What happened
On May 31, 2018, a Piper PA-25-235 Pawnee, registration SE-KHF, departed from Breda International Airport for a banner towing mission. During the local circuit, the pilot attempted to pick up a banner. Shortly after the attachment, the aircraft lost airspeed and began a descent. The plane fell into an almost vertical attitude just outside the airport boundary, resulting in a fatal impact and a subsequent fire. The pilot was fatally injured and the aircraft was destroyed.
The investigation
The Dutch Safety Board conducted a comprehensive investigation into the operator, noting that this was the company's fourth incident or accident within a five-year period. The inquiry examined the mechanical configuration of the aircraft, the operator's safety management systems, and the level of regulatory oversight provided by the Human Environment and Transport Inspectorate (ILT).
Findings
The investigation established that the primary cause of the crash was that the aircraft was equipped with an improper propeller for banner towing operations. Because the engine could not produce sufficient RPM at low speeds, the propeller failed to generate the thrust required to accelerate and climb after the banner pick-up. This situation was further aggravated because the aircraft was flying above its maximum takeoff weight.
Furthermore, the Board identified significant failures in the operator's safety management, including a neglect of maintenance risks and a failure to recognize the limitations of the aircraft's equipment. The operator had been using the aircraft for banner towing for over six years without the necessary supplemental type certificate or authorized limitations. Additionally, the investigation found that the installation of an extra fuel tank in the fuselage had reduced the pilot's survivability in the event of a crash.
Safety action
The Board highlighted a lack of active oversight by the ILT, noting that the inspectorate had not performed active monitoring of the operator despite a long history of safety deficiencies. The investigation also noted a general reluctance within the general aviation sector to report unsafe situations, emphasizing the need for more responsive regulatory supervision.