Investigation Summary
The flight was a late-night medical evacuation mission to collect a patient with a ruptured appendix. The pilot had not flown for 32 days prior to the accident and was required to perform a short currency flight at Glasgow before picking up the paramedic. During the approach to Campbeltown, which lacked radar and full Air Traffic Control services, the pilot was receiving a Flight Information Service. After reporting the completion of the 'base turn' for Runway 11, the aircraft continued a steady descent into the sea. Wreckage analysis showed the aircraft was in a stable, slightly nose-down attitude with symmetric power at the time of impact. Investigators found that the Horizontal Situation Indicator (HSI) and Omni Bearing Indicator (OBI) were incorrectly set for the approach, suggesting a high workload or degraded situational awareness. The pilot's seatbelt was found unbuckled, and his body was never recovered. The paramedic was found strapped into his seat in the submerged fuselage; he had sustained a fatal head injury from impacting the pilot's seat. The AAIB concluded that this injury was a direct consequence of the aircraft not being equipped with upper torso restraints for passengers, which allowed his head to strike the seat in front during the impact.
Final Conclusions
The AAIB concluded that the accident was a Controlled Flight Into Terrain (CFIT). The primary cause was the pilot allowing the aircraft to descend below the minimum procedure altitude. Contributing factors included fatigue, high workload, and the pilot's lack of recent flying practice (32 days). The AAIB also noted that the presence of a second pilot or a radio altimeter might have prevented the accident. The final report, AAR 2/2006, was published in November 2006.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Had not flown for 32 days prior to the accident flight.
Systems & Failure Modes
Horizontal Situation Indicator (HSI)
A primary navigation instrument; investigators found it was incorrectly set to 103 degrees for an approach that required 115 degrees.
Omni Bearing Indicator (OBI)
A secondary navigation instrument; it was found incorrectly set to 309 degrees instead of the required 115 degrees for the approach.
Radio Altimeter
The aircraft lacked this system, which provides an absolute height reading above the surface; the AAIB recommended its mandate for single-pilot IFR operations.
Carburettor Heat
Post-impact analysis confirmed the carburettor heat levers were in the OFF position, though engine damage was consistent with symmetric power at impact.
Interesting Facts
- 01The pilot had not flown for 32 days prior to the day of the accident.
- 02The aircraft was found in three main sections at a depth of 78 metres.
- 03The Horizontal Situation Indicator (HSI) course selector was set to 103° instead of the required 115°.
- 04The aircraft was not equipped with a radio altimeter or a low-height warning device.
- 05The pilot's seat belt and shoulder harness were found undamaged and unbuckled.
Safety Actions & Advisories
Radio Altimeter Mandate
The CAA and JAA were recommended to consider mandating radio altimeters or other low-height warning devices for single-pilot public transport IFR flights.
Air Ambulance Crewing Review
A recommendation was made to review the circumstances in which a second pilot should be required for air ambulance flights.
Upper Torso Restraints
EASA and JAA were asked to review proposals to mandate upper torso restraints on all seats of transport category aircraft below 5,700 kg.