What happened
On 14 June 2000, a Piper PA-31-350, registration G-BMBC, was conducting an air ambulance mission from Ronaldsway, Isle of Man, to Liverpool. The flight was carrying a crew of one and four passengers, including a patient being transported for medical care. The aircraft was operating under Special Visual Flight Rules (VFR) within the Liverpool Control Zone.
As the aircraft approached Runway 09 at Liverpool Airport, the pilot followed the coastline of the Merely Estuary. Radar data indicated that while the flight was initially stable at 1,500 feet, the aircraft began a gradual descent to 800 feet, followed by a further descent to 300 feet during the final stages of the approach. During the turn onto the final approach leg, the aircraft overshot the extended centreline to the south. Shortly after communicating with the tower that the aircraft was on final, the plane disappeared from radar. The aircraft struck the water in the Mersey Estuary, approximately 0.8 nm from the runway threshold, causing the aircraft to break up. There were 5 fatalities (one crew and four passengers).
The investigation
The investigation examined the wreckage found on the sands of the Mersey Estuary and analyzed radar and meteorological data. Investigators found that the aircraft's engines and flight controls were fully functional prior to impact. The aircraft struck the water with its left wing tip while in a left-hand turn. The investigation also reviewed the pilot's medical history and the company's operational procedures for air ambulance flights.
Findings
- The approach was performed at a speed significantly higher than standard operating procedures, with the aircraft traveling 20 to 30 kt faster than expected for a normal landing.
- The aircraft was not in the correct configuration for landing, as the flaps had not been extended.
- Reduced visibility due to light drizzle and the lack of visual contrast between the sky and the sea may have contributed to pilot disorientation.
- The pilot's medical examination, conducted six weeks prior, had not detected significant heart disease, which was found to be a potential cause of sudden incapacitation.
Safety action
- A recommendation was made to review the medical examination requirements for pilots operating single-pilot public transport flights, specifically regarding the detection of conditions that could lead to sudden incapacitation.
- A recommendation was also made to review the necessity of requiring a second pilot for certain public transport operations to mitigate the risks of distraction or incapacitation.