Agenzia Nazionale per la Sicurezza del Volo ANSV

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OBJECTIVE OF THE SAFETY INVESTIGATION, The Agenzia nazionale per la sicurezza del volo ANSV instituted with legislative decree No 66 of. 25 February 1999 is the Italian Civil Aviation Safety Investigation Authority art 4 of EU Regulation. No 996 2010 of the European Parliament and of the Council of 20 October 2010 It conducts in an. independent manner safety investigations, Every accident or serious incident involving a civil aviation aircraft shall be subject of a safety. investigation by the combined limits foreseen by EU Regulation No 996 2010 paragraph 1 and. paragraph 4 of art 5, The safety investigation is a process conducted by a safety investigation authority for the purpose of. accident and incident prevention which includes the gathering and analysis of information the. drawing of conclusions including the determination of cause s and or contributing factors and when. appropriate the making of safety recommendations, The only objective of a safety investigation is the prevention of future accidents and incidents. without apportioning blame or liability art 1 paragraph 1 EU Regulation No 996 2010. Consequently it is conducted in a separate and independent manner from investigations such. as those of Judicial Authority finalized to apportion blame or liability. Safety investigations are conducted in conformity with Annex 13 of the Convention on International. Civil Aviation also known as Chicago Convention signed on 7 December 1944 approved and made. executive in Italy with legislative decree No 616 of 6 March 1948 ratified with law No 561 of 17. April 1956 and with EU Regulation No 996 2010, Every safety investigation is concluded by a report written in a form appropriate to the type and.
seriousness of the accident or serious incident The report shall contain where appropriate safety. recommendations which consist in a proposal made with the intention of preventing accident and. A safety recommendation shall in no case create a presumption of blame or liability for an. accident serious incident or incident art 17 paragraph 3 EU Regulation No 996 2010. The report shall protect the anonymity of any individual involved in the accident or serious incident. art 16 paragraph 2 EU Regulation No 996 2010,AGL Above Ground Level. AMSL Above Mean Sea Level, ANSV Italian Civil Aviation Safety Investigation Authority. AOA Angle of Attack,AOB Angle of bank see BANK, APC Aircraft Pilot Coupling rare unexpected and unintended excursions in aircraft attitude and flight. path caused by anomalous interactions between the aircraft and pilot. BANK AOB Angle of Bank aircraft inclination in degree along its longitudinal axis. BRIEFING preventive description of manoeuvres or procedures. CAS Caution and Advisory System,CAS Computed Air Speed. CFD Computational Fluid Dynamic,COCKPIT Flight Deck Compartment.
CVR Cockpit Voice Recorder records communications voices and noises inside the flight deck. DCP Differential Collective Pitch FCC control law responsible for stabilization and control of the yaw. axis behaviour of the aircraft in response to pedal inputs lateral accelerations and yaw rate sensors. DIVE steep descent manoeuvre in flight at high speed. EASA European Aviation Safety Agency,ENAC Italian Civil aviation Authority. EPDU Engineering Pilot Display Unit screen in the cockpit representing the values of the parameters. relative to flight tests, FAA Federal Aviation Administration American Civil Aviation Authority. FCC Flight Control Computer,FCS Flight Control System. FDR Flight Data Recorder,FFC Fixed Flight Controls. FH Flight Hours, FLAPPING blade movement of the proprotor that by pivoting around the coupling amplifies.
movement more on the extremities,FSTD Flight Simulation Training Device. FTI Flight Test Instrumentation,G gravitational acceleration. GS Ground Speed,HDG Heading,IAS Indicated Air Speed. ICAO OACI International Civil Aviation Organization. ICDS Interconnecting Drive Shaft,ICS Intercommunication System. IDLE engine thrust lever position corresponding to minimum thrust. KIAS IAS in knots kt, KT knot unit of measure a nautical mile 1852 metres per hour.
MCC Multi Crew Coordination,METAR Aviation routine weather report. MN Mach Number relationship between the speed of an object in movement in a fluid and the speed of. sound in the fluid itself, MPFR Multi Purpose Flight Recorder combined flight recorder CVR FDR. MRT Multi Radar Tracking,MTOM Maximum Take Off Mass. NACELLE casing of an aerodynamic shape made to contain the engine and proprotor system of the. NM nautical miles 1 nm 1852 metres,NTSB National Transportation Safety Board. OML Valid only as or with qualified co pilot,PDU Pilot Display Unit.
PF Pilot Flying,PIC Pilot in Command,PITCH rotation on the lateral axis of an aircraft. PNF Pilot Not Flying,PRGB Propeller Gearbox, PROPROTOR rotating airfoil used as a propulsion device both in airplane mode propeller and. helicopter rotor during the same flight, QBAL Torque Balancing which is the integral term within the algorithm of the FCS control logic. responsible fro the compensation of the asymmetries influencing the directional control. QBALTH Torque Balancing Ratio which is the real time ratio between th QBAL value and the FCS. total Pedal authority and is displayed in the cockpit on the EPDU. ROLL rotation on the longitudinal axis of an aircraft. SHP Shaft Horse Power, SIDESLIP aerodynamic state in which an aircraft rotates around its vertical axis while at the same time. moving in the direction of motion, SIMRX engineering flight simulator developed for the aircraft AW609.
S N Serial Number, SPATIAL D Spatial Disorientation temporary or permanent disturbance characterized by mental. confusion difficulty in remembering recent or past events and in movement coordination. T B T radio communications ground aircraft ground, TML Valid only for months limitation of the medical certificate applied when the validity is limited. in time for reasons described by the authorized aeromedical examiner. UTC Universal Time Coordinated,YAW rotation of the aircraft on the vertical axis. VMO Velocity Maximum Operating, VNL limitation of the medical certificate by which the holder has to dispose of corrective lenses for near. sightedness and has to hold with him a reserve pair of eyeglasses. This report has been translated and published by the ANSV for the English speaking concerned public. The intent was not to produce a factual translation and as accurate as the translation may be the original. text in Italian is the work of reference, Questa relazione d inchiesta stata tradotta e resa disponibile in lingua inglese a cura dell ANSV a.
beneficio delle persone interessate Bench grande attenzione sia stata usata allo scopo di offrire una. traduzione accurata il testo di riferimento rimane quello in lingua italiana. Aircraft AW609 registration marks N609AG, Type of aircraft and registration Tiltrotor experimental AgustaWestland AW609 registration. marks N609AG photo 1 attachment A, Date and time 30th of October 2015 around 09 42 UTC 10 42 local time. Place of the event Tronzano Vercellese VC location coordinates N 45 21 24 E. 008 09 22 figure 1, Event Description The aircraft took off from Cascina Costa VA location of. production and headquarters of the manufacturer for a. programmed and planned test flight that foresaw the transfer to a. reserved airspace near the city of Santhi VC, While performing a high speed descent the third from the start of. the test flight T664 the aircraft entered initially an uncontrolled. flying condition due to a series of lateral directional oscillations. then suffered structural breakup followed by in flight fire and. impacted the ground,Both test pilots on board suffered fatal injuries.
Aircraft Operator AgustaWestland Philadelphia Corporation. Nature of the flight Test flight of an experimental aircraft. Persons on board Crew 2,Damage to aircraft Destroyed. Other damage No damage to third parties on the ground resulted. Personnel information Captain,Male age 53 American US nationality. He had more than 20 years of flying experience on 35 different. aircraft types aeroplanes and helicopters and obtained the. qualification as experimental test pilot in 1997 at the Naval Test. Pilot School of Patuxent River USA He had then been hired as. test pilot by Bell Helicopter and assigned to the Tiltrotor BB609. project until it was acquired by AgustaWestland where he had. been employed in 2011 in the meantime the project had been. renamed AW609, At the time of the accident he did not cover any other specific. hierarchical position within the Company s organization. He held 2 pilot licenses issued respectively by the competent. Civil Aviation Authorities of the United States FAA and Italy. ENAC Both licenses were valid at the time of the event in. particular he held an American ATP Airline Pilot Licence with. current ratings on helicopters AB139 and AW139 He was also. authorized to exercise the provisions foreseen by a commercial. pilot licence on single and multi engine aircraft He had a current. The FAA via a letter of temporary authorization dated 12th of. November 2014 and valid until the 30th of November 2015. authorized him to exercise the role of PIC on experimental aircraft. AgustaWestland AW609 registration marks N609AG prototype. 2 The licence issued by ENAC comprised the title of production. test pilot Cat 1, The first class medical certificate was valid with VNL limitation. Before being employed in AgustaWestland he had a total flight. experience of 4100 flight hours of which 1300 as test pilot. Between 2010 and 2015 for one year in Bell Helicopter and from. 2011 in AgustaWestland he had performed 357h 40 of flying. activity on both tiltrotor prototypes AW609 Part of the test flight. activity on the tiltrotor had been done on prototype 1 as co pilot. and in part on prototype 2 In particular from January 2010 until. the 30 th of June 2014 he had performed test flight activity on. prototype 2 In July 2014 he had performed 12h 20 of flying. activity on prototype number 1 S N 60001 in the United States. Some months after a temporary stop of the prototype 2 due to the. proprotor strike event that occurred on the 17th of July 2014 he. had started again test flight activity on prototype 2 in January. 2015 In the month of July 2015 he had flown once more on. prototype 1 for 04h 25 and after that in August 2015 at the date. of the accident on prototype 2 In the 90 days preceding the. accident he had flown around 99 hours total of which 13h 45 on. aircraft AW609 registration marks N609AG,Male age 52 Italian nationality.
He had more than thirty years of flying experience on more than. 50 different aircraft types both aeroplanes and helicopters He. was a pilot in the Italian Air Force for more than 16 years and he. obtained the experimental test pilot qualification in 1993 at the. Naval Test Pilot School of Patuxent River USA and had been. employed after a long experience in the Air Force as. experimental test pilot in AgustaWestland in 1999, At the time of the accident he also covered the role of AW609. Development Lead Pilot in AgustaWestland, He held 2 pilot licenses issued respectively by the competent civil. aviation authorities of the United States FAA and Italy ENAC. Both licenses were valid at the time of the event in particular he. held an American ATP Airline Pilot Licence with current ratings. on single and multi engine aircraft and on helicopters AB139. AW139 AW169, The FAA via a letter of temporary authorization dated 22nd of. June 2015 and valid until the 1st of June 2016 to exercise the role. of PIC on experimental aircraft AgustaWestland AW609. registration marks N609TR prototype 1 and N609AG prototype. As previously mentioned he also held an airline helicopter pilot. licence issued by the Italian Aviation Authority ENAC in. accordance with Part FCL and he held the following valid type. ratings A139 A139 IR A109 A109 IR AW189 IR,experimental test pilot Cat 1. The first class medical certificate was valid with VNL TML and. OML limitations, Before 2010 he had a total flight experience of 7400 flight hours.
of which 5000 as experimental test pilot Between 2010 and 2015. at AgustaWestland he had flown 5563h 05 flight hours on. prototypes of which 315h 35 on tiltrotor prototype AW609 The. test flight activity on the tiltrotor had been done partly on. prototype 1 and 2 In particular 129h 45 hours of flight had been. performed on prototype 1 and e 185h 50 on prototype 2. After some months of temporary stop of the prototype 2 due to the. proprotor strike event that occurred on the 17th of July 2014 he. had started flight test activity again on prototype 2 in January. In the 90 days before the accident he had flown a total of 77 hours. of which 15h 55 on aircraft AW609 registration marks N609AG. Aircraft and engine information The AW609 is an experimental tiltrotor aircraft able to convert in. flight from helicopter to aeroplane by rotating the two proprotors. installed on the nacelles on the wingtips from the vertical position. 90 degrees to the horizontal position 0 degrees and viceversa. The MTOM used only in the experimental phase is 8 165 kg with. a MTOM assigned at certification of 7 620 kg the aircraft can. The Agenzia nazionale per la sicurezza del volo ANSV instituted with legislative decree No 66 of In the month of July 2015 he had flown once more on

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