Fatal Helicopter / Crane Collision – London Jan 2013
While manoeuvring over the River Thames, an AgustaWestland A109E helicopter, G-CRST, operated by charter company Rotormotion, collided at 700ft amsl with a crane in Vauxhall, Central London. The crane was atop the 50 storey St George Wharf Tower. The helicopter pilot and a passer-by died. The UK Air Accident Investigation Branch (AAIB) have now issued their report into the accident, which occurred in poor visibility on 16 January 2013.
Circumstances of the Accident
- The pilot is reported to have commented that morning he felt ‘under pressure’ into doing the flight to collect a prominent businessman, and appears to have reversed an initial intent to cancel the flight.
- Despite a poor forecast, the aircraft departed Redhill (South of London) at 07:35 to see what conditions were like at the planned pick-up location (Elstree, North West of London).
- The pilot received and sent text messages during the flight, including one at 07:55 regarding a possible diversion to London Heliport (Battersea) to rendezvous with the client.
- Its not clear if the pilot had seen current NOTAMs.
- The helicopter had been fitted with a Garmin 430 which could display obstacles, though was no certified as a terrain awareness and warning system (TAWS). AAIB report that it was not included in the helicopter’s Maintenance Programme as it was a ‘customer option’ and the operator only updated such databases annually.
- While awaiting a request for feedback of the availability of London Heliport made at 07:56, the helicopter was holding near the H4 helicopter route that follows the River Thames.
- The construction of buildings on either side of the river created what the AAIB called a “challenging positional separation requirement for pilots if they plan to achieve the required 500 ft separation when the cloud base is low”.
- At 07:59:13 ATC cleared the pilot to proceed to London Heliport.
- AAIB conclude: “The pilot turned onto a collision course with the crane attached to the building and was probably unaware of the helicopter’s proximity to the building at the beginning of the turn. The pilot did not see the crane or saw it too late to take effective avoiding action.” The collision occurred at about 07:59:24.
AAIB Safety Recommendations
AAIB have made 10 safety recommendations. Six relate to obstacles. Julian Firth, a principal inspector from the AAIB, told the BBC:
The AAIB has recommended improvements in the way obstacles are notified to the regulator so that their effect on aviation factors can be considered and before the planning permission is granted on the case of new developments.
Two more relate to pre-flight risk assessment processes and the last two to Helicopter TAWS. These are matched pairs to the European Aviation Safety Agency (EASA) and the Civil Aviation Authority (CAA). The CAA currently are responsible for rule-making for civil ‘state’ aircraft operations, perhaps an acknowledgement of the regulatory differences no doubt to feature in the awaited Glasgow Clutha Vaults police helicopter accident report.
Helicopter Safety Observations
AAIB highlight the European Helicopter Safety Team (EHEST) Pre-flight Planning Checklist as one potential tool to increase awareness of risk and improve decision making pre-flight. However it is still vital to appreciate how changes in-flight affect risk. In many ways this accident neatly highlights how circumstances and changes once a flight is underway can magnify risk in a matter of minutes. In-flight texting, while it may not have distracted the pilot during the final manoeuvre, was a mechanism that could increase stress and introduce rapid changes of plan. Texting in-flight was a factor in a US 2011 Helicopter Emergency Medical Service (HEMS) fatal accident. CAA issued a safety notice on crew distraction days after the Vauxhall accident. There is however surprisingly little on the operator, its organisation, training, crew supervision and procedures in the AAIB report. Apart from brief mentions of obstacle database updates and NOTAM policy, the main detail is in just the three sentences of para 1.17.7. There is also no detail on the contractual arrangement with the customer. Even though the Garmin 430 was fitted as a ‘customer option’ it should have been included helicopter’s Maintenance Programme and database updates could have scheduled more regularly. The prioritisation of non-mandatory systems introduced for safety and other reasons, in that case HUMS, is a theme of a Norwegian AS332L accident from 2007 (LN-OPG). Clearly there are systemic issues on how planning permission is given for large buildings, particularly near published heli-routes:
- The CAA had not responded to the consultation for the planning application for the St George Wharf development. It did comment on previous applications that they had no affect on London Heathrow or London City airports and stating the building would need to be lit as it was adjacent to a helicopter route (as indeed it was).
- London Heliport contacted CAA in August 2008 and January 2009 about the implications of the St George Wharf development. The AAIB report that no evidence was forthcoming of a reaction to these concerns.
- The building/crane were only in the UK’s master database of tall structures (the Digital Vertical Obstruction File) by coincidence (spotted by an off duty serviceman who used his initiative to add it) rather than through a systematic process of notification via the CAA.
In March 2014 CAA issued CAP1096 ‘Guidance to crane operators on aviation lighting and notification’.
UPDATE 20 November 2014: The CAA issued a safety notice on 20 November 2014 on the issue of flight planning, citing this accident, which highlights the EHEST material mentioned above.
UPDATE 25 November 2015: A coroners inquest is underway. The AAIB have also updated the progress on their recommendations. Oddly some CAA responses are dated ‘December 2015′. This is potentially a typo. The CAA witness statements were discussed at the CAA Board in July.
UPDATE 2 December 2015: The Air Traffic Controller, gives evidence to the inquest.
UPDATE 8 December 2015: The inquest jury retires to consider their verdict.
UPDATE 1 April 2016: The CAA issued a revised safety notice.
UPDATE 5 April 2017: The UK CAA have issued a revised Safety Notice: SN–2017/003 Helicopter Operations Flight Planning and Safe Flight Execution that references this accident.
UPDATE 11 September 2016: Another case were a last minute change of plan and possible perceived pressure were partly responsible for an accident: Final Report: AS365N3 9M-IGB Fatal Accident
UPDATE 18 October 2016: Yet another case with great similarity: CFIT Gangnam Style – Korean S-76C++
UPDATE 1 December 2016: The European Helicopter Safety Team (EHEST) has issued this video on decision making:
UPDATE 10 May 2017: EASA made the following response during 2016 (catalogued in their Annual Safety Recommendations Review 2016 issued today) on TAWS:
The Agency understands that, based on the type of operation performed during the accident, this safety recommendation is related to Commercial Air Transport (CAT) operations. Whilst it is acknowledged that the aircraft involved in the subject accident was operating under national legislation at the time, it should be noted that, since 28 October 2014 at the latest, CAT operations are required to be conducted in accordance with Commission Regulation (EU) No 965/2012 on air operations. Helicopters used in offshore Commercial Air Transport (CAT) operations, with a Maximum Certificated Take-Off Mass (MCTOM) of more than 3175 kg or a Maximum Operational Passenger Seating Capacity (MOPSC) of more than 9, and first issued with an individual Certificate of Airworthiness (CofA) after 31 December 2018, are required to be equipped with a Helicopter Terrain Awareness Warning System (HTAWS) (see SPA.HOFO.160 (c) of Commission Regulation (EU) 2016/1199 amending Regulation No 965/2012 on air operations). EASA has conducted a Preliminary Impact Assessment (PIA) to determine and prioritise any actions that the Agency should take to address the related safety issues.
One of the candidate actions is Controlled Flight into Terrain (CFIT) prevention with HTAWS. In response to the September 2016 PIA findings, the Agency intends to introduce a new Rulemaking Task (RMT) into its Rulemaking Programme (RMP) for 2017-2021, in order to: – consider extending the existing HTAWS requirements for offshore helicopter operations to include those helicopters first issued with an individual Certificate of Airworthiness (CofA) on or before 31 December 2018 (ie retrofit). – consider mandating HTAWS on board helicopters used for CAT other than offshore helicopter operations, including Helicopter Emergency Medical Service (HEMS) operations.
The helicopter size threshold will be determined during the task, and may be expressed in MCTOM, MOPSC, Instrument Flight Rules (IFR) or Visual Flight Rules (VFR), or a combination of these criteria. For VFR operations, the PIA results foresee the MCTOM threshold to be between 2 500 kg and 3 175 kg. It should be noted that research programmes have been taking place to improve HTAWS software in order to increase the time between the first caution or warning and impact without generating more false warnings. Further research may still be needed, and an improved European Technical Standard Order (ETSO) be published, before mandating retrofit for the existing helicopter fleet. The Agency’s Rulemaking Programme for 2017-2021 is expected to be published in the fourth quarter of 2016, after consultation with the EASA Member States’ Advisory Body (MAB) and the Stakeholders Advisory Body (SAB).
In the meantime, safety promotion material produced by the European Helicopter Safety Team (EHEST) already addresses some of the root causes of CFIT accidents. For example, ‘HE9 Automation and flight path management’ for IFR flights (published in September 2015) and ‘Helicopter Flight Instructor Manual’ for unplanned flying in Instrument Meteorological Conditions (IMC) during VFR flights (published in June 2015).
UPDATE 28 April 2018: An AW109SP, Overweight VIPs and Crew Stress A heavy landing after a crew were put under considerable stress during a poorly planned VIP flight booking and a hurried overweight take off in the UAE.
UPDATE 5 April 2020: HEMS AW109S Collided With Radio Mast During Night Flight
UPDATE 1 November 2020: Tragic Texan B206B3 CFIT in Dark Night VMC
UPDATE 2 January 2021: A Short Flight to Disaster: A109 Mountain CFIT in Marginal Weather
UPDATE 9 February 2021: The NTSB held a board meeting that determined the pilot’s decision to continue VFR flight into IMC, resulting in spatial disorientation and a loss of control, led to the fatal 26 January 2020 crash of a Sikorsky S-76B helicopter N72EX in Calabasas, California.
The pilot and eight passengers [including baseball legend Kobe Bryant] died when the helicopter, operated by Island Express Helicopters, Inc., entered a rapidly descending left turn and crashed into terrain.
Contributing to the accident was the pilot’s likely self-induced pressure and plan continuation bias, which adversely affected his decision making. The NTSB also determined Island Express Helicopters Inc.’s inadequate review and oversight of its safety management process contributed to the crash.
“Unfortunately, we continue to see these same issues influence poor decision making among otherwise experienced pilots in aviation crashes,” said NTSB Chairman Robert Sumwalt. “Had this pilot not succumbed to the pressures he placed on himself to continue the flight into adverse weather, it is likely this accident would not have happened. A robust safety management system can help operators like Island Express provide the support their pilots need to help them resist such very real pressures.”
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