Accident Repor: Divi Divi BN2P near Bonaire on Oct 22nd 2009

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Accident Repor: Divi Divi BN2P near Bonaire on Oct 22nd 2009

Unread post by bimjim » Tue May 17, 2011

http://avherald.com/h?article=4219e895/0000

Accident: Divi Divi BN2P near Bonaire on Oct 22nd 2009, engine failure, ditched in the Caribbean
By Simon Hradecky
Tuesday, May 17th 2011
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The Dutch Onderzoeksraad (Dutch Safety Board DSB) released their final report concluding:

Causal factors

1. After one of the two engines failed, the flight continued to Bonaire. By not returning to the nearby situated departure airport, the safest flight operation was not chosen.

- Continuing to fly after engine failure was contrary to the general principle for twin-engine aircraft as set down in the CARNA, that is, to land at the nearest suitable airport.

2. The aircraft could not maintain horizontal flight when it continued with the flight and an emergency landing at sea became unavoidable.

- The aircraft departed with an overload of 9% when compared to the maximum structural take-off weight of 6600 lb. The pilot who was himself responsible (self-dispatch and release) for the loading of the aircraft was aware of the overloading or could have been aware of this. A non-acceptable risk was taken by continuing the flight under these conditions where the aircraft could not maintain altitude due to the overloading.

3. The pilot did not act as could be expected when executing the flight and preparing for the emergency landing.

- The landing was executed with flaps up and, therefore, the aircraft had a higher landing speed.

- The pilot ensured insufficiently that the passengers had understood the safety instructions after boarding.

- The pilot undertook insufficient attempts to inform passengers about the approaching emergency landing at sea after the engine failure and, therefore, they could not prepare themselves sufficiently.

Contributing factors

Divi Divi Air

4. Divi Divi Air management paid insufficient supervision to the safety of amongst others the flight operation with the Britten-Norman Islanders. This resulted in insufficient attention to the risks of overloading.

Findings:

- The maximum structural take-off weight of 6600 lb was used as limit during the flight operation. Although this was accepted by the oversight authority, formal consent was not granted for this.

- A standard average passenger weight of 160 lb was used on the load and balance sheet while the actual average passenger weight was significantly higher. This meant that passenger weight was often lower on paper than was the case in reality.

- A take-off weight of exactly 6600 lb completed on the load and balance sheet occurred in 32% of the investigated flights. This is a strong indication that the luggage and fuel weights completed were incorrect in these cases and that, in reality, the maximum structural take-off weight of 6600 lb was exceeded.

- Exceedances of the maximum structural landing weight of 6300 lb occurred in 61% of the investigated flights.

- The exceedance of the maximum allowed take-off weight took place on all three of the Britten-Norman Islander aircraft in use and with different pilots.

- Insufficient attention was paid to aircraft weight limitations during training.

- Lack of internal supervision with regard to the load and balance programme.

- Combining management tasks at Divi Divi Air, which may have meant that insufficient details were defined regarding the related responsibilities.

5. The safety equipment and instructions on-board the Britten-Norman Islander aircraft currently being used were not in order.

Findings:

- Due to the high noise level in the cabin during the flight it is difficult to communicate with the passengers during an emergency situation.

- The safety instruction cards did not include an illustration of the pouches under the seats nor instructions on how to open these pouches. The life jacket was shown with two and not a single waist belt and the life jackets had a different back than the actual life jackets on-board.

Directorate of Civil Aviation Netherlands Antilles (currently the Curacao Civil Aviation Authority)

6. The Directorate of Civil Aviation's oversight on the operational management of Divi Divi Air was insufficient in relation to the air operator certificate involving the Britten-Norman Islander aircraft in use.

Findings:

- The operational restrictions that formed the basis for using 6600 lb were missing in the air operator certificate, in the certificate of airworthiness of the PJ-SUN and in the approved General Operating Manual of Divi Divi Air. The restrictions entail that flying is only allowed during daylight, under visual meteorological conditions, and when a route is flown from where a safe emergency landing can be executed in case of engine failure.

- The required (demonstrable) relation with the actual average passenger weight was missing in relation to the used standard passenger weight for drawing up the load and balance sheet.

- The failure of Divi Divi Air's internal supervision system for the load and balance programme.

- Not noticing deviations between the (approved) safety instruction cards and the life jackets on-board during annual inspections.

- The standard average passenger weight of 176 lb set after the accident offers insufficient security that the exceedance of the maximum allowed take-off weight of flights with Antillean airline companies that fly with the Britten-Norman Islander will not occur.

Other factors

Recording system of radio communication with Hato Tower

7. The recording system used for the radio communication with Hato Tower cannot be used to record the actual time. This means that the timeline related to the radio communication with Hato Tower cannot be exactly determined.

The alerting and the emergency services on Bonaire

8. There was limited coordination between the different emergency services and, therefore, they did not operate optimally.

Findings:

- The incident site command (CoPI) that should have taken charge of the emergency services in accordance with the Bonaire island territory crisis plan was not formed.

- Insufficient multidisciplinary drills have been organised and assessed for executive officials who have a task to perform in accordance with the Bonaire island territory crisis plan and the airport aircraft accident crisis response plan in controlling disasters and serious accidents. They were, therefore, insufficiently prepared for their task.

9. The fire service and police boats could not be deployed for a longer period of time.

The DSB reported, that the aircraft had climbed to FL035, reduced climb to cruise power with the pilot (32, US ATPL, 1739 hours total, 565 hours on type) just adjusting a power lever, when the passengers felt a jolt and engine power ceased from the right hand engine - some passengers also reported the engine sputtered just prior to the jolt. The pilot increased the power on the left hand engine, feathered the right hand propeller and trimmed the rudder forces off. He then attempted to restart the right hand engine two or three times to no avail. 5 minutes after departure the pilot reported the engine failure to Curacao tower and requested a priority landing in Bonaire.

From the moment of engine failure the aircraft descended at approximately 140 feet per minute with the pitch attitude increasing being unable to maintain altitude.

10 minutes after departure the pilot contacted Bonaire and reported 24 miles out at 3000 feet and requested a priority landing on Bonaire's runway 10. Bonaire Tower cleared the approach.

The passengers, recognizing from their frequent flights that the airspeed was slower than normal and the attitude was higher than normal, got concerned and, although no communication came from the pilot, fetched their life jackets from underneath their seats and put them on. The passengers also agreed on a course of action in case of an emergency landing on the water.

21 minutes after departure the pilot reported to be 10nm out at 1000 feet expecting to land in 10 minutes. Another 2 minutes later the pilot reported 8nm out at 600 feet, another 2 minutes later the pilot reported 6nm out at 300 feet. Another minute later the pilot reported 5nm out at 200 feet in his last radio transmission, he was still losing altitude and needed to perform an emergency landing near Klein Bonaire. The airplane turned a bit left towards Klein Bonaire, the pilot advised the passengers using hand signs that they were going to land on water. All cabin doors were closed during approach and impact.

The passengers observed intermittent stall warnings in this last phase of flight, shortly before impact with the water the stall warning activated and continued until after impact.

30 minutes after departure from Curacao the airplane impacted water 0.7nm from Klein Bonaire and 3.5nm west of Bonaire. The left front door broke off the cabin, other parts separated from the aircraft. The aircraft came to rest upright floating normally on the water, the windshield was shattered, waves of about 0.5 meters in height started to fill the cabin with water through the door and windscreen. A passenger behind the pilot was trapped but could free herself, all 9 passengers were able to leave the aircraft through the left door.

A passenger reported the pilot had hit his head on the vertical door/window frame in the cockpit or instrument panel (which was supported by autopsy results) and had lost consciousness. One or two passengers attempted to free the pilot from his seat but were unsuccessful and needed to leave, a few minutes after impact the airplane sank with the pilot still on board.

Approximately 5 minutes after impact two boats with recreational divers arrived at the impact location, divers of the first boat attempted to locate the aircraft based on the passenger indications while the second boat took the passengers ashore. 6 passengers were taken to a hospital and discharged after an examination, 3 passengers went their own ways. The DSB stated 4 passengers received minor injuries and 5 remained without injuries.

The aircraft was later recovered from a depth of 190 meters.

The load sheet assumed a standard weight of 160lbs per person including hand luggage, also for the pilot. Substantial deviations between the assumed and actual weights were determined by the investigation, that found the actual average weight was 187 lbs. The heaviest persons were located in the back rows moving the CG backwards. In addition, the load sheet only contained the pilot and 8 passengers, the weight of the 9th passenger was missing. Luggage and freight were estimated at 157 lbs. According to the load sheet 700 lbs of fuel were on board, the fuelling bill showed the tanks were full, confirmed by passengers observing the fuel quantity meter indicating full amounting to 822 lbs of fuel. The DSB analysed that the only reason for incorrect weights and the weight of the 9th passengers missing was that the load sheet would have gone above 6600 lbs, the maximum structural takeoff weight.

The DSB concluded that the actual zero fuel weight was 6431 lbs and the actual takeoff weight was 7211 lbs, 611 lbs (9%) above the maximum structural takeoff weight of 6600 lbs with an estimated landing weight at Bonaire of 7121 lbs.

The DSB analysed that the pilot likely was aware of the airplane being overloaded and continued: "The aircraft climbed to FL035 instead of the usual 2000 feet altitude. An explanation for this could not be found. It is possible that the pilot choose this altitude due to the overweight. This choice, therefore, implicitly infers the consideration that a higher altitude is required should there be engine failure with overweight to cover the same distance than without overweight."

The maximum structural landing weight is set at 6300 lbs. Due to the fuel consumption of 90 lbs from Curacao to Bonaire the maximum permitted takeoff weight would have been 6390 lbs.

The DSB considered a number of scenarios to explain the engine failure, perhaps by inadvertent pilot actions like switching magnetos or inadvertently moving the fuel mixture control levers instead of the propeller pitch levers, the scenarios were considered unlikely. As a result the DSB could not explain why the engine failed.

The DSB analysed that the pilot did not regard the engine failure an emergency situation. Having the choice of returning to Curacao or continuing to Bonaire he decided to continue to Bonaire against the principle of diverting to the nearest suitable airport in case of an engine failure. The pilot was fully aware of the aircraft position and situation. At the time of the engine failure the aircraft had covered about one quarter of the distance, Curacao was clearly closer than Bonaire. The situation was further exacerbated by prevailing eastern trade winds between 15 and 20 knots increasing the necessary flying time to Bonaire, while a return to Curacao would have provided the benefit of 20 knots tailwind.

The DSB analysed that with a gross weight of 6300 lbs in the existing environmental conditions the aircraft would have been capable to maintain altitude of 3500 feet. Even at 6600 lbs gross weight the aircraft would have been able to maintain 2000 feet. Due to the overweight the airplane however was not able to maintain any altitude.

The DSB determined that the actual center of gravity was at 25.1 inch, close to but within the aft limit of 25.6 inches.

The DSB was highly critical of the supervision of Divi Divi Air as well as the oversight provided by the Civil Aviation Regulations Netherlands Antilles (Civil Authority) stating that landing overweight was a regular event. The ICAO had also listed numerous points during an audit of the Civil Aviation Regulations Netherlands Antilles in 2008.
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By Simon Hradecky, created Thursday, Oct 22nd 2009 18:30Z, last updated Tuesday, May 17th 2011 22:22Z
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A Divi Divi Air Britten-Norman BN2 A Islander, registration PJ-SUN performing flight 016 from Curacao to Bonaire (Netherlands Antilles) with 9 passengers and 1 pilot, ditched before the coast of Bonaire when the pilot realized he could not reach the airport anymore following the failure of the right hand engine (Lycoming IO-540). The airplane impacted the water with considerable force at around 11:15L (15:15Z) causing the pilot to strike the windscreen with his head and being knocked unconscious. The passengers were unable to open his seat belt, but all 9 passengers were able to leave the airplane and were taken aboard a boat that quickly arrived at the scene. The airplane sank, the pilot was killed.

The airline confirmed, that the pilot was still on board when the airplane sank. Emergency services are currently trying to recover his body. The passengers were taken to local hospitals.

There were rumours around, that the pilot may have gotten out of the airplane and was swimming to the coast. All emergency services and the airline said, those rumours were untrue.

According to first preliminary investigation results the pilot had declared emergency and reported an engine failure when he was about 5 minutes before estimated landing at Bonaire, but then needed to ditch the airplane.

Curacao and Bonaire airports are 41nm apart.

On Dec 18th 2009 the airplane was recovered and taken to Curacao. The body of the pilot was found still in his seat. An autopsy has been scheduled.


Metars:
TNCB 221700Z 11013KT 9999 SCT020 31/23 Q1010
TNCB 221600Z VRB11KT 9999 SCT020 31/24 Q1011
TNCB 221500Z 11010KT 9999 SCT019 30/23 Q1011
TNCB 221400Z AUTO 11009KT 9999 SCT019 30/22 Q1012
TNCB 221300Z 11011KT 9999 SCT019 30/24 Q1011
TNCB 221200Z 11010KT 9999 FEW018 29/24 Q1011
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