Agusta A109E, G-PWER, 3 March 2004

58 AAIB Bulletin No: 6/2005 Ref: EW/C2004/03/01 Category: 2.2 Aircraft Type and Registration: Agusta A109E, G-PWER No & Type of Engines: 2 PW206C turboshaft engines Year of Manufacture: 2000 Date & Time (UTC): 3 March 2004 at 1939 hrs Location: 1 mile east of Bournemouth (Hurn) Airport, Dorset Type of Flight: Private Persons on Board: Crew - 1 Passengers - 1 Injuries: Crew - 1 (Fatal) Passenger - 1 (Fatal) Nature of Damage: Aircraft destroyed Commander's Licence: Airline Transport Pilot's Licence Commander's Age: 35 years Commander's Flying Experience: 3,094 hours (of which 78 were on type) Last 90 days - 54 hours Last 28 days - 11 hours Information Source: AAIB Field Investigation Synopsis The pilot was flying a visual approach to Bournemouth Airport in poor weather at night; radar data indicated that the aircraft was tracking the extended centreline of Runway 26 at between 800 to 1,000 feet amsl. The pilot declared that he was visual with the airport but, shortly afterwards, the radar data indicated that the aircraft had entered a turn to the left. The aircraft turned through about 540° before striking the ground, fatally injuring both the pilot and the passenger. The pilot had probably become disorientated, and his limited instrument flying background did not equip him to cope with degraded visual environment. There was no evidence from the wreckage recovered of any mechanical failure or unauthorised interference with the aircraft or its systems that may have contributed to the accident. History of the flight The pilot had planned to collect the owner of the aircraft from Battersea Heliport and fly him back to Bournemouth Airport. He was familiar with the route to be flown and was notified of the task on the 59 day of the accident. Prior to the flight he was seen accessing meteorological data from a computer terminal at the company premises; this was the normal method used for meteorological briefing but there was no record of the weather information that he obtained. At 1819 hrs the aircraft departed Bournemouth Airport on a Special VFR 1 clearance to transit to Battersea Heliport where it landed at 1856 hrs; the pilot was the sole occupant of the aircraft on this flight. The owner walked to the aircraft accompanied by a member of the ground staff and occupied the rear left seat in the passenger cabin; his three pieces of hand luggage, which he had brought with him, were placed onto the seat opposite him. Having seen the passenger secure his seat belt the ground handler closed the cabin door and indicated to the pilot that the aircraft was secure. No other bags or freight were loaded onto the aircraft. The aircraft departed from Battersea Heliport at 1859 hrs. The reported meteorological conditions at 1820 hrs had included a visibility of 7 km, broken cloud at 3,800 feet with no significant weather. Recorded radar data indicates that the helicopter followed a direct track towards Bournemouth. The helicopter was initially cleared to an altitude of 1,400 feet and, when clear of the London Control Zone, received further clearance to an altitude of 1,700 feet. At 1920 hrs the pilot contacted Solent Radar, who provided a Flight Information Service. Because of traffic departing from Southampton, Solent Radar cleared G-PWER to fly not above 1,500 feet on a route via Romsey. Recorded radar data indicates that the aircraft descended to an altitude of 1,400 feet and followed the required routing. A professional pilot at Whitenap, on the south-east outskirts of Romsey, heard a helicopter pass overhead at what he estimated to be approximately 1,500 feet. He stated that the weather was cold and misty and that he could see the cloud reflecting the ground illumination, he estimated the cloud base to be at about 500 to 600 feet. He did not see the helicopter and considered that it was in or above the cloud. After a hand-over from Solent Radar, Bournemouth Approach control cleared the aircraft " TO ENTER BOURNEMOUTH CONTROLLED AIRSPACE SPECIAL VFR VIA STONEY CROSS NOT ABOVE 2,000 FEET QNH IS ONE ZERO TWO THREE MILLIBARS ": (Stoney Cross is a visual reference point (VRP) to the northeast of Bournemouth Airport). After acknowledging this clearance the pilot was instructed to change to the Tower frequency and to " REPORT VISUAL WITH THE FIELD". Having changed to the Tower frequency the pilot requested permission to " POSITION STRAIGHT IN FOR 26": this was approved and he was instructed to report the airfield in sight. The most expeditious route to comply with this clearance, and one with which the pilot was familiar, would have been direct from Stoney Cross to the airfield. This route transits large areas of poor cultural lighting but at Stoney Cross any low cloud should have been visible silhouetted against or obscuring well illuminated areas such as 1 Special VFR: Clearance for Special Visual Flight Rules is an authorisation by ATC for a pilot to fly within a Control Zone although he is unable to comply with Instrument Flight Rules. 60 Ringwood. The weather at Bournemouth Airport, recorded at 1920 hrs was: surface wind 180°/10 kt, visibility 2,700 metres in light rain with a few clouds at 1,200 feet, scattered cloud at 1,700 feet and broken cloud at 2,500 feet. The last recorded radar position was at Stoney Cross VRP, when the aircraft was tracking parallel to the M27/A31 which, with the vehicle lights, would have been a well defined line feature at night. The subsequent track of the aircraft was not recorded on radar due to terrain screening. Progress along the A31 and then down the A338 would have provided a simple routing to follow, with the lights of Ringwood giving good references and an easily identifiable position. If however low cloud and poor visibility prevented that option then using the ILS localiser would have provided an accurate track along the extended runway centre line and the best opportunity to acquire the runway and approach lights. The Tower Controller and the Radar Controller were both in the visual control room of the ATC tower at Bournemouth Airport but were unable to see the helicopter which was observed on a remote radar monitor to be tracking the extended centreline of Runway 26. The pilot acknowledged his clearance to land and the tower controller asked, " ECHO ROMEO JUST CHECK YOU ARE VISUAL WITH THE FIELD ". The pilot stated "ER NEGATIVE NOT THIS TIME ECHO ROMEO ". The controller confirmed that they could not see the aircraft either and turned the runway and approach lighting up to the maximum intensity. Shortly afterwards the pilot transmitted, " ER JUST BECOMING VISUAL THIS TIME ". The controller recalled that just as that transmission was made the aircraft, which was about 1 to 1·5 nm from the airport, commenced a descending turn to the left. The controller transmitted " GOLF ECHO ROMEO DO YOU REQUIRE RADAR AT ALL " to which the pilot responded " YEAH", eleven times in quick succession. Having acknowledged that response, the controller asked " GOLF ECHO ROMEO EVERYTHING OK "; the pilot responded "NEGATIVE NEGATIVE". The radar returns indicated that the height of the aircraft reduced from about 1,000 feet to 400 feet during the first 180° of the turn and, as the aircraft continued the left turn, it climbed back towards 1,000 feet. Having completed a turn of approximately 360° the left turn continued through a further 180°, continually descending before the height readout was lost on the radar. During these manoeuvres, the pilot twice maintained an 'open mike' with continuous transmissions, initially for 29 seconds followed nine seconds later by a further 18 second transmission. During these transmissions the pilot confirmed that he had a problem but did not des

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Agusta A109E, G-PWER, 3 March 2004

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