Incident Overview

Date: Friday 31 July 2015
Aircraft Type: Embraer EMB-505 Phenom 300
Owner/operator: Salem Aviation
Registration Number: HZ-IBN
Location: Blackbushe Airport (BBS) – ÿ United Kingdom
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 4 / Occupants: 4
Component Affected: The Embraer EMB-505 Phenom 300 aircraft’s flight control systems, including the TCAS (Tandem Control System), the aircraft’s navigation and flight management systems, and the aircraft’s aerodynamic control surfaces.The Embraer EMB-505 Phenom 300 aircraft’s flight control systems, including the TCAS (Tandem Control System), the aircraft’s navigation and flight management systems, and the aircraft’s aerodynamic control surfaces.
Investigating Agency: AAIBAAIB
Category: Accident
An Embraer EMB-505 Phenom 300 jet crashed into a car auction near Blackbushe Airport, U.K., resulting in the deaths of all four occupants. The aircraft, operating on a flight from Milan-Malpensa Airport to Blackbushe, descended through the London Terminal Manoeuvring Area (TMA) and was instructed to descend at its own discretion. During the descent, the pilot experienced a series of critical events, including a ‘descent’ RA alert, a ‘maintain vertical speed’ change, and a ‘adjust vertical speed’ maneuver, potentially triggered by a light aircraft above. The aircraft then deviated from its planned path, approaching the airfield and encountering a microlight. The TCAS generated a ‘descent’ RA alert, leading to a change in vertical speed, and the aircraft then flew a curving base leg, descending to 3,000 feet per minute. The aircraft’s TCAS annunciated ‘clear of conflict’ at 1.1 nm from the runway threshold, but the pilot’s descent rate was high, and the aircraft’s TAWS generated six ‘pull up’ warnings. The aircraft subsequently crossed the runway threshold, impacting a car park and subsequently striking cars, leading to a fire. The fire spread to the aft fuselage, causing a rollover, and the aircraft then landed 710 m beyond the runway, resulting in a groundspeed of 83 kt. The aircraft’s landing gear was down, and it departed the end of the paved surface at a speed of 83 kt, striking an earth bank, causing the aircraft to become airborne again. The fire burned intensely, limiting the ability to control the situation, and the aerodrome’s fire services were unable to reach the accident site due to a locked gate.An Embraer EMB-505 Phenom 300 jet crashed into a car auction near Blackbushe Airport, U.K., resulting in the deaths of all four occupants. The aircraft, operating on a flight from Milan-Malpensa Airport to Blackbushe, descended through the London Terminal Manoeuvring Area (TMA) and was instructed to descend at its own discretion. During the descent, the pilot experienced a series of critical events, including a ‘descent’ RA alert, a ‘maintain vertical speed’ change, and a ‘adjust vertical speed’ maneuver, potentially triggered by a light aircraft above. The aircraft then deviated from its planned path, approaching the airfield and encountering a microlight. The TCAS generated a ‘descent’ RA alert, leading to a change in vertical speed, and the aircraft then flew a curving base leg, descending to 3,000 feet per minute. The aircraft’s TCAS annunciated ‘clear of conflict’ at 1.1 nm from the runway threshold, but the pilot’s descent rate was high, and the aircraft’s TAWS generated six ‘pull up’ warnings. The aircraft subsequently crossed the runway threshold, impacting a car park and subsequently striking cars, leading to a fire. The fire spread to the aft fuselage, causing a rollover, and the aircraft then landed 710 m beyond the runway, resulting in a groundspeed of 83 kt. The aircraft’s landing gear was down, and it departed the end of the paved surface at a speed of 83 kt, striking an earth bank, causing the aircraft to become airborne again. The fire burned intensely, limiting the ability to control the situation, and the aerodrome’s fire services were unable to reach the accident site due to a locked gate.

Description

An Embraer EMB-505 Phenom 300 jet was destroyed when it crashed into a car auction next to Blackbushe Airport, U.K., killing all four occupants. The aircraft operated on a flight from Milan-Malpensa Airport, Italy to Blackbushe, U.K. After descending through the London Terminal Manoeuvring Area (TMA) it was handed over from London Control to Farnborough Approach. Its descent continued towards Blackbushe and, having reported that he had the airfield in sight, the pilot was instructed to descend at his own discretion. When the aircraft was approximately four miles south of its destination, he was instructed to contact Blackbushe Information. The weather at Blackbushe was fine with light and variable winds, visibility in excess of ten kilometres, and no low cloud. HZ-IBN entered the left-hand circuit for runway 25 via the crosswind leg. Towards the end of the downwind leg, it overtook an Ikarus C42 microlight aircraft, climbing to pass ahead of and above that aircraft. As the climb began, at approximately 1,000 ft aal, the TCAS of HZ-IBN generated a ‘descend’ RA alert to resolve a conflict with the microlight. The TCAS RA changed to ‘maintain vertical speed’ and then ‘adjust vertical speed’, possibly to resolve a second conflict with a light aircraft which was above HZ-IBN and to the east of the aerodrome. Neither the microlight nor the light aircraft was equipped with TCAS. Following this climb, HZ-IBN then flew a curving base leg, descending at up to 3,000 feet per minute towards the threshold of runway 25. The aircraft’s TCAS annunciated ‘clear of conflict’ when HZ-IBN was 1.1 nm from the runway threshold, at 1,200 ft aal, and at a speed of 146 KIAS, with the landing gear down and flap 3 selected. The aircraft continued its approach at approximately 150 KIAS. Between 1,200 and 500 ft aal the rate of descent averaged approximately 3,000 fpm, and at 500 ft aal the descent rate was 2,500 fpm. The aircraft’s TAWS generated six ‘pull up’ warnings on final approach. The aircraft crossed the runway 25 threshold at approximately 50 ft aal at 151 KIAS. The aircraft manufacturer calculated that the appropriate target threshold speed for the aircraft’s mass and configuration was 108 KIAS. The AFISO initiated a full emergency as the aircraft touched down, because “it was clear at this time that the aircraft was not going to stop”. Tyre marks made by the aircraft at touchdown indicated that it landed 710 m beyond the runway 25 threshold. The runway 25 declared Landing Distance Available (LDA) was 1,059 m; therefore the aircraft touched down 349 m before the end of the declared LDA. The paved runway surface extended 89 m beyond the end of the LDA. The aircraft continued along the runway, decelerating, but departed the end of the paved surface at a groundspeed of 83 kt (84 KIAS airspeed) and struck an earth bank, which caused the aircraft to become airborne again. It then struck cars in a car park, part of a large commercial site adjacent to the aerodrome. The wing separated from the fuselage, and the fuselage rolled left through 350ø before coming to rest on top of the detached wing. A fire broke out in the underside of the aft fuselage and burned with increasing intensity. The aerodrome’s fire services responded to the crash alarm but their path to the accident site was blocked by a locked gate between the aerodrome and commercial site. The first two vehicles arrived at the gate 1 minute and 34 seconds after the aircraft left the runway end. The third vehicle, which carried a key for the gate, arrived approximately one minute later, and the three vehicles proceeded through the gate 2 minutes and 46 seconds after the aircraft left the runway. As the aircraft was located in an area of the car park surrounded by a 2.4 m tall wire mesh fence, the vehicles had to drive approximately 400 m to gain access to the accident site. Despite applying all their available media, the fire service was unable to bring the fire under control. The intensity of the fire meant that it was not possible to approach the aircraft to save life. All four occupants of the aircraft survived the impact and subsequently died from the effects of fire. Among the passengers were the stepmother and sister of Osama bin Laden. CONCLUSION: “Towards the end of the flight, a number of factors came together to create a very high workload situation for the pilot, to the extent that his mental capacity could have become saturated. His ability to take on new and critical information, and adapt his situational awareness, would have been impeded. In conjunction with audio overload and the mental stressors this can invoke, this may have lead him to become fixated on continuing the approach towards a short runway”

Source of Information

http://www.skybrary.aero/index.php/E55P,_Blackbushe_UK,_2015http://www.skybrary.aero/index.php/E55P,_Blackbushe_UK,_2015

Primary Cause

A combination of factors likely contributed to the incident, including the pilot’s mental state, the complex flight dynamics, and the unexpected interaction with a microlight. The pilot’s ‘descent’ RA alert, coupled with the subsequent changes in vertical speed, suggests a potential stressor impacting his situational awareness.A combination of factors likely contributed to the incident, including the pilot’s mental state, the complex flight dynamics, and the unexpected interaction with a microlight. The pilot’s ‘descent’ RA alert, coupled with the subsequent changes in vertical speed, suggests a potential stressor impacting his situational awareness.

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