Air Accident Investigation Sector of the UAE Review …...2017 Ultra Magic Balloon –Accident - Fire During LandingContributing Factors to the Accident: (a) The Pilot performed the

MENASASI Seminar, Abu Dhabi, November 2019

Air Accident Investigation Sector of the UAE

Review of three years of investigations

2017 AAIS Investigations:

• Ultra Magic Balloon – Accident - Fire During Landing

• AgustaWestland AW139 Helicopter – Accident – Controlled Ditching

• C130 Military Aircraft – Serious Incident - Approach Below MSA

• Boeing B737 – Incident - Tire Failure and Hydraulic System Failure

• Airbus A380 – Serious Incident - Descent Below Glideslope

• Boeing B777 – Serious Incident - Pilot Incapacitation

• Embraer P100/Diamond DA42 – Serious Incident - Loss Of Separation

• Boeing B787 – Serious Incident - Kuwait DGCA Investigation Assistance

MENASASI November 2019 – Abu Dhabi


• Ultra Magic Balloon – Accident - Fire During Landing

• AgustaWestland AW139 Helicopter – Accident – Controlled Ditching

• C130 Military Aircraft – Serious Incident - Approach Below MSA

• Boeing B737 – Incident - Tire Failure and Hydraulic System Failure

• Airbus A380 – Serious Incident - Descent Below Glideslope

• Boeing B777 – Serious Incident - Pilot Incapacitation

• Embraer P100/Diamond DA42 – Serious Incident - Loss Of Separation

• Boeing B787 – Serious Incident - Kuwait Investigation Assistance


2017 Ultra Magic Balloon – Accident - Fire During Landing

Occurrence:

Following liftoff the flight proceeded normally.

During the descent to the landing area, the Pilot instructed the passengers to adopt the landing position, as briefed before takeoff.

When the Balloon came to a full stop, the gas was still feeding the burner and the flame was continuous.

The basket tilted over with the Pilot and all of the passengers still on-board,

The burner flames affected the Balloon structure and the Pilot suffered burns to his face.

The ground crew were at the landing site and they started to lift the basket with the assistance of some of the passengers in order to release those still on-board.

The ground crew quickly extinguished the fire.



Cause:

Fractured nylon rods during the hot inflation phase resulting in a failure to support the burner frame during landing and the collapse of the basket, which tilted upside down with the all passengers and the Pilot on-board.



Contributing Factors to the Accident:

(a) The Pilot performed the takeoff with most of the nylon rods fractured.

(b) Failed communication between ground crew Pilot during pre-takeoff.

(c) Burner pilot-light remained active during the landing.

(d) Before landing, the Pilot failed to switch off the pilot-light.

He grabbed the burner handle by both hands, causing inadvertent

activation of the liquid valve.



Safety Recommendations:

To the Balloon Operator

Improve communication procedures between the pilots and the ground crew.

During internal training and the annual flight check, emphasize the importance of the pre-flight check, and the requirement as to when to turn off the pilot lights.

To the GCAA

Consider a red and green flag system for the ground crew to clearly indicate to the pilot that the balloon is considered serviceable for takeoff.



• Sky Runner – Accident - Paramotor Accident During Take-off

• Airbus A320 – Incident - Oxygen Mask Deployment

• Airbus A320 – Serious Incident - Takeoff Into Wrong Rwy Direction

• Airbus A320 – Incident - Water Salute and Slide Ramp Deployment

• AgustaWestland AW139 – Accident - SAR Helicopter Investigation Assistance



• Sky Runner – Accident - Paramotor Accident During Take-off

• Airbus A320 – Incident - Oxygen Mask Deployment

• Airbus A320 – Serious Incident - Takeoff Into Wrong Rwy Direction

• Airbus A320 – Incident - Water Salute and Slide Ramp Deployment

• AgustaWestland AW139 – Accident - SAR Helicopter Investigation Assistance


2018 A320 – Incident - Water Salute

Occurrence:



Cause:

The cause of the Incident was the unpredictable directional movement of the water jet, onto emergency exit hatch.

This pushed the panel inwards and resulted in the emergency exit hatch opening and falling into the cabin

The passenger seated in the window seat was slightly injured



Contributing Factors to the Incident:

The fire vehicle’s hand controller potentiometer failed to control the movements of the roof turret.

The process of a water salute had not been formally described and risk assessed by the airport fire service, thus the possibility of erratic water turret movement was not identified.



Safety Recommendations:

To the GCAA:Conduct a formal risk assessment and draft a procedure for the conduct of water salutes, to ensure that identified risks are mitigated so that water salutes can be conducted safely.

Introduce a routine “dry” turret check procedure, to ensure that malfunctioning turrets are identified during maintenance, or prior to their operation with water or foam.



• McDonnell Douglas MD11 – Serious Incident - Uncontained Engine Failure During Take-off

• Ultra Magic Balloon – Accident - Serious Injury During Hard Landing

• Diamond DA62 – Accident - Loss of Control During Approach

• Airbus A320 – Serious Incident - Runway Excursion

• Airbus A380 – Accident - Serious Injury During Severe Turbulence



• McDonnell Douglas MD11 – Serious Incident - Uncontained Engine Failure During Take-off

• Ultra Magic Balloon – Accident - Serious Injury During Hard Landing

• Diamond DA62 – Accident - Loss of Control During Approach

• Airbus A320 – Serious Incident - Runway Excursion

• Airbus A380 – Accident - Serious Injury During Severe Turbulence


2019 Diamond DA62 – Accident - Loss of Control During Approach

Occurrence:

The Diamond DA62 departed OMDB for an aerodrome ground lighting calibration flight for runway 30L.

After a uneventful nine circuits performing different aerodrome lighting checks, the Aircraft entered the final to runway 30L for the tenth approach, following a Thai Airways Airbus A350-900.

The Airbus was approximately 3.6 nm ahead of the Diamond on approach to the parallel runway 30R.

When the Diamond leveled off after turning onto final at an altitude of approximately 1,100 ft and at an airspeed of approximately 130 kt, it rolled slightly but was recovered after nine seconds.

Seven seconds later, the diamond abruptly rolled to the left until it became inverted and entered a steep dive.

The Aircraft impacted the ground approximately 3.5 nm from the runway 30L threshold, while travelling at high speed in the direction opposite to the direction of flight.


2019 Diamond DA62 – Accident - Loss of Control During Approach

The Investigation is ongoing, however…

based on the potential consequences of a wake turbulence encounter due to close proximity between the Diamond and the preceding Airbus during the approach, the Investigation believes that prompt safety action was warranted.The Investigation issued a prompt safety recommendation recommending that:“The General Civil Aviation Authority issue a safety alert to all air navigation service providers in the United Arab Emirates and to all operators of light aircraft, to enhance awareness among pilots and air traffic controllers of their separation procedures, particularly under visual flight rules.”


AAIS Investigation Classifications 2017 to 2019:

• 7 Accidents

• 8 Serious Incidents

• 3 Incidents


2017 AAIS’ assistance as Accredited Representatives:

• Challenger CL604 – Loss of Control Inflight (BFU)

• Airbus A380 – Ground Damage During Taxiing (Singapore TSIB)

• Airbus A320 – TCAS RA (Pakistan CAA)

• Boeing B777 – Runway Incursion (Pakistan CAA)

• Airbus A380 – TCAS TA (Mauritius CAA)

• Boeing B777 – Cargo Compartment Smoke (ATSB)



• Airbus A320 – Fire in Overhead Bin (Sudan CAA)

• Boeing B777 – Passenger High Loader (Pakistan CAA)

• Dassault DA50 – Flight Control Jamming (San Marino CAA)

• Challenger CL604 – Loss Of Control Inflight (Iran CAA)

• Bombardier BD-700 – Instrument Failure (Greek AAIASB)

• Boeing B737 – System Failure (Saudi Arabia KSA)

• Boeing B737 – TCAS RA (Ukraine NBAAIA)

• Boeing B777 – Runway Incursion (India CAA)



• Boeing B777 – High Speed Rejected Take-off (Egypt EAAID)

• Boeing B777 – Brake System Damage (Morocco AIB)

• Boeing B777 – Pneumatic System Failure (UK AAIB)

• Boeing B737 – Runway Incursion (India CAA)

• Boeing B787 – Descent Below MSA (Hong Kong AAIA)

• Boeing B777 – Severe Turbulence (Indonesia KNKT)


Issued Safety Recommendations 2017 to 2019:

• 91 Safety Recommendations issued by the AAIS

• 61 Safety Recommendations closed (70%)


Issued Safety Recommendations:

• 43 Safety Recommendations issued to State Regulators

• 24 Safety Recommendations issued for Airlines

• 2 Safety Recommendations issued for Manufacturers

• 6 Safety Recommendations issued for Air Navigation Services Providers

• 16 Safety Recommendations issued for Airport Operators


Issued Safety Recommendations:


Documents

Air Accident Investigation Sector of the UAE Review …...2017 Ultra Magic Balloon –Accident - Fire During LandingContributing Factors to the Accident: (a) The Pilot performed the