What happened
On 12 May 2007, a Reims Aviation F182Q, registration D-EBAA, crashed into the Waddenzee, west of Harlingen, the Netherlands. The flight originated from Heringsdorf, Germany, with the intention of reaching Emden, Germany. During the en-route phase of the flight, the pilot's last radio contact with air traffic control occurred at 18:14 hours, after which the aircraft became unresponsive to communications.
By 19:30 hours, the aircraft entered Dutch airspace at approximately 9,000 feet. Due to the lack of contact, the Royal Netherlands Air Force dispatched two F-16 fighters to intercept the plane. The intercepting pilots observed that the pilot of the D-EBAA appeared slumped forward and was unresponsive to signals. Radar tracking showed the aircraft began a gradual descent at 20:07 hours. At 20:33 hours, the aircraft was recorded at an altitude of only 400 feet before impacting the water. Although the aircraft remained afloat briefly after the ditching, the pilot, who was the sole occupant, died in a hospital later that evening.
The investigation
Investigators examined the wreckage and the aircraft's maintenance history. Technical analysis of the engine exhaust assembly revealed cracks in the muffler end plates. Laboratory testing indicated that the steel used in the muffler was unsuitable for the operating conditions, leading to corrosion and cracking. Furthermore, the investigation found that the materials used for the muffler did not match the original design specifications.
Pathological findings confirmed that the pilot had a 60% carbon monoxide concentration in his blood. This high level of intoxication was identified as the cause of the pilot's loss of consciousness. The investigation also noted that while the aircraft was equipped with an autopilot, the cabin ventilation vents were closed, which prevented fresh air from diluting the accumulating gas.
Findings
- Cracks in the engine exhaust muffler allowed carbon monoxide to leak into the cabin.
- The pilot was incapacitated by the toxic fumes, leading to the eventual loss of control of the aircraft.
- The materials used in the construction of the exhaust muffler were not in accordance with design specifications.
- The most recent scheduled inspection of the exhaust system, conducted eight months prior to the accident, failed to detect the existing cracks.