Firefighting CH-54 Flying Control FOD Find
Firefighting CH-54 Flying Control FOD Find It has been reported that on 17 June 2021 a firefighting Sikorsky CH-54B, operated by an unspecified civil contractor, had just been started up to depart for a second water-drop flight of the day in Montana for the US Forest Service (USFS). Upon performing system checks the PIC noticed resistance in the flight controls when pushing the cyclic forward. When standard checks were made and the issue wasn’t resolved, the aircraft shut down for further inspection. Upon examination by maintenance personnel: Initially the problem presented itself as hydraulic which led the mechanics to what seemed to be a suspect primary servo. The servo was replaced, but the problem persisted. Further trouble shooting was done by disconnecting flight control rods from the primary servos forward and moving the cyclic in an attempt to isolate the problem to a specific section of the aircraft. This proved to be beneficial in that the crew was able to locate the source of the cyclic obstruction. What was found was… A loose, non-flight control, standard AN4 bolt was located behind a link in the cyclic mixer. The bolt was removed, and a safety stand down inspection of the flight control system was performed with no other defects or obstructions noted. Ground control checks were performed as well as an operational check flight. All results were found satisfactory. It was reported that the aircraft was “just out of re-build and this was their first time out for the season since the re-build” and that the bolt most likely had “been dropped during the re-build and found its way into the flight controls mixer area”. The operator promptly initiated an investigation and introduced additional mitigations. Also noted by the USFS “is the importance of doing a flight control check upon every start up”. 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: Rotor Blade Tool Control FOD Incident USAF Tool Trouble: “Near Catastrophic” $25mn E-8C FOD Fuel Tank Rupture Lost Tool FODs Propeller Blade, Penetrating Turboprop’s Fuselage Micro FOD: Cessna 208B Grand Caravan Engine Failure & Forced Landing FOD Damages 737 Flying Controls Crew Bag FOD Shatters Hawk Canopy C-130J Control Restriction Accident, Jalalabad Flying Control FOD: Screwdriver Found in C208 Controls B1900D Emergency Landing: Maintenance Standards & Practices Professor James Reason’s 12 Principles of Error Management Back to the Future: Error Management Maintenance Human Factors: The Next Generation Airworthiness Matters: Next Generation Maintenance Human Factors Aerossurance‘s Andy Evans will be running two training sessions at European Rotors in November 2021. One will be on safety leadership and the other on how to procure and assure aviation services. He discussed these in a recent European Rotors Digital Series interview: 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...
read moreEC130 Door Loss Damaged Main Rotor Blades
EC130 Door Loss Damaged Main Rotor Blades (Blue Hawaiian N11QP) On 19 August 2018, Airbus Helicopters EC130B4 N11QP, operated by Blue Hawaiian Helicopters (an Air Methods subsidiary), was damaged when a cabin sliding door fell from the aircraft during a rotor track and balance (RTB) flight. There were two occupants aboard the helicopter. The passenger received minor injuries. The Accident Flight The US National Transportation Safety Board (NTSB) explain in their safety investigation report (published 24 June 2021) that this was the second RTB flight of the day from Hilo International Airport (ITO), Hawaii. The first was abandoned due to issues with the RTB equipment. Before the second flight… …the pilot conducted a walk-around inspection of the helicopter, during which he visually checked to ensure all the doors, cowlings, and equipment were closed and secured. The pilot, who had 10,014 hours of flying experience, 2122 hours on type, was sat in the left front seat. The passenger, a maintenance apprentice was sat in the right front seat. After gathering the RTB data the helicopter was en route back to ITO when the pilot lowered the collective to decelerate and began a slow descent. He then heard the left-rear sliding door suddenly slide open. The pilot looked back and saw the door off the helicopter in midair. He stated that he turned his head forward, then heard a loud noise and felt a jolt. The helicopter began to vibrate but remained controllable. The pilot initiated a precautionary landing onto a grass field. The field was part of the historic Shipman Estate (originally leased in 1856 by King Kamehameha IV to William Reed for cattle pasture). He indicated that the door appeared to have struck two main rotor blades and that he thought the door fell into the ocean. The apprentice concurred that “the door suddenly opened and separated from the helicopter”. He stated that on the takeoff for the previous flight, a maintenance technician had ensured the doors were closed correctly, but on the takeoff for the accident flight, the maintenance technician did not. RTB cabling had been re-routed between the two flights to cure the RTB system problem. The NTSB Safety Investigation The NTSB comment that the EC130 has “a sliding rear door on the left side” and there is a ‘plastic’ doorstop or ‘latch’ located on the baggage bay door. A review of the helicopter’s maintenance records [by the FAA] revealed no previous door-related issues. Examination of the helicopter revealed that… …two of the three main rotor blades exhibited dents and scratches across their undersides, generally initiating at or near the leading edge and propagating aft along the chord of the blade. Examination of the operator’s photographs and reports from the director of maintenance revealed that the helicopter’s left sliding door tracks and door latch assemblies were normal and unremarkable. The plastic latch on the fuselage was damaged, and a portion had separated from the fuselage. The sliding door was not recovered, thereby preventing examination of the door and its locking components. Continued Airworthiness Action On 10 December 2018, Airbus Helicopters issued Alert Service Bulletin (ASB) ASB EC130- 05A031 requiring an inspection of the sliding door locking system: The ASB indicated the check should be conducted with a spring scale and described an in-flight opening and loss of a sliding door as the reason for the bulletin. One month later, the EU Aviation Safety Agency (EASA) issued an Airworthiness Directive (AD 2019-0001) to make this inspection mandatory. That AD...
read moreRCAF Chinook Loss of Control (LOC) Investigation
RCAF Chinook Loss of Control (LOC) Investigation The Royal Canadian Air Force (RCAF) is investigating a Loss of Control (LOC) incident that occurred to Boeing CH147F Chinook CH147306 at Wainwright, Alberta on 11 May 2021. At the time the helicopter was conducting “a series of familiarization flights with various Military personnel onboard” at the close of the annual Exercise Maple Resolve. The investigators explain that: Each sortie involved landing sequences to unprepared surfaces out in the assigned training area. On the third sortie of the mission, with 12 passengers and 5 crew onboard, the Chinook attempted a landing to a selected spot in a grassy field. Very shortly after touch down, due to concerning perceptions of drift, the Flight Engineer (FE) called for the pilot to abort the landing with the command “Up, Up, Up.” The pilot flying (PF) aborted the landing and started to climb the aircraft into a hover. The aircraft entered into an unstable flight regime shortly after with strong lateral oscillations causing the PF to initiate an emergency landing. Upon touch down, the FE called for an emergency egress whilst the PF initiated an emergency shutdown of the aircraft. Two of the front rotor blades made contact with the fuselage and the rear landing gear collapsed. Three personnel received minor injuries. The investigation is reportedly focusing on “material and human factors”. UPDATE 8 April 2023: The investigators have released that: The investigation concluded that Human Factors contributed to the accident due to improper procedures. The investigation recommends a publication amendment to define the term “unprepared surface” and a review of the training syllabus for landing abort procedures. 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: RCAF Investigate Defect on Newly Delivered CH-148 Cyclone (S-92) High G Drama at Cold Lake Crew Bag FOD Shatters Hawk Canopy Perception and Fatigue: RCAF CH124 Sea King Engine Failure C-130 Fireball Due to Modification Error RCAF Production Pressures Compromised Culture NH90 Caribbean Loss of Control – Inflight, Water Impact and Survivability Issues Swedish NH90 CFIT: Pilot Experience and Skating on Frozen Lake Canadian Coast Guard Helicopter Accident: CFIT, Survivability and More Culture and CFIT in Côte d’Ivoire Investigation into F-22A Take Off Accident Highlights a Cultural Issue ‘Procedural Drift’: Lynx CFIT in Afghanistan USMC CH-53E Readiness Crisis and Mid Air Collision Catastrophe UPDATE 3 October 2021: French Cougar Crashed After Entering VRS When Coming into Hover UPDATE 9 April 2022: SAR Seat Slip Smash (RCAF CH149 Leonardo Cormorant LOC-I) Aerossurance has extensive air safety, flight 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...
read morePilatus PC-12 Collided with Pick-Up Truck During Dusk Take Off
Pilatus PC-12 Collided with Pick-Up Truck During Dusk Take Off (N1220A) On 14 September 2020 privately owned Pilatus PC-12/47E N1220A struck the aircraft owner’s own pick-up truck vehicle during a duck take off from a private airstrip at River’s End Ranch. Lake Abert near Lake View, Oregon. The three occupants of the aircraft were unharmed. The pick-up truck was unoccupied. The US National Transportation Safety Board (NTSB) report that the incident occurred at 1930 Local Time (sunset was at 1910) during take off from the 3000 x 100 ft strip. The pilot told the NTSB in a telephone interview that he “just didn’t see the truck”. There were no pre-impact aircraft defects. As of 8 January 2021 the pilot had not submitted an accident report form to NTSB. UPDATE 15 July 2021: NTSB Releases Probable Cause The pilot’s failure to maintain clearance from an object during the takeoff ground roll due to inadequate monitoring of the environment. As with most probable cause statements, this is more a statement of what happened rather than why. Safety Resources You may also find these Aerossurance articles of interest: Ground Collision Under Pressure: Challenger vs ATV: 1-0 UK AAIB Report on Two Ground Collisions S-92A Collision with Obstacle while Taxying A320 Collided with Two De-Icing Trucks Runaway Dash 8 Q400 at Aberdeen after Miscommunication Over Chocks Production Defect IFSD Triggers Night Deadstick PC-12 Landing Confusion of Compelling, But Erroneous, PC-12 Synthetic Vision Display Pilatus PC-12 Pacific Ditching UPDATE 30 October 2021: RLC B407 Reverses into Sister Ship at GOM Heliport UPDATE 5 March 2022: Taxiing AW139 Blade Strike on Maintenance Stand UPDATE 2 April 2022: Investigation into Collision of Truck with Police Helicopter 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 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 customize widget: Bing Webmaster Portal...
read moreEngine Life Limit Exceedance Caused Logging Helicopter Fatal Accident
Engine Life Limit Exceedance Caused Logging Helicopter Fatal Accident (UH-1B N64RA) On 8 March 2019 the pilot of restricted category Richards Heavylift Helo Inc (Bell) UH-1B N64RA, registered to Iron Eagle Helicopters, died while conducting Part 133 Helicopter External Sling Load Operations (HESLO) at a logging site near Forks, Washington. After responding to a mayday call of “I’m going down, I’m going down I’m going d…” fellow workers found the helicopter inverted amongst trees 1/4 mile way. The Safety Investigation The US National Transportation Safety Board (NTSB) safety investigation report was published on the 5 May 2021. The pilot was the owner of Iron Eagle and had 6610 flying hours in total, 729 on type. He was reportedly averaging 30 lifts per flying hour while logging, using a grapple logging system that only requires one person on the ground (vs four for choker logging). The investigators report that: Examination of the engine revealed that the gas generator first stage [static] sealing disk had fractured and separated into three major pieces. Multiple internal components of the engine were subsequently damaged as a result, including all four turbine rotors and nozzles. Subsequently, the Honeywell T53-L13B turboshaft engine… …lost all power, necessitating a forced landing via autorotation. Due to the low altitude and densely tree covered terrain, it is unlikely that the pilot had reaction time to release the load which became entangled in the trees… The NTSB explain that: An examination of the first stage sealing disk revealed fracture features consistent with low cycle fatigue. The overhauled engine was installed into the accident helicopter about 8 months before the accident [2 July 2018]. The sealing disk was installed into the engine at the time of overhaul and had previously accrued 1,067.3 hours and 2,134.6 cycles. Documentation of engine cycles was not accomplished daily. Engine cycles were documented irregularly from July 2, 2018, to September 17, 2018, after which there was no documentation of engine cycles. [however], the helicopter was equipped with an AKV N1/N2 cycle counter. According to Honeywell SB T53-L-13B-0020 the hour/cycle life limit of the first stage sealing disk is 25,000 hours or 6,900 cycles. A review of maintenance records and the helicopter’s electronic cycle counter revealed that the sealing disk had exceeded the published life limit of 6,900 cycles. The last documented cycle value was 9,023.13. The cycle counter had recorded 12,023.19 cycles. NTSB Probable Cause A total loss of engine power due to the failure of the gas generator sealing disk as a result of the operator’s exceedance of the sealing disk life limits at too low an altitude for the pilot to accomplish a successful autorotation which resulted in the collision with terrain. 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: UH-1H HESLO Fuel Exhaustion Accident Windscreen Rain Refraction: Mountain Mine Site HESLO CFIT HESLO Dynamic Rollover in Alaska When Habits Kill – Canadian MD500 Accident Loss of Control During HESLO Construction Task: BEA Highlight Wellbeing / Personal Readiness Shocking Accident: Two Workers Electrocuted During HESLO Load Lost Due to Misrigged Under Slung Load Control Cable Keep Your Eyes on the Hook! Underslung External Load Safety EC120 Underslung Load Accident 26 September 2013 – Report Unexpected Load: AS350B3 USL / External Cargo Accident in Norway Unexpected Load: B407 USL / External Cargo Accident in PNG Load Lost Due to Misrigged Under Slung Load Control Cable Fallacy...
read moreAir Tour Helicopter Force Landing After Improper Installation of Tail Rotor Bearings
Air Tour Helicopter Force Landing After Improper Installation of Tail Rotor Bearings (Magnum Helicopters H369D N369MH) On 8 August 2018 Magnum Helicopters Hughes (later MD) 369D N369MH, was damaged in an accident near Honolulu, Hawaii during an air tour flight with four persons on board. The US National Transportation Safety Board (NTSB) explain in their safety investigation report (published 27 May 2021) that: The pilot [who had 7300 hours of flying experience, 2400 on type]…stated that the helicopter was in cruise flight at an altitude of about 1,800 ft when, about 11 minutes after takeoff, he felt “severe” vibrations and then heard a “loud bang,” after which the helicopter began to shake “violently.” The pilot entered a power-on autorotation and stated that the severity of the vibration caused the transponder to shake free of its mount in the instrument panel. He also stated that even small tail rotor pedal inputs significantly worsened the vibrations. The pilot conducted a partial run-on landing in a field. The occupants were all uninjured. Subsequently: Without NTSB or FAA knowledge or approval, and contrary to applicable regulations, the operator recovered the helicopter back to its facility shortly after the accident and began disassembly for repair. More than a day after the accident, the NTSB became aware of these activities, and instructed the operator to cease repairs. Examination revealed that multiple tail rotor blade and gearbox components had failed in flight… The NTSB explain that as well as the original design of tailboom (now available from MD Helicopters) there is… …an aftermarket version produced by a company called Aerometals. The accident helicopter was equipped with the Aerometals tail boom. The primary difference between the two tail boom versions was the attachment method of the TR transmission to the tail boom. The MDHI version used studs and locking nuts, whereas the Aerometals version used bolts and locking nut plates. Both versions used a total of four attach[ment] fasteners. Postaccident examination revealed that the two bolts that attached the left side of the TR transmission to the tail boom had fractured and partially pulled through their nut plates. The two right side attach bolts were damaged, but had not failed; instead, their respective mounting lugs on the TR transmission had failed. The failure of all four attachments meant that the TR assembly was retained on the helicopter by only the TR drive shaft and the pitch control linkage. Neither of those components was designed to retain the TR transmission, and the pitch control system incurred damage during the event. The TR assembly was on the verge of imminent failure. Based on the observed damage, it is likely that with continued operation, the TR would have very shortly separated from the helicopter, rendering control difficult or impossible. All four TR blades remained attached to the fork, but the outer (furthest from the transmission) blade pair remained only partially attached to the fork. The outer teeter bolt was fractured and only a portion of it was recovered. Of the two teeter bearings that were normally mounted in the outer pair of fork arms, one was absent and presumed lost in flight. The remaining outer teeter bearing had debonded from its fork arm, and both it and its fork arm seat exhibited fretting damage on their mating surfaces. The fretting indicated that there was relative motion between the bearing and its seat, caused by helicopter operation with a debonded bearing. Laboratory examination showed… ….the fractured teeter bolt and the two fractured attach bolts had all failed...
read moreHESLO Dynamic Rollover in Alaska
HESLO Dynamic Rollover in Alaska (Trans Aero AS350B3 N354LA) On 25 July 2018 Trans Aero Airbus Helicopters AS350B3 N354LA was damaged in a Helicopter External Sling Load (HESLO) accident 23 miles from Kobuk, Alaska. The US National Transportation Safety Board (NTSB) explain in their safety investigation report (published 27 May 2021) that the pilot had 5061 hours of flying experience, 225 on type and was transporting equipment in support of remote mining operation using a 100-foot long-line. During takeoff, and while preparing to lift the external sling load, he inadvertently allowed the helicopter to drift laterally to the right and the right skid struck the ground, resulting in a dynamic rollover. The helicopter continued to roll to the right, and the main rotor blades struck the ground. The helicopter subsequently came to rest on its right side, sustaining substantial damage to the main rotor drive system, fuselage, and tail boom. The pilot sustained minor injuries… There were no pre-accident failures or malfunctions with the helicopter that would have precluded normal operation. The NTSB determined the Probable Cause to be: The pilot’s inadvertent dynamic rollover during takeoff. 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: Windscreen Rain Refraction: Mountain Mine Site HESLO CFIT When Habits Kill – Canadian MD500 Accident Loss of Control During HESLO Construction Task: BEA Highlight Wellbeing / Personal Readiness Shocking Accident: Two Workers Electrocuted During HESLO Load Lost Due to Misrigged Under Slung Load Control Cable Keep Your Eyes on the Hook! Underslung External Load Safety EC120 Underslung Load Accident 26 September 2013 – Report Unexpected Load: AS350B3 USL / External Cargo Accident in Norway Unexpected Load: B407 USL / External Cargo Accident in PNG Load Lost Due to Misrigged Under Slung Load Control Cable Fallacy of ‘Training Out’ Error: Japanese AS332L1 Dropped Load Helicopter External Sling Load Operation Occurrences in New Zealand Maintenance Issues in Fire-Fighting S-61A Accident Impromptu Landing – Unseen Cable Inadvertent Entry into IMC During Mountaintop HESLO HESLO AS350B2 Dropped Load – Phase Out of Spring-Loaded Keepers for Keeperless Hooks Unballasted Sling Stings Speedy Squirrel (HESLO in France) UPDATE 28 August 2021: Ditching after Blade Strike During HESLO from a Ship UPDATE 25 September 2021: Fuel Starvation During Powerline HESLO UPDATE 1 January 2022: Snagged Sling Line Pulled into Main Rotor During HESLO Shutdown UPDATE 3 September 2022: Garbage Pilot Becomes Electric Hooker UPDATE 18 March 2023: HESLO AS350 Fatal Accident Positioning with an Unloaded Long Line UPDATE 5 August 2023: A Concrete Case of Commercial Pressure: Fatal Swiss HESLO Accident Aerossurance has extensive air safety, operations, SAR, HESLO, 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...
read moreSAR AW101 Roll-Over: Entry Into Service Involved “Persistently Elevated and Confusing Operational Risk”
SAR AW101 Roll-Over: Entry Into Service Involved “Persistently Elevated and Confusing Operational Risk” On 24 November 2017, Royal Norwegian Air Force (RNoAF) Leonardo AW101-612 Search and Rescue (SAR) helicopter 0268 rolled over during start-up at Sola for an engine drying run following a routine compressor wash. The two pilots and the adjacent ground personnel were uninjured, but the helicopter suffered extensive damage. The helicopter was the first AW101 delivered to Norway, having arrived a week before, and had been operated by the military AW101 Operational Test and Evaluation (OT&E) unit for just three days. The Norwegian Military Accident Investigation Board (Statens havarikommisjon for Forsvaret [SHF]) released their investigation report on 11 November 2019 (in Norwegian only). We recently re-visted this report as it was mentioned in a recent Norwegian Safety Investigation Authority (NSIA) report on a 2020 RNoAF C-130J Hercules serious incident, which we discussed in: A Second from Disaster: RNoAF C-130J Near CFIT. That report made recommendations on creating an independent military aviation regulator in Norway, enhance risk management and develop the Air Force safety culture. The Ground Run The investigators comment that often compressor washes are conducted before scheduled flights to eliminate the need for a drying run. In this case there was no flight envisaged, so a specific ground run was planned. This can be done by one pilot, but two were allocated, both for reasons of safety and to help build type experience. The pilots had only 13 and 26 hours on type, plus about 60 hours of simulator time each. The former was the Pilot Flying (PF) and planned & briefed the task but the other was Pilot Monitoring (PM) and Aircraft Commander. The PF had not previously started up the aircraft just to dry the compressors. The PM had only done it once before. The investigators note the preparations were through and unhurried. Furthermore Cockpit Voice Recordings indicated the crew were unstressed and task-focused. There were 125 certified Flight Reference Cards (FRCs) for the AW101-612, which were the authorised procedures for flight operations. The FRCs were written on the basis that start-up and shutdowns are memory drills. Due to their low time on type, the AW101 OT&E crews also used a locally developed checklist for such tasks, called the Kneeboard Checklist v19. The two pilots started the helicopter’s three engines and set engines numbers 2 and 3 to accelerate the rotor. Surveillance video of the incident shows that the helicopter gradually lifting…for just over 15 seconds while the rotor accelerated. As the rotor reached full speed, the left-hand main wheel left the ground. Time (approx.) Event Note PF starts engine 1, The collective is initially approx. 53%. This is in it 2 and 3 in Ground Idle high end of what is normal when the helicopter (idle) has been standing still for a few hours. The collective comes down to 45% when the engines establish pressure in the hydraulic system. 00:00 The rotor is started The rotor accelerates to 30% with the three engines in Ground Idle. 00:30 PF sets engine 2 to This is to accelerate the rotor from 30% to 102%. FLIGHT 00:33 Engine 2 achieves During start-up, FADEC limits the engine power to 80% torque 80% torque. Normally this will be sufficient to rotor reaches full speed in approx. 10 seconds, and the torque on motor 2 will then be reduced automatically to approx. 50%. 00:35...
read moreDrone Pilot Injured in US Prison Geo-fence Incident
DJI Matrice 300 UAS/RPAS Pilot Injured in US Prison Geo-fence Incident On 6 May 2021 a DJI Matrice 300 Unmanned Air System (UAS) /Remotely Powered Air System (RPAS) / quadcopter drone was involved in an accident near Young Harris, Georgia. This was during a demonstration flight to a potential customer carrying a Zenmuse H20T camera and a Wingsland Z15 spotlight. The remote pilot in command (RPIC) sustained serious injuries. The US National Transportation Safety Board (NTSB) explain in their preliminary report that the flight location was very close to a ‘DJI GEO Zone‘ designated as a geo-fenced ‘Restricted Zone.’ The RPIC was apparently not aware of that geofencing (shown in red below), but it is clear from the NTSB report and check of digital mapping that the flight was conducted in the car park of what is Towns County Jail. NTSB state: The RPIC stated that he performed a normal takeoff and flew the drone to the west over a wooded area… He stated that during the spotlight demonstration the drone was unresponsive to control inputs, so he utilized the return-to-home (RTH) function. During the RTH descent toward the home point the drone hovered about 7 ft agl over a vehicle in the parking lot and was still unresponsive to any control inputs. When the drone would not land, the RPIC grabbed onto the landing gear and attempted to physically move the drone away from the vehicle. The drone resisted the physical displacement and maintained its position over the vehicle. The RPIC requested assistance from a demonstration attendee and handed him the remote controller. With guidance from the RPIC, he attempted several times to shut down the motors while RPIC held onto the landing gear with both hands. Finally, the RPIC attempted to remove the drone batteries when a propeller blade struck his right hand several times, which caused tendon and nerve damage. [T]he RPIC continued to hold onto the drone for several minutes until the batteries were exhausted and the motors stopped. Recorded data for the flight was retrieved:. A preliminary review of the flight logs showed that the RTH function was initiated about 7 minutes into the flight at 393 ft agl. A Restricted Zone notification was issued two times on the remote controller during the RTH procedure. NTSB Probable Cause (UPDATE: 19 August 2022) The remote pilot-in-command’s (RPIC) decision to physically hold onto the drone’s landing gear in flight, which resulted in the rotors striking his hand and causing serious injury. Contributing to the accident was the RPIC’s inadequate preflight planning and lack of airspace awareness. NTSB note that: The RPIC could have manually landed the drone if he had exited RTH mode. Also, the pilot should have discovered the restricted zone during preflight planning and used a landing zone and home point farther away from the restricted zone. Safety Resources You may also find these Aerossurance articles of interest: Drone Goes Walkabout: Hemispherical Human Factors Hiccup Software Bug and High Winds Down Drone Facebook Aquila Drone Accident: Gust Induced Structural Failure Drone Operation Injury Inspection UAS Collides with PNG LNG Export Jetty USAF MQ-9A Reaper Lever Confusion: Human Factors UPDATE 4 August 2022: Schiebel Camcopter S-100 Engine Failure Results in Baltic Crash Aerossurance has extensive air safety, regulatory, design, certification, airworthiness, operations and safety analysis experience, including UAS experience going back to the mid 1990s. 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. We will update this article...
read moreAir Ambulance B407 Hospital Helipad Deck Edge Tail Strike During Shallow Approach
Air Ambulance B407 Hospital Helipad Deck Edge Tail Strike During Shallow Approach (N947LH) On the afternoon of 22 January 2019 Executive Air Taxi Corp Bell 407 N947LH, an air ambulance operated for Trinity Health‘s NorthStar Criticair service, suffered a tail strike during a landing at the Trinity Medical Helipad (2ND4) near Minot, North Dakota. The pilot was uninjured, but the helicopter sustained substantial damage. The Accident and Safety Investigation The US National Transportation Safety Board (NTSB) explain in their safety investigation report (published 5 May 2021) that the aircraft was due to pick up a medical crew and was operating a Part 91 positioning flight. The pilot [6341 hours total, 98 on type] stated he performed a right 180° circling approach to the helipad. The helipad was on top of a 5-storey hospital building. “Enroute I punched up ATIS on the radio to confirm winds and they were NW (300 degrees) winds at 7 knots. So I flew over the big church (northeast of the pad a couple of blocks) and then performed a 180 right circling approach to the pad”. As he finished the turn, he thought he was a little low on final approach and “pulled in a little collective.” He applied more collective as he was levelling off and the “helicopter contacted the pad firmly.” The pilot added that it was firmer than a normal landing, but he thought everything was okay until he noticed a small vibration. Fortuitously: Before departing with the medical crew, the pilot still felt the vibration in the helicopter, so he shut the helicopter down to check. After shutdown, the crew walked toward the tail and noticed a slight bend in the lower vertical fin, the tips of both tail rotor blades missing, and the helipad safety fence [i.e. the helideck perimeter netting] was missing a small section of the fence-edge pipe. Subsequent examination of the helicopter identified surprisingly large cracks in the tailboom structure. The helicopter was removed by crane. NTSB Probable Cause The pilot’s failure to maintain clearance from fencing around the landing pad during landing, which resulted in the tail rotor contacting the fence. But What About Flight Data Monitoring? Oddly, there is no mention of the any flight data being analysed. Data can usually be extracted from GPS units for example if investigators are minded to make an effort. However, the FAA changed Part 135 in 2017 so that helicopter air ambulance operators had to comply with a new Flight Data Monitoring (FDM) System requirement, FAR 135.607: After April 23, 2018, no person may operate a helicopter in air ambulance operations unless it is equipped with an approved flight data monitoring system capable of recording flight performance data. FAA AC 135-14B Helicopter Air Ambulance (HAA) Operations explains that: The FDMS should record digital or analog raw data, images, cockpit voice or ambient audio recordings or any combinations thereof which ideally yield at least the following flight information: • Location; • Altitude; • Heading; • Speeds (airspeed and groundspeed); • Pitch, yaw, and roll attitudes and rate of change; • Engine parameters; • Main rotor RPM; • Ambient acoustic data; • Radio ambient audio; and • Any other parameter the operator deems necessary (e.g., high definition video recording looking forward including instrument panel and forward cockpit windshield view, intercommunications system (intercom) between pilot and medical crew, communications with air traffic control (ATC), OCS, base operations, first responders at scene, hospital,...
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