Background
On 4 August 2013, the air ambulance operator Mýflug received a priority F4 request for an ambulance flight from Höfn (BIHN) to Reykjavík Airport (BIRK). The flight was planned for the next morning. The operator’s home base was at Akureyri Airport (BIAR). The flight crew consisted of a commander and a co-pilot, plus a paramedic listed as a passenger.
Flight Sequence
The crew met at BIAR at 09:50 on 5 August. After a standard pre-flight inspection with no findings, the aircraft departed BIAR at 10:21 for the positioning flight to BIHN, landing at 11:01. The commander was pilot flying for that leg. Following the operator’s common procedure, the co-pilot became pilot flying for the ambulance leg from BIHN to BIRK, departing at 11:18 and landing at 12:12. After refuelling at BIRK, the aircraft departed at 12:44 for the return positioning flight to BIAR, with the commander as pilot flying. The flight was flown at FL 170 according to radar data.
Accident
During the cruise, the flight crew discussed the commander’s wish to deviate from the planned route to BIAR to fly over a racetrack area near the airport, where a race was about to start. Approaching BIAR from the south, the crew cancelled IFR at 10.5 DME. After passing the KN locator (Kristnes), they requested to overfly Akureyri town before landing. The tower approved and informed them of a Fokker 50 departing on RWY 01. The crew of TF-MYX acknowledged and stated they would keep west of the airfield. According to the co-pilot, altitude was approximately 800 ft MSL after passing KN. The co-pilot recommended a higher altitude, which was momentarily increased to 1000 ft. Approaching the racetrack, the aircraft entered a steep left turn. During the turn, altitude dropped until the aircraft struck the racetrack.
Probable Cause
The investigation by the Icelandic Transportation Safety Board (ITSB) identified the following causal factors: a breakdown in crew resource management (CRM); a steep bank angle needed to line up with the racetrack; the flyby was executed as a low pass; the maximum calculated bank angle during the last phase of flight was 72.9°, exceeding the aircraft’s manoeuvring limit; and the ITSB believes that the commander’s focus on a flyby that he had not planned thoroughly resulted in a low-pass with a steep bank, causing the aircraft to lose altitude and collide with the ground. Contributory factors included: the commander’s attention to the race club activity and his association with the club were likely a source of distraction and motivation to execute an unsafe manoeuvre; deviations from normal procedures were seen as acceptable by some flight crews; a flyby was discussed but not planned in detail; the flight crew reacted to departing traffic by flying further west, resulting in a steeper turn; the approach to the low pass was misjudged; and the steep turn was likely due to the commander’s intention to line up with the racetrack.