United Kingdom

The aircraft was scheduled to operate three commercial air transport (cargo) sectors: from Athens to Bergamo, then to Paris Charles de Gaulle, and finally East Midlands. The aircraft’s flap load relief system was inoperative, which meant that the maximum flap position to be used in flight was 30, rather than 40º. This defect had been deferred in the aircraft’s technical log and it had no effect on the landing of the aircraft. Otherwise, the aircraft was fully serviceable. The co-pilot completed the pre-flight external inspection of the aircraft in good light, and found nothing amiss. The departure from Athens was uneventful, but a combination of factors affecting Bergamo (including poor weather, absence of precision approach aids, and work in progress affecting the available landing distance) led the crew to decide to route directly to Paris, where a normal landing was carried out. The aircraft departed Paris for East Midlands at 0040 hrs, loaded with 10 tonnes of freight, 8 tonnes of fuel (the minimum required was 5.6 tonnes), and with the co-pilot as Pilot Flying. Once established in the cruise, the flight crew obtained the latest ATIS information from East Midlands, which stated that Runway 27 was in use, although there was a slight tailwind, and Low Visibility Procedures (LVPs) were in force. They planned to exchange control at about FL100 in the descent, for the commander to carry out a Category III autoland. However, as they neared their destination, the weather improved, LVPs were cancelled, and the flight crew re-briefed for an autopilot approach, followed by a manual landing, to be carried out by the co-pilot. The landing was to be with Flap 30, Autobrake 2, and idle reverse thrust. The final ATIS transmission which the flight crew noted before landing stated that the wind was 130/05 kt, visibility was 3,000 metres in mist, and the cloud was broken at 600 ft aal. The commander of EI-STD established radio contact with the tower controller, and the aircraft was cleared to land; the surface wind was transmitted as 090/05 kt. The touchdown was unremarkable, and the autobrake functioned normally, while the co-pilot applied idle reverse thrust on the engines. As the aircraft’s speed reduced through approximately 60 kt, the co-pilot handed control to the commander, who then made a brake pedal application to disengage the autobrake system. However, the system remained engaged, so he made a second, more positive, brake application. The aircraft “shuddered” and rolled slightly left-wing-low as the lower part of the left main landing gear detached. The commander used the steering tiller to try to keep the aircraft tracking straight along the runway centreline, but it came to a halt slightly off the centreline, resting on its right main landing gear, the remains of the left main landing gear leg, and the left engine lower cowl. The co-pilot saw some smoke drift past the aircraft as it came to a halt. The co-pilot made a transmission to the tower controller, reporting that the aircraft was in difficulties, after which the co-pilot of another aircraft (which was taxiing from its parking position along the parallel taxiway) made a transmission referring to smoke from the 737’s landing gear. The commander of EI-STD had reached the conclusion that one of the main landing gear legs had failed, but as a result of the other pilot’s transmission, he was also concerned that the aircraft might be on fire. The commander immediately moved both engine start levers to the cut-off positions, shutting down the engines. Three RFFS vehicles had by now arrived at the adjacent taxiway intersection, and their presence there prompted the commander to consider that the aircraft was not on fire (he believed that if it were, the vehicles would have adopted positions closer by and begun to apply fire-fighting media). The RFFS vehicles then moved closer to the aircraft and fire-fighters placed a ladder against door L1, which the co-pilot had opened. Having spoken to fire-fighters while standing in the entrance vestibule, the commander returned to the flight deck and switched off the battery. The flight crew were assisted from the aircraft and fire-fighters applied foam around the landing gear and engine to make the area safe. The commander had taken the Notoc2 with him from the aircraft, and informed fire-fighters of the dangerous goods on board the aircraft.

The aircraft was on a ferry flight from Seattle in the USA to Thailand via Canada, Greenland, Iceland, Scotland and across Europe. However the flight crew abandoned the aircraft in Greenland late in December 2013 after experiencing low oil pressure indications on both engines. This may have been due to the use of an incorrect grade of oil for cold weather operations. The aircraft remained in Greenland until 28 February 2014, when a replacement ferry pilot was engaged. Although the engine oil was not changed prior to departing Greenland, the flight continued uneventfully to Wick, in Scotland. Following some maintenance activity on the right engine, the aircraft departed for Le Touquet in France. However, approximately 25 minutes after takeoff, the engines successively lost power and the pilot carried out a forced landing in a ploughed field. Examination of the engines revealed that one piston in each engine had suffered severe heat damage, consistent with combustion gases being forced past the piston and into the crankcase.

At approximately 1830 hrs on 3 November 2013 the operator’s duty pilot received a request that the aircraft should be dispatched to carry out a search. The volunteer crew-members were alerted and made their way to the airport. Weather conditions in the Channel Islands were poor, with a southerly wind gusting up to 41 kt, turbulence, rain, cloud below 1,000 ft aal, and visibility of 3 to 6 km. On arrival at the aircraft’s hangar, the crew was established, consisting of a pilot, search director, and three observers. They donned immersion suits and life jackets and prepared for flight. The search director obtained details of the search request, which was to search for two fishermen near Les Écréhous (a group of rocks in the English Channel approximately 5 nm north-east of the north-eastern corner of Jersey). Some evidence suggested the men were in a small dinghy; other information was that they were in the water. The men were reported to be alive and communicating by mobile telephone. One crew-member carried out pre-flight preparations, although he did not check the fuel quantities or carry out a water drain check. When interviewed, he recalled having reported to the pilot that he had not checked the fuel. The aircraft was then pulled out of its hangar and the search director explained the details of the search request to the pilot and other crew-members. Bearing in mind the weather, the fact that it was dark, and the fishermen’s predicament, the pilot recognized the need for “a lot of urgency” about the task. In the context of the operation, he regarded the task as being routine, but the weather not so. The pilot “walked round” the aircraft, though he did not carry out a formal pre-flight inspection; it was the organization’s custom to ensure that the aircraft was ready for flight at all times. The technical log showed that the aircraft was serviceable, with no deferred defects, and that the wing tanks contained 55 USG each side and the tip tanks, 18 USG each side. The search director recalled asking the pilot whether he was content to fly in the prevailing conditions, and that the pilot stated that he was willing to fly. The crew boarded the aircraft. The observer in the front right-hand seat had recently obtained a Private Pilot’s Licence and this influenced the decision for him to be placed next to the pilot. The pilot reported that he carried out a “fairly rapid” start, although the normal pre-departure sequence was interrupted while a problem with switch selections, affecting the functioning of the search equipment in the aircraft’s cabin, was resolved. The pilot obtained clearance from ATC to taxi, enter the runway, and take off when ready. He described that he carried out engine power checks during a brief back-track, checking the magnetos and propeller controls at 2,100 rpm, before carrying out pre-takeoff checks. He did not refer to the written checklists provided in the aircraft but executed a generic set of checks from memory. Following an unremarkable takeoff, in the strong crosswind , the pilot corrected for drift and established a climb towards a cruising altitude of 900 ft. When interviewed, he described the conditions as being “awful” and “ghastly”, with turbulence from the cliffs contributing to occasional activation of the stall warner, even though the speed was “probably 100 plus knots” . At 900 ft, the aircraft was “in the bottom” of the cloud, which was unhelpful for the observers, so the pilot descended the aircraft to cruise at 500 or 600 ft, flying by reference to the artificial horizon, and making constant control inputs to maintain straight and level flight. He stated that, although he would normally have begun checking fuel flow, mixture settings, etc, shortly after establishing in the cruise, he found that the conditions required him to devote his full attention to flying the aircraft. As the aircraft passed north abeam the western end of Jersey, the rain and low cloud continued and the turbulence worsened, The pilot gained sight of red obstacle lights on a television mast on the north side of the island but had few other visual references. The pilot noticed a change in an engine note. He immediately “reached down to put the hot air on” which made little difference; the observer recalled that the pilot checked that the mixtures were fully rich at this time. The right-hand engine rpm then began surging. The pilot made a quick check of the engine instruments, before applying full throttle on both engines, setting both propellers to maximum rpm and beginning a climb. The observer noticed that the fuel pressure gauge for the right-hand engine was “going up and down” but did not mention this to the pilot; the pilot did not see the gauge indication fluctuating. Around this time the pilot switched the electric fuel pumps on. The pilot turned the aircraft towards Jersey and made a MAYDAY call to ATC; the search director made a similar call on the appropriate maritime frequency. These calls were acknowledged, and a life boat, on its way to Les Écréhous, altered course towards the aircraft’s position. Although the pilot was “amazed” at how few lights he could see on the ground, he perceived what he thought was the runway at Jersey Airport, and flew towards it. The aircraft reached approximately 1,100 ft amsl. The right-hand engine then stopped. The pilot carried out the shut-down checks, feathering the propeller as he did so. The aircraft carried on tracking towards Jersey Airport, descending towards the north side of the island. Some moments later, the left-hand engine’s rpm began to fluctuate briefly before it also stopped. The pilot later recalled being “fairly certain” that he “was trying to change tanks” but acknowledged that he could not recall events with certainty. He trimmed the aircraft for a glide, still heading towards the airport at Jersey, but with very limited visual references outside the cockpit. The crew-members prepared the cabin for a ditching or off-airport landing; the observers in the rear-most seats considered how they might deploy the aircraft’s life raft (stored behind their seats) should a ditching occur. The pilot’s next recollection was that the automated decision height voice call-out activated (he had selected it to announce at 200 ft radio height). He switched the landing lights on and maintained a “reasonable speed” in anticipation of landing or ditching. One crew-member recalled the pilot calling “brace, brace, brace”, while another recalled being instructed to tighten seat belts and brace. No brace position had been set out in the operations manual, or rehearsed in training, and the responses of the crew-members to this instruction varied. The pilot glimpsed something green in front of the aircraft, and flared for landing. The aircraft touched down and decelerated, sliding downhill and passing through a hedge. With the aircraft now sliding somewhat sideways, it came to a halt when its nose lodged against a tree, with significant airframe damage. The pilot made various cockpit selections safe and all the occupants vacated the aircraft, with some difficulty. The search director became entangled in his headset lead as he egressed but freed himself. The front seat occupants experienced difficulty because their door could not be opened. They climbed over the search director’s desk and vacated the aircraft via the door adjacent to the search director’s position (the rear-row observers simultaneously opened the pilot’s door from the outside). The pilot and crew made their way to nearby habitation where they were subsequently assessed by an ambulance crew; none were injured. The search director returned to the aircraft with fire-fighters, to ensure that pyrotechnics and the self-inflating life raft on board the aircraft did not pose a hazard. In his very frank account of the flight, the pilot acknowledged that a decision to turn back soon after departure would have been justified by the weather conditions. He added that before the engine power changed, his workload was already very high, on account of the task and conditions.

The aircraft was on a VFR flight from Dinan, France, to Jersey, Channel Islands and had joined the circuit on right base for Runway 09 at Jersey Airport. The aircraft turned onto the runway heading and was slightly left of the runway centreline. It commenced a descent and a left turn, with the descent continuing to 100 ft. The pilot made a short radio transmission during the turn and then the aircraft’s altitude increased rapidly to 600 ft before it descended and disappeared from the radar. The aircraft probably stalled in the final pull-up manoeuvre, leading to loss of control and impact with the sea, fatally injuring those on board, Carl Whiteley and his wife.

The pilot was carrying out a local flight with a friend. The weather was good (CAVOK), with a westerly wind of about 12 to 15 kt. The passenger occupied the front cockpit and the pilot the rear. The engine started normally and the aircraft departed, climbing to an altitude of 1,200 ft. The pilot carried out two medium banked turns and a gentle wingover manoeuvre before entering another steep turn to the left. When established in the turn, the engine stopped and the aircraft entered a spin to the left. The pilot recovered from the spin but, due to the limited height available, could only pull out of the dive and carry out a forced landing in an isolated grass area, amongst trees and other obstacles. In doing so, the aircraft struck a ridge and furrow, which destroyed the landing gear and much of the forward fuselage. A member of the public witnessed the accident and called the emergency services, who recovered both occupants from the wreckage. The pilot and his passenger had suffered serious injuries and were transferred to hospital. There was no fire.The aircraft had recently been re-weighed. During that process, the fuel tank had been drained and the same fuel was then used to refill the tank. After that, the aircraft had flown some five hours, during which it had been refuelled twice at a licensed aerodrome. The second refuel had taken place prior to positioning the aircraft back to the private site from which the accident flight departed. It was reported that the engine had been consistently reliable. No reason for the engine failure was identified. The pilot considered that he had avoided a serious head injury because he was wearing a protective helmet. Also, he commented that he had since had discussions with others in the historic aircraft community regarding energy absorbing foam in seat pans and its potential for reducing the level of back injuries in the event of an accident.

The crew, comprising a commander, co-pilot and cabin crewmember, reported for duty at 0620 hrs at Guernsey Airport. The commander was conducting line training of the co-pilot, a first officer who had recently joined the companyThe first sector was to be from Guernsey to Jersey. No problems were identified during the pre-flight preparation and the aircraft departed on time at 0705 hrs, with the commander acting as handling pilot. The short flight was without incident and the weather for landing was reported as good, with the wind from 210° at 16 kt, FEW cloud at 2,000 ft and visibility in excess of 10 km. The commander elected to carry out a visual approach to Runway 27 at Jersey, using a planned approach speed of 107 kt and flap 30 selected for landing. During the approach, the gear was selected down and the flight crew confirmed the three green ‘gear safe’ indication lights were illuminated, indicating that the gear was locked in the down position. The commander reported that both the approach and touchdown seemed normal, with the crosswind from the left resulting in the left main gear touching first. Just after touchdown both pilots heard a noise and the commander stated the aircraft appeared to settle slightly differently from usual. This made him believe that a tyre had burst. The cabin crew member also heard a noise after touchdown which she too thought was from a tyre bursting. The commander selected ground idle and partial reverse pitch and, as the aircraft decelerated through 70 kt, the co-pilot took over control of the ailerons, as per standard procedures, to allow the commander to take control of the steering tiller. The co-pilot reported that despite applying corrective inputs the aircraft continued rolling to the left. A member of ground operations staff, situated at Holding Point E, reported to the tower controller that the left landing gear leg of the aircraft did not appear to be down properly as it passed him. The aircraft continued to quickly roll to the left until the left wingtip and propeller contacted the runway. The aircraft remained on the runway, rapidly coming to a halt to the left of the centreline, approximately abeam Holding Point D. Both propellers continued to rotate and the commander selected the condition levers to the fuel shutoff position and pulled the fire handles to shut both engines down. The tower controller, seeing the incident, pressed the crash alarm and airfield emergency services were quickly in attendance.

The commander had retired from flying Commercial Air Transport operations with an airline in August 2011. He had recently renewed his single pilot Instrument Rating and Multi Engine Piston (Land) planes rating and his intention was to continue flying part-time. He had been invited to fly G‑BWHF, which was privately operated for business purposes, but his last flight in this aircraft was on 10 November 1998. Accordingly, he planned to conduct a re-familiarisation flight. The commander was accompanied by another pilot who was not a flight instructor but had recent experience of flying the aircraft and was familiar with the aerodrome. A webcam recorded the pilots towing the aircraft to the refuelling point, refuelling it and carrying out pre‑flight preparations. There were no witnesses to any briefings which may have taken place. The commander first started the right engine, which initially ran roughly and backfired before running smoothly. The left engine started normally. The second pilot took his place in the front right seat. The aircraft taxied to the holding point of Runway 22, and was heard by witnesses to be running normally. A witness who lived adjacent to the airfield but could not see the aircraft heard the power and propeller checks being carried out, three or four times instead of once per engine as was usual. The engines were heard to increase power and the witness observed the aircraft accelerate along the runway and takeoff at 1105 hrs. It climbed straight ahead and through a small patch of thin stratus cloud, the base of which the witness estimated was approximately 1,000 ft aal. The aircraft remained visible as it passed through the cloud and continued climbing. The witness turned away from the aircraft to continue working but stated that apart from the unusual number of run-up checks, the aircraft appeared and sounded normal. The pilot of a Robinson R22 helicopter which departed Welshpool at 1015 hrs described weather to the south of the aerodrome as drizzle with patches of broken stratus at 600-700 ft aal. He was able to climb the helicopter between the patches of stratus until, at 1,500 ft, he was above the tops of the cloud. Visibility below the cloud was approximately 5-6 km but, above the cloud, it was in excess of 10 km. He noted that the top of Long Mountain was in cloud and his passenger took a photograph of the Long Mountain area The R22 returned to the airfield and joined left hand downwind for Runway 22. As it did so, its pilot heard a transmission from the pilot of the PA-31 stating that he was rejoining for circuits. The R22 pilot transmitted his position in order to alert the PA-31, then continued around the circuit and called final before making his approach to the runway, landing at about 1115 hrs. After passing overhead Welshpool, it made a descending left circuit, becoming established on a left hand, downwind leg for Runway 22. A witness approximately 3.5 nm northeast of the accident site saw the aircraft coming towards him with both propellers turning. It made a turn to the left with the engines apparently at a high power setting and, as it passed over Long Mountain, commenced a descent. He could not recall whether he could still hear the engines as the aircraft descended. He then lost sight of it behind the rising ground of Long Mountain. A search was initiated when the aircraft failed to return to Welshpool. Its wreckage was located in an open field on the west slope of Long Mountain. There were no witnesses to the actual impact with the trees or surface of the field but the sound was heard by a witness in the wood who stated that the engines were audible immediately prior to impact. The accident, which was not survivable, occurred at 1117 hrs. Both pilots were fatally injured.

The pilot had planned to fly from Bournemouth Airport to Manchester Airport operating the flight as a single pilot, with a passenger seated in the co-pilot’s seat. He arrived at the airport approximately one hour before the planned departure time of 1130 hrs, completed his pre‑flight activities and went to the aircraft at approximately 1110 hrs. The 1120 hrs ATIS gave the weather at the airport as: surface wind from 230° at 10 kt, visibility 10 km or greater, few clouds at 1,000 ft, broken cloud at 1,200 ft and at 2,000 ft, temperature 16°C, dew point 12°C and QNH 1015 hPa. After starting the engines, the pilot was cleared to taxi to holding point ‘N’ for a departure from Runway 26 and he was given clearance to take off at 1127 hrs. At 1129:45 hrs, approximately 55 seconds after the aircraft became airborne, the aerodrome controller transmitted “four six bravo mike do you have a problem?” because he believed the aircraft was not climbing normally. The pilot replied “november four six bravo going around” and, shortly afterwards, “four six bravo requesting immediate return”. The controller cleared the pilot to use either runway to land back at the airport but received no reply. The pilot carried out a forced landing into a field 1.7 nm west of the Runway 08 threshold at Bournemouth Airport and neither he nor his passenger was hurt.

The pilot arrived at the aircraft at approximately 0900 hrs to prepare it for a flight to drop parachutists. The aircraft had been outside overnight and there had been a heavy frost. The pilot removed a cover from the windscreen and began his pre-flight check during which he noticed no ice or frost on the upper surface of the wings. He returned to the operations building to complete his pre-flight planning and went back to the aircraft in time to start the engine at 1000 hrs. There was a very light wind from the north-west across the grass Runway 06L, the temperature was -4°C and the QNH was 1004 mb. While the engine was warming up, eight parachutists boarded the aircraft and sat down in the cabin. There were three parachute instructors, who were connected to three students, and two other parachutists with video cameras, one of whom was the jump supervisor. After the pilot judged that the engine had warmed up, he carried out a power check and the before takeoff checks, during which he selected the flaps to TAKEOFF. All indications appeared normal to the pilot and he taxied onto the runway and selected takeoff power, which was 29 inches of Manifold Air Pressure (MAP)and 2,500 rpm. The acceleration seemed, to the pilot, to be normal but, although VR was 60 kt, he delayed the rotation until 65 kt. At about the time the aircraft rotated, the pilot selected the flaps to FULL. As the aircraft crossed the hedge at the upwind end of the runway, the pilot began a left turn, which was the usual noise abatement manoeuvre to avoid flying over buildings situated on the runway’s extended centreline. During the turn, he realised the aircraft was descending and checked the engine instruments, observing that the MAP, fuel pressure and rpm were indicating correctly. He called “BRACE, BRACE, BRACE” and the aircraft hit the ground immediately afterwards in a left wing low attitude. After crossing a ditch, during which the landing gear detached, the aircraft skidded to a halt in the next field. The pilot was able to exit the aircraft through the door on his left but found that he could not stand up because of an injury to his leg. The sliding door on the rear left side of the cabin was jammed and the parachutists were unable to use it to leave the aircraft and so they exited through the same door as the pilot. One parachutist received a whiplash injury but the rest were unhurt. The pilot was subsequently airlifted to hospital.

The flight crew reported for duty at Liverpool Airport at 0845 hrs. Their original task was to fly to Belfast City Airport, collect a transplant organ, and take it to Cambridge Airport. However, on their arrival at Belfast the transfer was no longer required, so they were given a new task to fly to Belfast Aldergrove Airport and collect an organ to carry to Birmingham Airport. The aircraft departed Belfast Aldergrove at 1450 hrs with the co-pilot as pilot flying. The flight was uneventful and the aircraft was given a radar vector to intercept the ILS for a straight-in approach to Runway 15 at Birmingham. The Runway 15 ILS course is 149°M. The autopilot was engaged and the aircraft was flying on a track of 135°M, 13 nm from the touchdown zone and at a groundspeed of 254 kt, when it crossed the localiser centreline. The aircraft then turned right onto a corrective track but once again passed through the localiser course. Further corrections were made and the aircraft passed through the localiser once more before becoming established at 5 nm. The co-pilot later reported that, because the autopilot was not capturing the localiser, he had disconnected it and flown the approach manually. When the aircraft was at 10 nm, the radar controller broadcast a message advising of the presence of a fog bank on final approach and giving RVRs of 1,400 m at touchdown and in excess of 1,500 m at both the mid-point and stop end. The airfield was sighted by the commander during the approach but not by the co-pilot. A handover to the tower frequency was made at around 8 nm. When the aircraft was at 6 nm, landing clearance was given and acknowledged. The tower controller then advised the aircraft that there was a fog bank over the airfield boundary, together with the information that the touchdown RVR was 1,400 m. The commander responded, saying: “WE’VE GOT ONE END OF THE RUNWAY”. The aircraft was correctly on the localiser and the glideslope at 4 nm. The Decision Altitude (DA) of 503 feet amsl (200 feet aal) for the approach was written on a bug card mounted centrally above the glare shield. Both pilots recollected that the Standard Operating Procedure (SOP) calls of “500 above” and “100 above” DA were made by the commander. However, neither pilot could recall a call of ‘decision’ or ‘go-around’ being made. At between 1.1 nm and 0.9 nm, and 400 feet to 300 feet aal, the aircraft turned slightly to the right, onto a track of 152°M. This track was maintained until the aircraft struck the glideslope antenna to the right of the runway some 30 seconds later (see Figure 3, page 11). The aircraft came to rest in an upright position on the grass with a fire on the left side. The co-pilot evacuated through the main cabin door, which is located on the left side of the fuselage, and suffered flash burns as he passed through the fire. The commander was trapped in the cockpit for a time.