Aircraft Accident Investigation Report

53 2.8 Tinson Pen Aerodrome Although the accident did not happen on the aerodrome, there were some deficiencies found in aspects of the operations of the aerodrome that had an adverse effect on the emergency response. These include the ambiguities in the draft Emergency Response Procedures Manual to be used by ARFF personnel, and the delayed decision to dispatch the ARFF Foam Tender to the accident Site. 2.9 Jamaica Fire Brigade The Jamaica Fire Brigade responded promptly to the emergency call with an adequate number of units and personnel. However, they were not equipped with the type of foam needed to extinguish the fire. 3.0 CONCLUSION 3.1 Findings as to Causes and Contributing Factors (Definition: “ Each Finding identifies an element that has been shown, through the results of analysis, to have operated in the occurrence or to have almost certainly have operated in the occurrence. These Findings are related to the unsafe acts, unsafe conditions or safety deficiencies which are associated with the safety significant events that played a major role in causing or contributing to the occurrence ”.) 1. The pilot(s) elected to continue the take-off phase after experiencing a partial loss of engine power. 2. The pilot(s) initiated a turn towards the north (left of runway course), while failing to maintain sufficient airspeed, resulting in a stall and spin condition causing loss of control and impact with the terrain. 3. There was a maintenance entry in the current engine logbook which stated that the engine was overhauled on June 17, 2014 by One Stop Aviation (Repair Station No. XR3R981L) under Work Order 25624 with an engine total time recorded as 1580.3 hours. 4. CATC was unable to provide a copy of the Authorised Release Certificates for the engine and the propeller under which they were stated to have been overhauled as required by their procedures despite numerous requests. 5. CATC was unable to provide a copy of the work order of the Repair Station under which the engine was stated to have been overhauled despite numerous requests. 6. The Repair Station identified in the maintenance entry was contacted in order to obtain a copy of the work order; in their response it was reported that the maintenance entry was forged and that they did not have any information regarding this engine. 7. The engine which was installed on the aircraft did not conform to its type design as the No. 2 engine cylinder intake valve was incorrect for model and type. 8. The engine internal timing was out of time by one tooth between the crankshaft and camshaft. This caused the timing mark on the starter ring gear support assembly to be