News & Comment

Police Helicopter Unanticipated Yaw & Fatal Water Impact

Posted by on 2:42 pm in Accidents & Incidents, Helicopters, Human Factors / Performance, Safety Management, Special Mission Aircraft, Survivability / Ditching

Police Helicopter Unanticipated Yaw & Fatal Water Impact (Huntington Beach Police Department MD520N N521HB) On 19 February 2022 at 18:34 Local Time MD Helicopters 500N (MD520N) N521HB of Huntington Beach Police Department (HBPD) was destroyed when it impacted the water off Newport Beach, California in a Loss of Control – Inflight (LOC-I) accident.  The police pilot escaped with minor injuries but the police Tactical Flight Officer (TFO) was fatally injured. The Huntington Beach Police Air Support Unit was formed in 1968, only the fifth in the US.  In 1992 they introduced their first MD520N and became an all MD520N fleet in 2002. Instead of having a conventional tail rotor for anti-torque control the MD520N has a NOTAR (NO TAil Rotor) design with a variable thruster and ducted fan system.  In 2023, the unit changed over to the tail rotor-equipped MD530F]. The Accident Flight The US National Transportation Safety Board (NTSB) issued their safety investigation report on 14 December 2023 into the Newport Beach accident. The law-enforcement helicopter was performing right turns at night over an waterfront peninsula supporting officers attending a street fight involving up to 10 people. The pilot estimated “that they were flying about 500-600 agl, which is standard practice” when the helicopter yawed aggressively to the right and he… …immediately applied full left foot pedal and forward cyclic to arrest the rotation, but there was no response. He then applied right pedal to see if the pedals had malfunctioned, and observing no change, he reverted to full left pedal. He continued to apply corrective control inputs, but the helicopter did not respond and began to progress into a spinning descent. The pilot stated that the rotation became more aggressive, and he began to modulate the throttle, collective, and cyclic controls to try to arrest the rotation rate. He stated that his efforts appeared to be partially effective, as the helicopter appeared to respond; however, because it was dark, he had no horizon or accurate external visual reference as the ground approached. The engine continued to operate, and he chose not to perform an autorotation because the area was heavily populated. He then had a sense that impact was imminent, so he pulled the collective control in an effort to bleed off airspeed. The helicopter impacted the water… …on the TFO’s side in a downward right rotation. The pilot recalled a sudden smash and saw water and glass coming toward him as the canopy shattered. He felt the rotor blades hitting the water, everything then stopped, and within a few seconds he was submerged. The Pilot’s Underwater Escape & the Attempted Rescue of the TFO The police department’s personnel… …fly with a full tactical vest, an inflatable “horse collar”, Submersible Systems “Spare Air” [Compressed Air – Emergency Breathing System] tank, gun, radio, magazines, and handcuffs, all carried on their chest. The pilot held on to the collective as a reference point.  He recalled that: He waited for the helicopter to stop moving, grabbed the Spare Air mouthpiece, cleared it, and started to breath. Holding the collective with one hand he reached down and released his seat harness. His eyes were closed, and he was able to move by feel. He did not recall opening the door.. He exited the helicopter and was upside down. He tried to relax and...

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Multi-Tasking Managers & Deficient Operational Control: Low Viz AS350B3 Take-Off Accident

Posted by on 11:05 am in Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Culture, Safety Management, Survivability / Ditching

Multi-Tasking Managers & Deficient Operational Control: Low Viz Take-Off Accident (Midtnorsk Helikopterservice AS350B3 LN-OBP, Norway) On 1 November 2022 Airbus AS350B3 LN-OBP of Midtnorsk Helikopterservice crashed shortly after take-off at Slottelid (ENVS), Verdal, Trøndelag County, central Norway.  The two passengers on board died.  The pilot was seriously injured.  A pet dog aboard also survived. The Norwegian Safety Investigation Authority (NSIA) published their safety investigation report on 5 December 2023. The Air Operator ad Pilot The operator was founded in 2002 and at the time of the accident operated one AS350BA, the AS350B3 and an EC120.  They employed 8 people. The pilot had 6,115 hours total experience, 3,800 on type.  He held 4 positions within the operator; Accountable Manager, Compliance Monitoring Manager, Safety Manager and Deputy Manager of Flight Operations.  The later potion was necessary because the Manager of Flight Operations was a retired fixed wing pilot, with no flight experience on rotorcraft.  The Manager of Flight Operations and Technical Manager were part time employees, the former running a human factors & CRM business. The Accident Flight The plan was to transport two passengers, a dog and cargo from the operator’s base Verdal to a mountain farm in Snåsa. Two days before the accident, the pilot had tried to fly the passengers to the farm, but had to abort due to fog in the mountains. The day before the accident there was fog in Verdal that prevented a flight. On the day of the accident the morning fog lay low in the terrain in Verdal, and followed the valley and river. The fog varied in density and two other company pilots had departed about 08:15 after a delay. The passengers due to travel on LN-OBP arrived at around 09:00. The pilot loaded their baggage / cargo and waited for the visibility to improve. The pilot told investigators “there was a calm atmosphere and that he did not feel any stress”. The pilot told investigators the fog had started to lift to the north east. He intended to take off in that direction, flying around a small cluster of trees near the landing site. The pilot to a photograph looking north east though the cabin at c 10:30.  Also evident is a large amount of unrestrained cargo. CCTV evidence shows the helicopter lifted off at c 10:35 but crashed less than 20 seconds later, 450 m away, bouncing several times and coming to rest 540 m from the landing site. The pilot, who suffered several back fractures, regained consciousness, egressed the helicopter and raised the alarm.  The Emergency Locator Transmitter [ELT] antenna had factored during the crash and the helicopter tracking system had not registered the short flight. Dense fog contributed to the problem of locating the aircraft. After 10–15 minutes, a doctor and rescue personnel arrived at the accident site. Both a rescue helicopter and an air ambulance helicopter were unable to land near the accident site due to fog. After a little while, the air ambulance helicopter was able to land in a field slightly higher up in the terrain about 2 km from the accident site. NSIA Safety Investigation & Analysis There are no indications of any pre-impact technical failures.  NSIA concluded the helicopter was most likely overloaded by c 60-80 kg. A key issue for the NSIA...

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Fire-fighting Bell 204B Underwater Escape

Posted by on 10:49 am in Accidents & Incidents, Helicopters, Special Mission Aircraft, Survivability / Ditching

Fire-fighting B204B Underwater Escape (Forest Air Helicopters VH-EQW, Queensland) On 20 September 2023, Bell 204B VH‑EQW of Forest Air Helicopters crashed into a reservoir during fire-fighting operations for the Queensland Fire and Emergency Services (QFES) at the Southern Downs fire, near Cunninghams Gap.  The pilot escaped from underwater and sustained minor injuries.  The helicopter was destroyed. The Australian Transport Safety Bureau (ATSB) released a preliminary report on 7 December 2023. The Accident Flight The aircraft was tasked with fire-fighting operations near Tarome, Queensland, using a 1,200 l bucket and a short line.  The single pilot (2,599 hours of total experience, 221 on type) was operating the helicopter from the left seat “for visibility” say ATSB.  During their first water uplift, the pilot… …heard an unusual noise and that the helicopter ‘kicked’. Remaining in the hover, the pilot checked that all engine indications were normal and that the bucket and line were in the appropriate place. However, the pilot reported that something still did not feel right. As a result, they elected to dump the water from the bucket and initiate a climb out. Within about 10-15 seconds, as engine power was being applied, and the water was being released from the bucket, the pilot heard what they described as a ‘loud roaring’ sound and the helicopter pitched up, yawed, and subsequently had a reduction in power. The helicopter rolled left and impacted the water at low [forward] speed.  The Pilot’s Escape Almost immediately after the impact, the helicopter inverted, started to fill with water, and sink rapidly. The pilot had previously undertaken practical HUET (helicopter underwater escape training) but does not appear to have been equipped with a Compressed Air – Emergency Breathing System (CA-EBS) or similar survival aid.  However, he was able to take a breath before the cabin filled with water.  The pilot removed their seatbelt and helmet, and attempted to open the front left door but could not open it with either the normal or emergency release handles. When the helicopter was almost fully submerged, the pilot swam to the rear of the cabin and tried to open the rear right door but could not open it either, making further attempts to get out by kicking the helicopter windows. Unlike a modern offshore helicopter, the cabin windows had not been modified into push out exits.  The pilot then moved to the rear left door and, utilising considerable force, was able to successfully open it. The pilot noted in interview, that when they initially attempted to open the doors, they may have been trying to move the door handles in the incorrect (opposite) direction due to the helicopter being inverted. The pilot escaped and swam a few metres to the surface and then to the side of the dam.  The ATSB Safety Investigation The helicopter was salvaged.  To date, the ATSB has interviewed the pilot and witnesses, and conducted preliminary examination of the helicopter wreckage. The…rotor systems, flight controls, exits, and engine were visually examined. No pre‑accident damage was identified. The pilot’s left front door emergency jettison system was tested serviceable. ATSB say they intend to examine the pilot’s training and records, maintenance documentation, and certain key components of the helicopter. We will update this article as further information emerges. Safety Resources The European Safety Promotion Network Rotorcraft...

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In-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice

Posted by on 10:26 am in Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Management, Special Mission Aircraft

In-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice (N3688P, Falcon Executive Aviation) On 10 July 2021 Beech King Air C90 N3688P broke-up in flight and crashed near Wikieup, Arizona. The aircraft was operated Falcon Executive Aviation in support of firefighting for the Federal Bureau of Land Management (BLM), The pilot and the US Forest Service (USFS) Air Tactical Group Supervisor onboard were fatally injured. The US National Transportation Safety Board (NTSB) issued their safety investigation report on 23 August 2023. The Accident Flight The aircraft was on station for about 45 minutes, completing multiple orbits over the Cedar Basin wildfire.  One witness saw the aircraft the descend in a steep dive.  No distress call was heard and it impacted mountainous desert terrain.  Another witness, a firefighter, observed the outboard left wing falling to the ground shortly after the aircraft had impacted the ground. The Safety Investigation Investigators found that: The main wreckage was mostly consumed by a post-crash fire. Debris was scattered over an area of several acres. The outboard left wing was found about 1250 m from the main wreckage.  It had separated outboard of the engine nacelle. The C90 was manufactured in 1980.  It had been flown as a aerial supervision / reconnaissance aircraft for firefighting since 2007.  This involved operating in orbits at c 1000-3500 ft AGL.   It was not used in the more demanding lead aircraft role (low level operation to lead in a larger firefighting aircraft for its drop). The aircraft had flown 17,262.6 hours and 15,475 cycles at the time of the accident.  Since 2007, it had accumulated 3,507 hours and 1,877 cycles. The NTSB examined the maintenance history of the aircraft.  Since 1990, FAA Airworthiness Directive (AD) 89-25-10, Wing Main Spar Inspection had been applicable. This required inspection of “the wing lower forward spar attach fittings, center section, and outboard wing spar caps adjacent to the attach fitting”.  It stated: If any crack is found in a main spar lower cap or fitting, prior to further flight repair or replace the defective part using the instructions and limitations specified in the Beech SIRM or other FAA approved instructions provided by Beech Aircraft Corporation. On this aircraft… A total of 16 wing spar inspections were accomplished since the AD became effective and 6 times since the airplane went on contract to the USFS in 2007. Further, the annual spar cap visual inspection for cracks and corrosion [as specified in the Beech Structural Inspection and Repair Manual (SIRM) 57-13-01] was accomplished 16 times since 2007. However, in March 2021… During a scheduled [AD 89-25-10 and SIRM 57-13-01] maintenance inspection…eddy current (EC) non-destructive testing (NDT) of a left wing’s lower forward spar cap detected a crack in a fastener hole. The hole was then oversized/reamed to a larger size, but the EC reinspection still produced a crack indication. The operator then submitted a structural damage report and service request detailing the crack indication to the aircraft manufacturer. The manufacturer responded in April 2021 that this necessitated the replacement of “the center section forward spar cap, center section forward lower fittings and both outboard main spar assemblies.” The email response…to FAS also included the warning below from their published instructions for wing structure inspections in the SIRM 57-13-01, (in part [emphasis in...

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South Korean Night Black Hole Spatial Disorientation Fatal Helicopter Accident

Posted by on 3:15 pm in Accidents & Incidents, Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, Helicopters, Human Factors / Performance, Safety Management, Special Mission Aircraft

South Korean Night Black Hole Spatial Disorientation Helicopter Fatal Accident (National 119 Rescue Airbus Helicopters H225 HL9619) On 31 October 2019 emergency service Airbus H225 HL9619 of National 119 Rescue crashed into the sea just 14 seconds after take off from the island of Dokdo during a patient transfer medevac flight.  All 7 occupants died in the accident. The South Korean Aviation and Railway Accident Investigation Board (ARAIB) issued their safety investigation report (in Korean) on 6 November 2023.  This accident summary is based on a translation of this report.  Note: ambiguities after translation did made interpretation challenging but we are confident the content here represents the final report accurately. The Accident Flight National 119 Rescue is fire-fighting, air ambulance, mountain & maritime Search and Rescue (SAR) organisation, ultimately a part of the Korean National Fire Agency. The helicopter was tasked to fly east from Daegu on the mainland to Dokdo Heliport on an rocky offshore island, to retrieve a fisherman who was on the island after had suffering a severed finger on a fishing vessel. On board were 5 crew (two pilots, a flight engineer / hoist operator, a winchman and paramedic).  The captain had 3,827 flying hours total experience, 444 on type.  The first officer had 2,666 flying hours total experience, 307 on type. The flight crew had no prior experience landing at Dokdo and investigators state that during their flight planning the crew were unable to obtain “information about the terrain of the landing area or the heliport to the extent the crew desired”. The helicopter departed Daegu at 22:33 and refuelled successfully at Ulleungdo island en route.  The captain complained of being tired during the flight.  The captain was working an extended shift due to a business trip involving another pilot. The aircraft was fitted with a Night Vision Imaging System (NVIS).  Investigators note that the… National Fire Agency does not have a clear basis for the operation of night vision equipment.,  Pilots selectively use night vision equipment depending on individual preference. Evidence from an Appareo Vision 1000 recording system confirmed the pilots were using their Night Vision Goggles (NVGs) when the aircraft departed, though the Vision 1000 video recording ceased during the flight.  Cockpit Voice Recorder (CVR) evidence was that the NVG continued to be used intermittently as necessary during the flight. CVR data suggested that Automatic Flight Control System (AFCS) selections were not being verbalised and “there were cases where the first officer did not realize the captain’s intentions”. The 25 m square Dokdo heliport, at an elevation of 177 ft, was operated by the Gyeongbuk Provincial Police Agency, but they lacked specific heliport procedures and personnel with relevant competencies. This was the first night landing at the site in 3 years.  Two of the four perimeter flood lights were unserviceable, though the green perimeter lights were serviceable. Visibility was good with no clouds or sea fog but little illumination form the waxing crescent moon.  There was a crosswind at Dokdo, that was likely to have induced turbulence and no illuminated windsock. The helicopter landed at Dokdo at 23:24 after one missed approach (with a torque exceedance).  The missed approach followed a miscommunication between aircraft and ground resulted in all lights at the site being briefly extinguished.  During the second landing attempt a person...

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Helicopter Water Impact Accident: Safety of Airborne Geophysical Survey Operations

Posted by on 10:56 am in Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Human Factors / Performance, Mining / Resource Sector, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

Helicopter Water Impact Accident: Safety of Airborne Geophysical Survey Operations (Synergy Aviation Guimbal Cabri G2 C-GSYN) On 8 October 2021, Guimbal Cabri G2 C-GSYN of Synergy Aviation impacted Wachigabau Lake, Quebec during a geophysical survey flight for survey company Novatem.  The pilot sustained serious injuries, but egressed underwater and swam to shore. Context of the Flight The Transportation Board of Canada (TSB) issued their safety investigation report on 31 August 2023.  TSB explain the helicopter was operating from Chapais, Quebec and that morning, the pilot (407 hours total, 235 on type and trained at the operator’s own flight school) was tasked with two low-level geophysical survey flights before ferrying the helicopter to Amos/Magny Airport (CYEY), Quebec, for maintenance. Synergy had started operating survey flights for Novatem in mid 2020, developing their Guimbal Aeromagnetic Survey Procedure (GASP).  TSB explain that: Under the heading Safety, the GASP stated that “[h]azards to consider are wires, persons or livestock, trees, rising terrain, and water.” However the document did not offer mitigations on how to deal with these hazards. Rather, it referred readers to the Exercise 22 – Low Level Operations of the Helicopter Flight Training Manual on TC’s website. The GASP’s section on flight planning and hazard assessment listed 9 hazards to consider, including lakes, rising terrain, and tall standalone obstacles (e.g., trees), but it did not provide clear guidance on how to assess and mitigate those hazards within the context of aerial work, aeromagnetic survey work, low-level flying, or over-water operations. The helicopter was equipped with a nose boom, or ‘stinger’, containing a magnetometer. The Novatem aeromagnetic survey monitor, mounted to the right of the console directly in front of the pilot, displayed the survey blocks and flight tracks. It displayed height above sea level but did not display height above ground because the helicopter was not equipped with a radar altimeter. A conventional barometric altimeter was the only instrument on board that provided a useable indication of the helicopter’s altitude. Importantly: To obtain quality data, the helicopter must consistently maintain the optimal height (approximately 25 m [82 feet] over land and water) on all survey lines.  This means that the helicopter is required to fly the contour of the terrain as much as possible. Novatem has stated that some variations in height due to obstacles and other safety concerns are acceptable, and data collected can be corrected with software calculations and extrapolation algorithms. However: While some pilots, including the occurrence pilot, had been briefed verbally by the chief pilot on the requirement to fly the contour of the terrain, the requirement to fly at and maintain the optimal height of 25 m (82 feet) was not clearly communicated. Neither the requirement to fly and maintain the optimal height of 25 m (82 feet) nor the requirement to fly the contour of the terrain was included in the GASP. As it was not part of the Operations Manual, the GASP was not reviewed by the regulator, Transport Canada. Without the integration of a precise height indication on board, the pilots were left to visually estimate and rely solely on feedback from Novatem to determine whether they had flown a proper flight profile at the correct height. This also left them to determine and maintain their height using visual cues only. In relation to training to prepare for this...

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Investigation into B212 Accident off UAE 7 September 2023

Posted by on 3:35 pm in Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Safety Management, Survivability / Ditching

Investigation into B212 Offshore Helicopter Accident off UAE 7 September 2023 (Aerogulf A6-ALD) On 7 September 2023 Aerogulf Services Bell 212 A6-ALD crashed into the Arabian Gulf of the UAE at c 20:06 Local Time during a night offshore training flight.  Both pilots were fatally injured. The Accident Flight The Air Accident Investigation Sector (AAIS) of the United Arab Emirates GCAA, in a preliminary report, issued 6 October 2023, stated that the helicopter departed Al Maktoum International Airport (OMDW), Dubai, for the Aras Driller jack-up drilling rig located off the emirate of Umm Al Quwain at c 19:18 Local Time.  The Aircraft Commander (9011 hours total time), the trainer, was in the left seat as pilot monitoring (PM), and the Co-pilot (7031 hours total time) was the pilot flying (PF) in the right seat. The intent was to make 5 offshore landings to maintain night recency.  The Aerogulf Ops Manual Part D states… ..flight crew will keep their night recency using a FFS [Full Flight Simulator] or the real aircraft completing 3 night take off, each followed by a traffic pattern and a subsequent landings every 90 days. The training objective were: The helicopter climbed to 1100 ft and proceeded along the coast to the jack-up with an ETA of 19:40 Local Time. At 19:38 Local Time the radio operator on Aras Driller passed the latest weather data: “rvariable windspeed ranging from 7 to 9 knots coming from the 60°, visibility between 7 to 8 knots [sic – presumably nautical miles or km] and 1002 millibar air pressure”. At 19:46 Local Time the PM contacted the radio operator to inform him that they were 2 minutes away from landing. The radio operator confirmed they had a ‘green deck’ (i.e. the helideck was available). At 19:50 Local Time, the Bell 212 landed on helideck, heading southeast. It took off ay 19:52 Local Time and headed  north east. Within 3minutes, it turned and descended for a second landing, again heading south east.  After the second landing, it took off again at 19:59 Local Time and performed a second circuit landing for the third time at 20:03 Local Time. At 20:05 Local Time, the helicopter took off again. One minute later the Helideck Landing Officer (HLO) called the radio operator, reporting that the helicopter had crashed c 600 m away to the north west. The Search and Rescue (SAR) Activity At 20:08 Local Time, the radio operator notified the rig management and initiated a distress call for SAR.  The rig launched a fast rescue craft.  They were not able to locate any survivors but found an inflated liferaft with some debris attached The investigators say: The SAR rescue team reached the site in about 45 minutes after they were notified.  The team swiftly initiated operation within the designated area. Its not clear what SAR asset this was, but it appears to have been a boat, as they go on to say: About 1 hour 20 minutes after the initial notification, a SAR helicopter arrived at the site. Equipped with powerful high beam focus lights fitted on it, the SAR helicopter conducted an intensive survey of the anticipated site. At the same time, the SAR rescue boat gathered all floating debris, which encompassed a small part of the helicopter. The following day after…the...

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Maintenance Distraction in Bell 407 Accident

Posted by on 10:25 am in Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Management

Maintenance Distraction in Bell 407 Accident (N98ZA, Zip Aviation) On 4 June 2022 Bell 407 N98ZA of New York air tour operator Zip Aviation crashed shortly after commencing a positioning flight to JFK International Airport, New York following maintenance at Caldwell Essex County Airport, New Jersey. The Accident Flight According to the NTSB safety investigation report published on 20 September 2023, about 5 minutes after departure, at an altitude of about 500 ft amsl, the Appareo Vision 1000 onboard recording system captured the pilot (872 hours total time, 29 on type) saying, “what is going on here?”. The pilot [when about 2 miles south of Teterboro Airport] subsequently contacted air traffic control and requested to return to the departure airport, but he did not declare an emergency or state that he needed assistance. Upon initial contact with the tower controller at the destination airport, the pilot stated that he “might need the runway”. As the helicopter approached the airport and its indicated airspeed began to decay below about 30 knots, the helicopter entered a right yaw and completed several 360° rotations around the main rotor mast before impacting terrain next to the runway, resulting in substantial damage. The Safety Investigation The Bell 407’s tail rotor was installed the day before after the replacement of four feathering bearings. Examination by investigators revealed that the tail rotor crosshead drive plate, which was positioned behind the pitch change rod attachment nut, was not bolted to the tail rotor crosshead, as prescribed in the maintenance manual. The two attachment bolts were not present, and no remnants of any bolts were found in their threaded receptacles in the crosshead drive plate The threads were undamaged and showed no signs of corrosion, deformation, smearing, or cross-threading. During interview… The director of maintenance (DOM), who performed the task, stated that he conducted the tail rotor assembly installation by laying out the parts on a maintenance cart; performing the installation procedure, including the mast nut torque application; and having a mechanic verify the mast nut torque. He then finished the installation and had another mechanic verify the work. The mechanic who did the verification did hold a Inspection Authority and Zip Aviation did not “have an active RII [Required Inspection Item] program”.  Despite promoting maintenance human factors (HF) for many years, there is still no FAA requirement to do independent inspections on this size of aircraft. A company pilot performed a preflight inspection of the helicopter, ground functional checks, and three consecutive maintenance runs to balance the tail rotor. The accident flight was the first flight after completion of this work. Significantly: According to the DOM, between the mast nut torque application and completion of the tail rotor assembly installation, he was “called out” to consult on two different aircraft repairs. The DOM did not recall the amount of time that elapsed before he resumed the installation work. After the accident Zip Aviation developed an RII program. NTSB Probable Cause The failure of maintenance personnel to properly secure the tail rotor crosshead drive plate and the failure of maintenance personnel, the maintenance pilot, and the accident pilot to detect the error, which led to the helicopter’s loss of tail rotor antitorque. Also causal was the pilot’s failure to maintain the helicopter’s airspeed at or above effective translational lift and...

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Lighthouse HESLO Accident

Posted by on 8:15 am in Accidents & Incidents, Helicopters, Human Factors / Performance, Logistics, Offshore, Safety Management, Special Mission Aircraft

Lighthouse HESLO Accident (AS350B2 F-GJRP, La Vieille, Brittany) On 6 July 2022 Airbus AS350B2 F-GJRP operated by Mont Blanc Hélicoptères, part of HBG France, was involved in an dramatic loss of control accident during a Helicopter External Sling Load Operation (HESLO) in support of maintenance at La Vieille lighthouse, off Pointe du Raz, Brittany for the Brest Lighthouses and Beacons Service (SPBB).  One member of the ground party was crushed between a load and the stone balconey of the lighthouse. The accident was caught on video: The Accident Flight The BEA issued their safety investigation report in French on 21 September 2023. At c09:00 the helicopter landed at a staging area on the mainland, a short distance from the lighthouse. The SPBB site manager was present at the landing site but the SPBB ground party was already at the lighthouse.  The helicopter operator’s Task Specialist was briefed that they would be unable to travel to the lighthouse to inspect the loads due to tidal conditions.  Furthermore the SPBB team at the lighthouse, who were to hook up the returning loads, contrary to normal practice, had no radio. At 10:45 the first operations commenced with a 30 m sling.  On board were the pilot (4,130 flight hours,  2,310 on type) and the Task Specialist, who was in the cabin, in the left rear seat, to provide the pilot with guidance.  The wind was from the north at around 6 kt, gusting 8 kt.  Initially loads were moved from the base of the lighthouse. The pilot explained that during lighthouse missions, he uses the rearview mirror, rather than the vertical reference window, to prevent his gaze from being focused on the waves, which, according to him, can lead to spatial disorientation. With the 30 m sling to collect packages at the bottom of the lighthouse, its visual reference was the weather vane at the top of the dome of the Vieille lighthouse. A sea mist around noon led the pilot to pause flying.  The wind strengthened and was from north-northwest, at 15 kt, gusting 20 kt. Operations commenced again at 14:00.  One more load was moved from the base of the lighthouse, then a 10 m sling was fitted to move load from the balcony of the lighthouse that surrounds the lantern.  The first was a 326 kg load. The pilot explains that piloting with a 10 m sling to recover the loads at the top of the lighthouse was simpler due to the position of the helicopter in relation to the dome of the lighthouse. However there was concern about the strengthening wind.  The BEA explain that: From 14:26:55., the pilot turned to follow a westerly course before turning towards the lighthouse five seconds later. It then turns left to translate vertically to the lighthouse balcony facing west, at an altitude of approximately 40 m. From 14:27:26 ( point❶), the pilot turns to the left and translates eastwards slightly south of the lighthouse balcony. During this period, vertical or close to the vertical of the lighthouse terrace, the pilot sees in the rearview mirror that an SPBB agent on the terrace is trying to catch the hook. After taking his eyes off the rearview mirror to maintain control of the helicopter and the trajectory, the pilot no longer sees the...

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The Loss of RAF F-35B ZM152: An Organisational Accident

Posted by on 11:15 am in Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Regulation, Safety Culture, Safety Management, Survivability / Ditching

The Loss of RAF F-35B ZM152 from HMS Queen Elizabeth: An Organisational Accident On 17 November 2021, Lockheed Martin F-35B Lightning II ZM152 (BK-18) of Royal Air Force (RAF) 617 Squadron, crashed into the eastern Mediterranean, during take off from HMS Queen Elizabeth.  As the ship sailed past the wreckage before it sank, an intake blank was seen to float free. Was the loss of this £81.1 million fighter simply because ‘someone’ was negligent or incompetent?  No.  In this deep dive case study we will demonstrate that real life is more complex. We look at how the 148 page Service Inquiry Report, published by the Defence Safety Authority on 10 August 2023, identified systemic organisational factors. This requires understanding the organisational context of the accident, not just the actions of individuals in the minutes and hours beforehand. Organisational Accidents James Reason, Professor Emeritus, University of Manchester popularised the expression ‘organisational accident’ with his seminal 1997 book Managing the Risks of Organizational Accidents.  He used the term to differentiate simple ‘individual accidents’ involving just one person from complex accidents involving more people, organisations, technology and systems.   Reason explained that: Organizational accidents have multiple causes involving many people operating at different levels of their respective companies. Such accidents result from ‘latent organisational failures’ that are like pathogens that have infected the organisation. In the earlier, 1995 book, Managing the Risks of Organizational Accidents, Maurino, Reason, et al give examples: Lack of top-level management safety commitment or focus Conflicts between production and safety goals Poor planning, communications, monitoring, control or supervision Organizational deficiencies leading to blurred safety and administrative responsibilities Deficiencies in training Poor maintenance management or control Monitoring failures by regulatory or safety agencies Reason famously illustrated how pathogens build up through the concept of the swiss cheese model, where each layer of cheese represents a defensive barrier. Latent holes in the cheese, the pathogens, are introduced by both local workplace and organisational factors that remain dormant until holes in every layer align.  Often the last line of defence is breached by a human action but focusing on that in safety investigations, means the inherent pathogens are ignored and barriers and control remain unfixed. The Aerossurance visualisation of this model is that as time progresses many of these holes will dynamically change size and position as circumstances change, either increasing or decreasing the risk. In practice human actions also routinely plug the holes too, knowingly or unknowingly.  Another reason that focusing on the actions or inactions of one individual can mean missing the big picture. Pathogens as Precursors to this Accident: Critical Context on How the ‘Holes in the Cheese’ were Created 617 Squadron and HMS Queen Elizabeth In 2017  the National Audit Office (NAO) summarised the wider UK’s Carrier Enabled Power Projection (CEPPP) programme as follows: After personnel underwent training at MCAS Beaufort, South Carolina, 617 Squadron reformed at RAF Marham, home of the UK Lightning Force, in April 2018 with the F-35B, the Short Take Off and Vertical Landing (STOVL) variant of the F-35.  The aircraft is powered by a Pratt and Whitney F135 engine.  For STOVL operations there is a Rolls-Royce three-bearing swivel nozzle at the rear, a shaft driven vertical lift fan forward and two wing mounted roll posts. HMS Queen Elizabeth is the first of a pair of 65,000 t Royal...

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