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Air ambulance tragedy in Mersey

PUBLISHED: 11:25 23 June 2011 | UPDATED: 14:04 10 October 2012

The Piper PA-38-31 Chieftain was on an air ambulance operation from Ronaldsway in the Isle of Man to Liverpool. Having flown under VFR on a direct track to the Seaforth dock area, the pilot flew by visual reference along the northern coast of the Mersey Estuary to carry out a visual approach to Runway 09.

THE PIPER PA-38-31 Chieftain was on an air ambulance operation from Ronaldsway in the Isle of Man to Liverpool. Having flown under VFR on a direct track to the Seaforth dock area, the pilot flew by visual reference along the northern coast of the Mersey Estuary to carry out a visual approach to Runway 09.

During the turn onto final, about 0.8 nm from the threshold and 0.38 nm south of the extended centreline, the aircraft flew into the sea and disappeared. The pilot and the four passengers lost their lives.

The approach controller watched his radar screen after handing over control to the Tower. He saw the aircraft overshoot the extended runway centreline to the south and turn onto an intercept heading.

The visibility was 3,000 metres in slight drizzle with few clouds at 500 feet, broken at 1,000 feet, overcast at 1,800 feet. The pilot of an R22 helicopter, hovering above the floating wreckage, estimated the visibility as 3,000 to 5,000 metres in light drizzle.

The aircraft had crashed in the estuary in the area of Eastham Sands. The tide was nearly at high water giving a depth of about eight metres. The wreckage was revealed at low tide.

Post-mortem examination of the pilot revealed evidence of enlargement of the left side of the heart and moderate to severe coronary artery atherosclerosis. The pathologist's report stated that, although the significance of this finding was uncertain, this degree of heart disease was potentially sufficient to cause sudden cardiac problems, including abnormal heart rhythms, chest pains and collapse.

The progress of the flight until turning final was routine. Recorded radar showed the track was flown without deviation and generally at a consistent altitude. R/t transmissions from the pilot did not reveal any abnormalities.

The pilot may not initially have been visual with the airfield or runway and was using his local knowledge to position the aircraft for the final. The approach appears to have been hurried in that the aircraft was not in the configuration expected. It was some 20 to 30 knots faster than normal and overshot the runway centreline before adopting a heading to regain the correct approach.

Although the landing gear was selected down, the normal selections of fuel booster pumps and landing lights had not been carried out, the flaps had not been selected and the pilot never transmitted to ATC that he was 'visual with the field'.

The pilot may have been disorientated during the final turn. The reduced visibility in drizzle combined with the homogeneous surface of the water may have reduced the visual cues. Some unknown event or activity within the aircraft may have distracted him. Manoeuvring at a height of less than 300 feet in marginal VMC would have required the pilot's total concentration.

The pilot's heart disease was potentially sufficient to cause sudden cardiac problems. He had an aviation medical examination, including an ECG, some six weeks previously and yet no abnormalities had been detected and a Class I Medical Certificate had been issued by the AME.

The difficulty of predicting an occurrence of physical incapacitation at routine medical examinations is well recognised. It is recommended that the JAA review the medical requirements for a certificate issued to pilots who are likely operate single pilot public transport flights.

Whilst the majority of public transport flights require an operating crew of two pilots, the aircraft involved in this accident was legally only required to have a single pilot. In this instance, in which the pilot was either disorientated, distracted or incapacitated (or a combination of all three), the presence of a co-pilot could have averted the accident. It has been recommended that the CAA, with the JAA, reviews the circumstances in which the carriage of a second pilot is required for public transport flights.

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