. The first officer described the commander as 'standing up in his seat' whilst applying full right rudder. As the aircraft traveled down the runway it felt to the crew as if it was 'skidding or floating with ineffective brakes'. The first officer did not assist with the braking. Sixteen seconds into the ground roll the aircraft started to turn uncontrollably to the left. Realizing that the aircraft would leave the paved surface the commander instructed the first officer to transmit a 'Mayday' message. The aircraft overran the end of the runway and entered the grass to the left of the extended center-line at a speed estimated by the crew to be 60 kt. It then impacted and crossed a narrow earth bank before stopping in an adjacent field.
Probable cause:
The following causal factors were identified:
- The commander decided to continue with the landing knowing that touchdown was beyond the normal point,
- The commander was not aware at touchdown that the crosswind component of the surface wind affecting the aircraft exceeded the Flight Manual limit,
- The commander could not apply maximum braking to both main landing gear brakes at the same time as maintaining directional control through differential braking and full rudder application.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander in Saint Peter

Date & Time: Sep 18, 1981 at 1842 LT
Type of aircraft:
Operator:
Registration:
G-BDNP
Survivors:
Yes
Schedule:
Jersey - Guernesey
MSN:
496
YOM:
1976
Flight number:
JY245
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5400
Captain / Total hours on type:
250.00
Aircraft flight hours:
2174
Circumstances:
Jersey European Airways Flight 245 departed from Jersey Airport (JER) at 17:29 hrs UTC. This was a delayed flight since the aircraft originally allocated to the service G-BESO, had developed an engine fault shortly after takeoff and had returned to Jersey. Britten-Norman Islander G-BDNP was then made available as a replacement aircraft. The prevailing weather was a westerly wind with a cloud base of around 1,500 feet, and Flight 245 was cleared on a Special VFR flight plan to Guernsey (GCI) at a height not above 1,000 feet. When about 8 miles from the Guernsey coast the aircraft, under Guernsey Approach Radar Control, was directed to turn north towards the island of Herm as a delaying manoeuvre to allow a Partenavia, G-BFSU, inbound from the north-east to approach first. Shortly after making the turn the starboard propeller of G-BDNP began to hunt - a condition where the propeller blade angle alters in order to maintain a constant propeller RPM as the engine power fluctuates. The engine did not fail completely, so the Commander decided not to feather the propeller but requested from Air Traffic Control (ATC) a more direct approach to Guernsey Airport. This was agreed by ATC who then requested the Partenavia to carry out a right hand orbit in order to allow the Islander to approach first. Following closely behind the Islander was a Twin Otter, call sign G-BIMW. This resulted in a new landing sequence of the Islander, the Otter and then the Partenavia. The Commander of the Islander meanwhile had been trying to rectify the erratic running of the starboard engine by adjusting the carburettor heat and mixture controls, and by switching 'On' the auxiliary fuel pumps, but this did not achieve any improvement. He was, however, able to maintain 600 feet until established on a long final approach to runway 27 when the port engine suddenly lost power. As the aircraft yawed to port due to the power loss the starboard engine suddenly regained power for about one second, further accentuating the yaw. Realising that he could not now continue his approach to the airport he chose a landing site in an area of fields. He then selected the engine fuel mixture controls to 'Off' in order to prevent a sudden burst of power upsetting the approach, lowered full flap and carried out an emergency landing. The pilot stated that after touching down in one field the aircraft cleared a 6 feet high stone wall and then landed in the next field. Ground marks showed that it then travelled about 190 feet before the port main plane struck and then rode over a stone wall. This broke off the port undercarriage and deflected the aircraft to the right. It then continued through a five-bar gate, crossed a road, and came to rest in the driveway of a guest house. There was no fire and the passengers and the Commander were able to leave the aircraft through the doors and emergency windows. The Commander sustained severe laceration of his legs, broken fingers, and a head injury, but was able to assist in the evacuation of the eight passengers who had received only minor injuries. One of the passengers went immediately to the guest house and made an emergency telephone call for fire and ambulance assistance.
Probable cause:
The accident occurred because of the Commander's mismanagement of the aircraft's fuel system in that both engines failed through fuel starvation because the usable contents of the tip tanks, which were feeding the engines, became exhausted when there was ample fuel remaining in the aircraft's main tanks. Contributory factors were the Operator's procedures, inadequacies in the checklists, and the position of the fuel selector panel and switch levers in relation to the pilot's eyes.
Final Report:

Crash of a Bristol 170 Freighter 32 in Saint Peter

Date & Time: Sep 24, 1963 at 1123 LT
Type of aircraft:
Registration:
G-AMWA
Flight Phase:
Survivors:
Yes
Schedule:
Saint Peter - Bournemouth
MSN:
13073
YOM:
1953
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8500
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
7800
Copilot / Total hours on type:
1600
Circumstances:
The aircraft was returning to Bournemouth from Guernsey on a passenger and vehicle service flight. The copilot was flying the aircraft from the left-hand seat, and the pilot-in-command was performing the duties of the copilot. The engines were started at 1112 hours GMT. The brakes operated satisfactorily at this time. Following a normal run-up and check of the engines and the throttles were opened slowly because of a 17 kt crosswind component. The aircraft' reached a speed of 50 kt, and the rpm of the port engine began to rise. The pilot-in-command tried to control it by moving back the propeller control lever. The rpm commenced to surge and, as the aircraft's speed was then about 4 kt less than the single-engine safety speed (84 kt), the pilot-in-command ordered the copilot to abandon the takeoff. According to the testimony of the pilot-in-command following the accident, the brakes had little or no effect, and realizing that the aircraft would overrun the runway, he pulled back both propeller pitch control levers in order to stop the engines. Shortly before reaching the end of the runway the aircraft was turned to the left to avoid the approach lights. The aircraft became airborne for about 33 yd, then passed through the boundary fence of the stopway and struck a bank surmounted by a hedge where its port landing gear collapsed. Thereafter it crossed a hedge-lined road, and the starboard landing gear was deflected rearward. Finally it slid about 60 yd on its belly and stopped near a house. The accident occurred at 1123 hours GMT.
Probable cause:
The pilot-in-command abandoned the take-off due to a malfunction of the port power unit but was unable to bring the aircraft to a stop on the runway remaining.
Final Report:

Crash of a Bristol 170 Freighter 31M in Guernsey: 2 killed

Date & Time: Nov 1, 1961 at 1426 LT
Type of aircraft:
Operator:
Registration:
G-ANWL
Survivors:
Yes
Schedule:
Cherbourg – Saint Peter
MSN:
13260
YOM:
1956
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8143
Captain / Total hours on type:
471.00
Copilot / Total flying hours:
3315
Copilot / Total hours on type:
486
Circumstances:
The aircraft was making a daylight scheduled vehicle and passenger public transport flight from Cherbourg, France and during an attempt to land at Guernsey in conditions of low cloud the captain missed his approach. He opened up the engines to go round again, but the aircraft failed to gain height. Veering to the right it flew a short distance with the starboard propeller rotating slowly until the starboard wing struck the ground, and the aircraft cartwheeled. The passenger cabin broke away from the main wreckage which caught fire. Both pilots were killed. The steward and all 7 passengers aboard were seriously injured. The accident occurred at 1416LT.
Probable cause:
The accident was due to the malfunctioning of the automatic pitch coarsening unit of the starboard propeller. This deprived the captain of the necessary degree of control of the aircraft at a critical stage of the flight.
Final Report:

Crash of a De Havilland DH.114 Heron 1B in Saint Peter

Date & Time: Aug 15, 1958
Type of aircraft:
Operator:
Registration:
G-AMYU
Flight Type:
Survivors:
Yes
Schedule:
Saint Helier - Saint Peter
MSN:
14017
YOM:
1953
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was performing a cargo flight from Jersey to Guernsey with mail and foods on board. On approach, weather conditions worsened and the pilot decided to make a go around. Few minutes later, a second attempt to land was made on the opposite runway. With a tailwind component, the airplane landed on a grassy area, went out of control, lost its undercarriage and came to rest by a road. The pilot was uninjured while the aircraft was damaged beyond repair.

Crash of a Vickers 648 Varsity T.3 at Saint Peter

Date & Time: Nov 2, 1957
Type of aircraft:
Operator:
Registration:
WJ470
Flight Type:
Survivors:
Yes
MSN:
595
YOM:
1952
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew completed the landing in strong crosswinds. After touchdown, the airplane went out of control and veered off runway. It lost its undercarriage and came to rest, broken in two. There were no casualties.

Crash of a Miles M.57 Aerovan IV in St Peter

Date & Time: Aug 20, 1950
Type of aircraft:
Registration:
G-AILF
Flight Type:
Survivors:
Yes
Schedule:
Saint-Helier - Saint Peter
MSN:
6400
YOM:
1946
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On touchdown, the twin engine aircraft went out of control and came to rest upside down. Both pilots were injured and the aircraft was written off.