ASN Wikibase Occurrence # 211712
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| Date: | Thursday 31 May 2018 |
| Time: | 10:58 LT |
| Type: |  Piper PA-25-235 Pawnee D |
| Owner/operator: | CNE Air |
| Registration: | SE-KHF |
| MSN: | 25-7756019 |
| Fatalities: | Fatalities: 1 / Occupants: 1 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Breda Airport, Noord-Brabant -
 Netherlands
|
| Phase: | Manoeuvring (airshow, firefighting, ag.ops.) |
| Nature: | Banner and glider towing |
| Departure airport: | Breda International Airport (EHSE) |
| Breda International Airport (EHSE) | |
| Investigating agency: | Dutch Safety Board |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Piper PA-25-235 Pawnee D aircraft impacted terrain and burst into flames after a banner pick-up manoeuvre. The pilot, the only on board, died in the crash.
On 31 May 2018 the operator had an assignment for a banner towing flight near the town of Almere in the Netherlands. The planned take-off time was 10:00 hours and the planned duration of the flight was approximately four hours.
The pilot of the aeroplane (SE-KHF) made preparations for the flight. He checked the weather and informed the airport manager of his planned banner towing flight. The banner was prepared by the ground crew for pick up at the pick-up location of the airport. During the flight preparation, a thunderstorm front passed the airport which caused the take-off time to be delayed to 11:00 hours. After the thunderstorm front had passed, the flight preparations were resumed. The pilot discussed the location and duration of the banner flight with the owner of the company.
SE-KHF taxied to runway 25 from where it took off at 10:56 hours. A left hand circuit was flown, according to local procedures. Next, he approached the pick-up location for the banner.
At 10:58 hours the aeroplane picked up the banner. During the pick-up, the banner deployed normally. After the pitch up manoeuvre and levelling off, the aeroplane almost immediately began to lose altitude with a wings level and a nose high attitude.
The aeroplane continued to fly in a descending flight path veering slightly to the left, passing over a residence bordering the airport at approximately 100 feet.
At approximately 100 metres west of the residence and slightly left of the grass strip’s extended centreline, the pilot released the banner. Immediately after that, the aeroplane rolled over its right wing and crashed with an almost vertical nose down attitude just outside the airport boundary on the grassy slope of a highway ramp area. The released banner fell in the yard of the residence.
Performance
The standard propeller for this aeroplane is a fixed pitch 2-blade McCauley 1A200/FA8453 propeller. On 9 May 2018, this propeller was removed and changed, because it was due for maintenance. As a replacement, a Hoffman fixed pitch, 4-blade propeller with type number HO 4/27B HM-185 125 was installed on the aeroplane. The aeroplane had flown five times for banner or glider towing with the Hoffmann 4-blade propeller until the day of the accident.
This propeller was allowed for use on PA-25 Pawnee aircraft. However, flight tests and operational experience showed a significant reduction in climb performance.
While SE-KHF was also allowed to use this prop, the aircraft did not have a supplemental type certificate to allow banner towing operations.
The maximum takeoff weight with this type of propeller was 2,010 pounds (912 kilograms). The estimated take-off weight of SE-KHF was 2,341 pounds (1,065 kilograms).
Conclusions
The Dutch Safety Board concluded:
1. The aeroplane stalled and crashed because it was equipped with an improper propeller for banner towing operations. As the aeroplane was flying slowly and the engine did not have enough power to produce sufficient rpm, the propeller could not produce enough thrust for the aeroplane to safely accelerate and climb after the pick-up of the banner. Furthermore, the aeroplane was flown above its maximum take-off weight, which worsened the power deficient situation. In this unsafe situation, the experienced pilot had no options to regain control of the aeroplane.
2. The operator’s safety management was characterized by a neglect of safety risks in maintenance and flying operations. Safety responsibilities were delegated to the maintenance organisation, the on-demand hired engineer and the pilots. Furthermore, the operator did not foster an environment where safety was an integral part of maintenance and flying operations. In this environment it was possible that: 1) an improper propeller was fitted on the aeroplane; 2) the limitations of the aeroplane and propeller were not sufficiently known to the operator and pilots; 3) the aeroplane was used for banner towing for more than six years while not having a supplemental type certificate for banner towing operations and without having authorized banner towing limitations; 4) there was no assessment of operational performance of the aeroplane after
the installation of the fuselage fuel tank and the installation of the 4-blade propeller; and 5) the pilot’s survivability in case of a crash and post-crash fire was reduced by the installation of an additional fuselage fuel tank. These shortcomings signify that the certification and operational limitations of aeroplanes are not just obligatory requirements that can be taken for granted, but they are essential for ensuring safe operations and the wellbeing of personnel.
3. The Human Environment and Transport Inspectorate (ILT) did not perform active oversight on the operator from the moment it was founded in 2008 until the day of the accident. The long history of safety deficiencies of the operator would have justified an active role of the inspectorate. This history of unnoticed deficiencies, signifies the importance of active oversight in the general aviation sector to identify and reduce the safety risks for specialized operations and third parties.
Accident investigation:
 |
|
Sources:
https://www.bndestem.nl/roosendaal/sportvliegtuigje-neergestort-bij-breda-airport-piloot-komt-om-het-leven~ab13a723/
https://www.jetphotos.com/photo/8690818
Location
Images:
Piper PA-25-235 Pawnee SE-KHF; EHSE 6 Feb. 2016, (c) Aviation Safety Network)
Piper PA-25-235 Pawnee SE-KHF; EHSE 17 June 2017 (c) Aviation Safety Network
Media:
Sportvliegtuigje neergestort bij Breda Airport, piloot komt om het leven https://t.co/9RzL8qUmTE pic.twitter.com/ECrbftGJNx
— BN DeStem (@BNDeStem) May 31, 2018
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 31-May-2018 10:57 | HansAir | Added |
| 31-May-2018 10:59 | Anon | Updated [Other fatalities, Embed code] |
| 31-May-2018 11:34 | Iceman 29 | Updated [Time, Photo, ] |
| 31-May-2018 11:36 | Iceman 29 | Updated [Photo, ] |
| 31-May-2018 11:46 | Iceman 29 | Updated [Photo, ] |
| 31-May-2018 13:35 | HansAir | Updated [Registration, Cn, Source] |
| 31-May-2018 15:15 | harro | Updated [Location, Narrative] |
| 31-May-2018 15:58 | harro | Updated [Photo, ] |
| 31-May-2018 15:59 | harro | Updated [Aircraft type, Photo, ] |
| 31-May-2018 16:09 | harro | Updated [Registration, Cn, Narrative] |
| 06-Jun-2018 05:56 | lmdejee | Updated [Departure airport, Destination airport] |
| 18-Jul-2018 09:42 | harro | Updated [Registration, Cn, Narrative] |
| 12-May-2021 13:36 | harro | Updated [Time, Aircraft type, Departure airport, Destination airport, Narrative, Accident report] |
| 12-May-2021 13:59 | harro | Updated [Narrative] |
| 12-Jun-2022 00:53 | Ron Averes | Updated [Location] |
| 13-Jun-2022 00:18 | Ron Averes | Updated [Location] |
| 28-Jun-2022 11:31 | harro | Updated [Category] |
Corrections or additions? ... Edit this accident description
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