Air Accident Investigation & Prevention Unit
AAIPU# A14-005111AIR ACCIDENT INVESTIGATION& PREVENTION UNITCIVIL AVIATION DEPARTMENTNASSAU, N. P., BAHAMASAIRCRAFT ACCIDENT REPORTCONTROLLED FLIGHT INTO TERRAIN (OBSTACLE)DIPLOMAT AVIATION (BAHAMAS) LTD.GATES LEARJET MODEL 35AN17UFGRAND BAHAMA SHIPYARDFREEPORT, GRAND BAHAMA, BAHAMASNOVEMBER 9, 2014
Air Accident Investigation & Prevention UnitBahamas Department of Civil AviationAir Accident Investigation and Prevention UnitThe Air Accident Investigation and Prevention Unit (AAIPU) is the accident investigation unit of the BahamasCivil Aviation Department (BCAD).The AAIPU’s function is to promote and improve safety and public confidence in the aviation industry throughexcellence in: Independent investigation of aviation accidents and other safety occurrences Safety data recording, analysis and research Fostering safety awareness, knowledge and action.The AAIPU does not investigate for the purpose of apportioning blame or to provide a means fordetermining liability.The AAIPU performs its functions in accordance with the provisions of the Bahamas Civil Aviation (Safety)(Amendment) Regulations (CASAR) 2014, Schedule 19, International Civil Aviation Organization (ICAO) Annex13 and, where applicable, relevant international agreements.The Civil Aviation Department is mandated by the Ministry of Transportation and Aviation to investigate airtransportation accidents and incidents, determine probable causes of accidents and incidents, issue safetyrecommendations, study transportation safety issues and evaluate the safety effectiveness of agencies andstakeholders involved in air transportation.The AAIPU makes public its actions and decisions through accident reports, safety studies, special investigationreports, safety recommendations and safety alerts. When the AAIPU issues a safety recommendation, the person,organization or agency must provide a written response within 90 days. That response must indicate whether theperson, organization or agency accepts the recommendation, any reasons for not accepting part or all of therecommendation, and details of any proposed safety action to give effect to the recommendation.Official Copies of accident reports can be obtained by contacting:Mr. Ivan CleareDirector (Acting)Bahamas Department of Civil AviationP. O. Box N975Nassau N. P., Bahamas(242) 326-0339/40Unofficial copies of the reports can be viewed on our website at www.aaipu-bcaa.comN17UF Final ReportPage ii
Air Accident Investigation & Prevention UnitBahamas Department of Civil AviationAir Accident Investigation and Prevention UnitP. O. Box AP-59244JL Center, Second Floor, Blake RoadNassau N. P., BahamasAIRCRAFT ACCIDENT REPORTCONTROLLED FLIGHT INTO TERRAIN (OBSTACLE)DIPLOMAT AVIATION (BAHAMAS) LTD.LEARJET 35A, N17UFGRAND BAHAMA SHIPYARDFREEPORT, GRAND BAHAMA, BAHAMASNOVEMBER 9, 2014Abstract: This report outlines the accident involving a Bombardier Learjet, Model 35A, registered to and operated byDiplomat Aviation (Bahamas) Limited. The aircraft struck a crane, stationed at Dock 2 of the Grand Bahama ShipyardCompany, during a second landing attempt to runway 06 at the Freeport International Airport in Freeport Grand Bahama,Bahamas. After hitting the crane the aircraft crashed into a garbage pile and Generator Housing Unit at the City ServicesLimited Garbage and Metal Recycling Plant adjacent to the Grand Bahama Shipyard. The accident occurred on November 9at 4:52 pm local (2152Z) and resulted in nine (9) fatal injuries. The weather at the time of the accident was bad.N17UF Final ReportPage iii
Air Accident Investigation & Prevention UnitTable of ContentsFOREWARD . viEXECUTIVE SUMMARY. viiTITLE . viiiABBREVIATIONS and TERMINOLOGY . ixDEFINITIONS . xPART 1FACTUAL INFORMATION: . 11.1HISTORY OF THE FLIGHT . 11.2INJURIES TO PERSONS. 21.3DAMAGE TO AIRCRAFT . 21.4OTHER DAMAGE . 21.5PERSONNEL INFORMATION . 21.5.1 The Captain (Pilot Flying). 31.5.2 First Officer (Pilot not Flying) . 31.6AIRCRAFT INFORMATION . 31.6.1 Aircraft Fuelling Information . 41.6.2 Weight and Balance and Stall Information . 41.6.3 Maintenance Records and actions prior to the accident. 41.7METEOROLOGICAL INFORMATION. 41.8AIDS TO NAVIGATION. 61.9COMMUNICATIONS . 61.10 AERODROME INFORMATION . 61.11 FLIGHT RECORDERS . 71.11.1Cockpit Voice Recorder . 71.11.2Digital Electronic Engine Control . 71.11.3Flight Data Recorder (FDR) . 71.11.4Analysis - N1 Digital Electronic Engine Control . 71.12 WRECKAGE AND IMPACT INFORMATION . 81.12.1Airframe and Ground Damage. 81.12.2The Cockpit . 101.13 MEDICAL AND PATHOLOGICAL INFORMATION .131.14 FIRE .131.15 SURVIVAL ASPECTS .131.16 TESTS AND RESEARCH .141.17 ORGANIZATIONAL AND MANAGEMENT INFORMATION .141.17.1General . 141.18 ADDITIONAL INFORMATION .141.18.1Crew Resource Management Training (CRM) . 141.18.2Bahamas Civil Aviation Safety Regulations 2013(BASR) . 14PART 22.12.22.32.42.52.62.72.8PART 33.13.23.3ANALYSIS. 18General .18The approach and attempted landing .18The Fire .19Airplane handling .20PHYSIOLOGICAL / PSYCHOLOGICAL FACTORS .20Survival Factors.20FLIGHT RECORDERS .20Maintenance Oversight.21CONCLUSIONS . 22FINDINGS.22PROBABLE CAUSE .23CONTRIBUTING FACTORS .23N17UF Final ReportPage iv
Air Accident Investigation & Prevention UnitPART 4SAFETY RECOMMENDATIONS:. 24PART 5APPENDICES . 25Appendix 1ILS z Runway 06 Instrument Approach Chart. 25APPENDIX 2 Overview of Approach to Runway 06 . 26APPENDIX 3 Overlay of Weather conditions over Freeport before and after the accident . 27APPENDIX 4 Overlay of Weather Conditions Approach Chart over weather . 28APPENDIX 5 Overlay of Weather Conditions Approach Chart under weather . 29APPENDIX 6 Satellite Loop for the period 21:30 (4:30pm) . 30APPENDIX 7 Satellite loop for the period 22:30 (5:30pm) . 30APPENDIX 8 Actual weather conditions prior to, during and after the accident . 31APPENDIX 9 Instrument Approach Chart Rwy 06 Google Earth View . 33N17UF Final ReportPage v
Air Accident Investigation & Prevention UnitFOREWARDFebruary 20, 2015Mr. Ivan CleareDirector (Acting)Bahamas Civil Aviation DepartmentJL Center, Blake RoadP. O. Box N-975Nassau, N.P.,BahamasSirI am duty-bound to submit this report on the circumstances of the fatal accident involving N17UF, aBombardier Learjet 35A aircraft, registered in the United States to Diplomat Aviation (Bahamas) Limitedat 1421 SW 107th Ave #300 Miami, Florida, USA. This accident occurred on November 9th, 2014 at4:52pm local time (2152Z) when the aircraft hit a stationary crane at the Grand Bahama Shipyard and agenerator unit in the City Services Limited Garbage and Metal Recycling Plant adjacent to the GrandBahama Shipyard while on approach and attempting to find the runway at Freeport Int’l Airport visuallyduring instrument meteorological conditions.This report is submitted pursuant to Part XII, Regulation 80, and Schedule 19 of the Bahamas CivilAviation (Safety)(Amendment) Regulation (CASR 2014) and in accordance with Annex 13 to theConvention on International Civil Aviation Organization (ICAO).In accordance with Annex 13 to the Convention on International Civil Aviation (ICAO), and Schedule19 of the Bahamas Civil Aviation (Safety)(Amendment) Regulations (CASAR), the fundamentalpurpose of such investigations is to determine the circumstances and causes of these events, with a viewto the preservation of life and the avoidance of similar occurrences in the future. It is not the purpose ofsuch investigations to apportion blame or liability.This report contains facts that have been determined up to the time of publication. Information ispublished to inform the aviation industry and the public of the circumstances surrounding this accident.The contents of this report may be subjected to alterations or corrections if additional factualinformation becomes available.RegardsDelvin R. MajorInvestigator in ChargeAir Accident Investigation and Prevention UnitBahamas Department of Civil AviationJL Center, Blake RoadNassau, N. P., BahamasN17UF Final ReportPage vi
Air Accident Investigation & Prevention UnitBAHAMAS CIVIL AVIATION DEPARTMENTAIR ACCIDENT INVESTIGATION AND PREVENTION UNITEXECUTIVE SUMMARYOn November 9, 2014 at 4:52pm (2152Z) a Bombardier Learjet 35A, Registration N17UF, registered to andoperated by Diplomat Aviation (Bahamas) Limited, crashed into a garbage and metal recycling plant after strikinga towering crane in the Grand Bahama Shipyard, while attempting a second landing approach to runway 06 atFreeport International Airport (MYGF), Freeport, Grand Bahama, Bahamas.The aircraft made an initial ILS instrument approach to Runway 06 at the Freeport International Airport but dueto poor visibility and rain at the decision height, the crew executed a go around procedure. The crew requested tohold at the published holding point at 2,000 feet while they waited for the weather to improve.Once cleared for the second ILS approach, the crew proceeded inbound from the holding location to intercept thelocalizer of the ILS system associated with the instrument approach. During the approach, the crew periodicallyreported their position to ATC, as the approach was not in a radar environment. The crew was given currentweather conditions and advised that the conditions were again deteriorating. The crew continued their approachand descended visually while attempting to find the runway, until the aircraft struck the crane positioned at Dock#2 of the Shipyard at approximately 220 feet above sea level, some 3.2 nautical miles (nm) from the runwaythreshold.A fireball lasting approximately 3 seconds was observed as a result of the contact between the aircraft and thecrane. The right outboard wing, right landing gear and right wingtip fuel tank, separated from the aircraft onimpact. This resulted in the aircraft travelling out of control, some 1,578 feet (526 yards) before crashing invertedinto a pile of garbage and other debris in the City Services Garbage and Metal Recycling Plant adjacent to theGrand Bahama Shipyard. Both crew and 7 passengers were fatally injured.No person on the ground was injured. The crane in the shipyard that was struck received minimal damages whilethe generator unit and other equipment in the recycling plant received extensive damages.The Air Accident Investigation & Prevention Unit (AAIPU) determines that the probable cause(s) of this accidentwere: The poor decision making of the crew in initiating and continuing a descent in IMC below the authorizedaltitude, without visual contact with the runway environment andContributing Factors includes: Improper planning of the approach Failure of the crew to follow the approved ILS approach while in IMC conditions. Insufficient horizontal or vertical situational awareness Poor decision making Deliberate actions of the crew by disabling the terrain alert warning system Inadequate CRM practiceN17UF Final ReportPage vii
Air Accident Investigation & Prevention UnitBAHAMAS CIVIL AVIATION DEPARTMENTAIR ACCIDENT INVESTIGATION AND PREVENTION UNITTITLERegistered Owner:Diplomat Aviation (Bahamas) LimitedOperator:Diplomat Aviation (Bahamas) LimitedManufacturer:Bombardier Learjet1Model:35AAircraft Type:Fixed Wing Multi EngineNationality:United StatesRegistration:N17UFPlace of Accident:Grand Bahama Shipyard and City Services Limited Recycling PlantDate and Time:November 9th, 2014 at 2152Z (4:52pm local EST)Notification:DCA, NTSB, ICAO, FAA, BombardierInvestigating Authority:Bahamas Department of Civil AviationAir Accident Investigation and Prevention UnitInvestigator in Charge:Mr. Delvin R. MajorAccredited Representative:Advisors to ACCREP:An Investigator from the NTSB assisted in the investigation.Accident Investigators from both the FAA as well as Bombardier were advisorsto the accredited representativeReleasing Authority:Civil Aviation Department, Nassau, N. P., BahamasDate of Report Publication:February 20, 20151At the time of manufacture, the type certificate for the aircraft belonged to Gates Learjet Corporation. The type certificate now belongs toBombardier.N17UF Final ReportPage viii
Air Accident Investigation & Prevention UnitABBREVIATIONS AND TERMINOLOGYWhen the following terms are used in this report, they have the following meanings:AAIPUAISATSBDCA /CADCASRC of AC of RCRMCVRDCADEECESTFAAICAOILSIFRIMCMETMETARNM or nmNTSBNVMRVSMSOPSTCUSAVFRUTC / ZN17UF Final ReportAir Accident Investigation and Prevention UnitAutomatic Information ServicesAir Traffic ServicesBahamas Department of Civil AviationBahamas Civil Aviation (Safety) Regulations (April 17, 2001)Certificate of AirworthinessCertificate of RegistrationCrew Resources ManagementCockpit Voice RecorderDirector of Civil AviationDigital Electronic Engine ControlEastern Standard Time (-4 hours to convert from UTC)Federal Aviation AdministrationInternational Civil Aviation OrganizationInstrument Landing SystemInstrument Flight RulesInstrument Meteorological ConditionMeteorological Office / DepartmentWeather Report furnished by Meteorological DepartmentNautical MilesNational Transportation Safety BoardNon Volatile MemoryReduced Vertical Separation MinimumsStandard Operating ProceduresSupplemental Type CertificateUnited States of AmericaVisual Flight RulesUniversal Coordinated Time / Zulu timePage ix
Air Accident Investigation & Prevention UnitDEFINITIONSWhen the following terms are used in the Standards and Recommended Practices for Aircraft Accident andIncident Investigation, they have the following meaning:Accident. An occurrence associated with theoperation of an aircraft which takes place betweenthe times any person boards the aircraft with theintention of flight until such time as all such personshave disembarked, in which:a) a person is fatally or seriously injured as a resultof:— being in the aircraft, or— direct contact with any part of the aircraft,including parts which have become detached fromthe aircraft, or— direct exposure to jet blast, except when theinjuries are from natural causes, self-inflicted orinflicted by other persons, or when the injuries are tostowaways hiding outside the areas normallyavailable to the passengers and crew; orb) the aircraft sustains damage or structural failurewhich:— adversely affects the structural strength,performance or flight characteristics of the aircraft,and— would normally require major repair orreplacement of the affected component, except forengine failure or damage, when the damage islimited to the engine, its cowlings or accessories; orfor damage limited to propellers, wing tips,antennas, tires, brakes, fairings, small dents orpuncture holes in the aircraft skin; orc) the aircraft is missing or is completelyinaccessible.Note 1.— For statistical uniformity only, aninjury resulting in death within thirty days of thedate of the accident is classified as a fatal injuryby ICAO.Note 2.— An aircraft is considered to be missingwhen the official search has been terminated andthe wreckage has not been located.Accredited representative. A person designated bya State, on the basis of his or her qualifications, forthe purpose of participating in an investigationconducted by another State.Adviser. A person appointed by a State, on the basisof his or her qualifications, for the purpose ofassisting its accredited representative in aninvestigation.N17UF Final ReportAircraft. Any machine that can derive support in theatmosphere from the reactions of the air other thanthe reactions of the air against the earth’s surface.Causes. Actions, omissions, events, conditions, or acombination thereof, which led to the accident orincident.Fatal injury. - means any injury which results indeath within 30 days of the accident.Flight recorder. Any type of recorder installed inthe aircraft for the purpose of complementingaccident/incident investigation.Investigation. A process conducted for the purposeof accident prevention which includes the gatheringand analysis of information, the drawing ofconclusions, including the determination of causesand, when appropriate, the making of safetyrecommendations.Investigator-in-charge. A person charged, on thebasis of his or her qualifications, with theresponsibility for the organization, conduct andcontrol of an investigation.Note.— Nothing in the above definition is intendedto preclude the functions of an investigator-in-chargebeing assigned to a commission or other body.Maximum mass. Maximum certificated take-offmass.Operator. A person, organization or enterpriseengaged in or offering to engage in an aircraftoperation.Preliminary Report. The communication used forthe prompt dissemination of data obtained during theearly stages of the investigation.Safety recommendation. A proposal of the accidentinvestigation authority of the State conducting theinvestigation, based on information derived from theinvestigation, made with the intention of preventingaccidents or incidents.State of Design. The State having jurisdiction overthe organization responsible for the type design.Page x
Air Accident Investigation & Prevention UnitState of Manufacture. The State having jurisdictionover the organization responsible for the finalassembly of the aircraft.State of Occurrence. The State in the territory ofwhich an accident or incident occurs.State of the Operator. The State in which theoperator’s principal place of business is located or, ifthere is no such place of business, the operator’spermanent residence.Note.— In the case of the registration of aircraft ofaninternational operating agency on other than anational basis, the States constituting the agency arejointly and severally bound to assume theobligations which, under the Chicago Convention,attach to a State of Registry. See, in this regard, theCouncil Resolution of 14 December 1967 onNationality and Registration of Aircraft Operated byInternational Operating Agencies which can befound in Policy and Guidance Material on theEconomic Regulation of InternationalState of Registry. The State on whose register theaircraft is entered.N17UF Final ReportPage xi
Air Accident Investigation & Prevention UnitPART 11.1FACTUAL INFORMATION:HISTORY OF THE FLIGHTOn November 9, 2014 at 4:52pm (2152Z) a Diplomat Aviation (Bahamas) Limited Bombardier Learjet 35Aaircraft, registration N17UF crashed into a garbage and metal recycling plant after striking a towering crane in theGrand Bahama Shipyard while attempting a landing at Freeport International Airport (MYGF).N17UF was a business flight operated under the provisions of the USA 14 Code of Federal Regulations Part 91.Day, instrument meteorological c o n d i t i o n s prevailed and an instrument flight rules flight plan was filedfor the 24-minute flight from Lynden Pindling International Airport (LPIA)(MYNN) destined for FreeportInternational Airport (MYGF), Freeport, Grand Bahama, Bahamas.The accident resulted in two (2) wreckage sites. Site one (1), the initial impact site, identified as dock number 2 inthe Grand Bahama Shipyard, and site two (2), the garbage and metal recycling plant owned and operated by CityServices Limited. Portions of the right hand wing and right hand wingtip tank were located at site 1. The rest ofthe aircraft was located at site 2, with the exception of the right-hand main landing gear, which was never found.The aircraft made an initial ILS instrument approach to Runway 06 (ILS z RWY 06) at the Freeport InternationalAirport but, due to poor visibility and rain at the decision height, the crew executed a go around procedure. Thecrew requested to hold at the published holding point (which was located on the 146 degree radial of the FreeportVOR/DME beginning at the 12 nm mark at 2,000 feet) while they waited for the weather to improve.Once advised by ATC that the weather wasimproving, the crew requested to return andattempt the ILS z RWY 06 approach a secondtime. ATC cleared the aircraft for the ILS zRWY 06 approach a second time withinstructions to proceed from the holdingposition direct to HOLIR2 Intersection, whichis the initial fix for this approach. The crewproceeded inbound from the holding locationto intercept the localizer of the ILS systemassociated with the instrument approach.During the approach, the crew periodicallyreported their position and altitude to ATC, asthis approach was not in a radar environment.The crew was given current weather conditions and advised that the conditions were again deteriorating. The crewacknowledged the instructions and continued the “Before Landing Checks” from the aircraft checklist. The crewdeliberately continued descending below the published minimum altitude for this approach while attempting tofind the runway visually. Repeated warnings about altitude and terrain proximity from the onboard TerrainAwareness Warning System (TAWS) were ignored. One of the crew disabled the warning alert system (unable todetermined who did it) and continued with the “Before Landing Checks”.The crew continued the descent while looking visually for the runway until the aircraft right wing struck the cranepositioned at Dock #2 of the Grand Bahama Shipyard, some 3.2 nautical miles (nm) from the runway threshold.The impact occurred with two support beams above the crane operator’s cab, approximately 115 feet abovethe base of the loading dock which was an additional 90 feet above sea level.2HOLIR intersection is defined by intercepting the 248 degree radial of the Freeport VOR/DME inbound, 12 nm at 2,000 feetN17UF Final ReportPage 1
Air Accident Investigation & Prevention UnitThe crane was stationed at coordinates, Latitude 26 degrees, 31.617 minutes North and Longitude, 78degrees, 45.363 minutes West. Just seconds prior to the impact upon seeing the crane, the first officer exclaimed“climb, climb, climb.”A fireball lasting approximately 3 seconds was observed (despite the heavy rain conditions) from a tower camerasystem stationed at an industry partner facility. The right outboard wing and fuel tank that struck the crane, aswell as the right main landing gear, separated from the aircraft on impact. The separation of the wing structurefrom the aircraft resulted in the aircraft becoming inverted while it travelled in a downward direction someadditional 1,578 feet (.4809km / 526 yards) from the point of initial impact. The aircraft eventually crashed into apile of garbage and came to a sudden stop after making contact with a generator unit in the City Services Garbageand Recycling Plant (identified as site 2) adjacent to the Grand Bahama Shipyard (identified as site 1). Thesudden stop proved catastrophic for all occupants and resulted in the captain being ejected from the aircraft afterthe cockpit was compromised due to the impact. He landed on the top of the generator unit. Other occupants ofthe aircraft were found in the fuselage which
Nov 09, 2014 · Bahamas Civil Aviation Department JL Center, Blake Road P. O. Box N-975 Nassau, N.P., Bahamas Sir I am duty-bound to N17UF, a submit this report on the circumstances of the fatal accident involving Bombardier Learjet 35A aircraft, registered in the United States to Diplomat Aviation (Bahamas
accident reporting and investigation of each accident and incident (near-miss); and periodic review of the program to keep it up to date. The direct cause of an accident usually results from one or more previous unsafe actions or conditions. A good accident investigation program discovers the events leading up to an incident or accident.
This report is an independent product of the Paducah Gaseous Diffusion Plant Accident Investigation Board appointed by William E. Murphie. The Board was appointed to perform a U.S. Department of Energy Type B Accident Investigation of this accident and to prepare an investigation report in accordance with DOE O 225.1A, Accident Investigations.
National Training Center appointed a Type B Accident Investigation Board (the Board) to investigate the accident in accordance with DOE Order 225.1A, Accident Investigations. Although the accident investigation encompassed the cases of all three competitors who became ill, the Board focused primarily on the illness suffered by
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are taken following an accident, an investigation of the accident will be conducted by the immediate supervisor, in conjunction with any witnesses to the accident to determine the cause. The findings of the investigation shall be documented on the Supervisor's Report of Investigation form. Distribution of the completed form will be as follows: a.
On-Farm Hazards and Accident Prevention - FSA-1061 Author: Sammy Sadaka Subject: This fact sheet explores some on-farm hazards and presents some tips for accident prevention. It also emphasizes the importance of considering safety first. Keywords: arkansas,division,agriculture,fsa1061,on-farm accidents,on-farm hazards,accident prevention .
ACCIDENT INVESTIGATION AND ACCIDENT STATISTICS . 9.1 REPORTING OF ACCIDENTS/INCIDENTS . 9.1.1 Contractor's Responsibility (a) Accidents involving death or serious injury . 24 hours of an accident/incident listed below occurring in Hong Kong waters: -a vessel is involved in a collision with another vessel, a port . 3.
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