aircraft accident investigation report
Contents
1. Estimated Flight Route 2 1 2 Statements of Persons Relevant to the Accident 1 An Air Traffic Service Flight Information Officer at Miho Airport Office of the Ministry of Land Infrastructure Transport and Tourism The captain and the passenger visited our office past 08 00 on the day of the accident I checked the flight plan submitted by the captain and found no particular problem The captain told me that the flight was originally scheduled for the previous day but that it was postponed due to bad weather He did not particularly refer to the weather condition for the day I did not notice any particular problem with his manner When I was monitoring communications between the Aircraft and the control tower at the time of departure I recognized that it was the captain who was talking to the controller The captain did not seem to be flurried and there were no reports of malfunctioning or irregularities about the Aircraft either 2 An official at the Flight Service When the Aircraft was at 6 nautical miles west of the Tajima Airport we received a position report from the captain that he would hope to land on the Tajima Airport while supposing instrument meteorological conditions there We informed the captain that the Tajima Airport was in visual meteorological conditions and we provided him with the METAR as of 09 00 We also advised him that there were fairly large amounts of fogs in the west of the Tajima Airport but fewer in the2. and no abnormality was found 3 The magnetos were found burned out on both sides 4 The starter ring gear and the alternator were damaged 2 12 2 Teardown Inspection of Main Gearbox A teardown inspection of the main gearbox revealed many places of damage but these were all sections displaced or broken due to the impact at the time of the accident The inspection found no failure and defects regarding components which may be linked to the cause of the accident The outline of the result of the inspection is as follows 1 There was no abnormality with the gear and the gear carrier 2 There were no metals and stains with the chip detector 3 The gearbox housing was found broken in the bearing sheet section of the input pinion bearing holder 4 The main rotor drive shaft had traces of contact with the mast tube or components like that in a section slightly above the middle 5 The mast tube was broken in a section slightly above the middle 6 The pitch link of the black blade of the main rotor was broken but that of the red blade of the main rotor was bent only partially and it was not broken The red blade was found rotated 180 degrees with its pitch link left connected Both blades had traces of contact with the spindles inside of the hubs There were dents in the middle of the teeter stops on both sides 2 12 3 Teardown and Functional Inspections of Instruments but there was no abnormality with the dro
3. Em res Ep men Jr Ku ra SF ARTE La GPS Truck Kik Radar Truck Route t Hig ashitokonoo 8G Tail rotor blade Contour 510m Western Slope Approach direction Figure 2 Accident Site Layout Body of passenger Instrument panel Eastern Slope Contour 520m Body of captain Contour 510m 66 Figure 3 The Asia Pacific Surface Analysis Chart 0900JST 20 July ASAS JMH 200000UTC JUL 2009 SURFACE ANALYSIS adost 1014 STAR ASAS JMH 200000UTC JUL 2009 SURFACE ANALYSIS JAPAN METEOROLOGICAL AGENCY TOKYO OG Figure 4 Je mm h kyoudo 2009 07 20 0900JST 0 1 2 4 8 12 16 24 32 40 48 55 64 80 0920JST 20 July Ne p Je MM h kyoudo 2009 07 20 0920JST D 1 2 4 8 12 16 24 32 40 48 56 64 80 Ad 0900JST 20 July amp ERGE The Radar Echo Charts dd A 0910JST 20 July ec 4 9 R mm h kyoudo 2009 07 20 0910JST 0 1 2 4 8 12 16 24 32 40 48 56 64 80 de 0930JST 20 July amp iti mm h kyoudo 2009 07 20 0930JST 0 1 2 4 8 12 16 24 32 40 48 56 64 80 Figure 5 Three Angle View of Robinson R441 Unit m 31 Photo 1 Accident Site Re Mt Higashitokonoo Approach direction VE J i W gt Pine tree hit by the nose Weeteeisection of the aircraft TR d 48 Ne ae Fi J F n EA we iW se gear box amp p 32 Photo 3 Cr
4. beneath the fog I have no memory of strength of a rain but I remember it was foggy 6 Witness D About 4 kilometers northwest of the crash site When I was playing catch with my child in front of my house I heard fairly strong sounds something like the sounds when trees are cut down from the top of the mountain in the back The time was between 09 30 and 09 40 I think I did not hear any sounds of a helicopter nor did I see a helicopter itself Clouds were hanging over the mountain on that day I could not see the upper part of the mountain but the outskirts of the mountain were visible It was not raining The sound was very large but it was not a metallic sound It was a sound of something which hit trees and cut them down This accident occurred at about 09 30 on the western slope of Mt Higashi tokonoo of Izushi Town Toyooka City Hyogo Prefecture at 519 meters about 1 700 feet elevation Latitude 35 25 12 N and Longitude 134 53 52 E See Figure I Estimated Flight Route Figure 2 Accident Site Layout Photo 1 Accident Site Photo2 Wreckage of Accident Aircraft 2 2 Injuries to Persons The captain and the passenger were killed 2 3 Damage to the Aircraft 2 3 1 Extent of Damage Destroyed 2 3 2 Damage to the Aircraft Components Fuselage Entirely broken and damaged partially burned Main rotor blades Both blades broken Tail cone Broken and detached Tail rotor blades and tail wing Broken and detached Landing ge
5. east The captain reported to us that the Aircraft was flying above the clouds and that it would approach from the east after passing over the Tajima Airport We informed the captain that the runway can be approached from either direction and asked him to communicate with us when the Aircraft came out of the bottom of the clouds The captain replied that he would do so though he also said he was not sure about the exact time The voice of the captain was relatively composed and there was no sense of flurry with him Later we received a report from the captain that he thought that that the Aircraft was above the runway and that it would move to the east There were no communications from the captain even after about 10 minutes passed We called the captain several times but we could not communicate with him 3 Witness A About 8 kilometers north of the crash site On the day I heard a sound of a helicopter flying around in the direction of a mountain to the south I did not see the helicopter itself but I was surprised when I heard sounds like the tip tap of slippers I think the sounds came from fairly close There were clouds in the sky but it was not raining on that day The time was before 10 00 4 Witness B About 3 9 kilometers northwest of the crash site On the day I saw a helicopter flying at a low altitude to the direction of Mt Tokonoo southeastward I think the time was before 09 40 I also heard sounds and the helicopter wa
6. in 2 1 2 5 it is considered highly probable that the Aircraft could confirm the ground temporarily In the circumstances as such the position of the aircraft must be confirmed by using navigation equipment and the aeronautical chart But it is considered highly probable that 923 the captain in this case was unable to confirm the location of the Aircraft because he is believed to have descended through a small opening in the clouds or through the clouds and because the Aircraft was seen by witnesses flying at a remote place from the Tajima Airport in the opposite direction to the Tajima Airport It is considered probable that the captain did not use the aeronautical chart and other materials as he continued the flight while looking for the Tajima Airport but he unexpectedly pushed into the clouds It is considered somewhat likely that the captain failed to use the aeronautical chart and other materials when he could temporarily confirm the ground can be ascribed to insufficient preparations for collecting necessary pre flight information including data about the flight route 3 13 Preventive Landing As described in 2 1 2 5 the Aircraft was seen flying normally though the altitude was low Therefore it is considered highly probable that the ground could be visibly observed by the Aircraft too temporarily As described in 2 13 6 fields spread in areas around the Tajima Airport and there were many places for safely making an emergency
7. landing Therefore it is considered probable that this accident would have been avoided if the captain had made an appropriate judgment mainly by choosing a preventive landing while ensuring the safety of the Aircraft and areas around the place of landing 3 14 Condition of ELT ELTs are so designed as to send emergency signals when they are activated on the strong impact of crashes But no emergency signal was received from the Aircraft despite the fact that the Aircraft crashed into the ground from the nose Judging from the condition of the damaged connector part of the cable that links the ELT itself to the antenna as described in 2 9 2 1 it is considered highly probable that when the Aircraft crashed into the mountain the section of the ELT near the antenna was destroyed and the core wire inside was torn apart making it impossible to send out an urgency signal In addition it is considered somewhat likely that a weak signal was sent till ELT was damaged by fire if it was operated even if the cable had been cut off As described in 2 9 2 2 rules such as those of the U S Federal Aviation Administration call for attaching an ELT to the aircraft at a place where damage to the equipment may be minimized But as far as small aircraft such as the Aircraft in this case are concerned the places where ELTs can be installed are limited due to structural reasons As a result it is considered highly probable that ELTs cannot be protected agains
8. last periodical check 100h check on January 28 2009 Unknown The total flight time mentioned above is a record as of the date of the 100h check Instrument flights and instrument flight rules are not authorized in the operating limitations See Figure 5 Three Angle View of Robinson R44 II 2 6 2 Engine Type Lycoming IO 540 AE1A5 Serial number L 32239 48E Date of manufacture May 8 2007 Total time of use 93 h 48 min Flight time since last periodical check 50h check on June 24 2009 Unknown The total time of use mentioned above is a record as of the date of the 50h check 2 6 3 Weight and Balance When the accident occurred the Aircraft s weight is estimated to have been 2 052 3 pounds and the center of gravity is estimated to have been 97 6 inches aft of the reference point and 0 04 inch right of the centerline all of which are estimated to have been within the allowable ranges the maximum takeoff weight of 2 500 pounds and 92 0 to 102 5 inches and 3 0 inches left to 3 0 inches right of range of the center gravity corresponding to the weight at the time of the accident 2 7 Meteorological Information 2 7 1 Weather Information General weather forecasts issued by the Kobe Marine Observatory for Hyogo Prefecture at 04 30 on July 20 is as follows In Hyogo Prefecture rain should be observed intermittently in some areas due to the influence of the Baiu rain front staying in western Japan sometimes heavy rainfa
9. of western Japan was covered by a humid air area As the tip of the area extended to the Kinki region the weather condition was highly likely to create clouds A cloud imagery by a geostationary meteorological satellite indicated the whole of western Japan was enveloped by many layers of clouds over a wide area See Figure 3 The Asia Pacific Surface Analysis Chart 0900JST 20 July 2 7 4 Radar Observation Data Echo Intensity Radar observation data and echo intensity hereinafter referred to as the Radar Echo Chart for the day of the accident indicates a strong echo area believed to have been caused by cumulonimbus existed mainly over Yamaguchi Prefecture But the echo intensity was relatively weak at less than 6 millimeters an hour in the Sea of Japan coast areas from Tottori to Hyogo prefectures According to the radar echo chart around the time between the beginning of communications between the Aircraft and Osaka FSC and the occurrence of the accident at 09 00 a long echo area with a relatively weak reading of 0 to 4 millimeters an hour was lying from the east to west 15 kilometers south of the Tajima Airport and moving slowly to the east At about 09 20 the time when the captain started communications with the Flight Service the echo area observed exactly to the south of the Tajima Airport had temporarily disappeared and became so weak that it could not be shown up on the radar screen At about 09 30 the time when the Aircraft is beli
10. show that the captain changed the direction and the altitude several times after taking off on the flight to the Tajima Airport It is considered highly probable that the captain continued the flight while trying to avoid the clouds as many clouds were believed to be hanging as an obstacle to visual meteorological conditions on the scheduled flight route It is considered probable that if the captain had obtained detailed information beforehand he would have been able to foresee that the maintenance of visual meteorological conditions may become difficult along the scheduled flight route It is considered highly probable that a route over a coastal area where the weather was relatively favorable may have been selected As described in 2 7 2 2 visibility at the Tajima Airport as of 09 00 was 6 kilometers and the ceiling was 1 000 feet Landing with visual flight rules was barely possible But the surrounding areas had been covered with many layers of clouds at altitudes of 1 000 feet or higher as reported by the scheduled flight in 2 7 5 Therefore it is considered highly probable that the situation was difficult for the captain to maintain the visual flight Because the Aircraft reported to the Flight Service from a position which is not exactly above the runway that it was supposed to be over the runway of the Tajima Airport it is considered highly probable that the Aircraft was making an on top flight and unable to confirm the ground and other geogr
11. the investigation 1 2 3 Implementation of the Investigation August 6 10 2009 Interviews on site investigation and aircraft examination August 24 26 2009 Interviews and aircraft examination September 24 December 20 2009 Analysis of ATC radar records November 6 and 7 2009 Teardown inspections of flight instruments and navigation equipment December 7 9 2009 Teardown inspections of engine and main gearbox February 3 2010 Examination of data retrieved from navigation equipment November 24 2010 Examination of data retrieved from portable GPS receiver 1 2 4 Comments from Parties Relevant to the Cause of the Accident Comments were not obtained from the parties relevant to the cause of the accident because they were dead 1 2 5 Comments from the Participating State Comments were invited from the participating State 2 FACTUAL INFORMATION 2 1 History of the Flight On July 20 2009 a Robinson R44 II registered JA32CT hereinafter referred to as the Aircraft privately owned took off from Miho Airport at 08 37 for the purpose of familiarization flight with the captain and a passenger on board and began a flight toward Tajima Airport The outline of the flight plan was as follows Flight rules Visual Flight Rules VFR Departure aerodrome Miho Airport Estimated off block time 08 40 Cruising speed 100 knots Cruising altitude VFR Route Tottori Destination aerodrome Tajima Airport Total estimated e
12. the same time it can display the courses Inside of the equipment there was a trace of liquid crystal leaked in the display but 15 no apparent damage was seen on any of the substrates When it was connected to an outside power source to get activated it was confirmed that its switch turns on But the display did not work due to the inaction of the main processor As a result the state of the equipment at the time of the accident could not be reenacted 2 Portable GPS receiver GARMIN GPSMAP 495 According to the user s manual the location of the aircraft airports navigational aid and map data can be indicated on the color display Areas with an altitude above 100 feet down from the aircraft are indicated in red and lower areas in yellow and warnings are issued on a terrain page The lower part of the equipment was seriously damaged due to the impact of the accident The liquid crystal panel an antenna and control buttons were damaged but they were not burned There was no apparent damage to the substrate inside After the equipment was repaired data on the aircraft track were retrieved from an internal memory 3 Portable collision avoidance system XAON PCAS XRX According to the user s manual the positions of aircraft flying around are indicated and if and when the threat of a collision emerges an advisory is issued The front part and the indicator display were seriously damaged An antenna inside and the substrat
13. AA2011 2 AIRCRAFT ACCIDENT INVESTIGATION REPORT PRIVATELY OWNED JA3 2 CT February 25 2011 Japan Transport Safety Board The objective of the investigation conducted by the Japan Transport Safety Board in accordance with the Act for Establishment of the Japan Transport Safety Board and with Annex 13 to the Convention on International Civil Aviation is to determine the causes of an accident and damage incidental to such an accident thereby preventing future accidents and reducing damage It is not the purpose of the investigation to apportion blame or liability Norihiro Goto Chairman Japan Transport Safety Board Note This report is a translation of the Japanese original investigation report The text in Japanese shall prevail in the interpretation of the report AIRCRAFT ACCIDENT INVESTIGATION REPORT PRIVATELY OWNED ROBINSON R44 II ROTORCRAFT JA32CT AT ABOUT 15 KILOMETERS SOUTHEAST OF TAJIMA AIRPORT JAPAN AT ABOUT 09 30 JST JULY 20 2009 February 4 2011 Adopted by the Japan Transport Safety Board Chairman Norihiro Goto Member Shinsuke Endoh Member Toshiyuki Ishikawa Member Sadao Tamura Member Yuki Shuto Member Toshiaki Shinagawa 1 PROCESS AND PROGRESS OF THE INVESTIGATION 1 1 Summary of the Accident On July 20 Monday 2009 at 08 37 Japan Standard Time JST UTC 9hr unless otherwise stated all times are indicated in JST based on a 24 hour clock a Robinson R44 II registered JA32CT privately
14. Equipment and Others As described in 2 12 4 and 2 12 5 the Aircraft had been equipped with VOR ILS and GPS receivers Therefore it is considered probable that the captain had an intention to use information obtained with these equipment as auxiliary information during the flight When the weather is favorable the location and other matters can be easily confirmed because strong attention is less needed for flight operations But when the weather is bad with many layers of clouds hanging as was the case with the situation in this accident much attention must be paid for the flight and as a result it is considered probable that the captain didn t have enough time to fully use information from VOR and other equipment during the flight 3 9 Meteorological Condition 3 9 1 Confirmation of Meteorological Condition before Departure According to a statement of the refueling trader as described in 2 13 1 2 the captain was paying attention to the meteorological condition on the previous day Therefore it is considered probable that the captain had knowledge that the weather along the flight route was generally unfavorable However because the weather at Miho Airport was good as described in 2 7 2 1 and because it is considered probable that the captain had not received a briefing as described in 2 13 2 it is considered probable that the captain decided to depart without obtaining the latest meteorological information for areas on his flight rou
15. Stratus Cloud Base 600 feet Amount 6 8 Type Cumulus Ceiling 1 000 feet Temperature 22 C Dew point 21 C Altimeter setting QNH 29 78 in Hg Visibility northwestward 3 kilometers Fogs in the directions from northwest to southwest 10 00 Wind velocity 2 knots Wind direction Variable Visibility 10 kilometers Cloud Amount 1 8 Type Stratus Cloud Base 100 feet Amount 3 8 Type Stratus Cloud Base 600 feet Amount 6 8 Type Cumulus Ceiling 1 000 feet Temperature 22 C Dew point 21 C Altimeter setting QNH 29 76 in Hg 3 Weather observations at the Toyooka weather station of the Kobe Marine Observatory located about 15 kilometers northwest of the accident site around the time of the accident were as follows 09 00 Wind direction northeast Wind velocity 1 5 m s Visibility 28 3 kilometers Hours of sunshine 0 Temperature 24 2 C Dew point 20 7 C Humidity 81 Atmospheric pressure 1 007 4 hPa Atmospheric pressure change 0 2 hPa 10 00 Wind direction east southeast Wind velocity 0 7 m s Visibility 26 5 kilometers Hours of sunshine 0 Temperature 24 5 C Dew point 20 6 C Humidity 79 Atmospheric pressure 1 006 6 hPa Atmospheric pressure change 0 6 hPa 2 7 3 Information from Weather Charts and Others Asia Pacific Surface Analysis Chart as of 09 00 on July 20 indicated the Baiu rain front extending from the Yellow Sea to western Japan which was seen almost stationary The 850 hPa and 700 hPa weather charts showed the whole
16. ade for acquisition of meteorological information and a judgment based on the information and the Aircraft further continued the flight before meeting an unexpected situation To prevent this kind of accident as described in 2 13 4 the Civil Aviation Bureau of the Ministry of Land Infrastructure Transport and Tourism has been striving to ensure that the importance of obtaining meteorological information and using the information to make a necessary judgment is thoroughly understood by aviation related organizations However the acquisition of meteorological information and a judgment based on the information are entirely left to the captain s hands particularly in cases of privately owned aircraft and as a result the captains sometimes fail to properly take these procedures and confirm necessary matters before departure and these results have become causes for some aircraft accidents and incidents Therefore the Civil Aviation Bureau of the Ministry of Land Infrastructure Transport and Tourism is required to make further efforts to ensure that the related parties abide by basic procedures without fail for making flights 26 LG Figure 1 Estimated Flight a ir OS I Enlarged drawing Pa a ra Service 6nm W l PE Capes 5a ACFT PSN reported to Flight mal PE Service that looking for an m er F La 2 Natta A ing in the clouds FIRE Ne BEE TE 09 19 53 4 Tottori Airport 4 Miho Airport DI
17. aphical features Mountainous areas extend from the south to the east of the Tajima Airport and it is considered highly probable that the mountains could not be visibly observed with clouds and fogs hanging around Further as described in 2 7 4 a thick rain cloud area was coming from the west Therefore it is considered probable that the Aircraft was flying amid clouds temporarily 3 9 4 Appropriate Acquisition of Meteorological Information after Departure As far as the acquisition of meteorological information after departure is concerned ground assistance systems for privately owned aircraft are less prepared than those for commercial air carriers Therefore captains have to collect meteorological information by themselves But it is considered highly probable that the captain did not collect meteorological information from Osaka FSC and other organizations during his flight As described in 2 13 3 it was fully possible to confirm meteorological information by contacting the FSC on the flight route in the latest case Therefore it is considered highly probable that the captain should have tried to precisely grasp the weather 22 condition and made a judgment about how to maintain the safety of flight while considering whether the meteorological condition is appropriate for continuing the flight and whether to return to the departure aerodrome or land on Tottori Airport as an alternate aerodrome in the course of its flight 3 10 Cap
18. ar Broken Aircraft control system Broken See Figure 2 Accident Site Layout Photo2 Wreckage of Accident Aircraft Photo 3 Crash Site Photo4 Main Rotor Blades 2 4 Other Damage Dozens of trees were cut down and burned 2 5 Personnel Information 1 Captain Male Age 58 Private pilot certificate Rotorcraft October 5 1993 Type rating for single piston land October 5 1993 Class 2 aviation medical certificate Validity December 4 2009 Total flight time 1 385 h 06 min Flight time in the last 30 days Unknown Total flight time on the type of aircraft Unknown Flight time in the last 30 days Unknown The flight log on the Aircraft was lost in the fire The figure for the total flight time mentioned above is a record as of May 10 2009 2 Passenger Male Age 37 Private pilot certificate Rotorcraft Issued by U S Federal Aviation Administration January 18 2009 Total flight time 41h18 min When the accident occurred he was in the process of switching from the U S issued certificate to a Japanese pilot certificate The total flight time mentioned above is the figure recorded in the Aeronautical Experience Form attached to his application form 2 6 Aircraft Information 2 6 1 Aircraft Type Robinson R44 II Serial number 11948 Date of manufacture October 17 2007 Certificate of airworthiness DAI 20 641 Validity February 2 2010 Category of airworthiness Rotorcraft Normal N Total flight time 64 h 06 min Flight time since
19. ash Site n z Gi WE Fuselage f MENER E E Body of passenger I 4770 GT 7 aC J ve Main gear box rate SD 3 ANN A 2 SS ar A Le Photo 4 Main Rotor Blades Fuselage 33 Photo 5 Impact of the Crash i Gouged ground 1 5m X 0 8m X 0 5m i 34 Photo 7 Radio Instruments 35 Photo 9 Pine Trees Hit by the Accident Aircraft ELT pedestal K a oe t pl Torn core wire 36
20. authorities 2 INCERFA means cases in which there is no report about the aircraft s location even after a lapse of 30 minutes past the scheduled time or in which the aircraft has not reached the destination even after a lapse of 30 minutes past the scheduled time Search will be made mainly by communications organizations 3 DETRESFA means cases in which information about the aircraft was not obtained by the above mentioned search by communications organizations and cases in which the aircraft s fuel loads got exhausted or they are believed to be insufficient for safely arriving at the destination Search and rescue organizations will start necessary actions 132 Aircraft ships vehicles and personnel mobilized for search and rescue operations in total Japan Coast Police Self Defenses Force Fire Defense Guard Aircraft Vehicle Person Aircraft Vehicle Person Aircraft Ship Aircraft Vehicle Person 32 460 2084 85 101 504 4 9 7 17 100 2 12 Tests and Research for Fact Finding 2 12 1 Teardown Inspection of Engine The result of the inspection is as follows No defects or component failures were identified other than the damage caused by the crash 1 There were no defects inside the engine Abnormal conditions such as binding and interference were not found in each of the driving sections 2 The condition of burning in each cylinder was favorable and uniform
21. cation because it had to concentrate on finding an opening in the clouds in a situation where the ground could not be visibly confirmed It was considered highly probable that the Aircraft later flew on to the east southeast and changed its direction to the south from around a point 0 8 nautical mile north of the accident site and at the same time it started descending and then after turning to the left at a point northeast of the accident site it crashed into the mountainside 3 4 Progress of the Aircraft s Crash Judging from the condition of the chopped top parts of trees at the accident site it is considered highly probable that the Aircraft came from the direction of north northwest and crashed into a slope with a height of about 1 700 feet with no time to avoid a collision with the ground The chopped parts of trees cut down by the Aircraft had an angle of about 25 degrees downward 19 Therefore it is considered highly probable that the Aircraft came to approach the slope with its nose slightly downed and then its main rotor cut down trees in an area around the site and finally the Aircraft crashed into the ground with its body inclined to the left side because of power applied by the tail rotor to turn the nose to the left and the body lied sideways with its right down on the ground It is considered highly probable that when the Aircraft crashed the front part of the aircraft broke down and the captain and the passenger were thro
22. e The Aircraft crashed into a slope beneath the peak of the ridge with its nose lying in the direction of south southeast The main rotor blades and the wreckage were found widely scattered around the ridge and on eastern and western slopes The fuselage of the Aircraft was lying in the direction of southeast with its right side down on the ground The front part of the Aircraft was destroyed that its original shape could not be observed When the Aircraft crashed into the ground it is believed that the nose broke down and flew ahead toward a pine tree and the tree was found burned from the bottom of its trunk The body of the passenger was found at a place about 4 meters ahead left of the fuselage while the body of the captain was found on the eastern slope of the ridge about 16 meters ahead right of the place where the passenger s body was found Their seat belts were found to have been torn apart in the joints with which they were fixed to the Aircraft The shell plating of the tail cone barely remained connected to the fuselage but the shaft of the inside was found broken The tail rotor and the stabilizer were removed and scattered around The main gearbox was detached from the fuselage and found at a place about 4 meters ahead of the fuselage with the mast lying in the direction of the west The crash created a dent 2 7 meters in length 1 8 meters in width and 0 5 meter in depth on the ground The nose section of the Aircraft and some trees
23. e Occurrence of the Accident Based on the following points it is considered highly probable that the accident occurred at around 09 30 1 As described in 2 9 3 the Aircraft became undetected by the ATC radar at 09 20 40 at a place 7 6 nautical miles west of the Tajima Airport at an altitude of 2 900 feet The Aircraft also reported at 09 25 04 that it was flying above the runway While considering the place where it disappeared from the range of the radar and the position report from the captain as well as the GPS records at that time the Aircraft s speed is estimated at 100 knots when figured out from the position where the report was made that the Aircraft was supposed to be over the runway Assuming that the Aircraft continued to fly at this speed to the east southeast it takes about 5 minutes to reach the accident site 2 As described in 2 1 1 there was no response to a call from the Flight Service past 09 37 3 As described in 2 9 4 the sight of the Aircraft did not appear on TCAS installed on the scheduled flight which happened to fly near the accident site at 09 47 4 As described in 2 12 3 3 a teardown inspection of the clock shows that traces of blow believed to have stemmed from the impact of the crash exist at positions around 09 30 5 Judging from the GPS records as described in 2 1 1 the time when the Aircraft s track disappeared near the accident site is believed to be around 09 30 3 8 Use of Radio Navigation
24. e bottom of clouds was low in areas southeast of the Tajima Airport It is considered highly probable that after the captain started descending he lowered the altitude again while turning to the left after finding further openings in the clouds but the Aircraft pushed into the clouds later again and the captain became unable to determine the altitude from the ground with the ground visibly unconfirmed and he could not notice the existence of a mountain until the Aircraft crashes into the mountainside When geographical features are not clearly confirmed as is the case with the latest accident it is dangerous to continue the flight amid the clouds Therefore it is considered probable that the captain had to pull out of the clouds as quickly as possible It is considered probable that one of means to get out of the clouds was to turn the nose to the opposite position to get the Aircraft back to the direction where it came 3 11 Flight with Visual Flight Rules As described in 2 1 the Aircraft was flying with visual flight rules Therefore the captain needs to maintain visual meteorological conditions as described in 2 13 7 As described in 3 9 3 it is considered somewhat likely in this accident that most areas along the scheduled flight route had been covered with clouds As a result it is considered probable that it was difficult for the captain to continue the flight while satisfying the conditions all the time 3 12 Map Reading As described
25. e or land on airports and other appropriate places around the course of flight The order kokukuukou No 86 was issued by the Flight Standards Division of the Civil Aviation Bureau on April 30 2002 to the All Japan Air Transport and Service Association and the Japan Aircraft Pilot Association According to another official order issued by the bureau The operators must make preventive landing without delay when the continuance of flight under the visual meteorological conditions and the continuance of safe flight is feared to become difficult and it is considered to be difficult to return to the departure aerodrome or land on an alternate airport The order kokukuukou No 808 was issued by the Director of the Flight Standards Division of the Civil Aviation Bureau on January 27 2006 to the All Japan Air Transport and Service Association the Japan Aircraft Pilot Association and nonprofit organization AOPA JAPAN 17 2 13 5 Structure of Flight Control System of the Aircraft The Aircraft s main flight control system is installed mainly around the seat on the right side The press talk switch for radio transmission is equipped on the grips of the control sticks on both of the left and right seats The control stick on the right seat also has a switch to change the radio frequency but there is no such switch on the control stick on the left seat 2 13 6 The Tajima Airport and Areas around the Airport The Tajima Airport about 2 kilometer
26. e were also damaged Because this system has no log function the data received before the accident about the locations of other planes could not be recovered 2 13 Additional Information 2 13 1 The Aircraft s Flights on the Previous Day 1 Flights on the Previous Day On July 19 one day before the accident the Aircraft took off from Nagashima temporary operation site in Mie Prefecture with the captain the passenger involved in the accident and another person hereinafter referred to as the Other Passenger on board After a refueling stop at Kounan Airport the Aircraft landed on Miho Airport According to the Other Passenger the three were originally planned to return to Nagashima within the same day after refueling at the Tajima Airport after seeing a triathlon event in Tottori City But when the captain checked the weather condition at Kounan Airport he concluded that a return flight would be difficult due to bad weather in the Tottori area The captain changed the plan and they delayed the return on the following day after staying one night in Yonago City On the flight from Kounan Airport to Miho Airport the captain sat in the right seat and the Other Passenger in the left seat while the passenger sat in a rear seat The passenger possessed a U S issued competence certificate but he did not have a Japanese competence certificate 2 Statements of trader who refueled the Aircraft at Kounan Airport on the Day before Accident On tha
27. ed by contacting FSCs by radio When the weather condition changed abruptly FSCs give advice about the selection of alternate airports and accept requests for coordination to this end In the case in question it was possible for the Aircraft to obtain information from Osaka FSC in the course of its flight But according to records of communications at the FSC there was no request for meteorological information from the Aircraft 2 13 4 Ensuring Safety in Visual Flights The Civil Aviation Bureau of the Ministry of Land Infrastructure Transport and Tourism has issued an official order for ensuring the safety of flights under visual flight rules urging the operators to abide by the following points The operators must collect the latest meteorological information before making a judgment if the flight is possible or not and depart only when the visual meteorological conditions can be maintained all the time to ensure the safety of flight When the weather is expected to change the operators must consider an alternate flight plan for cases in which the weather condition becomes difficult to maintain the visual meteorological conditions and in the course of flight the operators must try continuously to obtain meteorological information When there is an unexpected sign of worsening weather they must determine as quickly as possible and with no hesitation whether the flight can be continued and if necessary choose to return to the departure aerodrom
28. ep the condition at the time of the accident But the indicator showed 90 RPM See Photo 6 Instrument Panel Photo7 Radio Instruments Photo 8 Clock and Hands 2 12 4 Radio Navigation Instruments Installed on the Aircraft 1 VHF transmitter receiver Burned out 2 VOR receiver Burned out 3 ILS receiver Burned out 4 ATC transponder Burned out 5 ELT Burned out 6 GPS receiver GNS430 Burned out This system had been installed on the Aircraft as auxiliary navigation equipment The user s manual indicates that the aircraft s location airports navigational aid and the geographical features of the surrounding areas can be colorfully displayed on the screen Its functions include a terrain mode designed to issue a warning on the screen when the aircraft descends too low toward the ground Because the equipment was burned out it was unable to retrieve records regarding the trace of the Aircraft at the time of the accident 2 12 5 Other Radio Equipment Not Authorized as Radio Navigation Equipment A teardown inspection and a function check were made for radio equipment believed to have been brought into the Aircraft by the persons on board The results are as follows These radio equipment were found damaged burned out or deformed 1 Handy receiver ICOM IC 22 According to the user s manual it can transmit and receive signals at all frequencies in the aeronautical mobile VHF frequency band and receive VOR and LOC signals and at
29. eved to have crashed into the mountain an echo area was moving from the west to the south side of the Tajima Airport or to the southeast side of the Tajima Airport which is in the direction of the accident site The cloud top height of the echo was at about 6 to 8 kilometers See Figure 4 The Radar Echo Charts 2 7 5 Weather Report from Scheduled Flight which Landed on Tajima Airport on the Same Day after Occurrence of the Accident 09 28 Took off from Osaka International Airport 09 49 Landed on Tajima Airport Cloud top height en route to ASAGI Point about 28 nautical miles south of the Tajima Airport 9 000 to 10 000 feet Cloud top height beyond ASAGI Point 6 000 feet Cloud amount 8 8 Airstreams were smooth while descending Many layers of clouds were seen from 6 000 feet with the ceiling at 1 100 feet Visibility was generally good beneath the clouds Height of runway insight around 1 100 feet airstreams were smooth 2 8 Accident Site and Wreckage Information 2 8 1 Accident Site Condition Mt Higashi tokonoo 839 1 meters elevation located about 15 kilometers southeast of the Tajima Airport is a craggy mountain with many ridges The accident site was near a ridge 519 meters elevation in the middle of the western slope of the mountain The eastern and western sides of the ridge are very steep slopes at inclines of about 50 degrees The western side of the ridge is occupied by copse while a cedar forest spreads on the eastern sid
30. facturer The installation manual calls for following rules set by the U S Federal Aviation Administration FAA about the manner of installing ELTs An FAA rule states as follows about the installation of ELTs FAR 91 207 The ELT must be attached to the aircraft in such a manner that the probability of 1 ELT transmits signals in frequency bands of 121 5 MHz 243 MHz and 406 MHz to get the location of accident known for search by parties involved mainly in cases in which the aircraft distressed or crashed qs damage to the transmitter in the event of a crash impact is minimized However specific position where the ELT must be installed is not stated 3 Types of ELT ELTs are roughly divided into the following types according to whether they can be automatically activated on an impact or they must be manually activated Automatic fixed ELT ELT AF This type is automatically activated and permanently fixed to the aircraft Automatic portable ELT ELT AP This type is automatically activated and usually fixed to the body but it can be easily detached from the aircraft Automatic deployable ELT ELT AD This type is fixed to the aircraft and automatically extended and activated on an impact It can also be deployed manually Survival ELT ELT S This type is equipped into the aircraft so that it can be easily used in the case of an emergency It must be activated manually Annex 6 to the Convention on International Civil Avia
31. in the surrounding areas were burned Branches and leaves of trees were found to have turned red brown in a broad area ahead of the fuselage On the western slope to which the Aircraft approached about 20 trees with a diameter of 4 to 23 centimeters were found chopped at the top A line linking the place of the chopped trees and the place where the blades hit the ground had an angle of about 25 degrees downward from the level surface See Figure 2 Accident Site Layout Photo I Accident Site Photo2 Wreckage of Accident Aircraft Photo 3 Crash Site Photo4 Main Rotor Blades Photo5 Impact of the Crash Photo9 Pine Trees Hit by the Accident Aircraft 2 8 2 Detailed Information on Damage 1 Fuselage The whole sections were extensively damaged with the original shape unseen The nose section was burned out by a fire and a part of it was burned down 10 2 Main rotor blades The red blade was found bent at a distance of 180 centimeters from the joint The black blade was found bent at distances of 65 and 235 centimeters from the joint Both blades were found partially broken and torn apart in the honeycomb structure section 3 Tail cone The tail cone was found broken and detached at the joint with the fuselage 4 Tail rotor and stabilizer The tail rotor drive shaft was found broken at the joint with the fuselage The clutch belt for power transmission was found totally displaced 5 Landing gears The skids on both sides were found broke
32. ircraft reported to the Flight Service at a point about 6 6 nautical miles west of the Tajima Airport that it was at a point 6 nautical miles from the Tajima Airport at an altitude of 3 000 feet and that it would 09 21 45 09 23 52 09 25 04 09 27 44 09 28 28 09 29 56 09 37 10 See Figure 1 approach from the east of the Airport because it was flying an on top flight The Aircraft changed its direction slightly to the south from the east at a point about 5 6 nautical miles west of the Tajima Airport The Aircraft reported to the Flight Service at a point about 2 9 nautical miles west southwest of the Tajima Airport that it was looking for an opening in the clouds The Aircraft reported to the Flight Service at a point about 1 9 nautical miles south of the Tajima Airport that it thought that it was above the runway and that it would fly to the east The Aircraft passed at a point about 0 9 nautical miles south southwest of Mt Shiroyama The Aircraft changed its direction to the south from the east southeast at a point about 0 8 nautical miles north of the accident site and its altitude began to lower slowly The Aircraft made left turn at a point about 0 2 nautical miles northeast of the Accident Site and its altitude suddenly lowered The GPS records were finished around the accident site The Flight Service called the Aircraft but there was no response Calls to the Aircraft had been continued but there was no response
33. ircraft under the circumstances 4 As described in 2 5 the passenger was in the process of shifting to a Japanese competence certificate from a U S issued competence certificate at the time of the accident He had no competence certificate that allows him to control an aircraft in Japan 3 6 Circumstances at the Time of the Accident According to a statement of the witness who heard big sounds at a place about four kilometers northwest of the accident site as described in 2 1 2 it was not raining but clouds were lingering low when the witness heard something like the sounds when trees are cut down twice between 9 30 and 9 40 The Aircraft contacted the Flight Service at 09 23 52 that it was looking for an opening in the clouds while flying above the clouds at 3 000 feet It also contacted the Flight Service at 09 25 04 at a point which is not exactly above the runway that the Aircraft was supposed to be over the runway and it would fly to the east As described in 2 7 2 2 the ceiling was 1 000 feet at the time of the accident As described in 2 7 5 a meteorological report from the scheduled flight indicated many layers of clouds were seen from 6 000 feet with the ceiling at 1 100 feet Based on these points it is considered highly probable that the areas around the accident site had been covered with clouds and fogs and the situation was difficult to maintain visual meteorological conditions in most of the areas 20 3 7 Time of th
34. l for disasters In the last contact with the Flight Service at 09 25 the Aircraft only said it would fly eastwardly from above the Tajima Airport Since the weather condition was bad around the Tajima Airport on that day with clouds hanging low in the sky it was considered somewhat likely that the Aircraft might have attempted to turn back As a result search activities for the day were carried out by aircraft and ships mainly along the Aircraft s estimated flight route and over areas from the Tottori Hyogo prefectural border to the Tango Peninsula of Kyoto Prefecture But the Aircraft was not found Search for the Aircraft had been continued for 18 days mainly in Toyooka City and neighboring areas At about 10 53 on August 6 a Hyogo prefectural police helicopter found discolored trees at a place with a height of about 1 700 feet on the western slope in the middle of Mt Higashi tokonoo Personnel descended on the ground near the discolored trees and examined the area Then they found the wreckage of an aircraft The registration number on the aircraft showed it was the Aircraft which went missing Search for the surrounding areas found the body of the passenger left ahead of the Aircraft and the body of the captain further ahead on the east side of a ridge Following figures show the numbers of personnel and gear mobilized by Hyogo Kyoto and Tottori prefectural police authorities the Self Defense Forces the Japan Coast Guard and fire fighting
35. lapsed time 1 hour and 00 minute Purpose of flight Familiarization flight Fuel load expressed in endurance 2 hours and 00 minute Persons on board 2 Color of the aircraft Silver The history of the flight up to the time of the accident is summarized below based on the records of communications between the Aircraft and a flight advisory service station the ATC radar records flight track records of portable GPS receiver hereinafter referred to as GPS records and the statements of witnesses 2 1 1 Records of Communications with a Flight Advisory Service Station ATC Radar Records and GPS Records 08 37 The Aircraft took off from Miho Airport 08 41 02 The Aircraft was detected by the ATC radar at a point about 3 5 nautical miles east southeast of Miho Airport 09 19 53 The Aircraft reported to the Osaka Flight Service Center hereinafter referred to as Osaka FSC of the Ministry of Land Infrastructure Transport and Tourism at a point about 8 6 nautical miles west of Tajima that it was flying 8 nautical miles west of the Tajima Airport Osaka FSC instructed the Aircraft to communicate with the Tajima Flight Advisory Service Station hereinafter referred to as the Flight Service 09 20 40 The Aircraft became undetected by the ATC radar at a point about 7 6 nautical miles west southwest of the Tajima Airport The ground speed just before the time was about 60 knots and the altitude was about 2 900 feet 09 21 13 The A
36. lls and thunders likely to be seen Warnings and advisories issued by the Kobe Marine Observatory for Hyogo Prefecture at 07 15 on July 20 did not include those for the northern and southern Tajima regions in which the accident site is located 2 7 2 Aeronautical Weather Observations around Airports 1 Aeronautical weather observations at Miho Airport were as follows 08 00 Wind direction 070 Wind velocity 7 knots Visibility 10 kilometers Light showers Cloud Amount 3 8 Type Stratus Cloud Base 600 feet Amount 3 8 Type Cumulus Cloud Base 3 500 feet Amount 7 8 Type Altocumulus Ceiling 9 000 feet Temperature 23 C Dew point 22 C Altimeter setting QNH 29 73 in Hg 2 Aeronautical weather observations at the Tajima Airport located about 15 kilometers northwest of the accident site around the time of the accident were as follows 08 30 Wind velocity 2 knots Wind direction Variable Visibility 1 600 meters light showers fog patches Cloud Amount 1 8 Type Stratus Cloud Base 0 foot Amount 4 8 Type Stratus Cloud Base 600 feet Amount 5 8 Type Cumulus Ceiling 1 000 feet Temperature 22 C Dew point 21 C Altimeter setting QNH 29 78 in Hg Visibility southeastward 700 meters Fogs in the directions from northeast to southeast Visibility eastward 8 kilometers 09 00 Wind velocity 2 knots Wind direction Variable Visibility 6 kilometers Fogs around the Airport Cloud Amount 1 8 Type Stratus Cloud Base 0 foot Amount 4 8 Type
37. n and scattered around 6 Flight control system The flight control system including the rudder pedal the collective stick and the cyclic grip etc was found broken and detached See Figure 2 Accident Site Layout Photo3 Crash Site Photo4 Main Rotor Blades 2 9 Communications 2 9 1 Circumstances of Communications The Aircraft made communications with Osaka FSC at a frequency of 118 4 MHz at 09 19 and with the Flight Service at a frequency of 130 8 MHz at 09 21 and 09 25 before the occurrence of the accident The condition of these communications was favorable The communications were made by the captain 2 9 2 Emergency Locator Transmitter 1 Distress signals The Aircraft was equipped with an emergency locator transmitter hereinafter referred to as ELT Regarding the ELT the core wire of the cable linking the body to an antenna was found cut off on the side of the connector for the antenna joint The ELT itself was burned out and the condition of batteries and others could not be examined Any distress signals were not received by the search and rescue satellite system Cospas Sarsat and airplanes which happened to be flying nearby around the time when the accident occurred 2 Position for ELT installation The Aircraft s ELT was installed by Robinson as the manufacturer of the Aircraft when the Aircraft was made The position where it must be installed and others were based on the installation manual prepared by the ELT manu
38. ng that the Aircraft was flying as scheduled it is considered highly probable that it had reached around the Tajima Airport at about 9 30 The Aircraft was detected by an ATC radar through a point about 7 6 nautical miles west of the Tajima Airport Even after the Aircraft disappeared from the range of the radar the Aircraft continued to fly to the east of the Tajima Airport After changing its direction slightly to the south at a point about 5 6 nautical miles west of the Tajima Airport it is considered highly probable that the Aircraft made a position report at a point about 1 9 nautical miles south of the Tajima Airport that it was supposed to be over the runway of the Tajima Airport As to the reason for its change of direction the radar echo chart showed the existence of echoes with a cloud ceiling of 2 kilometers or lower around an area where it changed its direction Therefore it is considered somewhat likely that the Aircraft flew toward an area where there were fewer clouds while avoiding clouds at high altitudes ahead Regarding its erroneous report that it was over the runway of the Tajima Airport at the time when the Aircraft was actually flying in the south of the Tajima Airport it is considered somewhat likely that the Aircraft avoided the clouds just ahead by changing its direction to the south but it was unable to return to its original course due to clouds which appeared further ahead and there was no enough time to confirm its own lo
39. op stops A teardown inspection and function checks of instruments revealed many places of damage but these were all parts damaged due to the impact at the time of the accident There were no problems and defects regarding components which may be linked to the cause of the accident The outline of the results of the inspection is as follows 1 Speed indicator There were no components lost The indication was 122 knots 2 Altimeter 14 The case the mechanical section inside and the front glass were mostly damaged The indications of altimeter setting the long needle which shows hundreds of feet and the short needle which points to thousands of feet were 29 74 in Hg around 40 feet and around 1 900 feet respectively 3 Clock The hands were found displaced inside When stains and scratches left on the dial were matched to traces of damage and scratches on the hands so that the hands may be brought back to where they were believed to be before the time proved to be around 09 30 4 Gyro horizon Compressive load was applied on the instrument from both sides horizontally and vertically The indication was left bank 20 degrees and dive 5 degrees 5 Directional gyro A trace of damage on the dial and the position of the base showed that the indication was 250 degrees 6 Engine rotor tachometer The mechanical section was seriously damaged while the indicator was broken and bent The movement became loose and unable to ke
40. owned took off from Miho Airport with visual flight rules for the purpose of familiarization flight While flying toward Tajima Airport the radio contact with the aircraft was lost and the aircraft went missing On August 6 Thursday 2009 the aircraft was found to have crashed into a forest on the western slope of Mt Higashi tokonoo with a height of 839 1 meters about 15 kilometers southeast of Tajima Airport The captain and a passenger were on board the aircraft and both of them died in the crash The aircraft was destroyed and a fire broke out 1 2 Outline of the Accident Investigation 1 2 1 Investigation Organization On August 6 2009 the Japan Transport Safety Board designated an investigator in charge and another investigator to investigate this accident Search and rescue activities for the accident aircraft had been continued by the National Police Agency the Fire and Disaster Management Agency the Ministry of Land Infrastructure Transport and Tourism the Japan Coast Guard and the Ministry of Defense since it went missing on July 20 2009 On August 6 2009 at about 10 53 a Hyogo Prefectural Police helicopter found aircraft wreckage and it was confirmed to be that of JA32CT This investigation was launched on the same day 1 2 2 Representatives from Foreign Authorities An accredited representative of the United States of America as the State of Design and Manufacture of the aircraft involved in this accident participated in
41. s flying at fairly low an altitude that I could see the bottom of the helicopter The altitude appeared to be lower than the line of the mountain ridges I saw the helicopter for about 10 seconds The color of the helicopter was gray I thought the height of the clouds was relatively high on that day 5 Witness C1 About 5 5 kilometers northwest of the crash site When I was driving a car I think it was between 09 30 and 10 00 I saw a helicopter flying on the right side of Mt Shiroyama 321 5 meters elevation from the driver s seat at a place between Izushi Tunnel and Hotarubashi Bridge on a bypass from Toyooka City to Izushi Town The altitude of the helicopter was 100 to 200 meters higher than the mountain I also heard sounds The color was whitish I thought it was a helicopter the base of which was located at Izushi but I thought the color of the helicopter was a little bit whiter than that Initially I thought the helicopter was flying from so early in the morning It was flying with the mountain in the left Witness C2 About 3 5 kilometers north of the crash site I was riding in the car driven by C1 I saw a helicopter on the right hand s side when we passed Terasaka Elementary School I remember this very well because then I thought we see helicopters so frequently today The altitude was so low that I suspected it was flying low because there was an event There was a fog hanging on the mountains and the helicopter was flying
42. s southwest of Toyooka City stands on a developed hill With a height of 176 meters the Airport has a runway 1 200 meters long and 30 meters wide in the direction of 01 19 As navigation aids VOR DME and LOC are installed in the Airport Meteorological information about the Airport and information about landing and take off are available from the Flight Service As far as geographical features are concerned the height of areas from the north to the east of the Airport is lower than that of the Airport Around the Airport there are dry riverbeds and fields that can be used for emergency landing 2 13 7 Visual Meteorological Conditions Article 5 of the Ordinance for Enforcement of the Civil Aeronautics Act of Japan states as follows for the visual meteorological conditions An excerpt from the part relating to the Aircraft 1 Fortheaircraft that flies at an altitude of less than 3 000 meters For the aircraft that flies in control area control zone or information zone a Flight visibility is over 5 000 meters b No cloud is within the vertical distance of 150 meters above and 300 meters below the aircraft c No cloud is within the horizontal distance of 600 meters from the aircraft 2 For the aircraft that flies at an altitude less than 300 meters from the ground surface or the water surface in the airspace other than control area control zone and information zones Regarding helicopter that flies at the speed of which collision with o
43. t all types of accident In this accident the Aircraft crashed into the mountain at a high speed and the main gearbox was broken and displaced It is considered probable that damage to ELT antennas cannot be avoided in this kind of accident But in general it is considered probable that when ELTs are installed maximum possible attention must be paid to not only the place of the transmitter but also that of its antenna so that damage of a crash may be minimized 24 4 PROBABLE CAUSES It is considered highly probable that while the Aircraft was flying to the destination aerodrome the captain became unable to maintain visual meteorological conditions due to clouds and without noticing that it had come close to a mountain he continued the flight and as a result the Aircraft crashed into the mountainside and it was destroyed causing the captain and the passenger to be killed It is considered probable that the fact that the captain failed to fully confirm meteorological information before and during the flight and the fact that he failed to make a judgment to ensure points for the maintenance of safe flight such as a possible return to the departure aerodrome or the possibility of changing to a different destination contributed to the cause of this accident 25 5 REMARKS In this accident it became difficult for the Aircraft to maintain visual meteorological conditions during its flight because appropriate efforts had not been m
44. t day I was told to fill it up and refueled 133 liters to the Aircraft When I asked them about their destination they said they were going to Miho They were worried about the weather condition They said they would return in case of bad weather The weather was good in the surrounding areas but they said the weather condition would be bad over the mountains I was asked if refueling would be possible if they turn back The three persons including the captain were standing around the Aircraft I did not know any of them 16 2 13 2 Acquisition of Meteorological Information at Miho Airport At Miho Airport flight crewmembers can obtain meteorological information through self briefing terminals set up at the Tajima Airport If necessary they can also receive briefings directly from weather forecasters via a direct telephone linked to the Aviation Weather Service Center at Kansai International Airport But logs at the center for the day showed no record that the captain of the Aircraft received a briefing from the center 2 13 3 Acquisition of Meteorological Information during Flight The Ministry of Land Infrastructure Transport and Tourism has Flight Service Centers FSC at eight airports across the country and provide various kinds of meteorological information including the meteorological radar echo to assist in flights of aircraft and aeronautical information for safe operations of aircraft These kinds of information can be obtain
45. tain s Judgment until Crash It is considered highly probable that based on an advisory received from the Flight Service that fogs are relatively limited on the east side of the Tajima Airport the captain concluded that clouds are also relatively limited on the east side and that after contacting the Flight Service at a position about 1 9 nautical miles south of the Tajima Airport that the Aircraft was supposed to be above the runway and after flying above the clouds to the east southeast it is considered highly probable that the captain started descending as he found a small opening in the clouds or without finding any opening after changing the direction to the south Even if the captain had descended through an opening he found in the clouds it is considered somewhat likely that the Aircraft would have entered the clouds again in the weather condition as described in 2 7 and the captain would have descended without confirming the ground As described in 2 1 2 the Aircraft was visually observed from the ground Therefore it is considered highly probable that the Aircraft got out of the bottom of the clouds temporarily but the captain continued the flight while he was unable to confirm the location of the Tajima Airport and that the Aircraft pushed into the clouds again and strayed into a mountainous area southeast of the Tajima Airport As described in statements of witnesses in 2 1 2 it is considered highly probable that visibility was poor and th
46. te 3 9 2 Judgment about Meteorological Condition for the Day As described in 2 7 clouds were broadly hanging and rain fell intermittently on the day of the accident as a Baiu rain front was staying in the western part of Japan But the radar echo charts 94 showed the echo area along the Sea of Japan coasts was relatively small and weak Similar echo charts are widely available through the broadcasting media Therefore it is considered somewhat likely that the captain checked these kinds of information at his hotel or elsewhere on the day of the accident and concluded that if the route is carefully selected it would be possible to maintain visual meteorological conditions while watching ground signs However the radar echo charts are drawn by collecting radio waves emitted from a meteorological radar and echoed back on raindrops to be recaptured by the radar and this means that the charts fail to show radio waves whose size is smaller than the standard level Signs on the charts do not necessarily correspond to actual cloud areas particularly at low altitudes which may become a hindrance to visual meteorological conditions It is considered somewhat likely that the captain s judgment that it would be possible to fly had been influenced by a slight improvement in the weather condition from the previous day and one day delay in the return schedule 3 9 3 Meteorological Condition during Flight As described in 2 1 1 the GPS records
47. ther object is avoidable excludes the item listed in a a Flight visibility is over 1 500 meters b The aircraft may fly away from clouds and that the pilot may visibly recognize the ground surface or water surface 3 For the aircraft that tries to take off or land at aerodrome etc within control zone and information zone or at aerodrome etc outside control zone and information zone designated in the public notice by the Minister of Land Infrastructure Transport and Tourism a Ground visibility is more than 5 000 meters b Height of cloud is more than 300 meters from the ground surface or the water surface 18 3 ANALYSIS 3 1 Flight Crew Qualifications The captain held both a valid airman competence certificate and a valid aviation medical certificate 3 2 Airworthiness Certificate The Aircraft had a valid airworthiness certificate and had been maintained and inspected as prescribed Judging from the condition of the chopped part of a tree cut down when the Aircraft crashed details of damaged parts of the fuselage and the result of a teardown inspection of major components it is considered highly probable that there had been no abnormality until the time when the Aircraft crashed into the mountainside and was destroyed 3 3 The Aircraft s Flight Route As described in 2 1 it is considered highly probable that the Aircraft took off from Miho Airport at 08 37 for a flight to the Tajima Airport via Tottori Assumi
48. tion states that all rotorcraft must be equipped with at least one automatically activated ELT It also states that the position where the ELT is installed is important to ensure that it is activated without fail when an accident occurred Japan has also required all rotorcraft to be equipped with automatic ELTs unless the equipment has been respited as a provisional measure The Aircraft was equipped with an ELT AF See Figure 5 Three Angle View of Robinson R44 II Photo 10 ELT 2 9 3 Track by Radar for Air Traffic Control After the Aircraft took off from Miho Airport the Aircraft s air traffic control transponder hereinafter referred to as the ATC transponder code 1200 was detected between a point about 3 5 nautical miles east southeast of Miho Airport 08 41 02 and a point about 23 6 nautical miles east southeast of Miho Airport 08 53 24 and between a point about 22 3 nautical miles west southwest of Tajima Airport 09 11 34 and a point about 13 3 nautical miles west of Tajima Airport 09 17 01 as well as between a point about 7 8 nautical miles west of the Tajima Airport 09 20 30 and a point about 7 6 nautical miles west of the Tajima Airport 09 20 40 During these periods the direction and the altitude of the Aircraft were changed several times When it was last detected at 09 20 40 its altitude was about 2 900 feet with its direction almost eastward and its speed about 60 knots 2 9 4 Information from Scheduled Flight
49. with Traffic Alert and Collision Avoidance System TCAS at the Time of Accident At 09 47 of the day the Flight Service asked a scheduled flight whether any aircraft are not be observed nearby with its TCAS The scheduled flight replied that while it was approaching from 5 nautical miles south of the Tajima Airport nothing could be seen in the 20 nautical miles range on its TCAS A 2 10 Medical Information According to the Hyogo prefectural police headquarters autopsies carried out on August 8 revealed that the causes of death for the captain and the passenger were bruises on the whole of the bodies 2 11 Information about Search and Rescue As contact with the Aircraft was lost the Flight Service made a notice to Osaka FSC at 9 40 Osaka FSC asked airports and others in the neighboring areas to provide information but no information on the Aircraft was obtained After coordinating with the Rescue Coordination Center of the Civil Aviation Bureau of the Ministry of Land Infrastructure Transport and Tourism Osaka FSC issued an INCERFA Uncertainty phase to related organizations at 10 06 As a result the Rescue Coordination Center started operation for search and rescue As necessary information remained unavailable Osaka FSC concluded that the Aircraft met an accident and issued a DETRESFA Distress phase at 10 30 The Rescue Coordination Center asked the Maritime Self Defense Force at 10 56 to dispatch search and rescue personne
50. wn out ahead with the impact of the crash along with the front part of the aircraft which hit a pine tree with a diameter of about 30 centimeters standing ahead of the place of the crash and that the passenger was thrown ahead to a place left of the nose section and the captain to a place beyond the ridge and his body further fell to the southeast down a steep slope on the east side The result of a teardown inspection as described in 2 12 3 5 estimates that the indication of the directional gyro was 250 degrees But judging from the condition of the accident site it is considered probable that this resulted from the impact of the accident 3 5 Flight Control by the Captain Based on the following points it is considered probable that the Aircraft was being controlled by the captain just before the accident 1 As described in 2 13 5 the main flight control system of the Aircraft is installed mainly on the right seat s side 2 As described in 2 9 1 it is considered probable that the captain was making communications with the ground As described in 2 13 5 the Aircraft was equipped with a switch to change the radio frequency for the radio transmitter receiver for communications with the ground on the cyclic grip on the right seat which makes it easier to make radio operations while seating on the right side 3 Judging from the meteorological conditions as described in 2 7 the less experienced passenger was unlikely to be let control the A
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