Service Bulletin

contact with the aircraft was intermittently lost amongst radar returns from a considerable amount of cloud in the area. However, during the time that the aircraft was able to be tracked, it appears to have been slowing down eventually to about 54 kt ground speed as it turned, for an unknown reason, onto a more westerly track. ni bolovs) 1521 odi Joaqui basqa dgid At 1940 hrs, the pilot changed from Liverpool Approach to Ronaldsway Approach, on 120.85 MHz, informing the controller that he had 60 nm to run to Ronaldsway, and giving an ETA of 2020 hrs. He was told to call again when he had 25 nm to run. At 1759:28 hrs, the pilot transmitted the single word "MAYDAY", followed by a short pause and then "MAYDAY, MAYDAY...". The latter transmission sounds as if it was suddenly cut off and it may have been the time of impact with the sea. Ronaldsway Air Traffic Control dordw dgim raidw base woli nad odio At Ronaldsway, Isle of Man, there are two RT channels operating on 120.85 MHz, 'Channel A' and 'Channel B', each comprising entirely separate equipment and each is recorded. The ATC controller, who can use either channel but not both, states that he was operating Channel B. Subsequent playback of this channel reveals that, at the time of the 'MAYDAY' call, only a brief burst of carrier wave was heard, followed by a very brief sound which might have been part of a syllable of speech. The controller states that this 'burst' of carrier wave meant nothing to him at the time. For this reason it was not immediately apparent to the controller that the aircraft had transmitted a distress message and it was only when he replayed the recording of Channel A, as a result of recalling these sounds, that he heard the 'MAYDAY' call. 38 The controller was expecting inbound IFR traffic at 2007 hrs so, at 2005 hrs, he called EI-AND to ascertain its position. He made several further calls to EI-AND between then and 2024 hrs, and also a request to another aircraft to attempt radio contact, but no response was received. Therefore, at 2025 hrs, he checked that Liverpool, Manchester and Blackpool did not have contact with EI-AND and then initiated full 'Overdue' action. Search and recovery XAM WIM 1021 SOES es jelomnol 20w 1 am braw 1551 000. SIT The Distress and Diversion cell at LATCC was alerted at 2026 hrs, HM Coastguard at 2027 hrs and the Edinburgh RCC at 2034 hrs. The military assets employed in the search were a Sea King helicopter from RAF Leconfield, a Wessex helicopter from RAF Valley and a Nimrod aircraft from RAF Kinloss. Lifeboats were launched from Port St Mary, Rhyl, Hoylake, Castletown and Douglas. The search area was also attended by five vessels which had volunteered to take part in the search. The first helicopter arrived on the scene at 2122 hrs and the first lifeboat at 2127 hrs. The search was continued until the endurance capability of the assets was reached and then resumed at first light on 31 October. Nothing was found and the search was terminated at 1655 hrs that day. On 9 November 1994, the body of the passenger was recovered off the east coast of the Isle of Man, near Laxey and, on 22 November 1994, pieces of aircraft wreckage were recovered by a fishing vessel in the area where the search had been conducted. Subsequently, further wreckage has been recovered. A post-mortem investigation of the body of the passenger revealed injuries consistent with those resulting from a fairly high speed impact. weblenoЯ r[bzorgqA Joogaevil mont bogneɗfo soliq ads dogo Wreckage examination brow min 00 5ad ng of ma In the absence of the complete wreckage only general conclusions could be drawn from those parts which were recovered. Their condition suggested that the aircraft had entered the water at high speed, rather than the low speed which might be associated with a controlled forced alighting. Aircraft history 28.01 no guro alannada to sizi ya wabung A This aircraft was constructed in 1960 and was originally registered in the UK as G-APYA. In 1963 it was transferred to the Irish register as EI-AND and, in 1988, it was registered to the owner who was also the pilot on the accident flight. Enquiries suggested that the engine and airframe log books were lost with the aircraft at the time of the accident and so its recent maintenance history has been derived, as far as possible, from the records of various maintenance organisations. As at December 1993, it has been estimated that the aircraft had accumulated 2,640 hours. 39 YAM odbud Maintenance history ylation onwood Laisiqqe air grivissan nequ boles be plea foul od bris nobilvo ono we anw or edi bat Home of solar blus od The Republic of Ireland airworthiness authorities required maintenance to be carried out on this aircraft in accordance with their Light Aircraft Maintenance Schedule (LAMS), a schedule which is essentially the same as that specified by the UK CAA. The only major difference is that the Irish Certificate of Airworthiness (C of A) is renewable every 2 years, not every 3 years as in the UK. The aircraft was registered in the Private Category which enabled a licensed pilot, as owner or operator, to certify the 50 hour checks as specified in the LAMS. dguod Late in 1989, the aircraft was flown to a maintenance organisation at Blackpool Airport where the owner requested that the brakes be repaired. This organisation reported that at that time, from a maintenance point of view, the aircraft was in very poor condition with instruments missing and few working. During a 50 hour inspection it was discovered that the engine oil filter was heavily contaminated with metal. The owner at first asked for the aircraft to be re-assembled so that he could take it away but when this was refused he arranged for the engine to be removed so that he could send it for overhaul. Some months later, following its return from a US maintenance company, it was refitted to the aircraft. After rectification of all the significant defects, the aircraft was deemed to be in an acceptable condition when released by the maintenance organisation. Subsequently, in late 1990, a full Irish C of A was issued for the aircraft. The next C of A inspection on the aircraft was carried out at an Irish maintenance organisation based at Abbeyshrule, west of Dublin, in November 1992, followed by a 50 hour check in May 1993 and an annual check in December 1993. At that time all cylinder compressions were recorded as being satisfactory and, since that time, it is assumed that the 50 hour checks, should any have been due, were carried out and certified by the aircraft owner. Following the aborted flight to the Isle of Man on 25 October 1994 the owner took his aircraft to a maintenance organisation on the airfield at Guernsey. After a run-up, it was discovered that the engine was operating on five instead of six cylinders. Despite his stated anxiety to return to his home airfield before nightfall, the owner was persuaded to allow a full assessment of the problem by the gulansla git maintenance organisation who discovered the following engine faults: doidya) Cracked insulation on one sparking plug. balon olor b) A blanking plug missing from the inlet to No 2 cylinder, which was allowing additional air to be drawn in and weaken the mixture. to Gr iFI STIL B c) No compression at all on No 1 cylinder. This was traced to burnt oil deposits on the exhaust valve stem jamming it in the open position. Upon re-assembly, it was also discovered that rockers in the cylinder head for the inlet and exhaust valves had been interchanged. This had resulted in the valve mechanism not being sufficiently lubricated. d) The hot air hose to the carburettor was found to be collapsed. e) Slight fuel leak from the belly area. WOH Ed Xudo 88015 doinwand 210E 40 40 Upon receiving this appraisal the owner reportedly stated that he was aware of the low compression on one cylinder and the fuel leak, and asked if he could take the aircraft in that condition. The maintenance organisation declared that it would be unsafe to do so and it was agreed that the necessary repairs be carried out. Several days later the work had been completed and, following a prolonged ground run at high power, the aircraft was considered to be in an airworthy condition. After confirming with the Irish airworthiness authorities that a UK Certificate of Release to Service, issued in accordance the Air Navigation Order, would be acceptable, copies of the appropriate documents were given to the pilot but the aircraft log books were not made available at this time. The engineer later expressed an opinion that, although fit to fly, the aircraft was in a poor, tatty condition, extremely dirty and generally in need of attention. The cockpit equipment was basic and it was noted that no transponder was fitted. Although a VHF radio was fitted the engineer also noted that the transmit switch on the left control wheel was broken and, when conducting engine runs after the repair, he was obliged to key the transmitter using the hand microphone and to listen out on a headset. Additional information od of signo sell 20 a mont The last known position of EI-AND, taken from the radar recordings, was timed at 1954:43 hrs but the 'MAYDAY' call recorded at Ronaldsway was timed some 5 minutes later at 1959:25 hrs. It is assumed that the aircraft was airborne during this time. Analysis of the ATC tape recording made at the time of the 'MAYDAY' radio call failed to identify any of the sound frequencies associated with the engine which had been heard earlier. The aircraft is believed to have been flying at 2,500 feet prior to the last radar paint and, if the engine had failed completely at this altitude it is unlikely, considering glide performance, that it would have remained airborne for some 5 minutes. It is therefore likely that some power was available from the engine during at least part of this period. In the absence of wreckage examination it was not possible to determine a cause for the apparent lack of engine power at the time of the 'MAYDAY' call. bastani svil sd) yd maldoq To inama iful swolle of bobsuzieq as wood shulgin protod Flight planning afoal signs guiwollol of barovoibody nousing to consentient In the course of the investigation it was noted that a VFR flight plan had been filed for the flight which was to be conducted at night. (Appropriate instrument qualifications are not necessary for a pilot to file an IFR Flight Plan). Under the provisions of the Rule 27 of Rules of the Air Regulations (Guernsey), a flight plan had to be filed for the Special VFR departure, which the pilot requested whilst taxiing. A flight plan was also required, under UK Rules of the Air Regulations 1991- Rule 20 (4), because the flight was planned to cross into the UK FIR. However, the ATC flight plan for the accident flight gave an ETD of 1715 hrs, which was later than the onset of official 'Darkness' (Sunset + 30 minutes). As this was a 41 flight at night, the Rules of the Air Regulations 1991- Rule 22 required that the flight be conducted under IFR or, in a control zone, under Special VFR. The VFR flight plan filed was therefore invalid. This anomaly was not noticed by the planning staff at Guernsey when the plan was filed, although, as the relevant portion of the ICAO Document 4444, General Provisions, paragraph 8.3.1, states that: 'The first Air Traffic Service Units (ATSU) receiving a flight plan shall a) check for compliance with the format and data conventions; and b) check it for completeness and, to the extent possible, for accuracy', it remains the responsibility of the pilot to ensure that all portions of the flight plan are valid. 42 LONDON FIR Wreckage Trawled from this Area Assumed Track Over this Section (No radar) Mayday call at 1959:25 1954:43 124-75 (SOUTH) 134-70 (NORTH) 135 95° 122-25 119-85 119-40 VOR Direct Track to 124-15 IOM (317°R) 134-35° 124-45 ST) 126-60 Area of Probable "Radar Returns from Cloud sD VAP Woodvale (J) 37 Ge 2 HOLYHEAD ASRA See Legend Note 3 L CROSB SEAFORTH B1/B3 2000' ALT FL245 WAL 1141 HOLYHEAD BARNSLEY ASR ASR ri Host Bunk Poins al Ar 1931:45. Talacre PRESTATIN 464 Os 2000' Wind 260°/30-35 kt RHYL Penrhyn Bay Bhos-on-Sea COLWYN BAY ST 112 1534 1048/ Lumer 1184 1520 1627 Liwyd Trent (785) Pleveni Park.am 138 DEN IGN 1313 A343 kira 1705 ONE 25 OYLAKE NHE 1483 3000 AFL245 1818 OTHIN 3531 13394 1744 PRIMARY RADAR DERIVED FINAL PART OF EI-AND'S TRACK 43 NESTON