Black Hawk Scud Running in Tennessee: IIMC & CFIT
Black Hawk Scud Running in Tennessee: IIMC & CFIT (Arista Aviation Services Sikorsky HH-60L N260MW near Tullahoma) At 15:00 on 28 February 2019, Sikorsky HH-60L N260MW of Arista Aviation Services suffered a Controlled Flight into Terrain (CFIT) near Tullahoma Regional Airport (THA), Tennessee during a ferry flight. A Visual Flight Rules (VFR) flight plan filed, however Instrument Meteorological Conditions (IMC) prevailed at the accident site, suggesting Inadvertent entry into Instrument Metrological Conditions (IIMC). At this time, three years after the accident, the US National Transportation Safety Board (NTSB) has still only published a preliminary report. On 9 March 2022 however, the NTSB public docket was released. The NTSB explain that: …the purpose of the flight was to reposition the helicopter for maintenance and inspection. Part of the purpose of the inspection was to add the helicopter to a specific Restricted Type Certificate for ex-military Black Hawks. There are some indications the helicopter was then due to be displayed at Heli-Expo in Atlanta, Georgia (4-7 March 2019). The special airworthiness certificate and ferry flight permit were issued for the flight from Enterprise Municipal Airport (EDN), Enterprise, Alabama, to THA, which included a restriction for VFR operation. The crew were aged 69 and 70, each coincidentally with 6800 flying hours of experience, 2500 on type. They reportedly knew the route well. According to the pilot-in-command, the crew departed EDN earlier that morning, destined for THA. They had stopped at 4A6 [Scottsboro Municipal Airport, Alabama], which was about 42 miles from the destination, for fuel [paid for at 12:27] and lunch. Arguably this was a breach of the ferry permit that was for a direct flight from EDN to THA. He recalled that the weather at that time appeared to be clear. They departed from 4A6 with no issues. The preliminary report does not state when the aircraft departed Scottsboro. The accident report form however claims it was at 14:00, i.e. an hour before the accident, even though the accident site was only “42 miles from the destination”. According to the preliminary report, the crew planned to fly at 500 ft and… While enroot [sic] to THA, the pilot recalled that they had encountered weather and were attempting to turn around when the accident occurred. The accident report form gives more detail (with our emphasis added): During the flight, approximately ten miles from THA, we encountered severe heavy rain, moderate turbulence, along with rapidly deteriorating visibility. We descended to approximately 100 feet AGL to maintain visual contact with the ground. This tactic is known as scud running. When VFR flight conditions were no longer possible we executed a turn and attempted to land the helicopter in an open field. Significantly, the accident site was only 2.5 nm from THA, so the helicopter had gotten very close before the decision to turnaround. The 14:55 weather conditions reported at the THA…included an overcast cloud ceiling at 300 ft above ground level (AGL), visibility 2.5 (statute) miles in mist, temperature 13° C, dew point 12° C. The visibility had reduced to 1 mile at the next recorded observation at 1515. A review of the graphical aviation forecast issued by the National Weather Service at 13:02 revealed that overcast skies were expected in the area around the time of the accident with cloud bases at 1,100 ft MSL and tops at 9,000 ft MSL. Furthermore: Two airmen’s meteorological information advisories were issued at 1200 and 1500, warning of instrument meteorological conditions...
read moreTaxiing AW139 Blade Strike on Maintenance Stand
Taxiing AW139 Blade Strike on Maintenance Stand On 10 March 2018, a Leonardo AW139 helicopter was ground-taxiing at a slow walking pace to park at Townsville Airport, Queensland when the main rotor blades struck a maintenance work stand. The Australian Transport Safety Bureau (ATSB) occurrence brief identifies neither aircraft or operator. They explain that: At the time of the impact, the helicopter was being positioned short of the refuelling area to allow another aircraft to utilise it. The impact was felt as a vibration through the rotor system and had no effect on the fuselage or forward movement. The crew conducted a normal shutdown. Post-flight, engineers inspected numerous components of the helicopter. Damage was isolated to the tip cap assemblies of the main rotor blades. ATSB investigation was conducted, they simply released a limited summary from the helicopter operator. Consequently, no details are provided of the stand and its colour, the background it was viewed against and whether its positioning was ‘normal’ or indeed in accordance with local procedures (whatever they were). Also, there is no detail on the communications (if any) regarding the other aircraft refuelling and whether its presence proved a distraction. ATSB Safety Message Even when operating in familiar environments, flight crew need to remain vigilant for potential hazards in the area and maintain a good look out to ensure distances from obstacles are maintained. 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: S-92A Collision with Obstacle while Taxying Pedestrian Seriously Injured by Air Ambulance Landing at Melbourne Hospital RLC B407 Reverses into Sister Ship at GOM Heliport Pilatus PC-12 Collided with Pick-Up Truck During Dusk Take Off SAR Hoist Cable Snag and Facture, Followed By Release of an Unserviceable Aircraft South Korean Fire-Fighting Helicopter Tail Rotor Strike on Fuel Bowser Ditching after Blade Strike During HESLO from a Ship US BSEE Helideck A-NPR / Bell 430 Tail Strike UK AAIB Report on Two Ground Collisions Ground Collision Under Pressure: Challenger vs ATV: 1-0 Fatal ATC Handover: A Business Jet Collides with an Airport Vehicle on Landing SAR AW101 Roll-Over: Entry Into Service Involved “Persistently Elevated and Confusing Operational Risk” Runaway Dash 8 Q400 at Aberdeen after Miscommunication Over Chocks Gazelle Caught Out Jumping a Fence A320 Collided with Two De-Icing Trucks Helideck Safety Alerts: Refuelling Hoses and Obstructions Air Ambulance Helicopter Downed by Fencing FOD Snagged Sling Line Pulled into Main Rotor During HESLO Shutdown Ambulance / Air Ambulance Collision Hazardous Hangar Hovertaxy Helicopter / Drone Mid Air Collision Filming Off-Road Race UPDATE 2 April 2022: Investigation into Collision of Truck with Police Helicopter The UK CAA has issued this infographic on distraction: Aerossurance has extensive air safety, operations, SAR, HEMS, 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 Hebrew Polish Bulgarian Hindi Portuguese Catalan Hmong Daw Romanian Chinese Simplified Hungarian Russian Chinese Traditional Indonesian Slovak Czech Italian Slovenian Danish Japanese Spanish Dutch Klingon Swedish English Korean Thai Estonian Latvian Turkish Finnish Lithuanian Ukrainian French Malay Urdu German Maltese Vietnamese Greek Norwegian Welsh Haitian Creole Persian TRANSLATE with COPY THE URL BELOW Back EMBED THE SNIPPET BELOW IN YOUR SITE Enable collaborative features and...
read moreAir Ambulance Leaps into Air: Misrigged Flying Controls
Air Ambulance Leaps into Air: Misrigged Flying Controls (Air Evac Lifeteam EC130T2 N894GT, Memphis, TN) On 28 January 2018 air ambulance Airbus Helicopters EC130T2 N894GT of Air Evac Lifeteam was damaged in a hard landing after it inadvertently became airborne while on the elevated landing site at Memphis Regional Medical Center in Tennessee. None of the 4 occupants were injured but impact was hard enough to spread the skids, caused minor structural damage and set off the Emergency Locator Transmitter (ELT). The US National Transportation Safety Board (NTSB) has so far only issued a factual report, although but some additional data is available in the NTSB Public Docket. The 58 year old pilot pilot had 6267 hours total time, but only 9 on type. having completed a 5 day EC130 course at Airbus in early November 2017. His last proficiency check was 11 days earlier. According to the NTSB: While on a long final approach to the heliport, there was a left crosswind present and he had to reduce collective pitch control friction three times in order to move the collective as fast as he felt he needed to. He brought the helicopter to a hover as he reached the heliport, then turned the helicopter to the right and landed. After landing, he started the after-landing portion of the checklist, then turned the throttle twist grip on the collective from “FLY to “IDLE,” believing [our emphasis] that he had engaged the collective lock. He then turned the horn mute switch to mute, grabbed the cyclic pitch control with his left hand, and reached for the clock start button with his right hand. As he was reaching for the clock button, the collective “popped up,” and the helicopter became airborne. He immediately grabbed the cyclic with his right hand, the collective with his left hand, and twisted the twist grip to “FLY.” The helicopter then landed hard, and the emergency locator transmitter (ELT) activated. After exiting the helicopter, the flight nurse advised the pilot that there was damage to the sheet metal of the helicopter. CCTV footage showed the occurrence: The Safety Investigation Examination of the helicopter revealed minor damage. The skid type landing gear was spread out, and both landing gear cross tubes were deformed. The forward belly panels were dented from contact with the forward landing gear cross tube, and the aft closeout panels were dented from contact with the aft landing gear cross tube. Investigators had access to engine data from the Safran Arriel 2D engine’s full authority digital engine control (FADEC) system stored on an engine data recorder (EDR). The helicopter was also equipped with an Appareo Vision 1000 unit, which records images, audio and limited flight data onto a removable SD memory card. NTSB comment that: Review of the onboard video depicted a series of events consistent with the pilot’s statement. Review of EDR data indicated that, during the incident portion of the flight, the recorded transducer position for the collective showed the collective rising from an unlocked position with the helicopter’s engine transitioning from “Idle” to “Flight.” The EC130 can be converted between a dual-pilot configuration (e.g. for training) to a single-pilot configuration. Two days earlier, a mechanic at the Air Evac base at Jackson, Tennessee had removed the right seat dual controls to reconfigured the helicopter for single-pilot operation. When an FAA inspector examined the aircraft… The collective was placed in the full-down position to attach a spring scale to the twist grip to measure the...
read moreSAR Hoist Cable Snag and Facture, Followed By Release of an Unserviceable Aircraft
SAR Hoist Cable Snag and Facture, Followed By Release of an Unserviceable Aircraft (AW139, Victoria, Australia) On 15 December 2020 a Leonardo AW139 air ambulance helicopter was involved in two incidents while attempting to rescue three people stranded on a cliff near Childers Cove, Victoria, 19 km SE of Warrnambool Airport, at 19:00 Local Time. The Australian Transport Safety Bureau (ATSB) report that the helicopter was being flown single pilot with an aircrew officer (winch operator) and a paramedic (winchman). ATSB do not identify the aircraft registration or the operator but images suggest an aircraft contracted by Ambulance Victoria, which online images suggest are only single hoist equipped. Incident 1 The ATSB explain that: The paramedic was winched to the ground and recovered the first stranded person. The aircrew officer then manoeuvred the paramedic and the first person into the aircraft cabin. To allow them to move into the aircraft seats, the aircrew officer winched out some cable to provide slack in the cable. Crucially: During this winch-out procedure, the slack cable was dispensed onto the aircraft floor and out the cabin door. The aircrew officer was aware that the cable was outside the cabin, but not the length of cable that was outside the cabin, and the looped section was not visible. When the aircrew officer commenced the winch-in of the hook assembly, the cable failed. The aircrew officer secured the loose end of the winch cable and the pilot landed the helicopter in a nearby carpark to assess the situation. Upon crew examination it was found that the hoist cable had looped around the right-hand main landing gear resulting in the failure of the cable and damage to several landing gear components. No information is provided on when the remaining two individuals on the cliff were rescued. Incident 2 An engineer was able to inspect the AW139 that evening in the car park shortly before last light. One might expect that even if nothing was said, there would be a perceived pressure to return the aircraft to its base to resume stand-by for the ambulance service as soon as practical. The engineer cleared the aircraft to return to base. However, the ATSB say that… …it was later determined that the damage to the undercarriage rendered the helicopter unserviceable. Safety Actions The ATSB choose not to conduct an investigation and have simply reported information supplied by the operator. ATSB say that the operator took three safety actions: A Safety Alert has been promulgated throughout the company to reinforce the importance of cable control during all phases of winching operations. All personnel have been reminded of the general safety philosophy of the company, which demands that safety related activities, including aircraft inspections and checks, are not rushed nor influenced by time pressures. Any activity should be stopped immediately if any person has any doubt about the safety in relation to a particular operation they are involved in. A learning package is being developed to facilitate sharing of the incident details and findings within the company and other helicopter emergency medical service operators. In summary the actions were ‘an alert, ‘a reminder’ and a ‘learning package’. Being prepared to share the learning package more widely is to be highly commended. Readers who become involved in a similar situation could usefully examine the effectiveness of prior training and competence assessment, the appropriateness of procedures,...
read moreErratic Flight in Marginal Visibility over New York Ends in Tragedy
Erratic Flight in Marginal Visibility over New York Ends in Tragedy (Agusta A109E N200BK) On Monday 10 June 2019 private Leonardo A109E N200BK crashed on to the roof of a 54 storey New York skyscraper killing the pilot, the sole occupant after an erratic flight in poor visibility. No one on the ground was harmed. The US National Transportation Safety Board (NTSB) explain in their safety investigation report (issued 9 February 2022) that the pilot had 2805 hours total time (but they don’t specify the time on type) and had worked for the company that owned the helicopter for about 5 years. That company was owned by the passenger, who had previously disembarked, who was also a pilot. As the pilot was preparing the helicopter for the flight [earlier that day]…he informed his brother that he was nervous about the flight due to the poor weather conditions. His brother suggested that he not fly the trip, the pilot responded that “[the pilot-rated passenger] is making me fly.” About 1200, during a telephone conversation while at 6N5 [the East 34th street heliport], the pilot told his girlfriend that he had a “window” to reposition the helicopter to LDJ [Linden Airport, NJ], and also said that he “shouldn’t be flying, but had to…” After dropping off a passenger during a routine weekly commuting flight, the noninstrument-rated pilot of the helicopter remained at the fixed-base operator (FBO) for about 2 hours, reviewing weather information before departing on the planned repositioning flight, which was the last flight leg of the commute [to LDJ, where the helicopter waited until Friday to reverse the journey]. While there, he was continuously checking weather conditions using his tablet computer. Before he departed, the pilot informed FBO staff that he saw a “twenty-minute window to make it out.” Significantly: According to staff at the FBO at 6N5, fees that would have been incurred for the helicopter to remain at 6N5 started at $200 per hour, with an overnight fee of $250… However: The extent to which those fees or other factors, such as the pilot’s obligation to reposition the helicopter as part of the normal commute, influenced his decision to depart could not be determined. The NTSB explain that the Part 91 corporate flight… …departed into marginal visual flight rules (MVFR) conditions, and soon after takeoff, encountered instrument meteorological conditions (IMC). Although the pilot communicated that he was attempting to return to the departure heliport; shortly thereafter, he transmitted to heliport staff that he didn’t know where he was.” Flight track data depicted an erratic flight path after takeoff, during which the helicopter climbed above the reported cloud base of 500 ft above ground level, and witness video recordings showed the helicopter flying in and out of clouds. About 8 minutes after takeoff, the helicopter descended rapidly and impacted the roof of a building. Examination of the wreckage on the rooftop revealed that all major components of the helicopter were present at the accident site and were confined to an area about 100 ft long and 20 ft wide… No preimpact anomalies with the helicopter were found by investigators, who comment that: The pilot’s decision to depart into MVFR conditions and the helicopter’s subsequent encounter with IMC were conducive to the development of spatial disorientation, and the helicopter’s erratic flight path and rapid descent were consistent with a loss of control due to spatial disorientation. NTSB Probable Cause The non-instrument-rated pilot’s decision to...
read moreWhy a Collective Control Came Loose in a Pilot’s Hand…
Why a Collective Control Came Loose in a Pilot’s Hand… (French Army ALAT Tiger) On the afternoon of 22 March 2021 French Army Airbus EC665 Tiger (Tigre) HAP s/n 2002 of the 5th Helicopter Combat Regiment (5e RHC) was engaged in an area reconnaissance training mission at Castres Le Pesquié. The helicopter had flown to the exercise area from its base at Pau that morning. Investigators of the BEA-Etat (BEA-E) explain in their safety investigation report (issued in French only) During transit to the exercise area, in visual flight at around 500 feet, the pilot in the front seat detected a fault on the collective stick. Holding this handle with his left hand, he notices during a vertical movement that one of his fingers rubs against the seat to the right of the handle, which is unusual. Very surprised, he warned the captain in the rear seat while realizing that the collective stick was moving abnormally in rotation around its axis. The captain in the rear seat decided to cancel the mission, took control of the helicopter and landed safely five minutes after takeoff. Subsequent inspection revealed that the top of the front collective pilot stick (1) could be separated from the lower tube (8) by simply pulling in the axis of the tube. The design is such that there is a cover (7), bolt (6), washers (4 and 5), nut (3) and pin (2). The screw was fitted through the stick and the cover but crucially it did not pass through the holes in the lower tube. The last recorded maintenance on the collective occurred on 28 October 2020, 53 flying hours and almost 5 months earlier. The BEA-E report that the task: …was carried out by a novice technician who had obtained the level 1 technical certificate (CT 1) but was awaiting a type rating course on EC665. The French Army practice is for technicians to gain 6 months of hands on maintenance experience before undertaking a type course. The French FR-145 military aviation maintenance regulations are based on EMAR-145, itself derived from EASA Part-145, so effectively this was a newly qualified A Licenced engineer. He was performing this maintenance operation for the first time, under the supervision of a team leader. The latter considered that the installation of the collective pilot stick was a simple operation with no possibility of error. The technician was given the work card for the task. The team leader remained present during the operation. However, he had no direct view of the actions of the technician during the fitment of the collective pilot stick due to the narrowness of the Tiger’s cockpit. He then checked the assembly a posteriori. At the end, the controller cross-checked the entire maintenance intervention on the flying controls as planned. He did not detect any improper installation of the collective pilot stick. The BEA-E believe it was during this task that the misassembly occurred. Crucially, the BEA-E describe the work card as “succinct”. While conciseness is usually a good thing, in this case the work card “did not present a detailed method for checking the conformity of the installation”. In particular, this was not identified a a critical task, while other tasks that had to be checked by the controller were. The BEA-E explain if the bolt was misaligned, then the cover would sit 6-8 mm proud rather than being flush. This is the distance between fitting the bolt through hole in both tubes and fitting it...
read moreHelicopter / Drone Mid Air Collision Filming Off-Road Race
Helicopter / Drone Mid Air Collision Filming Off-Road Race On 6 February 2020, Airbus Helicopters AS350BA N611TC of Icon Helicopters and a 0.9 kg DJI Mavic 2 Zoom drone collided in mid air during filming of the King of the Hammers off-road race in the Johnson Valley, in the High Desert of San Bernardino County, California. The helicopter escaped with scratches to its windscreen but the drone crashed after a motor arm severed. The US National Transportation Safety Board (NTSB) issued their safety investigation report into this mid air collision on 6 January 2022. The King of the Hammers event is part of the Ultra4 Racing series. The event production company, Hammerking Productions Inc, outsource the management of the video production to a contractor. Its that organisation that then hires in helicopter and UAS operators. The NTSB note that: Five helicopters and four drones were contracted to cover the event. The incident helicopter was operated under Part 91 with an FAA Certificate of Authorization or Waiver to 14 CFR 91.119(b) and (c) for low altitude TV and motion picture filming. The helicopter pilot had 4200 hours of experience including 10 years filming similar events (which suggests the age listed in the NTSB report [20] is incorrect) The incident drone had been leased by the production company from Lens Rentals and was being operated under a “verbal contract” by a 44 year old individual under Part 107 regulations. They had gained their FAA Remote Pilot Certificate in February 2019 and had 90 hours of experience. The NTSB explain that: Event organizers provided pre-race information to the helicopter pilots which included…the flight times and schedule for the race, insurance information, procedures for clearing the course of unauthorized persons, and helicopter landing zones and radio frequencies. They provided a Google Earth kmz map including details of the course and locations [too]. According to race management, the locations of the drones indicated on the map were not containment zones but were meant as an indication of the locations where they would have network connection to transmit the video feed. Organizers stated the drones were limited to less than 400 feet (note: this is in accordance with 14 CFR Part 107) and helicopters were required to remain above 500 feet in areas of spectators (note: this is generally in accordance with 14 CFR Part 91). The area of the collision was not accessible by spectators. A pilot meeting was held on February 2, including helicopter pilots and event management. It did not include the drone pilots. The NTSB report the incident drone pilot (or Remote Pilot-In-Charge [RPIC]) “did not have any operating manuals or checklists for the operation”. They also told the NTSB that, unlike the helicopter pilots, they were not given any event maps. The incident pilots were not in communication with each other, nor was there any provision or requirement to do so. The helicopter pilots covering the course communicated with each other via a common air-to-air frequency. The drone pilots did not use or monitor radio communications. The NTSB recount that: Video from the drone, and the accounts of each pilot, indicate the two aircraft were following a vehicle climbing an undulating dirt track in hilly canyon terrain. Video showed the helicopter visible in the drone camera (which was displayed on the drone pilot’s screen) above and to the right of the drone. The drone continued to follow the vehicle toward the position of the helicopter. As the track turned to the right, the helicopter passed...
read morePedestrian Seriously Injured by Air Ambulance Landing at Melbourne Hospital
Pedestrian Seriously Injured by Air Ambulance Landing at Melbourne Hospital (AW139 at The Alfred Trauma Centre HLS) The Australian Transport Safety Bureau (ATSB) report that on 28 October 2021, while a Leonardo AW139 air ambulance helicopter was landing at The Alfred Hospital Helicopter Landing Site (HLS) in Melbourne, Victoria a passer-by walking along Commercial Road, under the approach path, was blown over and seriously injured. ATSB identify neither the helicopter registration nor the operator. Ambulance Victoria contract five AW139s. The 39 by 42 m elevated Alfred’s HLS opened in 1988 as part of the development of Australia’s first dedicated trauma centre, instituted as part of a programme to tackle major road injuries in particular. It has been claimed that the availability of this centre, one of only two adult trauma centres in the state, has reduced the road traffic death rate by 50% in the state (VIDEO 1). The ATSB explain that: The crew approached the helipad from the west [at about 15:50 Local Time], using a steep approach profile aligned with Commercial Road. There does not appear to have been any subsequent assessment of FDR data to verify the approach. The pedestrian was “about 50 m” to the west of the HLS when they were blown over. The Alfred HLS is located on an elevated platform approximately 8 m above Commercial Road, a publicly accessible thoroughfare with both vehicular [road and tram] and foot traffic. This design is unique in Australia, exposing public vehicles and pedestrians to the possibility of helicopter downwash on landing. VIDEO 2: B412 approach and landing at The Alfred Hospital HLS from the west Previously helicopters had landed in Fawkner Park on the opposite side of Commercial Road. The elevated site was given a A$250,000 lighting upgrade in 2021. The ATSB also comment that they have… …received reports of 5 rotor wash events at various hospital HLSs since 2016. Of these, 3 occurred at The Alfred hospital HLS and all involved AW139 helicopters. After the incident the helicopter operator temporarily ceased operations from the site. They only recommenced operations after they had: Reduced the maximum number of helicopters on the helipad from two to one, removing the requirement to hover taxi away from the centre of the helipad Implemented pedestrian marshalling procedures for all helicopter movements, so that operations will only occur when no pedestrians are within 30 m of the helipad. The hospital has also commissioned a study of the site. Local HLS Regulations and Standards In Australia, CASA CAAP 92-2(2) provides ‘Guidelines for the establishment and operation of onshore Helicopter Landing Sites'(last updated in 2014). The Victorian Health Building Authority (VHBA) also publish Guidelines for helicopter medical transport landing sites Issued June 2020 and rebranded in June 2021). VIDEO 3: AW139 take off from The Alfred Hospital HLS to the west: VIDEO 4: AW139 take off from The Alfred Hospital HLS to the west VIDEO 5: B412 take off from The Alfred Hospital HLS to the north ATSB Safety Message Helicopters produce significant main rotor downwash, especially during hover taxi, take-off and while approaching to land. It is important that the risk of downwash related injuries, either by direct exposure or by being struck by loose items, be assessed prior to using a helicopter landing site (HLS). As pilots have limited ability to reduce rotor downwash during these phases of flight, securing loose items in the vicinity of the HLS and keeping people a safe distance away are the most...
read moreAir Ambulance Helicopter Struck Ground During Go-Around after NVIS Inadvertent IMC Entry
Air Ambulance Helicopter Struck Ground During Go-Around after NVIS Inadvertent IMC Entry (Mercy Flight, Bell 429, N505TJ) At 21:10 Local Time on 6 October 2021 air ambulance Bell 429 N505TJ of Mercy Flight was damaged near Genesee County Airport, Batavia, New York (midway between Buffalo and Rochester). Neither the pilot or the three medical personnel onboard were injured. Mercy Flight are a not-for-profit air ambulance operator that have transported 30,000 patients over 40 years. The Accident Flight Information released by the US National Transportation Safety Board (NTSB) in their public docket on 4 January 2022 reveals that the aircraft had been tasked to collect a patient and deliver them to Strong Memorial Hospital, Rochester, New York. A short 10 minute third sector was necessary to return to their home base at Batavia-Genesee County Airport. The pilot had been flying for 30 years, including flying for a Police Department, and most recently had flown for Mercy Flight for 5 years. He had flown 3583 hours in total, 621 on type and 1049 at night. He held an Instrument Rating. His instrument experience consisted of 11 hours actual and 49 simulated. He was working his usual 20:00-0800 shift and woken at 17:00 after a “good night’s rest”. All three sectors were conducted using a Night Vision Imaging System (NVIS) and Night Vision Goggles (NVGs) in what were stated to be Visual Flight Rules (VFR) conditions. The pilot had checked the weather before the first sector but did not recheck at Strong Memorial Hospital “because it was clear”. The automated data at 20:50 for their destination was cloud at 1400 ft and 10 mile visibility, 10ºC air temperate and a dew point at 9ºC . As the helicopter neared the airport several occupants noticed “patches of fog” which they discussed over the intercom according to an interview with the pilot. Curiously the brief narrative in the accident report form appears to contradict that by stating that no one onboard saw “the isolated fog bank” (although could relate to a specific patch of fog). Once the airport was in sight the pilot terminated the radar service and self-vectored for “a practice RNAV-28 LPV approach, under VFR”. In interview with the FAA the pilot reported that the 4-axis autopilot was coupled and that the “runway and lighting was in sight all the way down the glideslope”. The pilot stated he “did not notice the fog” through the NVGs. The FAA interview states he did not ‘look under’ (i.e. below) the googles and it is surprisingly stated that looking below was “not normal”. This was not apparently challenged by the FAA interviewers. An FAA interview summary then states: At about 200 feet, he inadvertently entered a fog bank and lost visual reference to the runway. According to comments by the operator on the accident form, the pilot decided to hand-fly the aircraft “because of the close-proximity to the ground”. However: He attempted a climbing right turn to exit the fog, but forgot to totally de-couple the autopilot. He was able to momentarily climb above the fog, but was fighting the autopilot for control, and the aircraft descended back down into the fog bank, while drifting north. During the attempted go-around, he made a radio call announcing the loss of visuals. Helicopter did not seem to be climbing as he pulled in collective. He managed to keep the aircraft level, and about...
read moreFatal ATC Handover: A Business Jet Collides with an Airport Vehicle on Landing
Fatal ATC Handover: Challenger 300 9M-TST Collides with an Airport Vehicle on Landing at Kuala Lumpur-Sultan Abdul Aziz Shah Airport (Subang) On 18 March 2019 Bombardier BD-100-1A10 Challenger 300 9M-TST of Berjaya Air, with 12 persons on board, was damaged when it struck an engineering vehicle when landing at night at Kuala Lumpur-Sultan Abdul Aziz Shah Airport (Subang) (SZB). The driver of the vehicle died later in hospital due to head injuries. The Malaysian Air Accident Investigation Bureau (AAIB) explain in their safety investigation report (issued 2 December 2021) that the aircraft had made an ILS approach and touched down at 03:11 Local Time and was decelerating through 100 knots when the aircraft commander felt an impact. The aircraft stopped on a taxiway and the cabin crew confirmed that they could see damage to the wing. The aircraft commander the proceeded to taxi to their stand. No one onboard was injured. On inspection there was significant damage to the left hand wing with embedded debris from the Perodua Kembara SUV that was hit. The SUV was found 1200 m from the runway threshold by the airport fire crew. Its roof was ripped off and the the driver was trapped inside. The AAIB Safety Investigation The SUV had been escorting a runway painting vehicle (with three occupants) that had been authorised to enter the runway at 01:00 Local Time to paint centre line markings, 10 minutes after a separate electrical working party had been cleared to conduct runway lighting work. The Duty Air Traffic Controller had radio communications with the escort vehicle not the painting contractors vehicle. There were two controller shift changes: However, in the handover between ATC shifts at 03:00 Local Time there was no mention of ongoing work. Although there was a written record of the work commencing, when the electrical working party left the runway at 02:15 Local Time the log recorded that all vehicles were clear. The team leader on the painting vehicle did see the landing lights of the business jet on approach. Fearing of the danger, all three workers boarded their vehicle and drove away from the runway. While making a 180 degrees turn, the driver realised the escorting vehicle was still static [about 120 m away]. …they flashed the headlights of their vehicle several times to attract the escort vehicle attention. No response was observed from the escort vehicle, and as the aircraft was getting closer to them, the [painting vehicle] driver drove…away from the runway and stop[ped] at taxiway Foxtrot to give way for the aircraft to land. The escort vehicle (only) was fitted with an amber flashing light. Neither the ATCO nor the flight crew saw the light which the painting crew confirm had been on. It was also not visible when CCTV footage was examined. As the light was destroyed the investigators could not determine its intensity or whether it was still operating at impact. The investigators explain that: ATC services [are] provided by Civil Aviation Authority of Malaysia (CAAM). The Aerodrome Control consist of Tower Supervisor, Aerodrome Control, Surface Movement Control, Assistant Surface Movement Control and Assistant Tower/Coordinator. During the time range of before and after the accident, Aerodrome Control manning have been reduced to one controller per shift for one and a half hour on each rotation from 0001hrs until 0600hrs in a system named as “Break Shift”. The...
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