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AAIB Bulletin4/2022TO REPORT AN ACCIDENT OR INCIDENTPLEASE CALL OUR 24 HOUR REPORTING LINE01252 512299

Air Accidents Investigation BranchFarnborough HouseBerkshire Copse RoadAldershotHants GU11 2HHAAIB Bulletin: 4/2022GLOSSARY OF ABBREVIATIONSTel: 01252 510300Fax: 01252 376999Press enquiries: 0207 944 3118/4292http://www.aaib.gov.ukAAIB investigations are conducted in accordance withAnnex 13 to the ICAO Convention on International Civil Aviation,EU Regulation No 996/2010 (as amended) and The Civil Aviation(Investigation of Air Accidents and Incidents) Regulations 2018.The sole objective of the investigation of an accident or incident under theseRegulations is the prevention of future accidents and incidents. It is not thepurpose of such an investigation to apportion blame or liability.Accordingly, it is inappropriate that AAIB reports should be used to assign faultor blame or determine liability, since neither the investigation nor the reportingprocess has been undertaken for that purpose.AAIB Bulletins and Reports are available on the Internethttp://www.aaib.gov.ukThis bulletin contains facts which have been determined up to the time of compilation.Extracts may be published without specific permission providing that the source is duly acknowledged, the material isreproduced accurately and it is not used in a derogatory manner or in a misleading context.Published 14 April 2022 Crown copyright 2022Published by the Air Accidents Investigation Branch, Department for TransportPrinted in the UK on paper containing at least 75% recycled fibreCover picture courtesy of Alan ThorneISSN PL RISAkgKCASKIASKTASkmabove airfield levelAirborne Collision Avoidance SystemAutomatic Communications And Reporting SystemAutomatic Direction Finding equipmentAerodrome Flight Information Service (Officer)above ground levelAeronautical Information Circularabove mean sea levelAerodrome Operating MinimaAuxiliary Power Unitairspeed indicatorAir Traffic Control (Centre)( Officer)Automatic Terminal Information ServiceAirline Transport Pilot’s LicenceBritish Microlight Aircraft AssociationBritish Gliding AssociationBritish Balloon and Airship ClubBritish Hang Gliding & Paragliding AssociationCivil Aviation AuthorityCeiling And Visibility OK (for VFR flight)calibrated airspeedcubic centimetresCentre of Gravitycentimetre(s)Commercial Pilot’s LicenceCelsius, Fahrenheit, magnetic, trueCockpit Voice RecorderDistance Measuring Equipmentequivalent airspeedEuropean Union Aviation Safety AgencyElectronic Centralised Aircraft MonitoringEnhanced GPWSExhaust Gas TemperatureEngine Indication and Crew Alerting SystemEngine Pressure RatioEstimated Time of ArrivalEstimated Time of DepartureFederal Aviation Administration (USA)Flight Data RecorderFlight Information RegionFlight Levelfeetfeet per minuteacceleration due to Earth’s gravityGlobal Navigation Satellite SystemGlobal Positioning SystemGround Proximity Warning Systemhours (clock time as in 1200 hrs)high pressurehectopascal (equivalent unit to mb)indicated airspeedInstrument Flight RulesInstrument Landing SystemInstrument Meteorological ConditionsIntermediate PressureInstrument RatingInternational Standard Atmospherekilogram(s)knots calibrated airspeedknots indicated airspeedknots true und(s)low pressureLight Aircraft AssociationLanding Distance AvailableLicence Proficiency Checkmetre(s)millibar(s)Minimum Descent Altitudea timed aerodrome meteorological reportminutesmillimetre(s)miles per hourMaximum Total Weight AuthorisedNewtonsMain rotor rotation speed (rotorcraft)Gas generator rotation speed (rotorcraft)engine fan or LP compressor speedNon-Directional radio Beaconnautical mile(s)Notice to AirmenOutside Air TemperatureOperator Proficiency CheckPrecision Approach Path IndicatorPilot FlyingPilot in CommandPilot MonitoringPilot’s Operating HandbookPrivate Pilot’s Licencepounds per square inchaltimeter pressure setting to indicate height aboveaerodromealtimeter pressure setting to indicate elevation amslResolution AdvisoryRescue and Fire Fighting Servicerevolutions per minuteradiotelephonyRunway Visual RangeSearch and RescueService BulletinSecondary Surveillance RadarTraffic AdvisoryTerminal Aerodrome Forecasttrue airspeedTerrain Awareness and Warning SystemTraffic Collision Avoidance SystemTakeoff Distance AvailableUnmanned AircraftUnmanned Aircraft SystemUS gallonsCo-ordinated Universal Time (GMT)Volt(s)Takeoff decision speedTakeoff safety speedRotation speedReference airspeed (approach)Never Exceed airspeedVisual Approach Slope IndicatorVisual Flight RulesVery High FrequencyVisual Meteorological ConditionsVHF Omnidirectional radio Range

AAIB Bulletin: 4/2022CONTENTSSPECIAL BULLETINS / INTERIM REPORTSNoneSUMMARIES OF AIRCRAFT ACCIDENT (‘FORMAL’) REPORTSNoneAAIB FIELD INVESTIGATIONSCOMMERCIAL AIR TRANSPORTFIXED WINGNoneROTORCRAFTNoneGENERAL AVIATIONFIXED WINGCessna 8-Aug-2127-Aug-21262933ROTORCRAFTNoneSPORT AVIATION / BALLOONSNoneUNMANNED AIRCRAFT SYSTEMSNoneAAIB CORRESPONDENCE INVESTIGATIONSCOMMERCIAL AIR TRANSPORTCessna 208B, Caravan (Cargomaster)Leonardo AW189G-OJMPG-MCGUGENERAL AVIATIONBeechcraft 95-B55 BaronReims Cessna F172NJodel D120A2-NOVAG-BGIYG-AVLYSPORT AVIATION / BALLOONSNone Crown copyright 2022iAll times are UTC

AAIB Bulletin: 4/2022CONTENTS ContAAIB CORRESPONDENCE INVESTIGATIONS ContUNMANNED AIRCRAFT SYSTEMSNoneRECORD-ONLY INVESTIGATIONSRecord-Only Investigations reviewedJanuary / February 202239MISCELLANEOUSADDENDA and CORRECTIONSNoneList of recent aircraft accident reports issued by the AAIB45(ALL TIMES IN THIS BULLETIN ARE UTC) Crown copyright 2022iiAll times are UTC

AAIB Bulletin: 4/2022AAIB Field Investigation ReportsA Field Investigation is an independent investigation in whichAAIB investigators collect, record and analyse evidence.The process may include, attending the scene of the accidentor serious incident; interviewing witnesses;reviewing documents, procedures and practices;examining aircraft wreckage or components;and analysing recorded data.The investigation, which can take a number of months to complete,will conclude with a published report. Crown copyright 20221All times are UTC

AAIB Bulletin: 4/2022G-CFIOAAIB-27664ACCIDENTAircraft Type and Registration:Cessna 172S, G-CFIONo & Type of Engines:1 Lycoming IO-360-L2A piston engineYear of Manufacture:2002 (Serial no: 172S9079)Date & Time (UTC):10 September 2021 at 0942 hrsLocation:Ruckinge, KentType of Flight:Private (unauthorised)Persons on Board:Crew - 1Passengers - NoneInjuries:Crew - 1 (Fatal)Passengers - N/ANature of Damage:Aircraft destroyedCommander’s Licence:Student pilotCommander’s Age:67 yearsCommander’s Flying Experience:74 hours (of which 74 were on type)Last 90 days - 16 hoursLast 28 days - 2 hoursInformation Source:AAIB Field InvestigationSynopsisAt 0958 hrs on 10 September 2021, without permission from the operator or clearancefrom the air traffic radio operator, a student pilot took off from Rochester Airport in G-CFIO.The aircraft was later observed to enter a steep descent to the left before it struck theground in a field adjacent to Tar Pot Lane near Ruckinge in Kent. The pilot did not survivethe accident.Immediately prior to taking off, the pilot had reported over the aircraft radio that he hadbeen diagnosed with a terminal illness and indicated that he intended to deliberately crashthe aircraft. The pilot had not declared his diagnosis to the doctor who issued his aviationmedical certificate.History of the flightAt 0958 hrs on 10 September 2021 a Cessna 172S Skyhawk aircraft, registration G-CFIO,took off from Rochester Airport and was later found extensively damaged in a farmer’s fieldnear Ruckinge, Kent. At the controls was a student pilot who was supposed to be flying adual training exercise with an instructor. When the instructor went via the Air Traffic Controlbuilding to gain flight approval, the pilot proceeded directly to G-CFIO, boarded it and then,without the instructor on board and without air traffic approval, taxied and took off. Priorto taking off, the pilot indicated over the radio his terminal diagnosis and his intention todeliberately crash the aircraft. Crown copyright 20223All times are UTC

AAIB Bulletin: 4/2022G-CFIOAAIB-27664Radar evidence showed that after departing Rochester Airport, G-CFIO had flown to anarea south of Ashford before loitering and carrying out a sustained series of turns. At1044 hrs a witness 1.5 km south-southeast of the accident site saw a white aircraft to thenorth of them and at low level enter a “sharp” descending turn to the left. The nature,location and timing of the sighting correlated with the location of the accident site. Thepilot did not survive the accident.Accident siteImpact evidence indicated that G-CFIO had struck the ground while in a descending leftturn. The area surrounding the accident site was relatively benign for a field landing.Several flat fields of an acceptable length were available to choose from, including the onein which G-CFIO’s wreckage was discovered. While the accident field was suitably long,the approach track was aligned across one corner rather than down the length of the field,leaving insufficient obstacle-free distance for a safe landing. A 30 track change to the rightwould have given ample ground distance for a successful field landing. There were nosignificant vertical obstacles close to G-CFIO’s final flight path that would have required thepilot to take avoiding action by entering a turn.Aircraft technical examinationA detailed technical examination of the aircraft revealed several overload failures but noevidence of any pre-impact disconnection or restriction of the flight controls. The fuel tanksstill contained fuel and there was evidence that the engine was under power when theaircraft struck the ground.MedicalWhile the pilot reported over the radio that he had received a terminal diagnosis, thishad not been declared to the Aero-medical Examiner (AME) who renewed his Class 2flying medical certificate in June 2021. Unless an AME is the applicant’s own GeneralPractitioner (GP) they are not entitled to review a pilot’s central medical records. Instead,pilots are required to disclose any significant medical conditions to their AME prior toissue of, and at any time during the validity of, their flying medical certificate. A diagnosisof cancer can result in the revocation of a flying medical certificate and pilots receivingsuch diagnoses are obliged to inform their AME.The pilot’s GP confirmed that the pilot was diagnosed in July 2021.AnalysisThe pilot had renewed his aviation medical before receiving the terminal diagnosis but hadnot subsequently informed the issuing AME of the change in his medical fitness. GPs arenot under any obligation to inform AMEs of significant changes to a pilot’s health.The investigation did not find evidence of any technical failure that would have caused theaircraft to enter an uncontrolled descending left turn leading to it striking the ground. Crown copyright 20224All times are UTC

AAIB Bulletin: 4/2022G-CFIOAAIB-27664Unless the pilot was distracted, disorientated, or medically impaired at the time, untilshortly before the aircraft contacted the ground, the pilot could have levelled the wings andestablished an appropriate flightpath to achieve a successful landing in the accident field.The aircraft was not equipped with recording devices capable of capturing evidence of pilotdistraction, disorientation, or impairment.ConclusionThe area where G-CFIO crashed was suitable for a powered or unpowered field landing.There was no evident operational or technical reason which might explain why the aircraftapproached the ground in a descending left turn from which a safe landing could not bereasonably assured. The investigation did not find evidence to support or discount a findingthat pilot distraction, disorientation, or impairment contributed to the accident. Had his AMEbeen made aware of the pilot’s diagnosis, it is likely that they would have revoked the pilot’sflying medical certificate.Inquest verdictAt the pilot’s inquest, the presiding Coroner recorded a verdict of suicide.Published: 14 April 2022. Crown copyright 20225All times are UTC

AAIB Bulletin: 4/2022AAIB Correspondence ReportsThese are reports on accidents and incidents whichwere not subject to a Field Investigation.They are wholly, or largely, based on informationprovided by the aircraft commander in anAircraft Accident Report Form (AARF)and in some cases additional informationfrom other sources.The accuracy of the information provided cannot be assured. Crown copyright 20227All times are UTC

AAIB Bulletin: 4/2022G-OJMPAAIB-27491ACCIDENTAircraft Type and Registration:Cessna 208B, Caravan (Cargomaster),G-OJMPNo & Type of Engines:1 Honeywell TPE331-12JR-704TT turbopropengineYear of Manufacture:2002 (Serial no: 208B0917)Date & Time (UTC):17 July 2021 at 1338 hrsLocation:Old Sarum Airfield, WiltshireType of Flight:CommercialPersons on Board:Crew - 1Passengers - NoneInjuries:Crew - 1 (Minor)Passengers - N/ANature of Damage:Damaged beyond economical repairCommander’s Licence:Commercial Pilot’s LicenceCommander’s Age:47 yearsCommander’s Flying Experience:5,390 hours (of which 3,746 were on type)Last 90 days - 171 hoursLast 28 days - 76 hoursInformation Source:Aircraft Accident Report Form submitted by thepilot and further enquiries by the AAIBSynopsisDuring the final approach to land, the pilot became distracted when he attempted to retrievehis kneeboard, which had fallen off the right seat into the footwell while on the downwindleg. Upon looking up after recovering it, the pilot found the aircraft was at a very low height.He therefore initiated an abrupt pitch up to arrest the rate of descent. The aircraft toucheddown hard in the undershoot.The pilot suffered minor injuries and the aircraft was significantly damaged.History of the flightThe pilot was scheduled to operate about 20 parachuting sorties from Old Sarum Airfield,Wiltshire, where the parachutists landed on the airfield. The weather was good with a windfrom 030 at 9 kt and Runway 06 was in use.During these flights, the pilot wore a full-face oxygen mask and did not secure the shoulderstraps on the five-point harness. He took an A5 sized metal kneeboard that he used torecord details of each flight. This was kept under his backpack-style flight bag on the rightseat, the flight bag being secured by routing the seat’s harness through the bag’s straps.The first 13 flights were uneventful, with the pilot taking a rest after the eleventh flight. Crown copyright 20229All times are UTC

AAIB Bulletin: 4/2022G-OJMPAAIB-27491During some of these earlier flights the pilot was informed, over the radio by the DropZone (DZ) controller, that gliders had been seen circling to the south of the airfield, but thepilot was unable to visually acquire them.The next flight proceeded without event until the post-drop descent. Prior to the descentthe DZ controller advised the pilot that gliders had now been seen to the south-west of theairfield. Mindful that he had not seen any of them, and conscious that they seemed to bemoving clockwise around the airfield, he decided to fly a shorter final approach path to keepthe aircraft closer to the airfield and further from the gliders, rather than potentially comeinto conflict with the gliders during the approach and landing. The pilot thus extended hisinitial descent further than on the previous flights, delaying the turn downwind, with theaim of being lower abeam the threshold of Runway 06 than previously. Given the shorterfinal approach path, he planned to land at the beginning of Runway 06, rather than slightlydeeper on the flatter section1, as he had done on the earlier landings.While descending on the downwind leg, the kneeboard slipped out from under the backpackinto the right footwell. The pilot initially dismissed this as a minor event and continued withthe circuit, which included configuring the aircraft for landing once abeam the threshold.However, on the final approach he became concerned that the kneeboard posed a possiblehazard in the form of a potential restriction of the rudder pedals as he landed on the 18 mwide runway. At about 200 ft aal, having checked that the aircraft was on an appropriateflight path, he reached down to pick up the kneeboard from the footwell.Upon looking up, after retrieving the kneeboard, the aircraft was a lot lower thanexpected. As a result, the pilot abruptly pitched the aircraft up in a bid to arrest the rateof descent (ROD). He described this as a “lifesaving manoeuvre”. The aircraft toucheddown very hard in a field about 2 m short of the airfield boundary. It then crossed aberm that borders the airfield, at which point the nosewheel began to oscillate beforecollapsing. The aircraft came to rest soon thereafter within the lateral confines of therunway (Figure 1).After the aircraft came to rest, the pilot secured the engine and aircraft systems andcompleted the normal shutdown items. The pilot exited the aircraft unassisted using thepilot’s side door. Once outside he noticed that the flaps were up and wondered whether hehad not lowered them for the landing.The pilot sustained two small cuts to his chin, which had been inflicted by his oxygen mask.The aircraft was damaged beyond economical repair.Footnote1See Airfield information section for more information about the profile of the runway. Crown copyright 202210All times are UTC

AAIB Bulletin: 4/2022G-OJMPAAIB-27491Figure 1G-OJMP after the accidentPilot’s commentsThe pilot commented that the aircraft’s technical log was A4 sized. As he deemed thistoo large to record each flight’s details as they progressed, he made his own A5 sizedkneeboard. He did not secure his kneeboard on his leg, as it could potentially cause acontrol restriction. He added that there were no other forms of stowage in the aircraft inwhich to secure his A5 kneeboard or the A4 technical log.The pilot said he had developed a habit of not wearing the shoulder straps on the five-pointharness. The reason for this was that in parachute aviation he was frequently required tolook over his right shoulder into the cabin or his left shoulder to see the parachutist’s door orwatch the dispatching ground crew. Using the shoulder straps hindered these movements,particularly rightward. While there was a small mirror on the cockpit coaming, he believedit was of limited practical use. During the moments after the landing, he vividly recalled notbeing able to straighten his upper body, or raise his head, as he had been effectively bentdouble over the control column during the landing. He added that in future he will alwayssecure the shoulder straps.He said that he would normally extend the flaps just before the aircraft rolled out on the finalapproach. He added that he would also normally complete some additional checks on thefinal approach to ensure the aircraft was correctly configured for landing. These included Crown copyright 202211All times are UTC

AAIB Bulletin: 4/2022G-OJMPAAIB-27491checking the flaps were down and the approach was stable. However, he did not have thetime to complete these due to the shortened circuit pattern and the distraction. While hewas not certain he landed with the flaps retracted, he believes he probably did.The pilot did not consider a go-around, principally because he was focused on recoveringthe kneeboard, although he added that executing a go-around would have introducedadditional risk given the majority of the parachutists were still landing on the airfield at thetime he made the approach. He also felt that had the kneeboard caused a restriction on therudder pedals during the go-around there may have been controllability issues given thatleft rudder would have been required when power is applied in a go-around.As a result of this accident the pilot recommended to the operator that they re-design thetechnical log so that it can be secured to a pilot’s leg without potentially causing a controlrestriction. He also recommended that all pilots be established on a stable approachno closer than ½ nm from the threshold. At the time of publication, the operator had notresponded to these recommendations.Recorded informationImage recorderThe aircraft was fitted with an image recorder in the ceiling of the cockpit, between the twopilots’ seats, that recorded the main instrument panel. The operator had installed it as ameans of engine health monitoring.The recording showed the pilot looking across the cockpit, in the direction of the right footwell,while the aircraft descended downwind. The aircraft entered the finals turn 18 seconds later.The recording ended just as the aircraft rolled out on the final approach at about 250 ft aal.It did not show the pilot reaching into the copilot’s footwell to recover the kneeboard.The final visible rate of descent was about 2,000 ft/min at 350 ft aal (Figure 2). This was justbefore the aircraft rolled out onto the final approach.Figure 2A still from the image recorder showing the ROD at 350 ft aal Crown copyright 202212All times are UTC

AAIB Bulletin: 4/2022G-OJMPAAIB-27491Airfield CCTVThe accident was recorded on the airfield’s CCTV camera that was pointing towards thethreshold of Runway 06. It initially captured the aircraft on the final approach with a steepnose down attitude and a high ROD. The aircraft continued in this attitude until it was veryclose to the ground, at which point its nose was seen to pitch up abruptly (Figure 3). Theaircraft then struck the ground, close to the airfield boundary.It could not be positively determined from the CCTV if the aircraft had its flaps down duringthe landing.Figure 3A series of stills from the CCTV showing the last moments of the approach Crown copyright 202213All times are UTC

AAIB Bulletin: 4/2022G-OJMPAAIB-27491Airfield informationOld Sarum Airfield is a disused airfield within a Parachute Drop Zone. The grass runway isorientated 06/24 and is approximately 792 m long and 18 m wide.There is an uncropped field in the undershoot of Runway 06. The boundary between thefield and the airfield has a berm that is about 7 cm high. The first part of Runway 06 has apronounced upslope. It is then level for about the next ¼ of its length. This flat section thencontinues until about halfway, at which point the runway starts to gently slope down towardsthe Runway 24 threshold.Electronic conspicuityG-OJMP was not fitted with any kind of electronic conspicuity (EC) device and there wereno portable EC devices at the airfield. However, the two aircraft that were used to replacethe accident aircraft both had an EC device fitted in the aircraft’s panel unit. Furthermore,colleagues of the pilot, who conduct parachuting flights at other locations, have been issuedwith portable EC devices. These devices may increase the chances of detecting othertransient traffic around the drop zone, including gliders.There is a Department for Transport funding scheme where a rebate of up to 50% of thecost of an EC device can be claimed until 31 March 20222.Operations ManualThe operator’s Operations Manual did not have any guidance on flying a stable approach.AnalysisConduct of the flightThe pilot was on his fourteenth flight of the day, with the previous 13 being uneventful.Conscious that some gliders may be flying close to the airfield he elected to fly a tighter thannormal circuit pattern to try to mitigate any potential conflict.The pilot was not able to visually acquire the gliders and there was no EC device in theaircraft that may have assisted him with his situational awareness. Had he had a betterawareness of where the gliders were, perhaps aided by an EC device, his perceived needto fly an abbreviated circuit and approach might not have been necessary. The shortercircuit pattern gave him less time to deal with any possible distractions during the approach.The image recording showed the pilot looking across the cockpit, in the direction of the rightfootwell, while the aircraft descended downwind about 18 seconds before the aircraft enteredthe finals turn. The pilot recalled that it was while on the downwind leg that the kneeboard fellinto the footwell. The recording ended just as the aircraft rolled out on the final approach atabout 250 ft aal. It did not show the pilot reaching into the footwell to recover the kneeboard.Footnote2See this link for more details: ices/ [Accessed February 2022] Crown copyright 202214All times are UTC

AAIB Bulletin: 4/2022G-OJMPAAIB-27491Any attempt to recover a loose article from the floor of an aircraft, while maintaining control,would need to be carried out very cautiously. However, doing so during the final 200 ft of anapproach required the pilot to stop concentrating on the key priority of flying the final approachand introduced risk at a critical stage of flight. Having retrieved the kneeboard and looked upagain, the aircraft was at such a low altitude that a late and abrupt pitch up was required toarrest the high ROD. Had the pilot needed an extra second or two to retrieve the kneeboardthere would not have been time to make any input and the aircraft would have struck theground in the undershoot. This would probably have led to a much worse outcome for thepilot, especially as he was not wearing the shoulder harness.The pilot did not wear the shoulder straps as he believed they restricted his movementin the cockpit. While this seems to have given him the ability to reach into the footwell toretrieve the kneeboard, had he been wearing them he would not have been able to reachthe kneeboard. This may have caused him to disregard the kneeboard and concentrateon the final approach, although he may still have been concerned that the kneeboardmay have caused a control restriction on the rudder pedals during the landing. Also,had he been wearing the shoulder straps and still had a landing accident, he would havebeen secured in an upright posture, thus preventing him from striking parts of the aircraftstructure.The pilot did not consider a go-around because he was focused on the kneeboard. Hadhe made a decision to retrieve it, soon after it had fallen into the footwell on the downwindleg, he could have flown around at circuit height, or higher, while he retrieved it. Had heflown a go-around after he had decided it posed a risk, and cleared the DZ and climbed toheight, he would have been better placed to look inside and recover the kneeboard. Hadhe had his shoulder straps secured these may have needed to be loosened or unlockedmomentarily. The go-around manoeuvre may also have resulted in the kneeboard slidingbackwards away from the rudder pedals, thus reducing the risk of them interfering with thembefore it was recovered. However, the go-around would have introduced additional risk,given the majority of the parachutists were still landing on the airfield at the time.The pilot discovered that the flaps were up after landing. While he is not certain he landedwith them up he feels he probably did. It thus seems that the distraction of the kneeboard,at such a critical stage of flight, caused the pilot to forget to lower the flaps. It also removedthe opportunity for him to do his checks on the final approach to confirm the aircraft wasappropriately configured for the landing.KneeboardThe pilot had made his own kneeboard to record flight details, but he did not strap it to hisleg as he felt it could cause a control restriction. Rather, he stowed it under his flight bagon the co-pilot’s seat. Had he had a kneeboard that was unlikely to restrict the controls itwould not have needed to be placed in an insecure place and the accident may not havehappened. Crown copyright 202215All times are UTC

AAIB Bulletin: 4/2022G-OJMPAAIB-27491ConclusionThe aircraft landed hard due to the pilot becoming distracted at a critical stage of flight byrecovering his kneeboard, which had fallen into the right footwell while on the downwindleg. The primary concern for any pilot, especially during the final approach to land, is tofly the aircraft. Had he disregarded the distraction and continued to land, or performed ago‑around before retrieving it, the accident is unlikely to have occurred. Crown copyright 202216All times are UTC

AAIB Bulletin: 4/2022G-MCGUAAIB-27128SERIOUS INCIDENTAircraft Type and Registration:Leonardo AW189, G-MCGUNo & Type of Engines:2 General Electric Co CT7-2E1 turboshaftenginesYear of Manufacture:2014 (Serial no: 92007)Date & Time (UTC):4 March 2021 at 1036 hrsLocation:3 nm south-east of Porthcawl, WalesType of Flight:Emergency Services OperationsPersons on Board:Crew - 4Passengers - NoneInjuries:Crew - NonePassengers - N/ANature of Damage:Collapsed heating duct, cabin air vent motorsand auto transformer rectifier units ingesteddebrisCommander’s Licence:Airline Transport Pilot’s LicenceCommander’s Age:45 yearsCommander’s Flying Experience:4,507 hours (of which 595 were on type)Last 90 days - 77 hoursLast 28 days - 24 hoursInformation Source:Aircraft Accident Report Form submitted by thepilot and additional enquiries by the AAIBSynopsisWhile returning from a SAR training sortie, shortly after selecting the cabin and cockpit heatingon, a heating duct failed causing fragments of duct insulation material to be dischargedthrough the heating vents. The heating system was turned off but the subsequen

AAIB Bulletin: 4/2022 AAIB Field Investigation Reports A Field Investigation is an independent investigation in which AAIB investigators collect, record and analyse evidence. The process may include, attending the scene of the accident or serious incident; interviewing witnesses; reviewing documents, procedures and practices;