US Air Ambulance Helicopter Hospital Heliport Tail Strike
US Air Ambulance Helicopter Hospital Heliport Tail Strike (Arkansas Children’s Hospital Sikorsky S-76D N761AF) The US National Transportation Safety Board (NTSB) has recently (19 April 2022) opened the public docket on an accident that occurred to Sikorsky S-76D air ambulance N761AF of Arkansas Children’s Hospital on 12 March 2022 at Texarkana, Texas The helicopter was substantial damaged in a tail rotor strike while landing at dusk on an elevated helipad at the Wadley Regional Medical Center (64XS). The helicopter was inbound to do a patient transfer from the medical centre. This was the pilot’s first flight of the day, having come on duty slightly ahead of schedule at 17:08. The pilot was aged 54 with 3,212 flying hours in total, 174 on type. Two medical personnel were also on board. Their seating positions were not noted in the accident report form. The pilot had not been to 64XS before and examined information on an app on an iPad to gain familiarity with the site when en route. Crucially, the data currently in the public docket does not explain the level of detail available in this app. The pilot reported setting a waypoint 3 miles from the hospital “to establish a descent and deceleration point prior to the landing point to make a smooth transition from cruise flight to landing”. At the near-by Texarkana airport wind was reported as 11 knots, 160° and visibility 10 miles. He explained: Prior to reaching the 3-mile waypoint, I started slowing to 80 KIAS, and initiated a descent to 1500 ‘ MR. I made a call to Texarkana Tower that the hospital was in sight. I told the flight crew that we were about 3 minutes inbound. Upon reaching 80 knots, I lowered the gear and turned on the landing lights and search light. I slowed to approximately 60 knots, and descended to about 1000’. My course inbound…was originally 225 degrees. At about 25-30′ AGL on a very slow approach to the pad [at 18:30], I felt/heard a “thump” in the pedals and immediately the aircraft began to vibrate. We assume “25-30′ AGL” actually means a height of 25-30 feet above the helipad, which is a 50 ft square helipad (so slightly sub 1-D sized for an S-76D whose D-value = 52.5 ft) on the roof of a fourth storey building. The TR GBOX CHIP/TR OIL TEMP HIGH light illuminated and the aircraft yawed to the right. The pilot says: I instinctively lowered the collective and flew to the pad. At almost the point of landing, I pulled the collective for cushion, and the aircraft yawed right about 60 degrees as we settled on the pad. The helicopter was safely shut down without injury. The public docket images indicate the tail rotor struck a building that was an obstacle very close to the helicopter landing area. Examination of imagery suggest the helicopter passed very close to a structure sited to the north east as well as directly over a structure containing a lift shaft that was at c 10 ft above the helipad surface and c 25 ft from the deck edge. The aircraft pitch angle will also have needed to be relatively high too. Our Observations One of the key indicators of whether a safety investigation is competently and thoroughly conducted is whether the focus falls on the person closest to the accident or whether systemic issues are examined. A public inquiry chaired by Anthony Hidden QC investigated...
read moreNTSB: Ergonomics Explain Main Rotor Loss During Flight Test
NTSB: Ergonomics Explain Main Rotor Loss During Flight Test (Bell 206B N61PH) On 16 April 2019 Bell 206B N61PH of Van Horn Aviation was destroyed during a test flight evaluating developmental main rotor blades near Fort McDowell, Arizona. Both occupants were killed. The US National Transportation Safety Board (NTSB) issued their safety investigation report on 6 April 2022. The Accident Flight The NTSB explain the flight was being conducted as a Part 91 test flight and the aircraft was in the Experimental (Special) category. The helicopter was modified to have Van Horn Aviation’s 20635000-501 main rotor blades. These were constructed using carbon fibre/epoxy pre-preg woven fabric and unidirectional tape. The pilot was aged 52, held a Commercial Pilots Licence and had 1200 hours flying experience according to the NTSB. He was accompanied by a 28 year old engineer who had a Private Pilots Licence. Neither the NTSB report nor the public docket mention either having any flight test qualifications. The helicopter made the first test flight of the day between 05:45 and 06:20. After 100 lb of ballast was loaded, it departed again at 06:32 for a flight that was to consist of… …multiple autorotations at maximum gross weight, entered following a 1-second delay after a simulated loss of engine power. The operator reported that the [pilot] would perform all the flight maneuvers and the flight test engineer would perform several tasks during the test flight, which included holding a 17-inch, 7.72-lb [3.5 kg] engineering laptop with his left hand above the cyclic control while simultaneously using and stowing a clipboard and pencil to manage data collection. Flight cards are prepared for each test flight and listed the maneuvers to be performed during the flight. The accident flight was to be the last test flight of the main rotor blades before their certification process. Cyclic controls were installed at both seat positions, reportedly a deviation from procedures according to the operator (although no procedural documents are reproduced or referenced in either the NTSB report or the public docket). A review of the radar data revealed that the accident flight duration was about 34 minutes. The pilot executed multiple turns and descent maneuvers near the area of the accident site. The…final radar-recorded altitude was…about 3,000 ft above ground level (agl). A witness saw the helicopter falling from the sky and saw several other objects descending to the ground before losing sight of it behind trees. NTSB Safety Investigation The examination of the accident site revealed post-crash fire and impact damage consistent with a right side-down, nose-level attitude during ground impact. The main rotor hub assembly, vertical fin stabilizer, tail rotor assembly, tail rotor driveshaft, and forward induction cowl fairing separated from the main wreckage and was found in the debris field. One main rotor blade was found furthest from the main wreckage. The other main rotor blade was found near the main wreckage. The debris field was about 1 mile long and 1,000 ft wide… Damage found was consistent with a mast bumping event. …a phenomenon specific to the 2-bladed teetering or underslung rotor system where the rotor hub flap stops shear the mast. Mast bumping is the result of excessive rotor flapping. No evidence of any prior mechanical malfunctions was found. The NTSB comment on the challenging ergonomics: In order for the engineer to operate the computer or take notes on the clipboard, he would have to hold the computer with one hand while using the other to enter commands or take notes....
read moreBusiness Jet Apron Jet Blast Injury
Business Jet Apron Jet Blast Injury (GX N307KP, Augusta, GA) On 16 October 2019 a passenger being escorted across the apron of Augusta Regional Airport (AGS), Augusta, Georgia to a waiting Learjet operated by department store Dillard’s was seriously injured by the jet blast from Bombardier BD-700-1A10 Global Express XRS N307KP that had just started to taxi. The US National Transportation Safety Board (NTSB) issued their safety investigation report on 6 April 2022. According to the injured passenger, she and six other passengers were being escorted by one of their pilots to a Learjet. She stated that she was about 70 ft from the Bombardier when she was knocked over by the jet blast from the engine. The first officer of the Learjet stated that he was walking to the airplane with two passengers, and the five remaining passengers were following behind them. As some of the passengers were about to board the airplane, he heard a loud roar and felt a strong, warm gust. He turned around and saw one of the passengers on the ground. He stated he initially thought the Bombardier only had its auxiliary power unit running and believed the airplane was far enough away. The FO also stated the injured person was briefly unconscious, A second passenger was blow over but only suffered cuts to her knees. The Bombardier aircraft had arrived to drop one passenger off: They shut down the left engine and deplaned the passenger, restarted the left engine, and taxied back to the runway. During the entire stop, the rotating beacon was on and the right engine was operating. The captain stated that he used normal breakaway power to get the airplane out of the parking spot, then taxied at normal speeds. An FAA inspector commented that there was a procedure “for marshalling the transit aircraft in, but not marshalling them out of the ramp”. The NTSB Probable Cause was: The first officer’s failure to maintain a safe distance from a large turbine-powered airplane while escorting passengers, resulting in a passenger encounter with jet blast. Safety Resources You may also find these Aerossurance articles of interest: Fatal ATC Handover: A Business Jet Collides with an Airport Vehicle on Landing Pedestrian Seriously Injured by Air Ambulance Landing at Melbourne Hospital Challenger Damaged in Wind Shear Heavy Landing and Runway Excursion Pilatus PC-12 Collided with Pick-Up Truck During Dusk Take Off Ground Collision Under Pressure: Challenger vs ATV: 1-0 Visual Illusions, a Non Standard Approach and Cockpit Gradient: Business Jet Accident at Aarhus Gulfstream G-IV Take Off Accident & Human Factors Fatal US G-IV Runway Excursion Accident in France – Lessons Execuflight Hawker 700 N237WR Akron Accident: Casual Compliance Unstabilised Approach Accident at Aspen Business Jet Collides With ‘Uncharted’ Obstacle During Go-Around Disorientated Dive into Lake Erie Fatal Falcon 50 Accident: Unairworthy with Unqualified Crew G-III Attempted Takeoff Using Runway Edge Lights as Centerline G200 Leaves Runway in Abuja Due to “Improper” Handling Cockpit Tensions and an Automated CFIT Accident Global 6000 Crosswind Landing Accident – UK AAIB Report BFU Report on Dramatic Challenger Wake Vortex Accident Falcon 7X LOC-I Due To Solder Defect Misfuelling Accidents A320 Rolls Back on Stand: Incomplete Maintenance Procedures and Ground Handling Deviations Runaway Dash 8 Q400 at Aberdeen after Miscommunication Over Chocks A330 Starts to Taxi Before Tug is Clear Jetstar Dispatcher Forced to Run After Distracted Pushback A320 Collided with Two...
read moreHelideck Heave Ho!
Helideck Heave Ho! (CHC/BHS Sikorsky S-76C++ PR-CHI) On 16 February 2014 Sikorsky S-76C++ PR-CHI of CHC‘s Brazilian Helicopter Services was damaged when landing on the bow deck of the drillship Aban Abraham while on charter to Brazilian state oil and gas company Petrobras. According to the Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA) safety investigation report (finally released 16 November 2021 in Portuguese only) the helicopter had departed Cabo Frio Airport (SBCB) at 07:12 Local Time. It was to route to Aban Abraham NS07 (9PDA), then the Petrobras P-63 FPSO (9PHD), back to the Aban Abraham and then returning to Cabo Frio. Details of the helideck pitch, roll and heave (P/R/H) was not available when the aircraft departed Cabo Frio but were to be radioed by each vessel no later than 20 minutes before landing. During the third sector from P-63 to Aban Abraham the drillship’s radio operator reported the P/R/H was “within the limits for landing”. The data came from the vessel’s Helideck Monitoring System (HMS) and limits had been set that “were known to the [helicopter] crew and [drillship] radio operator”. However, CENIPA do not detail the limits in use in their report. According to CENIPA: …minutes before, there had been variations in P/R/H greater than the maximum permissible for the operation of the aircraft, which were not reported. No document or standard was found that contained instructions for the radio operator about the time interval to be considered when reading the maximum P/R/H values of the helideck on the HMS… Indeed CENIPA state that the HMS also showed “several peaks of heave above the limits” shortly before the landing. However, the CENIPA report unhelpfully includes no HMS or FDR data. The flight crew “performed a direct approach for landing” and perceived “some more prominent movements of the helideck” once they were below 500 ft. They “considered the possibility of a go-around…about one minute before the occurrence” but decided to continue. Ultimately there was a heave that ‘surprised them”, followed by a second one about 2 seconds later that resulted in an abnormal contact between the helideck and the right main landing gear, which collapsed. The helicopter was shut down and all 12 occupants safely disembarked. The helicopters was subsequently removed as an underslung load by a Kamov Ka-32. CENIPA Analysis Firstly CENIPA state: …the lack of a time interval [defined in regulation] to be considered by the radio operator for reading the P/R/H data on the HMS…in order to determine a safe condition for landing inside operating limits, contributed to the occurrence, as it allowed the crew to proceed to the landing at the helideck with information different from that actually found by the aircraft at the time of landing. While this is a sound systemic focus, the investigators decided with hindsight bias, to use the crew’s candour against them by determining… …the piloting judgment of the crew also contributed to the event, since despite having perceived more relevant movements of the helideck and having been considered a go-around, the pilots decided to proceed with the landing, judging that the conditions were favourable, thus highlighting a deficiency in the assessment of the scenario… This is a classic case of Catch 22 in a safety investigation. A statement that indicated the crew had failed to notice high levels of heave would potentially have resulted in a determination that lack of attention was contributor, while mentioning worsening conditions is judged as a failure to act. Safety Actions...
read moreSAR Seat Slip Smash
SAR Seat Slip Smash (RCAF CH149 Leonardo Cormorant LOC-I) The Royal Canadian Air Force (RCAF) is investigating a Loss of Control – Inflight (LOC-I) accident that occurred to Search and Rescue (SAR) Leonardo CH149 Cormorant (AW101) CH149903 at Gander, NL on 10 March 2022. The SAR helicopter, callsign Outcast 903, of 103 Search and Rescue Squadron, 9 Wing was completing an onshore rear crew focused training flight, the first of two planned for the day at c15:42 Local Time. There were six crew members on board: two pilots, two Flight Engineers and two Search and Rescue Technicians. At the end of the first training mission, the crew conducted hover work in the vicinity of the intersection of Runway 31 and Runway 21. During the final clockwise hover turn sequence, the pilot flying’s seat unexpectedly descended to its lowest position. The aircraft flight vector immediately reversed from a clockwise rotation to an accelerated counter clockwise left yaw about the aircraft mast. As the aircraft continued to yaw left, the attitude of the aircraft became unstable resulting in an increasing right bank attitude. The aircraft rotated through approximately 400° and as the right rolling moment intensified, the right outboard wheel, the horizontal stabilizer assembly located on the right side of the tail section, and main rotor blades impacted the runway. Two of the crew received serious injuries, three minor injuries and one egressed uninjured. The aircraft was significantly damaged on impact with the ground (although AW101s, aka Merlins, have been successfully rebuilt after major accidents [in one case an accident in Afghanistan, followed by being dropped by a US helicopter during the recovery and being dragged into a compound by armoured vehicle!]). The RCAF report their safety investigation is focusing on “materiel and human factors“. We will update this article as they release more information. UPDATE 29 July 2023: The conclusions of the investigation have been published: The investigation determined that a combination of factors, including seat non conformances and the horizontal position that was maladjusted, allowed the seat to be in a false lock condition. When the seat dropped, the loss of outside visual references in combination with the severe vertical vibration resulted in an unrecognized spatial disorientation of the pilot flying. This caused the pilot flying to incorrectly perceive a right yaw and apply full left pedal input; this led to a severe left yaw and contributed to the change in roll attitude that likely rendered the helicopter unrecoverable. Multiple special inspections and aircrew information files were issued to address the seat non-conformances and avoid false lock conditions. Additional preventive measures have been identified to address deficiencies in fire fighting services, egress and tracking of armament as highlighted during this investigation. CBC have gone on to report that: The seat’s lock pins, which lock it in place, were shorter than manufacturing requirements… That could result in the pins not fully engaging with the locking mechanism…which could provide a false sense that the seat is locked. The pins can’t be seen when the seat is installed “meaning there is no opportunity for visual confirmation by the pilot to know the seat is locked in place”. The pilot checked whether the seat was locked before the flight by doing a “wiggle check,” according to the report, moving back and forth to make sure it was locked in place. CBC say that investigators… …also found that the...
read moreInvestigation into Collision of Truck with Police Helicopter
Investigation into Collision of Truck with Police Helicopter (AS350B2, PR-CJD, Brazil) On 18 January 2020 Airbus AS350B2 PR-CJD of the Public Security Department was hit by a truck while rotors running on a road in Rio Branco, Acre, Brazil. The two occupants and the truck driver suffered minor injuries. Three other occupants of the police helicopter and two passengers in the truck were unharmed. The Brazilian accident investigation agency CENIPA issued their safety investigation report on 9 February 2022. The Accident The tasking was to support a vehicle checkpoint. The helicopter had landed on one side of a two lane, 23 m wide, turning area between two carriageways, surrounded by overhead electric cables and lamp posts. The aircraft had remained on the ground for about 30 minutes. The tail was marked with a single traffic cone at that time. The collision occurred after the team had re-boarded the helicopter and was was rotor-running, preparing for departure. The crew believed that as turning vehicles would be travelling slowly and because the helicopter was “visible” and “noisy” it was not necessary for traffic to be stopped. The driver of a turning truck, approaching from behind the helicopter, did not notice the helicopter and struck the main rotor. Although not commented upon by CENIPA, the truck appears to have been carrying barrels of biological waste, some of which appear to have been damaged. The unit operated under RBHA 91 Sub-Part K regulations for Public Security / Civil Defence Operations as a ” Small Civil Aviation Service Provider”. 91.961 states in relation to operating from ad hoc urban sites: It is incumbent upon the [Public Security / Civil Defence] Agency to establish training programs and standard operating and flight safety procedures in order to guide the conduct of crews under such special conditions. The aircraft commander, who had a Commercial Pilots Licence, had 1142 hours flying experience, the co-pilot, who held a private Pilots Licence, 201. Neither had been formally trained in operating from public roads and the unit’s training manual did not cover the topic. They had only done this the day before for the first time. The unit also had no CRM training programme and recording irregularities were found in the aircraft’s technical records. CENPA Contributory Factors Analysis and Safety Recommendations Attitude: There was an inadequate assessment of the risks associated with the [start-up] while vehicles and people could move freely around the helicopter…which revealed a complacent attitude towards important procedures for the safety. Training: The lack of a formally implemented training program resulted in organizational failures that led to…operation on a public road, without the proper isolation of the area. Communication: …communication between the crewmembers and the crew on the ground (police checkpoint) did not involve the dissemination of relevant information about the operation. Crew Resource Management: There was inefficiency in the use of human resources available… Team dynamics: The inadequate evaluation of all parameters related to that operation…contributed to an inefficient performance by the team. Flight planning: The need to interrupt the traffic of vehicles, of people, and the [value] of carrying out a detailed briefing involving the crew and ground crew (police checkpoint) were not adequately considered. Management planning: [two occupants, wearing crewman’s ‘monkey’ harness but not strapped into their seats] were thrown out of the helicopter [which] revealed the inadequacy in the planning… with regard to the provision and control of the use of equipment. Organizational processes: The inefficiency…planning, documentation of standards and procedures, risk management and operational safety management led...
read moreDry Ice Packing Error Incapacitated Pilot on Taxiway
Dry Ice Packaging Error Incapacitated Pilot on Taxiway (West Air Cessna C208B N781FE) On 23 November 2018 the pilot of Cessna 208B N781FE, operated by West Air for FedEx, became incapacitated shortly before take-off at Meadows Field Airport (BFL), Bakersfield, California in a dangerous goods incident. The US National Transportation Safety Board (NTSB) has so far only published a preliminary report but did release the public docket on 23 March 2022. The Incident The aircraft was being operated single pilot. It landed at the airport at 16:10 Local Time and taxied to the FedEx ramp were FedEx personnel loaded cargo into the cabin. There were 41 boxes, marked as containing a total of 36 kg of dry ice (frozen CO2), among the cargo. A FedEx dangerous goods representative had approved the shipment as the dry ice mass furnished by the shipper was below the company’s limit of 76 kg for the C208B. The pilot stated that he infrequently flies with dry ice and when he does, he usually only has about 10 boxes with him (also at 0.9 kg per box) and usually places them in cargo zones 5 or 6 (near the back), not zones 1, 2, and 3, which are located right behind him. On the of the incident, the packages were placed behind the cockpit in zones 1, 2, and 3 for even weight and balance distribution. After the loading was completed, the pilot finished his paperwork and started the aircraft at 17:29. The evening was cool and so the pilot closed the ventilation. While taxing to runway 30R the pilot felt “strong sleepiness” accompanied by difficulty breathing. He stopped the aircraft at the runway run-up area and momentarily closed his eyes. Remarkably only after the pilot had failed to respond to repeated calls from air traffic for c20 minutes, did aid reach the aircraft. A firefighter on reaching the aircraft observed “an occupant with his head rolled back and his mouth open”. The fire service chocked the aircraft and shutdown the engine. The pilot was brought round by a ‘sternal rub‘ but initially his speech was unintelligible. Shortly after “he was able to demonstrate to the firefighter that he was coherent by answering a series of relatable questions”. Safety Investigation The boxes were found to be damp but in good condition. Some had frost on them. An FAA Inspector reported: Outer box had shipping and hazmat label, inside that box was thermal wrap/bag (see pics) which was basically bubble wrap with a Mylar coat, inside the thermal bag was the food product box and loosely placed dry ice pellets. The thermal bag was folded over and loosely taped closed. A driver/check-in clerk at a specialist food shipment company was interviewed by NTSB. They had worked in that post for 5 years and “also supported packing when the company needed help”. According to his understanding of the dry packing process at the time, for boxes that required 0.9 kg, he would place one and a half scoops of dry ice in the insulated packaging surrounding the box. They discovered after the incident that this was consistent with 3-4 lbs of dry ice instead of the 2 lbs prescribed by the label on the side of the box. For larger boxes, he would use 2 scoops of dry ice. The NTSB comment that: FAA calculations showed that the actual...
read moreHEMS Pilot Seizure While Rotor-Running
HEMS Pilot Seizure While Rotor-Running (ÖAMTC Airbus EC135T2+ OE-XVD) On 23 May 2019, HEMS Airbus EC135T2+ air ambulance OE-XVD of ÖAMTC was tasked to attend to an injured construction worker at the Galzig ski resort, near St. Anton, in the Tyrolean Alps, Austria. While on scene, rotors running, while the casualty was being loaded, the helicopter began to slide. The EC135 yawed approximately 270° until the tail struck a snow bank. The impact ejected the half-loaded casualty, who received a further minor injury. The Sicherheitsuntersuchungsstelle des Bundes (SUB) issued their safety investigation report (in German only) on 28 February 2022. The SUB report explains that the doctor alerted the pilot by radio to the aircraft movement when they detected it starting, but received no response. When the doctor looked into the cockpit, he saw that the pilot was standing on the anti-torque pedals, with his hands clenched in front of his chest, having a seizure. There had been no prior warning signs of an impending medical emergency. As a consequence of this seizure the pilot lost control of the helicopter. The helicopter’s tail brushed against an embankment before being stopped by the collision with a wall of snow. The pilots convulsions continued for 2-3 minutes. The pilot was aged 42 and held a Class 1 Medical Certificate issued on 28 March 2019 (less than 2 months before). The pilot had however suffered what was classed a traumatic brain injury in a domestic accident in May 2017 and spent 4 days in hospital. The pilot underwent a series of tests and medicals subsequent to the head injury that were considered ‘comprehensive’ by the investigation’s specialist advisor. Apart from a slight loss of hearing in one ear no long-term issues were detected. The pilot was cleared to fly again in November 2017 and was being examined by a specialist every 6 months. After the May 2019 occurrence, his medical certification was removed. As part of the investigation, the possibility of flicker vertigo induced fit due to flickering sunlight through the main rotor. On an EC135 this frequency is 26.3 Hz, which is outside the 4-20 Hz range that research has established is critical for flicker vertigo. The investigators report that the operator already had numerous elements from EASA AMC1 CAT.GEN.MPA.215 Pilot Support Programme in advance of the regulatory deadline. The investigators comment that the operator… …convincingly demonstrated that it has a Just Culture and a safety-oriented culture as a prerequisite for an EASA support program and that it has taken several damage-reducing and livelihood precautions in the event of a pilot losing his license. The Investigator’s Conclusions The helicopter lost control due to pilot medical emergency. The expert commissioned by the federal safety investigation agency sees the previous craniocerebral trauma as the most likely trigger for the tonic-clonic seizure. The company offered the pilot extensive support. 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: Dry Ice Packing Error Incapacitated Pilot on Taxiway Austrian Police EC135P2+ Impacted Glassy Lake Fish Spotting Helicopter Strikes Glassy Sea EC135P2 Spatial Disorientation Accident Canadian Flat Light CFIT HEMS EC135T1 CFIT During Mountain Take Off in Poor Visibility Air Ambulance Leaps into Air: Misrigged Flying Controls A HEMS Helicopter Had a Lucky Escape During a NVIS Approach to its Home Base Pedestrian Seriously Injured by Air Ambulance Landing at Melbourne Hospital Air Ambulance B407 Hospital Helipad...
read moreBig Bustard Busts Blade: Propeller Blade Failure After Bird Strike
Big Bustard Busts Blade: Propeller Blade Failure After Bird Strike (Airlink J41 ZS-NRJ vs a Kori Bustard, Venetia Mine, South Africa) On 3 January 2022, BAE Jetstream 41 ZS-NRJ of Airlink suffered a bird strike and propeller blade loss after touchdown at Venetia Mine Aerodrome (FAVM), Limpopo Province, South Africa. The propeller blade entered the cabin but fortuitously on this low load factor flight (there were only 4 passengers) none of the occupants were injured. The South African Civil Aviation Authority (SA CAA) Accident and Incident Investigations Division has issued their Preliminary Report: FAVM is an unmanned, licensed aerodrome; it has one runway [1538 x 15 m] oriented 08/26. Approximately 15 nautical miles (nm) to FAVM during descent, the first officer (FO) made a radio call to FAVM inspector…to inform him that they will be landing shortly. Thereafter, the aerodrome inspector went to performed runway inspection in preparation for the aircraft to land. After he had completed inspection, he called the crew and informed them that all was clear. The crew stated that touchdown was normal on Runway 08 [at c08:10 Local Time], however, during the landing roll at a ground speed of approximately 104.6 knots with the propellers in the reverse thrust configuration (course pitch), a large bird got airborne from the grass area next to the runway on the right side. The bird impacted the right-side propeller and one of the blades was severed. The aircraft was fitted with EASA certified MT Propeller MTV-27-1-NCFR(G)J/CFRL-285-82 propellers, whose installation on the J41 was certified under a local Supplemental Type Certificate (STC) to replace the original propeller. These propellers are made from ‘natural composite’ (i.e. laminated compressed wood). Blade debris penetrated the fuselage at the third row of passenger seats. Some debris exited through the left hand side cabin window. The out of balance force damaged the engine mounts and propeller gearbox. According to the crew, the bird strike caused the aircraft to shake and the number 2 engine to show over temperature indication. The Exhaust Gas Temperature (EGT) indication was over 750°C. The crew followed the engine shut down procedure while bringing the aircraft to a stop on the runway. The SA CAA say that the accident was “considered survivable”, though this appears to be simply because row 3 was unoccupied. In fact… The cabin crew member reported that the passenger who was seated in row 3 for weight and balance purposes, vacated the seat during flight to occupy one of the empty seats at the back of the aircraft. The bird was identified as a Kori Bustard. This species is described as: …. They live in grasslands and savannas in eastern and southern Africa. Male kori bustards range in weight from 24-42 pounds (11-19 kilograms), and females are roughly half the size of the males. They stand about 5 feet (1.5 meters) tall. Kori bustards are omnivorous birds… Insects form a large portion of their diet, especially when they are chicks. They also eat a variety of small mammals, lizards, snakes, seeds and berries. They have been observed eating carrion. The Kori Bustard far exceeds the size of bird that aircraft, engines and propellers are designed to withstand (19 kg is an order of magnitude greater than the maximum mass for propeller certification). Hence, airfield bird control measures are critical. The SA CAA publish this extract from the Aerodrome Operations Manual: UPDATE 6 February 2023: SA CAA...
read moreOffshore Night Near Miss: Marine Pilot Transfer Unintended Descent
Offshore Night Near Miss: Marine Pilot Transfer Unintended Descent (Le Havre AS365N3 F-GYLH) On the night of 11 February 2021 Airbus AS365N3 F-GYLH nearly collided with the surface of the sea off Le Havre during a Marine Pilot Transfer (MPT) flight with 4 people on-board. The BEA (the Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile) issued their safety investigation report (in French only) into this serious incident on 10 February 2022 that highlights issues of automation use in a high workload flight. Organisational Context The helicopter was operated by the Le Havre-Fécamp Pilot Station. Dating from the 16th century, that organisation provides pilotage for ships visiting Le Havre, Antifer and Fécamp. They use both launches and their own AS365N3 for marine pilot transfer. They first introduced helicopter in 1976, an Alouette III. They did suffer a fatal accident on 8 September 2005 when their previous AS365N3, F-GYPH, collided with the surface of the sea at night off Cape Antifer. It was manoeuvring to rendezvous with a tanker that has entered a fog bank. In the 2005 accident the contributory factors identified were, the pilots “overconfidence”, “uncorrected behavioural deviations” (such as the pilot not routinely wearing his seat harness) and “a management structure that did not allow sufficient surveillance of the activity to be exercised”. After the 2005 accident procedures for the use of autopilot upper modes were reportedly enhanced and greater emphasis made of crew resource management with the hoist operator. The Pilot Station is a form of collective, managed by an elected President. The President is the Accountable Manager for the purposes of European Regulation (EU) No. 965/2012. According to the BEA the operation is treated as non-commercial air transport operation under Part-NCC and Part-SPO for the hoisting operations. Although not required by Part-NCC, F-GYLH was equipped with a combined CVFDR (a Honeywell ARCOMBI) as a learning from the 2005 accident. The Pilot Station employed two helicopter pilots. One was also the Flight Operations Manager and the other the Safety Manager. The aircraft was maintained by two engineers, who were also trained as the hoist operators i.e. Technical Crew Members (TCM). The Head of Compliance Control was a part-time, outsourced role. The BEA do not comment on the management of Flight Training or Continued Airworthiness. The BEA explain that in 2019, due to a shortage of engineers, four having resigned over two years, flight operations had been paused for a period. The February 2020 annual internal audit had identified… …a significant decrease, over the 2019 period, in the level of performance of the helicopter department and the aircraft dispatch rate, with numerous machine stoppages for technical and human reasons. At the same time, a significant increase in non-conformities is noticeable in the present audit in contrast to the previous one… The audit report also highlighted cultural issues between the helicopter department and their parent organisation which created… …a slow but certain drift of the operational standards of the exploitation, a reduction of the attention during the times of duty, a professional disengagement of the crew members, creates blocking points in the daily operation and fosters a confrontational environment. The report acknowledged that meetings had been held to attempt to resolve the issues but it was a lingering issue. The issue had been raised during audits by the regulator and in particular the specifics of hoist operator training (topical due to the turnover in engineer / hoist ops). The BEA note that...
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