Accident
Last updated: 1 November 2014
Status:Definitief
Datum:donderdag 22 oktober 2009
Tijd:10:17
Type:Silhouette image of generic BN2P model; specific model in this crash may look slightly different
Britten-Norman BN-2A-26 Islander
Luchtvaartmaatschappij:Divi Divi Air
Registratie: PJ-SUN
Constructienummer: 377
Bouwjaar: 1973
Aantal vlieguren:16670
Motoren: 2 Lycoming O-540-E4C5
Bemanning:slachtoffers: 1 / inzittenden: 1
Passagiers:slachtoffers: 0 / inzittenden: 9
Totaal:slachtoffers: 1 / inzittenden: 10
Schade: Afgeschreven
Gevolgen: Written off (damaged beyond repair)
Plaats:4,7 km (2.9 mijl) WNW van Bonaire-Flamingo International Airport (BON) (   Nederlandse Antillen) show on map
Fase: Nadering (APR)
Soort vlucht:Binnenlandse lijnvlucht
Vliegveld van vertrek:Curaçao-Hato International Airport (CUR/TNCC), Nederlandse Antillen
Vliegveld van aankomst:Bonaire-Flamingo International Airport (BON/TNCB), Nederlandse Antillen
Vluchtnummer: 014
Beschrijving:
The pilot brought the aircraft into level flight at FL035 and reduced the power from climb power to cruise power. Engine power of the right hand engine ceased the moment that the pilot was adjusting (one of) the levers on the throttle quadrant. Passengers stated that the pilot increased the left engine power, feathered the right propeller and trimmed away the forces to the rudder pedals due to the failure of the right engine. They also reported that the pilot attempted to restart the right engine two or three times but to no avail. Around 09:52 the pilot reported to the Hato Tower controller: "Divi 014 requesting to switch to Flamingo, priority landing with Flamingo, have lost one of the engines." The controller acknowledged this message. The pilot continued the flight to Bonaire flying with the left engine running and contacted Flamingo Tower air traffic control at 09:57 and reported: "014, Islander inbound from Curaçao, showing, I got one engine out, so we are landing with one engine, no emergency at this stage, I’m maintaining altitude at, 3000 feet, we request priority to landing runway 10, currently 24 miles out, estimating at, 18." The Flamingo Tower controller authorised the approach to runway 10. The air traffic controller requested the pilot to report when he left 3000 feet altitude, which he immediately did.
The radar data shows that the PJ-SUN descended approximately 140 feet per minute on average from the moment the engine failed up to the emergency landing.
The pilot did not inform the passengers regarding the failure of the right engine or his intentions. A few passengers were concerned and started to put on the life jackets having retrieved them from under their seats. The passenger next to the pilot could not find his life jacket, while others had some trouble opening the plastic bags of the life jackets. They also agreed on a course of action for leaving the aircraft in case of an emergency landing in the water.
At 10:08 the pilot informed the Flamingo Tower that he was approaching and was ten nautical miles away, flying at 1000 feet and expected to land in ten minutes. At 10:12 the pilot reported the distance to be eight nautical miles and that he was having trouble with the altitude which was 600 feet at that moment. The traffic controller authorised the landing. At 10:14 the pilot reported to be six nautical miles away and flying at an altitude of 300 feet. During the last radio contact at 10:15 the pilot indicated to be at five nautical miles distance flying at 200 feet and that he was still losing altitude. The pilot was going to perform an emergency landing near Klein Bonaire. The aircraft subsequently turned a little to the left towards Klein Bonaire. According to a few passengers, the pilot turned around towards them and indicated with hand signals that the aircraft was about to land and he gave a thumbs-up signal to ask whether everyone was ready for the approaching emergency landing.
The aircraft hit the water at 10.17 at a distance of approximately 0.7 nautical miles from Klein Bonaire and 3.5 nautical miles west of Bonaire. The left front door broke off from the cabin and other parts of the aircraft on impact.
The cabin soon filled with water because the left front door had broken off and the windscreen had shattered. All nine passengers were able to leave the aircraft without assistance using the left front door opening and the emergency exits. A few passengers sat for a short time on the wings before the aircraft sank. The passengers formed a circle in the water. The passengers who were not wearing life jackets kept afloat by holding onto the other passengers. One passenger reported that the pilot hit his head on the vertical door/window frame in the cockpit or the instrument panel at impact causing him to lose consciousness and may even have been wounded. The attempts of one or two passengers to free the pilot from his seat were unsuccessful. A few minutes after the accident, the aircraft sank with the pilot still on-board. Approximately five minutes after the emergency landing, two boats with recreational divers who were nearby arrived on the scene and rescued the survivors.


Causal factors
1. After one of the two engines failed, the flight continued to Bonaire. By not returning to the nearby situated departure airport, the safest flight operation was not chosen.
- Continuing to fly after engine failure was contrary to the general principle for twin-engine aircraft as set down in the CARNA, that is, to land at the nearest suitable airport.
2. The aircraft could not maintain horizontal flight when it continued with the flight and an emergency landing at sea became unavoidable.
- The aircraft departed with an overload of 9% when compared to the maximum structural take-off weight of 6600 lb. The pilot who was himself responsible (self-dispatch and release) for the loading of the aircraft was aware of the overloading or could have been aware of this. A non-acceptable risk was taken by continuing the flight under these conditions where the aircraft could not maintain altitude due to the overloading.
3. The pilot did not act as could be expected when executing the flight and preparing for the emergency landing.
- The landing was executed with flaps up and, therefore, the aircraft had a higher landing speed.
- The pilot ensured insufficiently that the passengers had understood the safety instructions after boarding.
- The pilot undertook insufficient attempts to inform passengers about the approaching emergency landing at sea after the engine failure and, therefore, they could not prepare themselves sufficiently.

Contributing factors
Divi Divi Air
4. Divi Divi Air management paid insufficient supervision to the safety of amongst others the flight operation with the Britten-Norman Islanders. This resulted in insufficient attention to the risks of overloading.
Findings:
- The maximum structural take-off weight of 6600 lb was used as limit during the flight operation. Although this was accepted by the oversight authority, formal consent was not
granted for this.
- A standard average passenger weight of 160 lb was used on the load and balance sheet while the actual average passenger weight was significantly higher. This meant that passenger weight was often lower on paper than was the case in reality.
- A take-off weight of exactly 6600 lb completed on the load and balance sheet occurred in 32% of the investigated flights. This is a strong indication that the luggage and fuel weights completed were incorrect in these cases and that, in reality, the maximum structural take-off weight of 6600 lb was exceeded.
- Exceedances of the maximum structural landing weight of 6300 lb occurred in 61% of the investigated flights.
- The exceedance of the maximum allowed take-off weight took place on all three of the Britten-Norman Islander aircraft in use and with different pilots.
- Insufficient attention was paid to aircraft weight limitations during training.
- Lack of internal supervision with regard to the load and balance programme.
- Combining management tasks at Divi Divi Air, which may have meant that insufficient details were defined regarding the related responsibilities.
5. The safety equipment and instructions on-board the Britten-Norman Islander aircraft currently being used were not in order.
Findings:
- Due to the high noise level in the cabin during the flight it is difficult to communicate with the passengers during an emergency situation.
- The safety instruction cards did not include an illustration of the pouches under the seats nor instructions on how to open these pouches. The life jacket was shown with two and not a single waist belt and the life jackets had a different back than the actual life jackets on-board.
Directorate of Civil Aviation Netherlands Antilles (currently the Curaçao Civil Aviation Authority)
6. The Directorate of Civil Aviation’s oversight on the operational management of Divi Divi Air was insufficient in relation to the air operator certificate involving the Britten-Norman Islander aircraft in use.
Findings:
- The operational restrictions that formed the basis for using 6600 lb were missing in the air operator certificate, in the certificate of airworthiness of the PJ-SUN and in the approved General Operating Manual of Divi Divi Air. The restrictions entail that flying is only allowed during daylight, under visual meteorological conditions, and when a route is flown from where a safe emergency landing can be executed in case of engine failure.
- The required (demonstrable) relation with the actual average passenger weight was missing in relation to the used standard passenger weight for drawing up the load and balance sheet.
- The failure of Divi Divi Air’s internal supervision system for the load and balance programme.
- Not noticing deviations between the (approved) safety instruction cards and the life jackets on-board during annual inspections.
- The standard average passenger weight of 176 lb set after the accident offers insufficient security that the exceedance of the maximum allowed take-off weight of flights with Antillean airline companies that fly with the Britten-Norman Islander will not occur.

Other factors
Recording system of radio communication with Hato Tower
7. The recording system used for the radio communication with Hato Tower cannot be used to record the actual time. This means that the timeline related to the radio communication with Hato Tower cannot be exactly determined.
The alerting and the emergency services on Bonaire
8. There was limited coordination between the different emergency services and, therefore, they did not operate optimally.
Findings:
- The incident site command (CoPI) that should have taken charge of the emergency services in accordance with the Bonaire island territory crisis plan was not formed.
- Insufficient multidisciplinary drills have been organised and assessed for executive officials who have a task to perform in accordance with the Bonaire island territory crisis plan and the airport aircraft accident crisis response plan in controlling disasters and serious accidents. They were, therefore, insufficiently prepared for their task.
9. The fire service and police boats could not be deployed for a longer period of time.

Bronnen:
» Toestel Divi Divi in zee gestort (Amigoe, 22-10-2009)

Official accident investigation report
investigating agency: Onderzoeksraad Voor Veiligheid (OVV) / Dutch Safety Board - Netherlands
report status: Final
report number: 2009090)
report released:17-MAY-2011
duration of investigation:572 days (1 year 6.9 months)
download report: Emergency landing at sea with Britten-Norman Islander near Bonaire on 22 October 2009 (Dutch Safety Board 2009090))

Foto's

photo of Britten-Norman BN-2A-26 Islander PJ-SUN
photo of Britten-Norman BN-2A-26 Islander PJ-SUN
photo of Britten-Norman BN-2A-26 Islander PJ-SUN
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Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Curaçao-Hato International Airport en Bonaire-Flamingo International Airport bedraagt 75 km (47 miles).

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