Fatal EC130B4 Water Impact in the Tennessee River after “Entry to VRS” Say NTSB
Fatal EC130B4 Water Impact in the Tennessee River after “Entry to VRS” Say NTSB (N55GJ) On 3 August 2020 a privately owned Airbus EC130B4 N55GJ impacted the Tennessee River near Knoxville, Tennessee. One passenger, 84 year old local business man Joe Clayton, was fatally injured although the other three occupants escaped uninjured. History of the Flight The US National Transportation Safety Board (NTSB) safety investigation report, issued 28 June 2022, explains that the helicopter was making a local flight from McGhee Tyson Airport (TYS), Knoxville with the intention of landing at the pilot’s riverside property. The pilot, the deceased passenger’s 86 year old brother, had 12600 hours of flight experience, 300 on type. The pilot made a right circling approach at 1000-1200 ft AMSL. The landing site was at c840 ft AMSL according to one mapping site. The pilot stated… …he “was descending with low power and a 25° angle of descent, slowing to come to a hover at low speed over the water.” He…was planning to hover taxi to the landing site at a height about 75 feet above the water and that when he added power to arrest the descent, the helicopter “started to settle.” The pilot is said to have commented to another pilot the next morning that he made a “steep approach” with “little-to-no airspeed” and a rate of descent “greater than 300 feet per minute”. He stated he “pulled max power to stop the settling,” but it was as if the helicopter “didn’t have any power” and it continued to descend until it impacted the river. A passenger reported the helicopter to have been level when it descended and… …the left “skid hit and then rotor hit” and the helicopter was “torqued into the water on the left side.” The pilot and two passengers were able to egress before the helicopter sank. The helicopter came to rest on the bottom of the Tennessee River about 435 ft from the intended landing site. The body of the fourth occupant, seated in the front left seat, was recovered by divers later that evening. The autopsy report noted..[the deceased]…was free-floating in the fuselage and not restrained at the time of recovery. Safety Investigation Damage to the helicopter was “consistent with a low-energy impact”. No pre-impact malfunctions were identified. The…vehicle and engine monitoring display and a digital engine control unit…stored records of failure messages associated with engine operations. The data revealed no failures or limit exceedances prior to impact and indicated the engine was running at the time of impact. Weather reports and statements from the pilot and witnesses indicated that the helicopter descended steeply with little forward airspeed and a tailwind of about 5 knots… The NTSB highlight that the FAA’s Helicopter Flying Handbook (FAA-H-8083-21B) described the aerodynamic condition of Vortex Ring State (VRS) and states: Situations that are conducive to a VRS condition are attempting to hover out of ground effect (OGE) without maintaining precise altitude control, and approaches, especially steep approaches, with a tailwind component. According to ESPN-R / EHEST Leaflet HE 1 Safety Considerations, VRS… …is likely to occur when descending in powered flight at an airspeed below 30 Kts with a Rate of Descent (ROD) close to the main rotor “downwash velocity”. Downwash velocity (or induced velocity) is defined as the airspeed of the airflow drawn down through the rotor disc (Froude formula). The induced velocity is a function of the helicopter type and gross weight. For example, a...
read moreNYPD B429 Accident at Manhattan Heliport “Overapplication of Flight Controls”
NYPD Bell 429 Accident at Manhattan Heliport “Overapplication of Flight Controls” (N920PD) On 13 December 2021 New York City Police Department (NYPD) Bell 429 N920PD was damaged while landing at the Downtown Manhattan Wall Street Heliport, NY. The US National Transportation Safety Board (NTSB) explain in their safety investigation report (issued 14 June 2022) that: The pilot reported that during landing and once established directly over the helipad, he proceeded to hover taxi over to the assigned landing location, but during touchdown the helicopter unexpectedly shifted forward, rotating onto the front skids, then began to oscillate. The crew heard a loud “bang” and subsequently the helicopter became airborne briefly before settling down hard on the pavement and the helicopter started to go into ground resonance, becoming uncontrollable. The pilot reported that the helipad was congested with several other aircraft on the ground and two preparing to land, so when the helicopter became uncontrollable, he “dumped” the collective and rolled back the throttle. During the oscillations, the main rotor blades stuck the wire strike protection system, which resulted in substantial damage to the rotor blades. As well as damage to all four main rotor blades and the WSPS, the landing skids collapsed, the cockpit centre pedestal supports were bent, there was fuselage cracking, damage to the MX-10 turret and an antenna, and leaks of fuel and hydraulic fluid. NTSB Probable Cause The pilots overapplication of flight controls during landing, which resulted in the rotor blades contacting the wire strike protection system and subsequent hard landing. Safety Resources The European Safety Promotion Network Rotorcraft (ESPN-R) has a helicopter safety discussion group on LinkedIn. You may also find these Aerossurance articles of interest: Erratic Flight in Marginal Visibility over New York Ends in Tragedy Inadvertent PTT Pedal Input Causes Tail Rotor Tailboom Contact Loose Clothing Downs Marijuana Survey Helicopter HEMS A109S Night Loss of Control Inflight Air Ambulance A109S Spatial Disorientation in Night IMC A HEMS Helicopter Had a Lucky Escape During a NVIS Approach to its Home Base Air Ambulance Helicopter Struck Ground During Go-Around after NVIS Inadvertent IMC Entry CFIT Gangnam Style – Korean S-76C++ and Decision Making Fatal B206L3 Cell Phone Discount Distracted CFIT US Air Ambulance Helicopter Hospital Heliport Tail Strike Air Ambulance B407 Hospital Helipad Deck Edge Tail Strike During Shallow Approach Air Methods AS350B3 Air Ambulance Tucson Tail Strike NTSB on LA A109S Rooftop Hospital Helipad Landing Accident Air Ambulance Leaps into Air: Misrigged Flying Controls US Air Ambulance Near Miss with Zip Wire and High ROD Impact at High Density Altitude Hanging on the Telephone… HEMS Wirestrike Air Ambulance Helicopter Downed by Fencing FOD Ambulance / Air Ambulance Collision Beware Last Minute Changes in Plan Grand Canyon Air Tour Tragic Tailwind Landing Accident Pedestrian Seriously Injured by Air Ambulance Landing at Melbourne Hospital RLC B407 Reverses into Sister Ship at GOM Heliport Wire Strike on Unfamiliar Approach Direction to a Familiar Site Tool Bag Takes Out Tail Rotor: Fatal AS350B2 Accident, Tweed, ON When Habits Kill – Canadian MD500 Accident EC120 Forgotten Walkaround UPDATE 2 July 2022: Fatal EC130B4 Water Impact in the Tennessee River after “Entry to VRS” Say NTSB Aerossurance has extensive air safety, operations, SAR, airworthiness, human factors, aviation regulation and safety analysis experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates. TRANSLATE with x English Arabic...
read moreLimitations of See and Avoid: Four Die in HEMS Helicopter / PA-28 Mid Air Collision
Limitations of See and Avoid: Four Die in HEMS Helicopter / PA-28 Mid Air Collision (MAC) – EC135P2+ D-HDRV and PA-28 HB-PGF On 23 January 2018 DRF Luftrettung Airbus EC135P2+ HEMS helicopter D-HDRV and Flugschule Basel Piper PA-28RT-201T Turbo Arrow IV trainer HB-PGF crashed after a mid-air collision near Philippsburg, Baden-Wurttemberg, in south west Germany. The accident, which occurred while each was conducting training, resulted in four fatalities (two occupants aboard each aircraft). History of the Flights The BFU safety investigation report, issued 15 September 2021 (in German only), explains the helicopter departed Karlsruhe/Baden-Baden Airport at 12:04 Local Time. The intent was to carry out circuits and emergency procedure training at Speyer Airfield as part of a type training course. The first landing at Speyer took place at 12:29 before commencing further circuits to runway 16. The helicopter took off again at 12:56 and headed to the south-east. There it slowed to wait for a Cessna 172 that had taken off at about 13:06, before making an approach to runway 34. The approach in that direction as the aim was to train for a tail rotor failure and EC135 Flight Manual guidance is that a crosswind from the left was a more advantageous scenario. Meanwhile the PA-28 had also been conducting a training flight having taken off from Basel Mulhouse Freiburg Airport, France at c12:05. During the flight the aircraft twice changed its intended destination, ultimately to Speyer. At 13:02:49, the crew selected the Speyer radio frequency. The air traffic controller at Speyer informed the PA-28 crew both that the current landing direction was runway 16 and of the other traffic in the circuit. ATC subsequently informed the crew of the EC135 that an aeroplane would be landing shortly and told the PA-28 crew that a helicopter was hovering. The aeroplane’s crew reported “traffic not in sight”. ATC radar data shows the PA-28 was in a constant descent from about 130 knots at 3000 ft AMSL toward the downwind leg for runway 16. The helicopter was at 50-70 knots groundspeed at a nearly constant altitude, turning toward runway 34 at 13:07:01. At this point both aircraft were c 1.6 nm apart. At 13:07:12, about halfway through the EC135’s turn, separation was c1 nm. At 13:07:23, the helicopter was now flying towards runway 34 and separation was 0.6 nm. Witnesses had observed the conspicuous, slow-moving helicopter and then suddenly became aware of an aeroplane descending toward the helicopter. Despite a dramatic last moment evasive movement by the PA-28 a collision occurred at about 13:07:41. Witnesses stated that they saw a fireball and aircraft parts falling to the ground. The right wing of the PA-28 had made contact with the helicopter’s main rotor blades, severing the wing. The helicopter caught fire and its tail boom was also severed. Wreckage was scattered over an area of approximately 350 m by 170 m. VIDEO at the scene. At the time of the accident, the sun was c20° above the horizon at c190°. Visibility was c 15nm and the cloud base >4500 ft. The BFU Safety Investigation The BFU note that the EC135 was equipped with a…. …Bendix King MST 67A Mode S transponder, without ADS-B transmission, and a Garrecht TRX 1500A collision warning device… The TRX 1500A collision warning device was designed to be able to recognize possible collision traffic using FLARM and transponder transmissions, visually display this traffic on an external display and, if necessary, generate warning sounds via an audio channel....
read moreInadvertent PTT Pedal Input Causes Tail Rotor Tailboom Contact
Inadvertent PTT Pedal Input Causes Tail Rotor Tailboom Contact (Intermountain Healthcare AW109S N271HC) On 12 November 2019, at c20:08 Local Time, Leonardo AW109SP Grand helicopter air ambulance N271HC of IHC Health Services, was substantially damaged in an nightime event during cruise near Spanish Fork, Utah. The pilot and two flight nurses onboard were uninjured. History of the Flight The US National Transportation Safety Board (NTSB) note in their safety investigation report, issued on 3 June 2022, that it was usual for one of the flight nurses to be in the front left seat during flights without a patient aboard. The flight nurse had been in that role for 11 years, 5 with IHC, but “normally rode in the rear cabin of the helicopter”. About 16 minutes into the flight and 5 minutes from their destination (the scene of a motor vehicle accident on Highway 6)… …the flight nurse, seated in the left front seat, attempted to contact personnel on the ground to coordinate their landing. Rather than step on the push-to-talk (PTT) button located on the cabin floor to activate the radio microphone, he inadvertently stepped on the left anti-torque pedal, which resulted in a rapid yaw to the left. The pilot described this yaw as “severe and violent”. The flight nurse said it “felt like they got hit with strong turbulence over a mountain”. No abnormal noise or vibration was detected. The pilot re-established straight and level flight and landed the helicopter uneventfully. The pilot was 72 years old and had 11173 hours of flying experience, 985 on type. The pilot did not observe any unusual signatures on the exterior of the helicopter during a walkaround inspection after they landed…however, he did not inspect the tail rotor blades or tailboom. The rest of the flight was uneventful, and the pilot did not report any anomalies with the tail rotor blades or tailboom during the subsequent flights that took place during his shift. Next day the oncoming pilot… …conducted a walkaround inspection in daylight conditions and discovered damage to the tailboom as he approached the helicopter. The helicopter was immediately taken out of service and ferried to the company’s maintenance facility for repair. NTSB Safety Investigation The damage to the blades and empennage was consistent with their making contact, and the flight data suggest this occurred during the first leg of the shift flight as the crew did not experience any other events that would have caused the degree of damage observed. When the flight nurse stepped on the left pedal, the pitch of the tail rotor blades would have increased, increasing tail rotor thrust, and yawing the aircraft counter-clockwise. The helicopter was equipped with an Appareo flight data monitoring (FDM) system, which indicated that the yaw was about 11°. An NTSB performance study using data retrieved from the FDM corroborated the pilot’s statement and showed that the helicopter rapidly turned left from a heading of 153° to 142° in 1.25 seconds. When the pilot countered the movement with right tail rotor pedal, the helicopter returned to 151° in 2 seconds. During this time, the helicopter rapidly rolled from level flight to -15° to 15° and pitched up 2° before returning to its original altitude. When the pilot countered with right pedal, the tail boom would have swung back towards the rapidly unloaded the tail rotor. It is likely that this is when the tail rotor blades impacted the tail boom. Further: The helicopter manufacturer provided flight...
read moreNorth Sea Helicopter Struck Sea After LOC-I on Approach During Night Shuttling
North Sea Helicopter Struck Sea After Loss of Control on Approach During Night Shuttling (S-76A G-BHYB 1987) On 9 December 1987 Sikorsky S-76A G-BHYB of Robert Maxwell owned British International Helicopters, formerly British Airways Helicopters and later bought by CHC, contacted the sea during a night approach to the Shell Fulmar Alpha offshore installation in the Central North Sea. The UK Air Accidents Investigation Branch (AAIB) safety investigation report explains that the helicopter, temporarily based on Fulmar Alpha, was shuttling maintenance workers between Fulmar Alpha and the Auk Alpha. Six 6 round trips (12 sectors) were planned that evening between the installations that are 6.4 nm apart. On the fourth sector, whilst descending on an approach from a height of about 500 feet to the Fulmar platform and at about a quarter of a mile from the helideck, the aircraft lost all forward speed and entered a steep descent towards the sea. At a very late stage, the co-pilot managed to arrest the descent just as the aircraft touched the water. The flight was continued to a normal landing on the Fulmar helideck. While this accident is many years in the past and much has changed, the AAIB report does highlight a series of threats that are still relevant to offshore helicopter operations. History of the Flight The flight crew had been detached to Fulmar Alpha and were working a split shift: The duty day began at 0600 hrs and ended at approximately 2000 hrs, and included a “split-duty” rest period between 0745 hrs and 1745 hrs. Both pilot’s had the rank of Captain and so “and it was decided between them who was to be commander”. Because the prevailing wind dictated that all the approaches would be made from the left side of the helidecks, it was also decided that the commander, [seated] on the right side of the aircraft would be the handling pilot [to use the terminology of the time] throughout. The pilots remained in these respective roles throughout the evening’s flying. The Aircraft Commander was 47 and had 6540 hours of flight time, 870 on type. He was… …very enthusiastic about physical fitness and had taken part, with notable success, in both physically and mentally demanding television and social competitions. During the day on which the incident occurred, he had, most unusually, lost several recreational games. The Co-Pilot was 39 and had flown 5662 hours, 518 on type. The fourth sector, with 8 passengers, commenced at 18:43. The weather that evening was well within the requirements for a visual flight and approach to the platforms, the wind was 3500/11 kt, the visibility unlimited and the cloud 4 octas at 2500 feet. Although the sky was nominally less than half obscured by the cloud, it was totally dark, and this darkness was emphasised by contrast to the platform illuminations. On the approach from the south, no other platform or rig was visible to the crew and the sole source of visual reference was the brightly illuminated platform, with its attendant brilliant and pulsating flare. AAIB observe that: …the flare…together with the platform’s working lights, combine to produce a significant contrast to the otherwise dark environment. The short cruise was conducted at about 140 kt, at an altitude of 500 feet. Deceleration commenced about 1 nm from the destination and abeam a Fuel Storage Unit (FSU) vessel moored in the field. Up to this point, the...
read moreAW169 Birdstrike with a Turkey Vulture
AW169 Birdstrike with a Turkey Vulture (N307TC of Travis County EMS STAR Flight) On 22 November 2021, Leonardo AW169 air ambulance N307TC of STAR Flight (Travis County Emergency Medical Services) suffered a birdstrike from a Turkey Vulture near Austin, Texas. The helicopter, which had six occupants, was inbound with a patient from Bastrop, Texas. It was one of three STAR Flight introduced in 2019 as the US launch customer for the AW169 in HEMS operations. The US National Transportation Safety Board (NTSB) public docket, opened 19 April 2022 explains: The medical crew member sitting in the front left cockpit seat, was the first to see the bird and announced its presence. The vulture was first seen ascending from the lower left field of view, it maintained its current track. It looked as though it was going to impact directly in the middle of the right front windshield. As soon as {the Pilot-in-Command] PIC saw the vulture, he maneuvered the aircraft to the left and started to descend in an attempt to avoid the vulture or minimize the severity of the impact location on the aircraft. Seemingly, within a couple of seconds after maneuvering the bird impacted the aircraft. PIC quickly determined that they needed to divert from the intended point of landing at Seton Main Hospital, and land at the STAR Flight Hangar Helipad (TE94) as it was just over 1 minute away. PIC felt that going to the STAR Flight hangar helipad was the most expeditious means to safely terminate the flight. The aircraft landed safely with no injuries to the occupants. When inspected on the ground the damage reportedly consisted of: Cracked front right windshield Cracked windshield support beam Cracked greenhouse window Undetermined main rotor blade surface damage. The AW169 certification basis is CS-29 Amendment 2, dated 17 November 2008. This requires compliance with the following requirement: CS 29.631 Birdstrike: The rotorcraft must be designed to assure capability of continued safe flight and landing (for Category A) or safe landing (for Category B) after impact with a 1 kg bird, when the velocity of the rotorcraft (relative to the bird along the flight path of the rotorcraft) is equal to VNE or VH (whichever is the lesser) at altitudes up to 2438 m (8 000 ft). Compliance must be shown by tests, or by analysis based on tests carried out on sufficiently representative structures of similar design. Turkey Vultures typically weigh 0.8 to 2.41 kg (1.8 to 5.3 lb) so this bird mass most likely exceeded the certification requirements. The rotorcraft velocity at impact is not recorded for this impact. In a presentation on behalf of the Rotorcraft Bird Strike Working Group (RBSWG) to the 11th EASA Rotorcraft Symposium in December 2017 it was revealed that in the US 94% of the current helicopter fleet is made up of types that never needed to meet a birdstrike requirement. CS 29.631 is harmonised with US certification requirements. The AW169s nearest competitor only partially compliant with 29.631 (with the windscreens in particular being noted by the FAA as non-compliant, due to so-called grandfather rights). Safety Resources The European Safety Promotion Network Rotorcraft (ESPN-R) has a helicopter safety discussion group on LinkedIn. EASA have issued Safety Information Bulletin SIB 2021-07 on Bird Strike Risk Mitigation in Rotorcraft Operations and accompanying safety promotion material. You may also find these Aerossurance articles of interest: Safety Lessons from a Fatal Helicopter Bird Strike: A fatal accident occurred on 4 Jan 2009 involving Sikorsky S-76C++ N748P of PHI that highlighted a range safety lessons. We also discuss current...
read moreCompressive Creep and the Loss of a UH-1H’s Tail Rotor
Compressive Creep and the Loss of a Bell UH-1H’s Tail Rotor (N3276T, Mesa, AZ) On 24 April 2020 Bell UH-1H N3276T of VNC LLC / Southwest Rotors was destroyed in an accident at Mesa, Arizona. One pilot died and the other miraculously survived but was seriously injured. The helicopter was positioning from Jacqueline Cochran Regional Airport (TRM), Palm Springs, California to Falcon Field Airport (FFZ), Mesa. The helicopter was type certificated in the restricted category under the Federal Aviation Administration (FAA) Type Certificate Data Sheet (TCDS) H7SO, held by Overseas Aircraft Support Inc since 2008. In their safety investigation report, published 3 May 2022, the US National Transportation Safety Board (NTSB) say witnesses reported… …they observed…white smoke emitting from the tail rotor area. Suddenly, the tail rotor separated from the helicopter… [which] started to spin and impacted the ground. The debris trial was 1/2 mile long. The tail rotor assembly was found at one end and the fuselage, along with most of the debris, at the other end. The NTSB Safety Investigation The NTSB report that: The tail rotor gearbox was fracture-separated at the attachment studs, and four of the fractured attachment stud pieces were found loose within the vertical stabilizer. A fifth stud piece remained stuck in the vertical stabilizer support casting, and the nut end of the sixth stud piece was not located. The chip detector was removed from the tail rotor gearbox and metallic debris was present. The tail rotor assembly was mostly whole and intact. The linkages and tail rotor blades remained secured in place. Progressive crack growth was noted on the mounting studs within the tail rotor gearbox housing. The fracture surfaces were relatively rough, consistent with low cycle fatigue or cyclic overstress crack growth under relatively high cyclic stresses. Additionally, multiple layers of primer, paint, and sealant were observed on the input quill assembly, including paint on the flange clamping surface where it had mated to the vertical stabilizer. Paint was also observed on the vertical stabilizer support casting where it had mated to the input quill as well as the washers for the tail rotor gearbox attachment hardware. The US Army Depot Maintenance Work Requirement No. 55-1560-127 contains instructions for painting the tail rotor gearbox. The instructions contain a step to “mask the top part of the outer flange of input quill sleeve and also the entire studs.” In 2012, the gearbox was removed from another helicopter, repaired, painted, and installed on the accident helicopter. According to the NTSB, the TGB had a main input seal replaced before the painting at Heliponents Inc in Mesa. The FAA requested the detailed work order from the repair station, but those records were no longer available. Then in January 2019… …the helicopter was painted and photographs that were taken during this process indicated that the tail boom, tail rotor gearbox, and tail rotor assembly remained installed during the painting process. In addition, the tail rotor assembly and tail rotor gearbox were masked. Therefore, the paint found on the contact mounting surfaces was likely applied during the gearbox installation in 2012. Th NTSB go on to explain that 39 flying hours earlier… …in April 2019, the tail rotor gearbox was removed from the vertical stabilizer for a corrosion inspection; no defects were noted in the maintenance logs. A retorque and/or torque stabilization check was not completed after the gearbox was installed, nor was it required to be according to applicable technical manuals. A re-torque was included in the Maintenance Manual for the Bell 205, the original new...
read moreReview of “The impact of human factors on pilots’ safety behavior in offshore aviation – Brazil”
Review of: “The impact of human factors on pilots’ safety behavior in offshore aviation companies: A Brazilian case” (Dario Sant’Anna and Adriana Hilal of COPPEAD Graduate School of Business, Federal University of Rio de Janeiro in Safety Science 140 (2021)) Safety Science is the premier peer-reviewed safety journal. In August 2021 they published a paper on safety in the Brazilian offshore helicopter industry. In this article we summarise the context, methodology and key findings and then discuss the implications. Context Brazil’s offshore oil and gas exploration has driven one of the bigger offshore helicopter operation sectors. The main customer of these helicopters is state oil company Petrobras (described as the ‘Main Contractor’ in the paper). This IOGP member company has a dominant market position, contracting 80-90% of all offshore helicopter operations in Brazil. The authors say that there are three big helicopter operators “accounting for more than 85% of the entire sector” and a couple of smaller operators. Pilots typically work a roster with 15 consecutive days on duty for 12 hours per day and almost 8 hours flying each day according to the authors. Exploration of the deepwater ‘pre-salt region‘ had created a lot of oil and gas industry excitement and the potential was so huge that Brazil has started to open the sector to foreign investors operating offshore fields. It was predicted Brazil was heading for a fleet of 200 offshore helicopters in 2020, with particular growth in heavy helicopters for the long-range deepwater fields. The collapse in the oil price in Q3 2014 however had a catastrophic affect on the offshore helicopter sector in Brazil. The fleet declined from 100 helicopters to 70 in 2016, with a number of contracts terminated in 2015. One helicopter operator is reported to have made almost one third of their pilots redundant. New contracts also tended to be shorter two years rather than five. In 2020 Petrobras is reported to have used a reverse auction process to drive down prices. The authors also note that from 2014 onwards the company had been the centre of a major corruption inquiry (‘Operation Car Wash‘), which affected its own capital expenditure and may have further discouraged foreign investment in the oil and gas sector. Privatisation of Petrobas is now being considered. The last fatal offshore accident in Brazil occurred on 16 March 2022. Research Question and Methodology The authors state that the questions their paper was to address were: What are the main human factors that affect pilots’ safety behavior in offshore operations? How can offshore aviation companies manage to mitigate the adverse impacts of those human factors on their pilots’ safety behavior? The research was qualitative and based on transcribing structured one-to-one interviews of offshore pilots typically lasting 1.75 hours. This approach does ensure feedback is gathered from frontline personnel but such qualitative data will be of perception, opinions and more anecdotal facts. Some refer to such studies as being focused on ‘Thick Data‘ rather than ‘Big Data‘ from a more quantitative study. Both types of studies of course have their place. The authors explain that… Interviewees were encouraged to support their statements with examples, and the interviewer asked follow-up questions. The two authors then independently coded the interview feedback and collated their results into themes. Then, in a deductive way, evidence was gathered so as to support the themes and interpretations. Finally, the findings were compared to what...
read moreHeliOffshore 2022 Conference Review
HeliOffshore 2022 Conference Review After two years of virtual events, over 140 delegates from HeliOffshore’s international membership gathered in Cascais, outside of Lisbon, 23-24 April 2022 for the association’s annual conference. Aerossurance, as a committed HeliOffshore member, has attended all six in-person HeliOffshore conferences. HeliOffshore, founded in 2014, is the global collaborative safety association for the offshore helicopter industry. This year’s theme was “a safe and sustainable transition to 2040”. Offshore Helicopter Safety Performance Among the good news was that the industry has seen a significant positive improvement in safety performance in recent years (the subject of HeliOffshore’s eagerly awaited fourth safety performance report due out shortly). There have however been two fatal accidents in the offshore community in 2022 (one in the US and one in Brazil, with 3 fatalities in total). Safety Learning As part of a commitment to moving collaborative safety learning to a new level, two operators did a joint briefing on an lessons learning exercise they had done with HeliOffshore after one non-fatal accident and one serious incident in two different regions of the world that both involved approaches to helidecks at night. Further enhancements are also underway to the HeliOffshore Safety Intelligence Programme (HSIP), including a programme of proactive aggregated flight data analysis on the Sikorsky S-92A fleet. Safety Culture and Human Performance Sessions over both days discussed overlapping themes of sustainable safety culture and enabling human performance. This included mention of some particularly interesting research into “the re-design of the Just Culture process in an international energy company“. This excellent research, published in 2018, had already caught Aerossurance’s attention as a rare, peer reviewed, study that assessed how the implementation of Just Culture procedures were actually working in an organisation (looking at 353 cases). Spoiler alert: the procedures based on the original logic of James Reason were being routinely misapplied and the research went on to discuss how this was corrected. Such misapplication is something we commonly see in the aviation sector, with the process (often based on proprietary flowcharts) actually increases the focus on the capability (or not) of individuals rather than on driving system improvements. Safety Leadership An inspirational high point was a presentation by John Amaechi OBE, the psychologist, former former professional basketball player and author of The Promises of Giants (discussed in this VIDEO). He described a concept of ‘step theory’, namely that in life, everything you do is either a step closer to your vision or a step away from it and the direction you take is your choice. Amaechi advocates developing introspection, interpersonal and organisational abilities in order to enhance leadership skills and sharing ideas before you are ready (trusting your collaborators to contribute to refining the ideas). As he has explained in interviews: Leadership is not a title or role. It’s a promise of a kind of experience. It says if I only have the power to influence these two people, I will wield that wisely and well. After that presentation, HeliOffshore announced a new safety leadership bursary. Aerossurance immediately committed to co-funding that excellent initiative, more details of which will be announced later this year. Next Generation of People & Helicopters and the Rise of Renewables A number of participants commented on the need to thinking about developing the next generation of professionals in our community. Others highlighted that the average age of the offshore fleet is increasing due to the minimal number of new aircraft purchased in recent years (especially in...
read moreLoose Clothing Downs Marijuana Survey Helicopter
Loose Clothing Downs Marijuana Survey Helicopter (B206L3 N27TK) On 28 October 2021, Bell 206L3 N27TK, operated by Helico Sonoma, suffered substantial damage and made a forced landing during an aerial survey flight over illegal marijuana crops near Covelo, Mendocino County, Northern California. According to documents in the US National Transportation Safety Board (NTSB) public docket the Mendocino County Sheriffs Office had chartered the aircraft “explicitly to conduct aerial photography/film operations utilizing reporters from USA Today“. Indeed the newspaper published a feature in December 2021: Marijuana wars: Violent Mexican drug cartels turn Northern California into ‘The Wild West’: Lured by America’s push toward legalized cannabis, cartels have abandoned many decades-old marijuana farms in Mexico, moving their operations to Northern California where they can blend in seamlessly alongside legitimate grows… Mendocino, Humboldt and Trinity counties are known as the Emerald Triangle or Emerald Counties, a region that produces a significant portion of cannabis consumed in the U.S. through legal and illegal grows. Alderpoint, near the epicenter, is known as “Murder Mountain“…due to the prevalence of missing persons cases and shootings. During recent years, violence has intensified in Covelo, a remote valley town in Mendocino surrounded by mountains. The pilot, who was 29 with 1701 hours of flying experience (87 on type), described how: A standard weather briefing was gathered from my Foreflight account, and a company flight plan was filed. Three passengers were to be picked up at Ukiah Municipal Airport (KUKI). The pilot landed at 11:10 Local Time, briefed the passengers and they departed ay 11:40. The briefing included use of doors, headsets, emergency exits, smoking prohibitions, and hazards associated with doors-off operations. I specifically discussed that no loose articles in the cabin are authorization [sic] at any time, and each passenger verbally acknowledged the briefing. I personally inspected the cabin area and determined there were no loose items/articles of clothing that presented hazard to the flight. Only the photographer’s camera gear was present in the cabin, which was physically secured to ensure that it would remain in the aircraft. At 12:00, approximately 9 nm SE of Covelo… I heard the aft-right passenger gasp over the ICS [intercom] and exclaim that she “lost her jacket out the door”. Simultaneously with the gasp I felt something impact the aircraft. I became immediately aware of the potential danger and proceeded to assess the situation. I test the anti-torque pedals which responded normally. I then checked the fore-aft cyclic control to ensure freedom of movement. I experienced an increased amount of control forces associated with resistance against the elevator located on the trailing edge of the horizontal stabilizer. I immediately realized that the jacket had become lodged on the horizontal stabilizer, and therefore was placing the tail-rotor at risk of FOD ingestion. I then made the decision to make a precautionary landing at a gravel bar which was located within autorotative gliding distance at the aircraft’s 3 o’clock. I informed the passengers of the situation, made a distress call on the local CTAF, 122.8, and cautiously flew the aircraft in a circular right hand turn in order to descend and maneuver into the wind. I was deeply concerned the tail-rotor would fail at any moment and maintained an appropriate autorotative airspeed until about 200 agl. I reduced speed and altitude, terminating to a very gentle flare at 5 ft agl decelerating...
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