26 June 2025
The aircraft crash that killed 21-year-old pilot Harvey Dunmore almost two years ago was most likely caused by a runaway trim on the twin engine Piper Aztec he was flying, according to the Air Accident Investigation Branch (AAIB) which has today published its final report.
As a result of the AAIB’s investigation, the CAA is planning eight Safety Actions. The CAA is also continuing to investigate the maintenance organisation which looked after the aircraft.
The AAIB reports also says, “Other authorities are investigating the financial arrangements in place for the provision of pilots to operate the aircraft.”
Below: Excerpts from the AAIB report which can be downloaded in full here.
The pilot had departed Bagby airfield in the morning and flown to Deauville in France where he collected five passengers and delivered them to Abbeyshrule in Ireland. The accident occurred at the end of the return flight to Bagby, with the pilot the sole occupant of the aircraft.
After the pilot made a normal radio call to Bagby to say that he was four miles from the airfield, the aircraft was seen on radar and CCTV to join right base for Runway 06.
The CCTV video showed the aircraft’s descent angle start to steepen while it was on right base. There was then a slight reduction in descent angle before the descent angle steepened sharply and the aircraft struck trees and then the ground at an angle of about 35° to 40° nose-down, with no indication that the aircraft was starting to recover.
The ground impact caused a fire, and the accident was not survivable.
The post-impact fire destroyed a significant amount of physical evidence, but that which remained contained no identifiable defects that could have caused or contributed to the nose-dive. The one anomaly found was the position of the pitch trim drum which was 3 mm from the full nose-down position.
The aircraft was equipped with a Piper Altimatic IIIB autopilot system that was placarded inoperative but known to have some functionality. The build record for G-BKJW revealed that this system had been fitted at original manufacture.
The autopilot was disengaged by either pressing the Autopilot/Roll Engage switch off, or by pressing the autopilot disconnect switch on the control yoke; however, the yoke mounted disconnect switch was not fitted on G-BKJW – there was an empty hole for it.
The licensed aircraft engineer responsible for the annual inspection stated that the inspections would have included running the electric trim to check it worked and would have included examining all the control cables and pulleys. He also thought that the electric trim would have been tested during the post maintenance ‘air test’.
He did not know why the autopilot was placarded INOP and said that it was already placarded when the aircraft was bought. He said that the autopilot circuit breaker was not pulled and isolated because he thought it was needed either to run the electric trim or to power the intercom or a radio.
The CAA had conducted an audit of the maintenance organisation nine days before the accident resulting in two non-conformance level 2 findings. Following the accident to G-BKJW the CAA carried out a survey of the maintenance organisation. They found discrepancies in the maintenance of three aircraft by the maintenance organisation, which included G-BKJW. The findings included evidence that some Airworthiness Directives (ADs) had not been complied with on G-BKJW. The survey findings resulted in the CAA provisionally suspending the maintenance organisation’s approvals. The CAA investigation is ongoing.
The aircraft was owned by an Irish business, specifically set up to purchase and operate the aircraft on behalf of its four directors, and was based at Abbeyshrule airfield, Ireland.
The purchase was organised by a brokerage company, based in Ireland, one of the two directors of which was also a director of the maintenance company at Bagby which had conducted the post-purchase maintenance work on the aircraft.
The aircraft owners were involved in the horse racing industry and had no knowledge of operating aircraft. It has not been possible to confirm the exact arrangements under which the aircraft was operated, but a commercial pilot had advised and assisted in the insurance, hangarage and refuelling arrangements.
Other authorities are investigating the financial arrangements in place for the provision of pilots to operate the aircraft.
Evidence exists that the flights conducted by the pilot of G-BKJW on 6 July 2023 had already been offered to another private pilot with little twin-engine experience, and no experience on a PA-23, in return for payment. This pilot had turned the offer down.
None of the passengers on board the aircraft from Deauville to Abbeyshrule had paid for the flight. As such, it was considered a private flight, although any pilot being paid to conduct the flight would have needed to hold a commercial pilot’s licence to receive payment.
From 31 July 2021 onwards, the pilot’s logbook listed a significant number of flights being flown, some of which were recorded as being on behalf of the maintenance organisation at Bagby and the aircraft brokerage company in Ireland involved with the purchase of G-BKJW.
These flights included delivery flights, including one to Poland, and flights recorded in his logbook as demonstration flights.
During this time the pilot had been working as a contractor for the maintenance company in various roles, including IT, technical and secretarial work, although the company stated that they never paid contractors or staff for flying services.
They added that the pilot was able to fly aircraft in a flying group, that they provided maintenance for, at a discounted rate as a “perk of his position”. They also stated he was able to fly aircraft, owned by the brokerage company that were based at Bagby for sale, paying only for the fuel used.
In December 2022, the pilot completed a multi engine piston (MEP) rating. His logbook recorded this took seven flying hours, flown on a Cessna 310.
Two months later, in February 2023, he started a CPL flying course, but before he was able to complete it the flying school went into administration.
His last flight with the school was on 22 April 2023, at which time he had completed approximately 23 hours flying, including seven hours dual and one hour solo on the twin-engined Diamond DA42. He had needed to complete two further training flights and a successful test flight in order to have gained his CPL qualification. His training reports reflected he was a competent pilot.
At the time of the accident, he did not hold either a CPL or an instrument rating. He had a total of 4 hours 50 minutes instrument flying on a DA42 simulator and 6 hours 50 minutes instrument flying on single engine aircraft.
The AAIB notes that an MEP rating does not immediately give a pilot the privilege to fly any MEP aircraft. Apart from some exceptions, differences training is required before a pilot can fly another variant of an MEP aircraft.
None of the flights by the accident pilot in G-BKJW were recorded as training flights and there was no evidence of the pilot having received instruction from a qualified flying instructor on the PA-23.
A flight trial was carried out using a PA-23-250 ‘E’ model aircraft to obtain information about the pitch control forces that can be experienced in an out-of-trim situation, the ability to reach and pull the electric trim circuit breaker, and the aircraft’s response to a sudden flap retraction.
The test pilot considered that it was very unlikely that a pilot in a trim runaway event, under the circumstances described in this accident, would have sufficient time or capacity to find and pull the electric trim circuit breaker.
A number of possible causes for the final nose-dive were considered. Of all the causes reviewed, a pitch trim runaway was considered to be the most likely, but there was insufficient evidence to determine that it was the definitive cause of the accident. The CAA is planning eight safety actions to help reduce the risk of an accident involving a pitch trim runaway.
As a result of the findings of this investigation and discussions with the CAA, the CAA has agreed to the following safety actions:
