ASN Wikibase Occurrence # 226182
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| Date: | Wednesday 12 June 2019 |
| Time: | 15:40 LT |
| Type: |  de Havilland Canada DHC-6 Twin Otter 200 |
| Owner/operator: | Inter DZ |
| Registration: | F-GHRK |
| MSN: | 144 |
| Fatalities: | Fatalities: 0 / Occupants: 1 |
| Aircraft damage: | Minor |
| Category: | Serious incident |
| Location: | 1.4 km from Pau-Pyrénées Airport, Pyrénées-Atlantiques 64 -
 France
|
| Phase: | Landing |
| Nature: | Parachuting |
| Departure airport: | Pau-Uzein Airport (PUF/LFBP) |
| Pau-Uzein Airport (PUF/LFBP) | |
| Investigating agency: | BEA-E |
| Confidence Rating: |  Information verified through data from accident investigation authorities |
The Twin Otter was engaged in dropping French Army skydivers of the École des Troupes Aéroportées (ETAP) at Pau, France.
After dropping the skydivers, the aircraft descended back for landing on runway 31 at Pau-Pyrénées Airport.
On short final at about 175 ft and 75 kt, the pilot noticed the "R. Generator" light illuminating. The aircraft then yawed and turned sharply to the right. The pilot tried to control the aircraft, requested power from the engines and noted the lack of response from the right engine. The aircraft continued on a descending trajectory to a very low height (30 to 60 ft) and in a continuous right turn to a heading of 230°. The pilot tried to gain speed, while avoiding successive obstacles (hangars, wooded area). After crossing the top of a line of trees, the pilot landed the aircraft in a field , 1400 m short of the threshold of runway 31.
After the aircraft came to a standstill, the pilot shut down the engines and systems. Uninjured, he evacuated the aircraft. The aircraft sustain minor damage.
Causes of the event:
The shutdown of the right engine is the consequence of a fuel leak that originated from a crack in the right engine supply pipe, which caused the shutdown of the right engine:
- the crack propagated from corrosion points under a faulty brazing of the pipe, until it became through;
- the quality controls of the piping manufacturing process did not detect the defects in the solder;
- visual inspections during maintenance or in-line inspections did not detect the braze defect.
The loss of control and improvised landing in a field are the consequence of :
- the delayed detection of the failure of the right engine, favoured by :
* the focus on a generator failure;
* the cognitive overload generated by the final phase of the approach and the resetting of the generator;
* an erroneous representation of the situation leading to the treatment of an amber failure in the final phase;
* the drop in attention due to the repetitiveness of flights carried out almost systematically in the same sequence, and almost exclusively for ETAP at a single airport;
- the prioritisation of tasks delaying the management of the breakdown, favoured by :
* the migration of practices leading to a reduction in the room for manoeuvre in the event of a breakdown,
* the absence of auto-feathering ;
* the absence of engine failure drive, not allowing the mechanisation of movements;
- the insufficient control of the aircraft, whose controls were nevertheless fully effective, favoured by :
* the optimisation of the time required for the pilot to make a short landing;
* the ergonomics of the cockpit strongly constraining the full use of the flight controls;
* the demand for engine power without feathering the propeller, accentuating the yaw and roll phenomenon;
* a lack of practice in engine failure requiring the use of full flight control travel.
Accident investigation:
 |
|
Sources:
https://www.larepubliquedespyrenees.fr/2019/06/12/uzein-un-avion-bimoteur-rate-son-atterrissage-et-se-pose-dans-un-champ,2568034.php
Images:
1 km from Runway 31, Pau Airport, 16 May 2019
Sequence of events (source: BEA-É)
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 15-Jun-2019 13:57 | Lolo-pau | Added |
| 16-Jun-2019 16:52 | Lolo-pau | Updated [Operator, Location, Photo] |
| 18-Sep-2019 18:29 | TB | Updated [Aircraft type, Location] |
| 20-Jan-2021 18:07 | harro | Updated [Time, Location, Narrative, Category, Accident report] |
| 20-Jan-2021 18:12 | harro | Updated [Photo] |
| 10-Jun-2022 05:55 | Ron Averes | Updated [Location] |
| 10-Jun-2022 05:56 | Ron Averes | Updated [Location] |
Corrections or additions? ... Edit this accident description
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