Accident to the Raytheon 390 registered VP-CAZ operated on 04/03/2013 at Cranves-Sales
Décrochage après le décollage en conditions givrantes, collision avec le sol, incendie
The pilot and two passengers arrived at Annemasse aerodrome at about 7 h 00 for a private flight of about five minutes towards Geneva airport. The temperature was -2°C and the humidity was 98% with low clouds. The aeroplane had been parked on the parking area of the aerodrome since the previous evening. The taxiing and the takeoff run were nominal. As soon as the main landing gear wheels left the ground, the aeroplane stalled, as a result of the presence of ice on the surface of the wings. The low height reached by the aeroplane did not allow the pilot to exit the stall situation and to avoid the collision with the ground. The pilot and the passenger seated to his right were killed. The female passenger seated at the rear was seriously injured. The investigation showed that the pilot’s insufficient appreciation of the risks associated with ground-ice led him to take off with contamination of the critical airframe surfaces. This may have contributed to the occurrence of 32 accidents recorded since 1989 for which no de-icing of the aeroplane had been undertaken before takeoff. The investigation also showed that an onboard device for the detection of ice on the ground could have prevented the accident and that Annemasse aerodrome does not have any ground de-icing facilities.
The BEA addressed three safety recommendations to EASA and the DGAC.
4.1 Training on Risks on Takeoff with Contaminated Wings Contamination of the wings of an aircraft on the ground, even minor, may considerably degrade its aerodynamic characteristics and lead to a stall on takeoff. The regulation does not make it mandatory to recall the negative effects of ice for pilots flying non-commercial operations during their periodic checks. The latter may thus not be fully aware of the risk and may then find themselves in dangerous situations whenever frozen contaminants are present on the critical surfaces of their aeroplane. This insufficient appreciation of the risks may have contributed to the occurrence of 32 similar accidents reported since 1989 for which no de-icing of the aeroplane was undertaken before takeoff. In the context of the investigation into the accident to the Fokker 100 registered F-GMPG at Pau on 25 January 2007, the BEA already recommended that “DGAC ensure that operators put in place the necessary organisation and means, including training, that would allow effective implementation of the procedures to check the condition of the flight surfaces when there is a risk of ground icing.“. Following this recommendation, DGAC took steps targeting commercial transport. Consequently the BEA recommends that: EASA, in coordination with national civil aviation authorities, make changes to the training requirements for pilots so as to include periodic reminders on the effects of contaminants such as ice on stall and loss of control on takeoff. [Recommendation 2014-005] 4.2 Ground Ice Detection System Systems based on infra-red cameras or on sensors integrated into the aeroplane may help pilots and/or operators to detect the presence of frost or ice on the wings of an aircraft. Such systems have been in existence since the 1990s. An on-board system, if it had been available for VP-CAZ, would have made it possible to clearly warn the pilot of the presence of frozen contaminants on the critical surfaces of the aeroplane before he undertook the flight and of the consequent danger that should have led him to cancel the takeoff. This would also have helped to avoid the occurrence of 32 other accidents that happened on takeoff to aeroplanes whose wings were contaminated by frost or ice between 1989 and 2012. Consequently the BEA recommends that: EASA, in coordination with the FAA and the other non-European civil aviation authorities, study the technical and regulatory means to put in place in order to install systems for the detection of frozen contaminants on the critical surfaces of aircraft. [Recommendation 2014-006] VP-CAZ - 4 March 2013 34 4.3 Anti-icing/de-icing Facilities at Aerodromes The investigation was unable to determine if the pilot would have asked to de-ice the aeroplane before takeoff if de-icing/anti-icing facilities had been available at Annemasse aerodrome. However, ICAO recommends installation of such facilities at aerodromes where there is a risk of icing. This recommendation is included in the future European regulations on aerodromes. Despite the fact that the French regulation does not make it mandatory, many French aerodromes have them, according to the type and the volume of traffic. When they are available and the meteorological conditions warrant it, these facilities are used by pilots of aeroplanes comparable to the Beechcraft Premier 1A. Annemasse aerodrome is not equipped in this way, although icing conditions are nevertheless observed every winter and many business aircraft and/or complex motor-powered aircraft take off from it regularly. There are, however, no criteria for exposure to the risk that would make it possible to identify the necessity to install such equipment. Consequently the BEA recommends that: The DGAC define criteria intended to make it mandatory for aerodrome operators to have de-icing/anti-icing facilities at aerodromes. [Recommendation 2014-007]