On 15 March 2005, a Britten-Norman Islander air ambulance, operated by Loganair, crashed off the coast of Scotland, killing both people on board.

The aircraft was on route to Campbeltown Airport in Argyll, Scotland, to pick up a ten-year-old boy with acute abdominal pain, suspected to be appendicitis.

After a flight that included many navigational irregularities, the pilot was flying the normal approach, which took the aircraft out to sea before turning back toward the airport.

The pilot was also fatigued, overworked, lacked recent flying practice, and he might have suffered from an undetermined influence, such as disorientation, distraction, or subtle incapacitation, as evidenced by several navigational errors, miscommunications, and mismanagement of his instruments.

Despite the death of both occupants of the aircraft, the UK's Air Accidents Investigation Branch, or AAIB, considered the impact survivable by the pilot.

In February 2005 (a month before this accident), SAS announced they would be ending their contract with Loganair in October 2006 and replacing them with Gama Aviation, which would provide two fixed-wing aircraft and two helicopters.

[2] Loganair had one previous air ambulance accident, also involving a Britten Norman Islander, on 19 May 1996, in which the pilot was killed, and the two passengers, a physician and a flight nurse, were injured.

It was a high wing design with two wing-mounted Lycoming O-540-E4C5 piston engines, each delivering a rated 260 horsepower to a two-blade variable-pitch propeller.

"[8] Summarizing expert opinion of the Islander, Alastair Dalton of The Scotsman said the aircraft "had a good safety record and had proved versatile in operating from the shortest and roughest Highland runways.

[6]: 38  Therefore, upon his arrival at Glasgow Airport, Henderson was required to take off and land the aircraft one time (a currency flight) before allowing the paramedic to board for the ambulance mission.

For unknown reasons, the pilot requested an amended clearance to fly a course that took them west and then southwest toward Campbeltown, avoiding flight over the Isle of Arran, further delaying their expected arrival time.

[6]: 5, 47–48 When the aircraft was 6.5 nmi (12.0 km) north of the Machrihanish (MAC) VOR (a type of radio navigational beacon near Campbeltown Airport), the pilot requested descent clearance.

Other personnel in the air traffic control system asked other commercial aircraft in the area to attempt to make radio contact with the Islander.

At 0031, which was one minute past the latest time the aircraft could have landed, controllers entered "distress phase", calling out search and rescue personnel.

[6]: 6–7 Three lifeboats were dispatched from Islay, Campbeltown and Portrush to the area where the aircraft was last seen on radar, along with two helicopters from Prestwick and Anglesey and one from the Strathclyde Police (during daytime hours), and HMS Penzance, a Royal Navy minesweeper that was conducting training operations 35 nmi (65 km) away.

[6]: 7, 25 When it became clear that the air ambulance would not be arriving, the patient who was to be flown to Glasgow on G-BOMG was instead transported by road to the Royal Hospital for Sick Children at Yorkhill, where he underwent surgery to treat a ruptured appendix.

[10] Six days later the diving support vessel Seaway Osprey arrived on the scene of the accident with remotely operated vehicles (ROV's) and saturation divers capable of manually recovering debris.

Within twelve hours all major components of the aircraft had been recovered except for the left wingtip, which was discovered on 2 May 2005, in a trawler's fishing net about 2.5 nmi (4.6 km) from the debris field.

Nearly neutral trim settings indicated the pilot was not trying to compensate for some abnormal flying condition, such as an engine failure or flight control problems.

The pitch trim was set to a slight nose-down attitude, which the aircraft manufacturer calculated to indicate stable flight at 110–120 kn.

[6]: 27–28, 45–47  The AAIB concluded its analysis of the wreckage with the following statement: In summary, the aircraft appears to have hit the sea in a controlled flight attitude with symmetric power and no evidence of a technical fault could be found that might explain the flight into the sea.Although clouds extended down as low as 300 to 400 ft (91 to 122 m) above the sea surface and surface visibility had fallen to 1,500–2,500 meters at Campeltown Airport, the wind was from the west at 12 knots, and the aircraft was below the freezing level (reported at 6,500 ft (1,981 m)).

The AAIB's human factors analysis suggests this specific type of error might be a significant indicator that the pilot's stress level had increased to the point where it began to further diminish his ability to cope with the heavy workload.

If, as is probable, the last transmission was made very shortly before the accident, it indicates that the pilot's situational awareness may have been seriously degraded, as he was therefore unaware of the aircraft's very low altitude...

[6]: 31  The body of the paramedic was recovered, still restrained in the seat by his undamaged lap belt, during search and rescue operations six days after the accident.

The paramedic "almost certainly" lost consciousness instantly, and the head injury was potentially fatal, but changes in the lungs showed the cause of death to be drowning.

He added, "Six years ago, following a similar accident, the AAIB recommended a review of the circumstances in which a second pilot is required for air ambulance flights.

[13] The UK's Civil Aviation Authority (CAA) had conducted a study on the benefit of requiring upper torso restraints (UTR, i.e., shoulder harnesses) in passenger seats of aircraft weighing less than 5,670 kg in response to a safety recommendation arising from the investigation of a 1999 accident involving a Cessna Titan near Glasgow.

While considering this recommendation, the EASA took the interim step of issuing its own Safety Information Bulletin (SIB 2008–24), which advised the air transport community of the CAA's earlier study and of the benefits of shoulder harnesses.

[18]: 103 [19]: 88  The European Commission accepted the EASA opinion, and new regulations requiring shoulder harnesses as described in the AAIB's safety recommendation 2006-101 became law for commercial air transport operators in Europe.

[23] The 2013–2016 EASA status report on its 4-year Rulemaking Programme indicates they expect to issue an opinion on 2006-102 (requiring two pilots on air ambulance flights) by 2019 and a decision by 2020.