MINISTRY OF DEFENCE

MILITARY AIRCRAFT ACCIDENT SUMMARY

AIRCRAFT ACCIDENT TO ROYAL AIR FORCE CANBERRA T4 WJ866

AIRCRAFT: DATE: LOCATION: PARENT UNIT: CREW: INJURIES: RAF Canberra T4 WJ866 2 September 2004 RAF Marham 39(1PRU) Squadron, RAF Marham Two Pilots , One Navigator Two Fatal, One Major

Issued by: Directorate of Air Staff, Main Building, Ministry of Defence, Whitehall, London SW1A 2HB

June 2006

MINISTRY OF DEFENCE
MILITARY AIRCRAFT ACCIDENT SUMMARY

AIRCRAFT ACCIDENT TO ROYAL AIR FORCE CANBERRA T4 WJ866

AIRCRAFT: DATE: LOCATION: PARENT UNIT: CREW: INJURIES: RAF Canberra T4 WJ866 2 September 2004 RAF Marham 39(1PRU) Squadron, RAF Marham Two Pilots , One Navigator Two Fatal, One Major

Issued by: Directorate of Air Staff, Main Building, Ministry of Defence, Whitehall, London SW1A 2HB

SYNOPSIS 1. On the evening of 2 September 2004, Canberra T4 WJ866 was carrying

out a night check sortie to include simulated single engine approaches to overshoot, roll and land. On the third circuit, having touched down on the runway, the aircraft veered to the left; this was corrected by a sharp movement in yaw back to the right. Shortly after these events the aircraft became airborne for a short period before impacting the ground and coming to rest 1000 metres beyond the impact site. During the accident the three man crew ejected; both pilots were killed and the navigator suffered major injuries. The Inquiry concluded the accident was caused by the aircraft becoming airborne in an asymmetric power configuration below a safe speed.

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BACKGROUND

2.

WJ866 had flown three sorties on 2 September 2004. During the day of the

accident there were minor non-critical problems with the aircraft, such as an incorrectly stowed locking pin on the left hand ejection seat, which was corrected prior to flight, an instance of brake juddering and the starboard engine accelerating faster than the port engine on wind up prior to takeoff. However, the captain accepted the aircraft as fit for purpose and he expressed no undue concerns.

CIRCUMSTANCES

3.

In order to complete the second of two pilot night checks there was a pilot

change, after which WJ866 conducted two further uneventful circuits. The final circuit was to be a single engine approach to roll. The aircraft landed safely on the runway, prior to commencing a roll in the normal manner, with both engines at idle. Difficulties were encountered by the pilot in the left hand seat, who was handling the aircraft, as the power was advanced on both engines from idle. There was a rapid swing of the aircraft to the left, followed by a sharp correction back to the right. The power was further increased and the aircraft became airborne well below safety speed for engines with a marked power differential. Once airborne WJ866 sliced to the left before following a straighter path as it yawed back to the right. As the aircraft yawed right it started to descend and at this point the navigator ejected, he was followed shortly afterwards by the left hand seat pilot. WJ866 hit the ground in a slightly nose down attitude, sledging on the left main

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landing gear, fuselage and right wing tip, which slowed the aircraft sufficiently for it to come to a rest some 250 metres from the initial point of impact facing back down its flightpath. It is believed the right hand seat pilot ejected, either at the moment of, or very shortly after, initial impact.

RESCUE/SALVAGE OPERATION

4.

The navigator ejected at 100ft, just outside the safe ejection envelope,

followed within a matter of seconds by the handling pilot and then Captain. Fortunately, the navigators parachute opened normally, although he suffered major injuries on landing as there was not time for the chute to pull him into an upright position. The pilots also ejected outside the safe envelope, but their parachutes did not deploy effectively and both suffered fatal injuries. The navigator was given initial medical attention by RAF Marham medical staff before eventually being flown to hospital by Search and Rescue helicopter. WJ866 was removed to a hanger at RAF Marham for detailed investigation.

AIRCRAFT DAMAGE

5.

The aircraft suffered Category 5 damage (beyond economic repair).

INVESTIGATION

6.

A detailed investigation was undertaken which looked at all of the

aircrafts systems and computer modelling was undertaken to provide an

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understanding of the effect of differing power configurations on the aircrafts likely flight path. The aircraft was found to be serviceable apart from a propensity for the left hand engine to hang in the 4000 rpm range during testing. It is most probable that as power was applied to commence the roll, the left hand engine stagnated at around 4200 rpm, which meant that the aircraft was unbalanced, with more power coming from the right hand engine, causing the aircraft to yaw left. The handling pilot then instigated a correction to the yaw, shortly after which the aircraft became airborne, at a speed of 100kts, and well below the Canberras single engine safety speed of 140kts. As the aircraft became airborne the effect of the difference in power would cause the aircraft to roll and yaw in an uncontrollable manner. Shortly after take off both throttles were then retarded, the difference in power was now removed and this action allowed the aircraft to respond to the flying controls, which caused it to roll back to the right thus correcting the left hand yaw. With the throttles retarded, the aircraft descended back on to the grass adjacent to the runway. Had the throttles been retarded following the initial yaw caused by engine stagnation, the aircraft would have stopped on the ground in the remaining runway length. In addition, during the flight phase of the accident, the aircraft could probably have been flown back onto the grass, although the lack of visual cues at night would have made this a difficult prospect for the pilots, and it would have been damaged on the soft ground away from the runway. An assessment of the cockpit areas showed that they were relatively intact after the accident, suggesting that had the crew remained with the aircraft it is possible they may have survived the impact. The investigation concluded that the accident was the result of the aircraft becoming airborne well below the safety speed for its engine configuration.

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RECOMMENDATIONS

7.

The Board recommended that:

a.

All RAF aircraft should be fitted with an accident data recorder to

facilitate the timely investigation of aircraft occurrences or accidents. b. c. Canberra aircraft should be fitted with zero-zero ejection seats. There should be a review of the level of competencies and currencies of

duty medical personnel, who are likely to deal with aircraft accidents, to ensure that there is clear guidance on their training requirements. d. A dedicated SAR helicopter is always scrambled to attend any military

aircraft crash. e. A standard aircrew briefing is given on all Canberra pilot handling sorties

(where roller landings are authorised) covering the actions to be taken in the event of engine malfunctions during roller landings and below safety speed. f. Canberra SOPs should be amended to include a procedure to be followed

during running changes in the Canberra T4. This should include procedures to be carried out by the groundcrew. g. A review of local orders and Canberra documentation should be

undertaken to ensure that the Boards comments have been considered for staff action.

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h.

Canberra aircrew should be reminded of the particular need for vigilance

with regard to the correct setting of the altimeter subscale. i. A robust Quality Assurance system should be introduced to ensure that

Canberra F700s comply with the JAP100A-01 and other appropriate MOD regulations. j. Canberra aircrew and groundcrew should be reminded of their

responsibilities towards fault reporting, particularly in respect of recording Aircrew Accepted Faults in the F700. k. The Jaguar/Canberra IPT should consider the adequacy of the Avon Mk1

corrosion control policy, especially in consideration of the low usage of engines since last overhaul. l. The Jaguar/Canberra IPT should consider the adequacy of the measures in

place to manage Avon Mk1 damage accepted under concession and the impact of engine operation with the damage found within the combustion chambers. m. The engine set-up and health checks should be performed in line with

AP101B-0404-5A3B, AP102C-1522-6A and SI/AVON/083 to maximise the available surge margin. n. 39(1 PRU) squadron tradesmen should be reminded of the importance of

trend analysis and the need to record adjustments on MOD Form 707B and MOD Form 735 (Engineering Record card).

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The following recommendations were completed prior to the Board reporting to correct the engine anomaly and allow the flight of the other Canberra training aircraft: o. p. The Inlet Guide Vane (IGV) system should be investigated A check of the security of the IGV angle adjustment locking mechanism

on the Avon Mk206/PR9 be completed. q. IGV datum gap and adjuster security to be checked every 28 days and

after any engine surge event. r. Engine tests should be performed to confirm the overall margins of the

Avon Mk1 s. Thorough checks performed on the Avon Mk1 engine prior to flight by

Canberra WJ874

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