Flight Design CTSW, G-CFAZ, 8 October 2008

148 © Crown copyright 2009 AAIB Bulletin: 11/2009 G-CFAZ EW/C2008/10/01 ACCIDENT Aircraft Type and Registration: Flight Design CTSW, G-CFAZ No & Type of Engines: 1 Rotax 912 ULS piston engine Year of Manufacture: 2007 Date & Time (UTC): 8 October 2008 at 0855 hrs Location: Saddleworth Moor, Lancashire Type of Flight: Private Persons on Board: Crew - 1 Passengers - None Injuries: Crew - 1 (Fatal) Passengers - None Nature of Damage: Aircraft destroyed Commander’s Licence: Private Pilot’s Licence Commander’s Age: 41 years Commander’s Flying Experience: 123 hours (of which 29 were on type) Last 90 days - 11 hours Last 28 days - 0 hours Information Source: AAIB Field Investigation Synopsis The pilot was flying from Manchester Barton to Shacklewell Lodge, a small private airstrip near RAF Cottesmore. To the east of Manchester the aircraft descended rapidly and crashed into the ground at Saddleworth Moor, probably as a result of a loss of control following an inadvertent entry into cloud. One Safety Recommendation is made, concerning baggage restraints. History of the flight The pilot prepared the aircraft for a solo flight from Manchester Barton to Shacklewell Lodge, a small private airstrip near RAF Cottesmore, and placed three shotguns, in cases, into the rear of the aircraft; no ammunition was loaded into the aircraft. The pilot started the engine and taxied to the holding point, where the aircraft was seen to stop and the engine was shut down. The pilot walked back towards the hangars and told the Chief Flying Instructor of his flying club that the electronic flight display in the aircraft had been left on prior to flight, that he had shut the aircraft down to resolve a ‘voltage problem’, and that now, the engine would not start. The pilot obtained assistance from an engineer and re-started the aircraft. The aircraft took off without further incident at 0842 hrs, and the pilot transmitted to the aerodrome flight information service officer (AFISO) at Barton that he was changing frequency to Manchester Approach. No transmission was made on the Manchester 149 © Crown copyright 2009 AAIB Bulletin: 11/2009 G-CFAZ EW/C2008/10/01 Approach frequency (it was usual for pilots departing Barton to monitor the Manchester frequency, without transmitting). Later in the day, a member of the pilot’s family, who was expecting to meet him at Shacklewell Lodge, telephoned a local air traffic control unit to express concern that the aircraft had not arrived. Overdue action was taken, and Search and Rescue operations began. At about 1530 hrs, two farmers found the wreckage of the aircraft, and reported it to the police. The wreckage was on Saddleworth Moor, high ground to the east of Manchester, at an elevation of about 1,540 ft amsl. Accident site The aircraft had struck the ground close to the A635 on Saddleworth Moor and had suffered significant disruption on impact, with the wreckage trail extending for 155 metres. The first ground mark was made by the right wing tip and the nature of the groove indicated that the aircraft was in a bank of 45° to 55° to the right at impact. Beyond this mark there was a large area of disturbed ground which formed a shallow crater and, further on, several transverse slash marks characteristic of a rotating propeller. The wreckage trail continued for approximately 150 metres beyond the crater on a bearing of 084°. Both the wing fuel tanks had been disrupted and there was a strong smell of fuel across the accident site, with significant areas of grass discolouration, indicating the spillage of fuel. The engine, its mounting structure and propeller were located 1.5 metres under the surface of the main impact point and the peat surrounding the engine was heavily contaminated with fuel. One propeller blade was found attached to the hub and the remaining two blades were recovered separately, with one blade showing damage consistent with striking an object whilst rotating. Three shotguns, which had been in the aircraft, were recovered from the wreckage by the police. After initial examination the wreckage of the aircraft was recovered for detailed examination. The pilot The pilot learnt to fly first on gliders and then as a member of a University Air Squadron in 1987-88, accruing 22 hours flying experience. He then did not fly for some years, but took flying lessons at Manchester Barton beginning in August 2006 and he obtained a National Private Pilots Licence in April 2007 following 27 hours of training. Having obtained his licence, he bought a share in an Ikarus C42 aircraft, which he flew regularly until November 2007 when he sold that share. He then bought a share in the accident aircraft and began flying it in January 2008. The club CFI (Chief Flying Instructor) described the pilot as being very proficient at handling the aircraft but had, on a number of occasions, expressed concern to the pilot about his judgement. The areas of concern included decisions on whether to fly in weather which was marginal or unsuitable, and instances of flight recorded as flown at unusually high speeds and power settings. Members of the group which owned the aircraft had also discussed concerns about the pilot’s judgement, and whether he would continue as a member of the group. The pilot’s licence validity expired on 4 May 2008. The pilot did not hold a radio licence. 150 © Crown copyright 2009 AAIB Bulletin: 11/2009 G-CFAZ EW/C2008/10/01 Aircraft description The P&M Aviation/Flight Design CTSW is a two‑seat, high-wing three-axis microlight powered by a Rotax 912 UL engine, with a cruising speed of 120 kt. The ailerons are operated through a series of rods and bellcranks, which pass from the control columns, under the cockpit floor and upward behind the rear cockpit bulkhead. The aircraft is equipped with electrically‑operated flaps which have a range of -12° (cruise) to +40° (landing). The flaps are connected to the aileron system through a mixing unit which causes the ailerons to droop when the flaps are deployed, to improve the aircraft’s short field performance. The rudder is operated by a pair of cables from the rudder bars and the elevator is operated by a ‘push-pull’ Teleflex-type cable. The elevator is fitted with a mass balance arm at its hinge point within the fuselage. The fuselage is of carbon fibre/foam sandwich monocoque construction, without bulkheads or substantial fuselage frames. The manufacturer’s Operator’s Manual states that the aircraft has a maximum baggage weight of 25 kg, to be stowed in the rear fuselage immediately behind the rear cockpit bulkhead. Access is provided by a removable panel on either side of the fuselage immediately behind each cockpit door; the seatbacks can also be pulled forward to stow larger items. Any baggage is secured under two bungee nets (Figure 1). The aircraft was fitted with basic VFR flight instrumentation, much of it integrated into an electronic multi-function (MFD) display which showed airspeed, propeller rpm and altitude. The aircraft had a magnetic compass but was not fitted with an artificial horizon or direction indicator. The GPS fitted to the aircraft was capable of displaying a synthesised panel of ‘flight instruments’ 1 (though not an artificial horizon), but the club CFI believed that the accident pilot was not aware of this feature. The aircraft was fitted with an altitude-encoding transponder; the pilot often left it switched off during flight. The Garmin GPS fitted to the aircraft was capable of displaying terrain and obstacles on its moving map. Terrain within 100 ft vertically of the aircraft’s present GPS altitude was shown in red, terrain within 1,000 ft was shown in yellow. Footnote 1 Derived from GPS information; the device contained no gyroscopic instruments. Figure 1 G-CFAZ baggage restraint 151 © Crown copyright 2009 AAIB Bulletin: 11/2009 G-CFAZ EW/C2008/10/01 R

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