Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons
The UK Air Accidents Investigation Branch (AAIB) has published their report into the fatal accident to AgustaWestland AW139 G-LBAL on 13 March 2014. This accident reinforces many important past lessons on business aviation safety, managing clients, training, human factors and learning from previous accidents.
The helicopter, owned by Haughey Air, departed from a private site near Gillingham Hall, Norfolk, UK with little nearby cultural lighting, at night and in fog, impacting the ground shortly after. The four occupants, including millionaire Northern Irish peer Edward Haughey, Baron Ballyedmond (Chairman and CEO of Norbrook), were all fatally injured.
Pre-Flight Preparation and the Take-off
The AAIB note that the crew had been monitoring the deteriorating weather that afternoon and that while departure had been planned for 18:30, the passengers had not been ready until 19:20. At least one of the crew was concerned according to the Cockpit Voice Recorder (CVR) transcript:
One said: “[unintelligible] i don’t mind telling you i’m not **** very happy about lifting out of here”. The other replied: “it should be ok it’s… i don’t think it is because you can still see the moon”.
The Commander (the Pilot Flying) had briefed for a vertical departure, but shortly after the helicopter pitched progressively nose-down.
The Co-Pilot twice said ‘Nose Low’. The AAIB could not determine if these were to highlight the nose-down pitch attitude or prompt for more nose-down pitch. In both cases they were however followed by a further nose-down pitch.
The last nose-down pitch attitude recorded by the combined voice and flight data recorder (CVFDR) was 25° with the helicopter 82 ft above the ground, descending at 2,400 ft/min, with a ground speed of 90 kt.
The aircraft was destroyed in the impact with the ground. The AAIB discuss Somatogravic Illusions and possibly misidentify headlights on a car as as static lights.
Organisational Factors, a Past Accident and Safety Management
Haughey Air (a subsidiary of Norbrook Laboratories) had been formed in 1993 and had held an Air Operators Certificate (AOC) until 2008. During this period Norbrook had suffered another accident, while privately using Sikorsky S-76B G-HAUG in Ireland on 12 December 1996. Having examined the Irish Air Accident Investigation Unit (AAIU) report on that accident, the UK AAIB comment:
Similarities exist between the causal factors determined in that case and those around the loss of G-LBAL. The AAIU found that the primary cause of the accident to G-HAUG was ‘loss of situational awareness’ on the part of the pilot flying, and it is apparent that the pilot or pilots of G-LBAL experienced a similar condition.
This suggests a failure to learn (a topic Aerossurance has discussed recently).
The AAIB note that:
In the absence of an AOC, there was no regulatory requirement for an operations manual or safety management system for private flying. Some evidence suggested that an operations manual, including type-specific matters, procedures to be employed by pilots flying together, such as briefings and standard calls, and a safety management system had existed, at least in draft form, in recent years, but none was in use at the time of the accident.
Although in this case it appears the draft material had not progressed to publishing, we have previously written about ‘safety shelfware’, where policies and procedures are documented but in practice either ignored or ineffective. The European Aviation Safety Agency (EASA) has published Part NCC, covering regulation of non-commercial complex aircraft operations, adding extra formality in areas such as operational manuals and SMS for non-AOC operators of this size of aircraft. The UK will adopt Part NCC on 25 August 2016, (after apply the full transitional opt-out, and has recently held briefings with industry). AAIB asked the UK Civil Aviation Authority (UK CAA) to comment on how Part NCC might answer the recommendations made in the 1998 AAIU report. They say:
The CAA did not respond directly but stated that, following this investigation and in connection with previous work by the AAIB, it considered that: ‘A broader and deeper review of IFR flying outside controlled airspace in general is advised.’ Accordingly the CAA has proposed the following safety action: ‘The CAA intends that a multi-disciplined review be initiated, potentially involving industry participation, to review the whole subject and produce recommendations and suggested courses of action. Target date for completion of the review is 01 October 2015.’
At the time of writing, this has not been published. Aerossurance discussed this CAA study in April 2015, which was partly set up in response to an AAIB recommendation in their final report on a serious incident involving a chartered executive Sikorsky S-76C++, G-WIWI, at in East Sussex, 3 May 2012. That review is “broader and deeper” than originally planned based on feedback from the British Helicopter Association and an unnamed on-going accident investigation (which we identified then as most likely G-LBAL).
Training & Procedures
AAIB also comment that:
No evidence was found to show that either pilot had received training in vertical departures in low visibility. Both pilots maintained single-pilot qualifications to operate the helicopter; they were not trained or tested as a crew of two. The helicopter was operated privately, therefore no flight crew duty limitations applied. There were no procedures to dictate how the two pilots should co-ordinate as pilot flying and pilot not flying, in particular with regard to which pilot should maintain visual references outside the cockpit or monitor the instruments. Additionally, the pilots had not been formally trained or tested operating as a crew of two.
Aerossurance has previously written about a US business jet that collided with obstacles and a US helicopter take-off accident when both aircraft were being operated with two pilots but who were not trained in multi-crew operations. AAIB analysis of CVR recordings of earlier flights “showed that the pilots did not conduct formal briefings, but occasionally made short statements of their intentions” and “the habitual use of checklists and ‘standard call‑outs’ were not in evidence”. Aerossurance has previously discussed the benefits of formal briefing in light of a Boeing 747 ground collision and a fatal Gulfstream G-IV business jet accident were the crew critically omitted to use checklists.
On the accident flight, there had been a delay awaiting the passengers, even though weather was deteriorating. On the previous flight there was also a conversation regarding deteriorating weather:
Co-pilot: “is he aware of the weather situation is he” Commander: “told [name of owner’s personal assistant]”
Co-pilot: “yeah i know that (brief pause) what i’m saying is are you going to tell him”
Commander: “no… (pause) **** it it’s down to them (pause) if he asks i’ll tell him (pause) i said i’ll check the weather when i get to norwich and give them an update (pause) that’s what i’ll do”
Co-pilot: “if i had my [overnight] case with me i wouldnt mind you being so bold (pause) but (pause) the only people who’ll lose out is probably me and you”.
Aerossurance has previously written of a fatal AgustaWestland A109E helicopter accident in London were perceived pressure to pick up a client in poor weather appears to have been a factor. It is vital that crews stay mindful of weather and other threats and are assertive with passengers. A good charter operator will support their crews in making decisions that the client may find inconvenient. However, in a private operation, crews may feel reluctance to voice concerns. A wise client will realise that aeronautical decisions should be taken by professionals and be conscious of inadvertent pressure.
The helicopter departed the private site in fog and at night. Operation from the site in such conditions was permissible under existing regulation. Departure from a licensed aerodrome in such conditions would not have been permitted. Evidence suggests that the flight crew may have been subject to somatogravic illusion caused by the helicopter’s flight path and the lack of external visual cues. The absence of procedures for two pilot operation, the pilots’ lack of formal training in such procedures, and the limited use of the automatic flight control system, may have contributed to the accident. Opportunities to reduce the likelihood of such an event, presented by the report into the operator’s previous fatal accident, appeared not to have been taken. The UK will adopt new regulations involving non-commercial complex aircraft operations in 2016 and, following the accident to G-LBAL and other occurrences investigated by the AAIB involving helicopters, the CAA intends to complete a review the subject of IFR flying outside controlled airspace by 1 October 2015.
Two recommendations are made, both relate to certification definitions of Vmini, Minimum Instrument Speed.
UPDATE 12 January 2016: The Coroner’s Inquest has commenced:
Coroner Jacqueline Lake said an inquest would focus on events leading up to the take-off, the training of the pilots particularly when taking off in low visibility, the weather conditions and the regulation of private helicopters.
UPDATE 15 January 2016: The Coroner recorded an accidental verdict.
UPDATE 1 April 2016: The UK CAA issue Safety Notice SN-2016/001: Private and Aerial Work Helicopter Operations – Guidance on Aerodrome Operating Minima for IFR Departures
The purpose of this Safety Notice is to provide guidance on aerodrome operating minima and the aircraft commander’s responsibilities for private helicopter flights departing IFR from aerodromes not equipped for instrument departures.
UPDATE 9 June 2016: BCA discusses some ways to say no.
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 29 September 2016: Voice and flight data recordings will remain confidential, the High Court has ruled:
During an inquest earlier this year, the coroner demanded disclosure of the helicopter’s cockpit voice and data recorder.
The AAIB refused to comply and the coroner issued two £100 fines against the body’s chief inspector.
But Mr Justice Singh has said there would be no “public interest” in disclosing the information.
The judicial review challenge was upheld and the disclosure orders and fines were overturned.
See also our earlier article: Scottish Court Orders Release of Sumburgh Helicopter CVFDR
UPDATE 18 October 2016: Yet another case with great similarity: CFIT Gangnam Style – Korean S-76C++
UPDATE 20 October 2016: See this legal analysis: Stephen Spence dissects two recent High Court cases relating to the disclosure of ‘protected material’ held by the AAIB. Note it does incorrectly refer to the ‘Glasgow helicopter’ when it should say ‘Sumburgh’.
UPDATE 1 December 2016: The European Helicopter Safety Team (EHEST) has issued this video on decision making:
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 3 September 2017: Night Offshore Training AS365N3 Accident in India
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 26 May 2018: US Fatal Night HEMS Accident: Self-Induced Pressure & Inadequate Oversight Self-induced pressure and inadequate OCC support / oversight were behind a fatal US HEMS night accident were an AS350B2 departed an unprepared landing site into IMC in which an LOC-I occurred.
UPDATE 10 June 2018: Italian HEMS AW139 Inadvertent IMC Accident We look at the ANSV report on a HEMS helicopter Inadvertent IMC event that ended with an AW139 colliding with a mountain in poor visibility.
UPDATE 2 November 2019: Taiwan NASC UH-60M Night Medevac Helicopter Take Off Accident
UPDATE 19 April 2020: SAR Helicopter Loss of Control at Night: ATSB Report
UPDATE 23 August 2020: NTSB Investigation into AW139 Bahamas Night Take Off Accident
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.”
UPDATE 17 April 2021: Plan Continuation Bias & IIMC in Kenyan Police AW119 Accident
UPDATE 11 February 2022: Erratic Flight in Marginal Visibility over New York Ends in Tragedy
Aerossurance is pleased to again support (and present at) the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 7-8 November 2016.