S2/2011 - , VP-MON, 22 May 2011

1 © Crown copyright 2011 AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04 SERIOUS INCIDENT Aircraft Type and Registration: Britten-Norman BN2A-26, Islander, VP-MON No & Type of Engines: 2 Lycoming O540 piston engines Year of Manufacture: Not known Date & Time (UTC): 22 May 2011 at 2154 hrs Location: John A Osborne Airport, Montserrat Type of Flight: Commercial Air Transport (Passenger) Persons on Board: Crew - 1 Passengers - 7 Injuries: Crew - None Passengers - None Nature of Damage: None Commander’s Licence: Commercial Pilot’s Licence Commander’s Age: 34 years Commander’s Flying Experience: 3,600 hours (of which 2,000 were on type) Last 90 days - 13 hours Last 28 days - 13 hours Information Source: AAIB Field Investigation This Special Bulletin contains facts which have been determined up to the time of issue. It is published to inform the aviation industry and the public of the general circumstances of accidents and serious incidents and should be regarded as tentative and subject to alteration or correction if additional evidence becomes available. The investigation is being carried out in accordance with The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996, Annex 13 to the ICAO Convention on International Civil Aviation and EU Regulation No 996/2010. The sole objective of the investigation shall be the prevention of accidents and incidents. It shall not be the purpose of such an investigation to apportion blame or liability. Extracts may be published without specific permission providing that the source is duly acknowledged, the material is reproduced accurately and is not used in a derogatory manner or in a misleading context. Synopsis While attempting to land on Runway 28 the aircraft skidded after the commander applied the brakes. As a result the commander performed a touch-and-go and positioned for another approach to Runway 28. On landing after the second approach the aircraft skidded again when brakes were applied, and the commander continued with the landing roll. However, believing there was insufficient runway ahead in which to stop the aircraft the commander steered the aircraft onto the grass verge in an attempt to stop it before the end of the prepared surface. The aircraft came to rest beside the runway, 46 m from its end. There were no injuries to the passengers and no damage to the aircraft. This was the commander’s first landing on Runway 28. 2 © Crown copyright 2011 AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04 A previous serious landing incident at John A Osborne airport, involving the same operator, is also being investigated by the AAIB, which is responsible for investigating accidents and serious incidents that occur in the UK Overseas Territories. As a result of initial investigations three safety recommendations have been made. All times in this special bulletin are UTC. Local time in Montserrat is 4 hours behind UTC. History of the flight The aircraft was on a scheduled flight from VC Bird Airport, Antigua, West Indies, to John A Osborne Airport, Montserrat. The departure and cruise from Antigua were uneventful. As the aircraft approached Montserrat the pilot was instructed to join left hand downwind for Runway 10 and informed that the wind was from 090° at 5 kt. Approximately three minutes later the ATCO advised the pilot that the wind was now from 360° at 3 kt. The pilot replied that he would nevertheless like to conduct an approach to Runway 10. However the ATCO added that there were clouds at approximately 600 ft aal 1 drifting from the west with visibility of approximately 6 km. As a result the pilot requested Runway 28. He was instructed to report on final for Runway 28 and advised that the wind was from 350° at 4 kt. When the pilot reported that he was approximately 3 nm from landing the ATCO informed him that there was a light rain shower at the airfield. Shortly thereafter the ATCO reported that he could see VP-MON and cleared the aircraft to land on Runway 28, reporting a surface wind from 300° at 4 kt. The pilot stated that he touched down in the area of the Runway 28 identification numbers. After he applied the brakes the aircraft skidded, so he decided to Footnote 1 aal means ‘above aerodrome level’. perform a touch-and-go and to make another approach to Runway 28. The passengers, ATCOs and AFRS personnel stated that the aircraft appeared to have touched down approximately a third to halfway along the runway. On short final during the second approach the ATCO informed the pilot the wind was from 320° at 3 kt. The pilot stated that he touched down just past the runway threshold marker and the aircraft skidded again on the initial application of the brakes, however, he elected to continue with the landing roll. Most of the witnesses stated that the aircraft landed just before the Abbreviated PAPIs (APAPIs) 2 for Runway 28, which are located approximately 190 m from the Runway 28 threshold. As he continued the landing roll he continued to ‘pump’ the brakes; however, he judged he might overrun the runway. As a result he elected to steer the aircraft right onto the grass verge, approximately 156 m from the end of the paved surface, in an attempt to slow down the aircraft more effectively. The aircraft came to rest on the grass approximately 46 m from the end of the paved runway surface. The runway was described as ‘damp’ by the pilot and most of the witnesses. After the pilot had shut down the aircraft’s engines he vacated the aircraft, followed by the passengers. There were no injuries to the passengers and no apparent damage to the aircraft. After the passengers had been driven to the terminal in an airport vehicle the pilot started the aircraft’s engines and taxied it to the apron without requesting permission from ATC. Having informed the operator’s chief pilot and sought some engineering advice from an off-island maintenance organisation the pilot left the airport. Footnote 2 Abbreviated PAPIs consist of two lights to indicate the aircraft’s runway approach angle to the pilot; PAPIs have four. 3 © Crown copyright 2011 AAIB Special Bulletin: S2/2011 VP-MON EW/C2011/05/04 The following morning the pilot flew the aircraft empty to Anguilla for a scheduled maintenance inspection. Notification The locally based Accident Investigation Manager (AIM) was informed of the incident by Montserrat ATC at approximately 2200 hrs (all times in this report are UTC) and arrived at the airport at 2238 hrs. Initially he was unable to inform the AAIB by telephone, and made contact at 1230 hrs the following day. After further enquiries the AAIB travelled to Montserrat on 13 June 2011 to conduct a field investigation. Runway inspection The runway was inspected by the AIM and latterly by the AAIB. They noted a skid mark approximately 24 m long made by the aircraft’s right main tyres that started approximately 191 m from the beginning of the paved area of Runway 28 (163 m from the threshold), 12 m before the Runway 28 APAPIs. The aircraft’s tyre marks continued along the runway until the left and right tyre marks left the paved surface about 115 m and 148 m from the end of the paved surface respectively. Weather information The Terminal Aerodrome Forecast (TAF) for John A Osborne Airport issued at 1000 hrs on 22 May 2011 stated that the surface wind was expected to be calm and the visibility in excess of 10 km, with SCATTERED cloud at 2,200 ft aal. There was a 30% chance that between 1200 hrs on 22 May and 1200 hrs on 23 May there would temporarily be showers of rain. The surface wind was expected to become 10 kt from 120° between 1200 hrs and 1600 hrs. The reported conditions at 2100 hrs were surface wind from 110° at 12 kt, visibility in excess of 10 km, BROKEN cloud at 1,600 ft aal, temperature 26°C, dew point 25°C and QNH 1014 mb. There had been recent rain at the aerodrome and there was rain to the west. The reported conditions at 2200 hrs

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S2/2011 - , VP-MON, 22 May 2011

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Special Bulletin S2/2011 - Britten-Norman BN2A-26 Islander, VP-MON

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