2005 aviation accident
On 15 March 2005, a Britten-Norman Islander air ambulance, operated by Loganair, crashed off the coast of Scotland, killing both people on board.
The aircraft was on route to Campbeltown Airport in Argyll, Scotland, to pick up a ten-year-old boy with acute abdominal pain, suspected to be appendicitis. After a flight that included many navigational irregularities, the pilot was flying the normal approach, which took the aircraft out to sea before turning back toward the airport. The pilot informed controllers that he had completed the turn, and that was the last transmission received from the aircraft. Investigators conclude the aircraft hit the water a few seconds after that transmission. Both occupants of the aircraft, the pilot and a paramedic seated at his station behind the pilot, were killed. The ensuing investigation concluded that the pilot allowed the aircraft to fly too low, and it descended unchecked into the sea. The pilot was also fatigued, overworked, lacked recent flying practice, and he might have suffered from an undetermined influence, such as disorientation, distraction, or subtle incapacitation, as evidenced by several navigational errors, miscommunications, and mismanagement of his instruments. Although the weather might have precluded a safe landing in Campbeltown, the weather was not a cause of the accident. The patient was eventually driven overland to a Glasgow hospital, where he was treated for a ruptured appendix.
The paramedic's body was found strapped in to his seat with a severe, possibly fatal, head injury from an impact against the back of the pilot's seat in front of him. Despite the death of both occupants of the aircraft, the UK's Air Accidents Investigation Branch, or AAIB, considered the impact survivable by the pilot. Had the paramedic been wearing a shoulder harness, the AAIB concluded it was likely that the paramedic would have survived the impact with the water with little or no injury, though it is possible he might then have succumbed to the cold water. The pilot, whose uninjured body was found nine months after the accident, and who had been wearing a shoulder harness, most likely survived the accident and escaped the aircraft, only to die of hypothermia in the cold water. As a result of this accident, regulations were enacted in 2015 by the European Union (EU) that require all aircraft of similar size that are used to transport passengers to be equipped with a shoulder harness, or "upper torso restraint system" (UTR system), for each passenger seat.
Two more recommendations from the AAIB investigators of this accident were under consideration (as of the end of 2015) by EU regulators. These recommendations would require two pilots for all air ambulance flights and require a radar altimeter or "other independent low height warning device" (such as a GPWS) on all single-pilot public transport flights conducted in limited visibility (i.e., IFR passenger flights).
Background.
Loganair and the Scottish Ambulance Service.
In 1967, Loganair began operating air ambulances for Scottish Ambulance Service (SAS). In 2005, they were using three dedicated Britten Norman Islander aircraft, including the accident aircraft, to transport patients from hard-to-reach locations throughout the Scottish Highlands and the surrounding islands, flying roughly 2,000 ambulance flights per year. In February 2005 (a month before this accident), SAS announced they would be ending their contract with Loganair in October 2006 and replacing them with Gama Aviation, which would provide two fixed-wing aircraft and two helicopters.
1996 accident.
Loganair had one previous air ambulance accident, also involving a Britten Norman Islander, on 19 May 1996, in which the pilot was killed, and the two passengers, a physician and a flight nurse, were injured. (In 1996, flights were typically made with a nurse, and sometimes a physician, if needed. The passenger cabin of the Islander was of limited size, and typical of ambulance aircraft, working conditions could be quite cramped with more personnel.) This 1996 accident bore similarities to the 2005 accident. It occurred at night with a single fatigued and poorly rested pilot making an approach in difficult weather, though in this case it was a strong and gusting crosswind rather than poor visibility that was the primary meteorological challenge.
After successfully transporting the patient from Tingwall Airport in the Shetland Islands to Inverness Airport, the pilot, nurse, and physician were returning to their home base in Tingwall. There was a strong and gusting right crosswind at the runway. The pilot's approach procedure required him to make right turns to line up with the runway. However, these right turns obscured the pilot's view of the runway, and when the pilot made his final right turn, the aircraft had been blown to the left of the runway, too far to make a safe landing. The pilot executed a go-around procedure and attempted another approach. Again, the aircraft was blown far to the left of the runway centreline, and during the final approach turn, the aircraft lost a great deal of altitude, striking the ground 1.5 km short of the runway and approximately 0.3 km to the left of the runway centreline. The AAIB determined that nighttime visibility of the airport environment was inadequate, especially during right crosswind conditions, and recommended the Tingwall Airport add additional ground lighting to aid pilots' ability to acquire the runway during nighttime approaches.
Aircraft.
The aircraft was a British built BN2B-26 Islander manufactured by Pilatus Britten-Norman in 1989, registration G-BOMG. It was a high wing design with two wing-mounted Lycoming O-540-E4C5 piston engines, each delivering a rated 260 horsepower to a two-blade variable-pitch propeller. It had fixed tricycle landing gear, with the two main gear bogies (two wheels each) mounted on legs that extend down from the wing, just aft of the engines. It made its first flight on 20 March of that year. It was delivered to the original customer in Germany, FLN Frisia Luftverkehr, on 25 May, and re-registered in Germany as D-IBNF. On 14 August 2002, Loganair purchased the aircraft from FLN and registered it in the UK as G-BOMG. Loganair's chief executive, Jim Cameron, described the Islander as "robust" and "well suited to the vagaries of Scottish weather." Summarizing expert opinion of the Islander, Alastair Dalton of "The Scotsman" said the aircraft "had a good safety record and had proved versatile in operating from the shortest and roughest Highland runways."
Loganair converted the aircraft into an ambulance after purchasing it from FLN. It had one stretcher, a paramedic seat behind the pilot, two seats in the back of the cabin, and two cockpit seats. The aircraft had three doors, though the right cabin door was difficult to access because it was blocked by the stretcher. The aircraft was equipped with autopilot, and it was certified for single-pilot operation.10
The aircraft was equipped with a diagonal shoulder harness for each of the eight passenger seats when it was delivered new to FLN. However, when Loganair converted the aircraft for ambulance use, they installed the same seats and seat belts they used in the rest of their Islander fleet. The shoulder harnesses were designed to attach to a specific type of lap belt, which was different from the lap belts used by Loganair. At the time of the accident, shoulder harnesses were not required for passengers, and Loganair did not retrofit the seat belts or shoulder harnesses to be compatible with each other.40
The aircraft was not equipped with a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR), nor was it required to be.24
Personnel.
The pilot, 40-year-old Guy Henderson of Broxburn, Scotland, had 3,553 hours total flight experience, including 205 in the Islander. His Airline Transport Licence and Class I Medical Certificate were current.7 Due to flight scheduling and a family vacation, he had not flown for 32 days before the accident.8 On the day of the accident, Henderson awoke at 0645 h after eight hours of sleep. He was scheduled to begin standby duty from home that evening, lasting overnight, at 2300 h. (Standby duty from home means the pilot must be able to be at the airport, ready for duty, within one hour.) He was called early, at 2136 h, and reported for duty at the airport at 2220 h. There was no indication that the pilot tried to sleep during the day.9
Loganair had a requirement that a pilot must have flown within the previous 28 days before being allowed to carry passengers.38 Therefore, upon his arrival at Glasgow Airport, Henderson was required to take off and land the aircraft one time (a "currency flight") before allowing the paramedic to board for the ambulance mission. (Because the paramedic was not involved with flight operations, he was legally considered a passenger.38) The pilot made his currency flight by flying one circuit around the airport and returning to the Loganair apron to pick up the paramedic. There was heavy rain during this flight, but it was otherwise uneventful.4
The sole passenger on the accident flight was Paramedic John Keith McCreanor, 35, of Paisley, Scotland. He was seated in the paramedic seat, behind the pilot, for the duration of the flight. McCreanor had been a paramedic for twelve years and an employee of SAS for nine years and ten months.9 He arrived for the flight at 2300 h but had to wait for Henderson to complete his currency flight before boarding.4
Mission.
The operations officer at Loganair in Glasgow received a call at 2133 h from SAS requesting an air ambulance flight to pick up a ten-year-old boy named Craig McKillop at Campbeltown Airport, who was suffering from severe abdominal pain and suspected appendicitis, and fly him to Glasgow for treatment. The boy's father was scheduled to fly to Glasgow with his son and the paramedic. The requested maximum transfer time was three hours.3
The flight.
Departure and navigation.
The flight used the callsign LOGAN AMBULANCE ONE and was given ATC clearance to fly direct to Campbeltown. For unknown reasons, the pilot requested an amended clearance to fly a course that took them west and then southwest toward Campbeltown, avoiding flight over the Isle of Arran, further delaying their expected arrival time. The aircraft was airborne at 2333 h, with one hour remaining in the requested patient transfer time.4, 47
The aircraft climbed to its assigned cruising altitude of and left controlled airspace. The pilot kept in contact with ATC for information and advisory services. At 2359 h the controller noticed that the aircraft had not made its scheduled left turn toward Campbeltown. The controller asked the pilot to confirm his routing, and he advised the pilot that he was already west of his intended course. The pilot then made a sharp left turn to the southeast, followed by another to the southwest, toward Campbeltown. As the aircraft descended toward Campbeltown, it had not been on its approved course since it left the immediate vicinity of Glasgow.5, 47–48
Approach to Campbeltown.
When the aircraft was north of the Machrihanish (MAC) VOR (a type of radio navigational beacon near Campbeltown Airport), the pilot requested descent clearance. The controller cleared the aircraft to descend to at 0003 h, which was the minimum Sector Safe Altitude (SSA), the lowest altitude that can guarantee safe separation from all terrain and other obstacles in the area.5, 16, 48 When the aircraft was from the MAC VOR, it descended below the SSA to . This was the altitude needed to enter the airport's landing pattern, but the descent wasn't required until the aircraft was over the MAC VOR. This early descent below the SSA was described by investigators from the Air Accidents Investigation Branch (AAIB) as "contrary to safe practise as well as the operator's procedures".6, 48
The approach procedure in use for this flight in the low clouds and low visibility conditions that night required the pilot to fly over the MAC VOR at , then turn west-northwest to fly out over the water, descend to and level off within nine miles, then make a left "base" turn to fly east, back toward the airport (a teardrop procedure turn), and descend for final approach with the use of the MAC VOR. The pilot was not allowed to descend below until the turn was completed, and then not below unless he had the runway in sight.16 Once the pilot could see the airport from that altitude, he would be allowed to circle and land on the runway of his choice. This is called a circle-to-land manoeuvre, or sometimes a "cloud break procedure". The pilot elected to