News & Comment

CHC Scotia AS332L Rollover on West Navion Helideck After Loss of Dynamic Positioning

Posted by on 10:35 am in Accidents & Incidents, Airfields / Heliports / Helidecks, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Safety Management

CHC Scotia Rollover on West Navion Helideck after Loss of DP (AS332L Super Puma G-BKZE) On 10 November 2001, CHC Scotia Airbus AS332L G-BKZE, chartered by BP, rolled over while being rotors running refueled on the helideck of the Norwegian drillship West Navion, 80 nm west of Shetland. The copilot, who was on the helideck, suffered serious leg injuries from flying main rotor debris. The UK Air Accidents Investigation Branch (AAIB) published their safety investigation report in May 2004.  While their report was issued over 20 years ago this accident and the AAIB recommendations remains highly relevant for the safety of offshore helicopter operations. The Accident The helicopter departed on a routine crew change flight from Aberdeen, refuelling en route at Wick, before its approach to the Smedvig operated drillship. The helicopter touched down at 1242 hrs toward the forward edge of the deck on a heading of about 296°M (289°T). As used passenger disembarkation occurred while rotors running.  The co-pilot left the aircraft to assist the ship’s helideck crew with the refuelling. The drillship’s position over the seabed well head was maintained by a simplex computer controlled Dynamic Positioning (DP) system.  This determined position from navigation satellites and seabed transponders.  Electrically powered thrusters were used to maintain station. The DP system was programmed to take account of the prevailing sea current and wind to maintain station. The DP system is normally operated in AUTOMATIC mode but has a manual reversion capability. MANUAL control is selected via a ‘one-touch’ switch. In AUTOMATIC mode, the DP system gives the operator a warning if the ship’s heading deviates more than ± 2°, and an alarm when it deviates by more than ± 3°. In MANUAL mode no warnings are given and the only indication to the DP operator that the system is operating in MANUAL mode is the absence of a heading window on one of his DP screens. AAIB explain that: At about 1245 hrs the commander became concerned about the ship’s movement and requested the pitch, roll and heave readings from the ship’s Radio Operator (RO). The RO was on the bridge below the helideck and only had a partial CCTV view of the helideck. After some confusion over exactly what the commander had requested the RO provided the readings, all of which were within the helicopter’s operating limits. Noticeably: The RO’s position on the bridge was between, and to the right of, two parallel consoles from where the ship is controlled when underway and when drilling.   Weather, pitch, roll and heave information were normally available from a computer screen on the forward console. However, on the day of the accident, this screen was out of service and the RO had to use the information from the rear consoles, which were in use by the DP operator. Neither the forward computer screen nor the DP consoles were easily visible from the RO’s position and…much of the information on the DP screens is factored or averaged for use by the DP computers, [so] the basis of the data presented on the screen was not immediately evident. [Therefore]…the RO had to leave his station, walk to the DP operator’s position and ask for the requested data. The aircraft commander remarked that his instruments appeared to be showing greater movements. A little...

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Fukushima Police AW139 Loss of Control Accident: JTSB Final Report

Posted by on 9:48 am in Accidents & Incidents, Helicopters, Safety Management, Special Mission Aircraft, Survivability / Ditching

Fukushima Police Leonardo AW139 FTR LOC-I Accident: JTSB Final Report (JA139F) On 1 February 2020 Leonardo Helicopters AW139 JA139F of the Fukushima Prefectural Police Aviation Unit crashed near Mihota, Koriyama City, Fukushima Prefecture while transferring a human heart for a transplant operation.  All seven occupants were injured, four seriously. This was an accident that Aerossurance first covered just 28 days later. when we translated the  initial Japan Transport Safety Board (JTSB) release about the accident.  The JTSB published its final safety investigation report into this accident earlier this year. The Accident Flight The captain had 1400 hours total experience, 450 on type.  The co-pilot had 3800, 350 on type.  Both had accumulated their AW139 experience relatively slowly over c 5 years. 07:09 JST: JA139F takes off from the Fukushima Prefectural Police Heliport destined for Aizu Chuo Hospital where it was to collect the organs for transplant in Fukushima. 07:24 JST: The helicopter passes over the vicinity of the accident site at c 3,000 ft and an indicated airspeed (IAS) of c 120 kt. 07:28 JST: The captain receives information about a 20 minutes delay at Aizu Chuo Hospital before they will be ready with the organs via police radio. 07:29 JST: The captain and co-pilot discuss flying at a higher altitude on the return trip due to strong winds (about 50 kt from the northwest) observed over Lake Inawashiro. 07:56 JST: The helicopter lands at the Aizu Chuo Hospital Temporary Operation Site. 08:00 JST: The helicopter takes off from Aizu Operation Site with the organs and medical passengers. 08:05 JST: After climbing up to an altitude of about 5,700 ft over Lake Inawashiro, the helicopter started descending gradually.  The captain was conscious that they were flying with a strong tailwind. 08:07:31 JST: While flying over the Ou Mountain range at IAS 152 k, ground speed (GS) 198 kt and c 4,300 ft, the helicopter started rolling to the right at a rotational speed of 100 º/s or more after the IAS increased rapidly to 188 kt, and made right rolling motion exceeding 360º. The captain pressed the Force Trim Release (FTR) button on the cyclic stick (discussed more below and relevant to another AW139 accident we have discussed).  Shortly after we see an aircraft upset evident in flight data: 08:07:38 JST: The main rotor blades contact the tail drive shaft. During the roll and sideslip manoeuvre that occurred the left hand cockpit window fell from the aircraft and the forward right cabin window fell into the cabin, resulting in a high cabin noise.  This happened too in AW139 accidents in Spain and Nigeria which we have discussed previously.  The captain also banged his head and lost his headset.  Crew coordination was therefore difficult. The captain decided to attempt an autorotative landing. 08:07:49 JST: The captain operated the gear lever to extend the landing gears. 08:08:06 JST: The co-pilot reported by police radio that the helicopter would make a forced landing. 08:08:20 JST: The co-pilot set the AP switch to OFF in an attempt to reset the Autopilot (AP). 08:08:55 JST: The helicopter impacts a paddy field and rolls over.  According to the Flight Data Recorder (FDR), touchdown was at 45 ft/s, a right yaw rate was 87 º/s, and the ground speed < 20 kt.  Fortuitously the landing gear absorbed much of the load...

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Night Deck Landing Accident While Training off Brazil

Posted by on 8:37 am in Accidents & Incidents, Airfields / Heliports / Helidecks, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management

Night Deck Landing Accident While Training off Brazil (Omni Leonardo AW139 PR-OTF) On 2 June 2021 Omni Helicopters Leonardo AW139 PR-OTF, under charter to Petrobras, was involved in an accident landing at night on the SS-75 Ocean Courage Mobile Drilling Unit (MODU) off Brazil. The copilot and an occupational-safety technician who was on the helideck suffered serious injuries.  The aircraft commander suffered minor injuries and one other occupant, also a pilot, escaped uninjured. The Brazilian safety investigation agency CENIPA issued their safety investigation report on 17 September 2024. The Accident Flight It appears that at 18:53 Local Time the helicopter departed Jacarepaguá – Roberto Marinho Aerodrome, Rio de Janeiro for the Ocean Courage with three occupants.  The sun had set at 17:21.  Departure was c 30 mins later than planned because the aircraft commander had become stuck in traffic en route to the airport. Night offshore crew change flights are not permitted in Brazil.  However, night emergency flights for medevacs are allowed.  CENIPA indicate there was an exemption for night deck training flights and the operator did have approved night training procedures (albeit referencing a regulation repealed in 2018). In the previous 2 years the operator had only done 15 night offshore landings, in contrast to 12,000 daytime offshore landings.  Due to the rarity of night flights only a small cadre of pilots were rostered for night standby.  CENIPA say that… …there was an understanding within the company that carrying out a nighttime landing in the simulator would be sufficient to provide the pilot with the necessary qualification to conduct the real operation. [At] the time of the occurrence, the ANAC did not determine a specific requirement for night-time operation in helicopters… A further challenge to night training & recency was that Petrobras had not made offshore helidecks available for the 2 previous years. This training flight had been postponed several days so the crew was not the one originally intended, which had included an instructor with greater night recency.  Both pilots were captains. The aircraft commander, who was Pilot Flying, had 9,321 hours, 4,073 on type and was also an instructor. He had worked for the company for 11 years.  On 5 May 2021 he had completed a simulator session that include a night onshore landing. There were comments in the pertinent records on the concept of stabilized approach, with special attention to night-time flights, including the possibility of spatial disorientation and optical illusion phenomena.  However, the flight records did not inform precisely what had occurred during the training. The simulator instructor commented that the aircraft had operated the aircraft safely, complying with the profiles prescribed. His performance was considered “satisfactory”.  It does not appear that he had previously conducted an actual night offshore deck landing though. The copilot, the Pilot Monitoring, had 4,863 hours, 3,395 on type. He had completed an onshore night landing in the simulator in January 2021.  There were suggestions he had completed 3 night deck landings in 2018 but according to CENIPA no evidence was found that confirmed that. The third occupant was described as onboard to “change the pilot’s seats” when on the deck according to the CEIPA report. This was not elaborated on but is highly likely to be ‘lost in translation’ and they were in fact going to swap with the co-pilot to...

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Dramatic AW139 Accident at Houma: Skillful Recovery from a Latent Production Defect

Posted by on 5:45 am in Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Safety Management

Dramatic AW139 Accident at Houma, Louisiana: Skillful Recovery from a Latent Production Defect (ERA N811TA, 24 September 2022) On 24 September 2022, Leonardo AW139 offshore helicopter N811TA, of ERA Helicopters, was involved in an accident near Houma, Louisiana. The two pilots and four passengers were uninjured. The US National Transportation Safety Board (NTSB) released their safety investigation report on 11 September 2024. The Accident Flight The helicopter was returning from the then Murphy Oil Thunder Hawk offshore installation in the Mississippi Canyon (MC) Block 736 of the Gulf of Mexico.  The aircraft commander, who was Pilot Flying,  had 2160 hours of experience, 480 on type.  The copilot, the Pilot Monitoring, had 3760 hours, 218 on type.  The helicopter had ben flown for 7,491 hours in the 11 years since delivery. About 7 minutes from their destination of Houma-Terrebonne Airport (HUM), the occupants smelled “burning plastic” throughout the helicopter. Initially there was no smoke evident or any abnormal cockpit indications.  The helicopter was otherwise behaving normally and the flight crew decided to turn off the air conditioning system in case it was the source of the smell. However, a few minutes later there was a loud “whoof sound” accompanied by smoke emanating from the rear of the overhead circuit breaker panel. Within seconds the cockpit was engulfed with a “thick orange/brown smoke” resulting in “zero visibility”. Simultaneously there was a low main rotor speed (NR) audio warning, a rapid overspeed of both engines, an upward movement of the collective control and a left movement of the cyclic control. The copilot was unable to clear the smoke by opening the small ventilation window in the left-hand cockpit window. He then jettisoned the left-hand cockpit window and the smoke cleared. At this point the collective was down and the cyclic was to the forward right. The controls required significant force to stay in position.  The power index (PI) was about 145% on both engines.  The NR slowly rose to be above 83% and eventually recovered to 100%. Meanwhile, the helicopter climbed 3,500 to 4,000 ft as the crew were unable to establish a descent using normal flying control inputs. They tried selecting one of the engines to idle, but the NR decreased from 100% to the high 70s. Consequently, they returned that engine to a flight condition. The pilots needed to use their ”full body weight” to keep the collective down, but the helicopter neither descended or slowed in that condition. The pilots found they could descend if they forcibly pushed the cyclic further forward, but the helicopter descent was at 170 to 186 knots indicated airspeed (KIAS). They declared an emergency and requested fire and emergency medical services at Houma to be notified, and briefed the passengers. On arrival over Houma the crew made a high speed descent from 6,000 ft to 1,000 ft and flew an orbit of the airport to verify flight controllability. The tower controller confirmed that the landing gear was extended. However, the crew were unable to control engine power in manual mode via the beep switches on the collective. They tried to reduce airspeed by reducing the No. 2 engine to idle using the engine mode switch on the lower console with the No. 1 engine remaining at maximum continuous power. The helicopter only decelerated to about...

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Two Offshore Passengers in GOM Survive Single Pilot Fatal Incapacitation

Posted by on 8:37 am in Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Management, Survivability / Ditching

Two Offshore Passengers in Gulf of Mexico Survive Single Pilot Fatal Incapacitation (Westwind B407 N34BM) On 26 October 2022 Bell 407 N34BM of Westwind Helicopters ditched into the Gulf of Mexico, about 25 miles south of Morgan City, Louisiana under the partial control of a passenger. The pilot, who had become incapacitated, died.  The two passengers were recued by US Coast Guard (USCG) but suffered serious injuries (one a broken back and the other a broken leg). The US National Transportation Safety Board (NTSB) released their safety investigation report on 11 September 2024.  They determined the Probable Cause as: The pilot’s loss of consciousness due to a cardiovascular event. NTSB do however state that: The pilot’s autopsy did not identify a definitive cause of his loss of consciousness. The Pilot The pilot (21435 hours total, 520 hours on type) was 63.  The pilot’s LinkedIn page suggests they had flow AW139s for Aramco Sept 2019 to July 2021, joining Westwind in April 2022.  His last proficiency check was 3 October 2022, which seems to have followed training on the S-76. His last medical (Class 1 Without waivers/limitations) occurred on 12 October 2022 – just two weeks before.  NTSB report that: The pilot had a history of high blood pressure for which he had been prescribed the prescription medication losartan since December 2020.  Losartan is not generally considered impairing. Based on his reported height and mass his Body Mass Index was 29.3; overweight but not quiet obese.  The doctor… …did not document any complaints from the pilot. Physical examination and electrocardiography [ECG] were performed. No concerns were noted… The Accident Flight The pilot had departed Westwind’s base at Abbeville, Louisiana at 08:48 with two telecoms technicians from Tampnet who were to perform work on two offshore installations.  The pilot shut down on both installations to await the completion of their work.  The helicopter departed from the W&T Offshore Ship Shoal 349 (SS349) installation at about 16:31, ETA 17:55. One passenger was seated in the right rear cabin seat and the other in the left cockpit seat. While in the cruise at 1,500 ft, the front passenger recalled the pilot saying words to the effect of “this is not good; I am not going to make it.” The pilot told him that it is not a helicopter issue, “it is me” and “I’m overheating.” Then he pilot slumped over and was unresponsive. The passenger reached over to the flight controls, retarded the throttle, and attempted to control the helicopter until water impact.  The rear passenger was awoken by a “change in noise,” and saw the pilot “slumped over” and “the helicopter was descending toward the water”. The front passenger estimated that he started to control the helicopter about 400 ft above the water, presumably reaching across to the pilot’s controls.  At some point during the descent, the passenger activated the skid-mounted Apical float system, using the handle on the pilot’s cyclic. ADS-B data indicated that at 1710:26, the helicopter was flying in level flight about 1,400 ft mean sea level (msl). About 10 seconds later, the data showed the helicopter make a right descending turn to about 1,100 ft msl. About 5 seconds later, the data showed the helicopter make an abrupt left descending turn to about 800 ft msl. The data...

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B407 Worn Throttle Detent Power Loss Accident

Posted by on 9:51 am in Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management, Special Mission Aircraft

B407 Worn Throttle Detent Power Loss Accident (Air Methods N687AM) On 4 September 2022 Air Methods Corp (AMC) Bell 407 N687AM from Mercy Air 22 air ambulance base in Hesperia, California crashed near Mount Baldy, California. The pilot was seriously injured. The US National Transportation Safety Board (NTSB) issued their safety investigation report on 21 August 2024. The Accident Flight The NTSB lists the 58 year old pilot’s experience as 3447 hours total, 264 hours on type. In his statement the pilot explains he was tasked to support a public relations event for the Mount Baldy Fire Department and… …consisted of flying water and other supplies and people from a base camp at Cow Canyon Saddle to the summit of Mount Baldy, dropping them off and returning to the base camp to pick up more supplies. The base camp is at approximately 4300 feet MSL. The summit of Mount Baldy is at 10064 feet MSL. The summit is approximately 4 nautical miles from the base camp. The pilot was using the base’s spare aircraft.  He anticipated 5 trips would be needed.  After completing the second delivery to the summit… I flew down-canyon to lose altitude and set up for a steep approach to the confined area landing zone at Cow Canyon Saddle. I slowed from 60 knots to 40 knots as I turned final. Shortly after turning final I saw the low RPM warning light and heard the low RPM warning horn.  There were no other warning lights illuminated. There were no other audio annunciations. The controls were responding normally. The engine did not sputter. I saw that the rotor RPM dropped to approximately 95%. I lowered the collective and the rotor RPM went back up to 100%. I don’t remember looking at the throttle. I aborted the approach and turned left, down-canyon. I made a Mayday call to the firefighters at Cow Canyon Saddle. I told them I had a partial engine failure and that I was looking for a place to land. I attempted to raise the collective and once again the low RPM warning light and horn came on. I lowered collective again and proceeded down-canyon with a descent rate of 600-700 feet per minute. I did not attempt to put the FADEC into Manual mode because I didn’t want to divert attention away from looking for a place to land. I didn’t see any good places to land. I considered landing on the main road but decided against it because of the power lines along the road and the narrowness of the road. I saw a small paved road in a clearing at the bottom of the canyon and decided to land there. I did not autorotate. I decided to use what power the helicopter had for landing. There were trees and powerlines down-canyon from the clearing. I was slightly too high to land in the clearing so I flared into the top of a tree on the downcanyon side of the clearing. The flare brought the helicopter to a stop. I started to level the helicopter with forward cyclic. I pulled full collective to cushion the impact. The helicopter came to rest on its right side. The Safety Investigation The NTSB explain that: The engine control unit captured data consistent with main rotor impact. The...

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Fatal Offshore S-76C++ LOC-I & Water Impact Brazil 2022: CENIPA Investigation

Posted by on 8:36 pm in Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Survivability / Ditching

Fatal Offshore S-76C++ LOC-I & Water Impact Brazil 2022: CENIPA Investigation (Lider PR-LCT) On 16 March 2022 Sikorsky S-76C++ PR-LCT of Líder Táxi Aéreo struck the sea on approach to a Petrobras Normally Unattended Installation (NUI), Manati 1 (9PMM), after a Loss of Control In-flight (LOC-I).  The aircraft capsized but was kept afloat by its Emergency Flotation System (EFS).  The Aircraft Commander died but the other 12 occupants were rescued with only minor injuries. The Brazilian accident investigation agency CENPIA published their safety investigation report, on 5 August 2024. The Accident Flight & Crew Background The helicopter departed Salvador Bahia for a c 22 mins flight to the offshore installation. Four of the the 11 passengers had not completed Helicopter Underwater Escape Training (HUET). Survivors reported that it was common practice for crews to ask the passengers whether they had received the HUET training [before departure], but, specifically in the case of the accident the question was not made. This indicates that an absence of passenger HUET qualification was common.  It also meant there was nothing to stop two untrained passengers on this flight being sat next to push out windows they had not gained familiarity with using through practical training.  CENIPA describe the safety briefing given to passengers.  It does not appear to have included the brace position. The passengers were equipped with life jackets but no Personal Locator Beacon (PLB) or Emergency Breathing System (EBS). The pilots had life jackets and PLBs but no EBS. Both pilots were starting a two week period on-duty.  For this flight the Co-pilot was Pilot Flying (PF) and the Aircraft Commander was Pilot Monitoring (PM). The Aircraft Commander had 8670 hours flying experience, 7393 on type.  He had been an S-76 instructor since 2012. The Co-pilot (5800 hours, 1382 on type) had flown for CHC from 2008-2016 (and been an Aircraft Commander 2010-2016).  However in 2016 he had been made redundant at a time of contraction in offshore operations (the offshore fleet in Brazil declined from 100 helicopters in 2014 to 70 in 2016, with a number of contracts terminated in 2015).  In 2020 Petrobras is reported to have used a reverse auction process to drive down prices after COVID hit. The Co-pilot did not resume offshore flying until December 2020 upon recruitment by Lider.  The Co-pilot underwent 36 hours of initial simulator training 22-30 January 2021, needing 8 hours more than the standard course to gain an “acceptable” grade (the middle of 5 grades), with the comment “minimally qualified to perform his duties on board…” The SIC reported that, on that occasion, during the initial training sessions on the flight simulator, he had some trouble due to the automation of the S-76C++ helicopter. The SIC started flying operationally in February 2021 and over the next two months with an instructor accumulated 104:20 flying hours.  However, he then spent 10 months on a medevac stand-by roster logging just 36:40 flying hours and 22 offshore landings (most of which appear to have been as PM). Despite this, on the day of the accident the Co-pilot was commencing “operational-experience training” in preparation for promotion to be an Aircraft Commander with Lider.  In early 2022 the oil price was spiking as Russia invaded the Ukraine. The Co-pilot (or SIC) was therefore seated in the right hand...

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Deadly Delay: Catastrophic USAF CV-22B Osprey Gear Box Failure

Posted by on 4:26 pm in Accidents & Incidents, Design & Certification, Fixed Wing, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Safety Culture, Safety Management, Special Mission Aircraft

Deadly Delay: Catastrophic USAF Bell/Boeing CV-22B Osprey 10-0054 Gear Box Failure On 29 November 2023 US Air Force (USAF) Bell/Boeing CV-22B Osprey tiltrotor 10-0054 (call sign Gundam 22) of the 21st Special Operations Squadron (21 SOS), impacted the water 1/2 mile off the coast of Yakushima Island, Japan, while on approach to Yakushima Airport.  The aircraft was destroyed, and all 8 crewmembers sustained fatal injuries.  After this accident the V-22 fleet was grounded until 8 March 2024. The USAF Accident Investigation Board (AIB) issued its report on 1 August 2024. Context of the Accident Flight The report notes that 21 SOS was a small unit with a high operating tempo.   The period before the accident was reportedly particularly intense because of Air Force Special Operations Command (AFSOC) directions on achieving flying training requirements and several aircraft being down for base maintenance.  The unit were also suffering a shortage of flight engineers / rear crew. The aircraft was part of a two-ship formation, with a third airborne spare aircraft, that departed Yokota Air Base, near Tokyo, at 10:43 local time for a exercise with other US military units.  The Aircraft Commander (AC), a Major with 1363 total flying hours, 953 on type over c 7 years.  He was the lead air integration planner for the exercise and also the Airborne Mission Commander (AMC), unusual according to the AIB but allowed within AFSOC procedures.  He was also an advocate of the type on Reddit as UR_WRONG_ABOUT_V22.  This exercise had been months in the planning and there had already been a rehearsal on 7 November 2023. On the day it was decided the V-22s would depart 30 minutes earlier than planned due to forecast headwinds and changed plans to refuel at MCAS Iwakuni. 10-0054 had 19 deferred defects (‘Red Diagonal’ or ‘/‘ items in USAF parlance).  These are not listed or elaborated upon in the AIB report however.  The AAIB report discussed the last aircraft maintenance on 10-0054 but does not mention the Time Since New and Time Since Overhaul of the left-hand proprotor gearbox (PRGB), the key assembly involved in the accident. The Accident Flight On departure at 10:43 10-0054 had suffered a mission computer ‘warm-start‘, resulting in a “software glitch”.  En route they had to complete a 29 step checklist procedure to address this. They arrived at MCAS Iwakuni at 12:31 after a 348 NM flight. While there the crew of 10-0054 also had to deal with a number of advisory messages and several equipment failures, including two further warm-starts.  They then departed at 13:09 to rendezvous with a US Marine Corps (USMC) Lockheed Martin KC-130J Hercules for air-to-air refuelling, en route to Kadena AB. While en route at 13:50 the crew received the first left-hand PRGB CHIP BURN visual advisory on the Control Display Unit (CDU). This indicated an automatic ‘fuzz burn’ had occurred on a PRCG magnetic chip detectors. The  chip detector fuzz burn feature is designed to burn off minor metallic debris but not large chips. Repeated fuzz burns however could indicate a incipient failure.  When a fuzz burn can’t remove more substantial debris, a chip caution is displayed. Each PRGB transmits power from one of the V-22’s Rolls-Royce T406 engines to one of the V-22’s proprotors, reducing the speed by 38:1 while increasing the torque. The AIB...

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“Sensation Seeking” Survey Fatal Accident

Posted by on 11:05 am in Accidents & Incidents, Fixed Wing, Human Factors / Performance, Mining / Resource Sector, Safety Culture, Safety Management, Special Mission Aircraft

“Sensation Seeking” Survey Fatal Accident (Exact Air Piper PA-31 C-FQQB) On 30 April 2017 Piper PA-31 Navajo C-FQQB operated by Exact Air crashed 3.5 NM from Schefferville Airport, Quebec while returning there from its second magnetometric geophysical survey flight of the day.  Both pilots onboard died during the Controlled flight Into Terrain (CFIT) accident. The Accident According to the Transportation Safety Board of Canada (TSB) safety investigation report the survey area was 90 NM from Schefferville Airport.  The surveys were conducted at 300 feet above ground level with a crew of two. Although the regulations do not require it, the company decided to add a 2nd pilot on board the magnetometric survey flights and gave the pilots additional training in the right-hand seat on standard operating procedures (SOPs), including instrument approaches using the global positioning system (GPS). The occurrence pilots were 24 and 25 years old. [They] alternated the roles of pilot-in-command and co-pilot on each flight. Because survey flights are conducted at low altitude, the crew had conducted a reconnaissance flight over the survey area to identify potential hazards. TSB note that: The pilot-in-command had been employed by the company since March 2016. He had 462 hours total time, 112 on type. This was his first magnetometric survey contract, and he had conducted about 16 flights as co-pilot to familiarize himself with this type of aerial work before being assigned to the role of pilot-in-command the week before the accident. The pilot-in-command was the pilot flying for the accident flight. The co-pilot had been employed by the company since September 2014. He had 1693 hours total time, c650 on type. This was his 4th magnetometric survey contract, and he had trained the occurrence pilot-in-command during the first flights of the contract. The co-pilot was the pilot monitoring. C-FVTL, another Piper PA-31 of Exact Air was simultaneously taking part in the survey. The TSB investigation revealed that during the daytime return flight C-FQQB… …descended to a height of less than 100 feet AGL and maintained this altitude until colliding with the wires at 1756. Its ground speed during the last minute before the impact was 169 knots, or 286 feet per second.  At 1756, while the aircraft was flying over railway tracks, it struck power transmission line conductor cables and crashed on top of a mine tailings deposit about 3.5 nautical miles northwest of Schefferville Airport. Shortly after C-FVTL arrived at Schefferville its crew realised that C‑FQQB had not landed. After unsuccessful attempts to make radio contact, a search was initiated. Less than an hour later, the wreckage of the missing aircraft was located. The Safety Investigation [No] emergency locator transmitter (ELT) signal was captured. Damage to the antenna coaxial cable likely led to the rapid discharge of the battery. However, the broken antenna and the fact that the wreckage was upside down would have made it impossible to detect the signal. This is a common phenomenon.  TSB note that: The current emergency locator transmitter system design standards do not include a requirement for a crashworthy antenna system. As a result, there is a risk that potentially life-saving search‑and‑rescue services will be delayed if an emergency locator transmitter antenna is damaged during an occurrence. The left engine was separated from the main wreckage.  Electrical transmission cables were found  wrapped around its propeller drive shaft. TSB...

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Air Ambulance Bell 407 Pitch Links & Swashplate Drive Arm Bent in Double Bird Strike

Posted by on 10:24 pm in Accidents & Incidents, Helicopters, Safety Management, Special Mission Aircraft, Survivability / Ditching

Air Ambulance B407 Pitch Links & Swashplate Drive Arm Bent in Double Bird Strike (Med-Trans Corp N910GX) On the afternoon of 29 March 2024 Bell 407 air ambulance helicopter N910GX, operated by Med-Trans Corp, suffered a bird strike near Moran, Kansas. The pilot reported that the aircraft was in the cruise en route to a casualty.  Due to “strong gusty winds” the pilot “elected to transit to the scene location at approximately 2500 feet MSL and 130 KIAS ” when… …the aircraft encountered a small flock of 3 birds near Moran, Kansas. The pilot had been crossing check instruments and when continuing outside visual scan, he spotted the birds and attempted to briefly maneuver to avoid contact. This attempt was unsuccessful as the late spotting of the birds did not allow further maneuvers. Subsequently, there were two loud noticeable impacts to the aircraft. Following the impacts, the aircraft began to hop vertically and aircraft controllability was in question. The pilot found the helicopter was still controllable but as the amount of damage was unknown… …the pilot began to turn into the wind to find a suitable emergency landing site as he was unsure how long the aircraft would remain controllable. An open pasture was selected as an emergency landing site. The pilot proceeded to land (trying to maintain an autorotational profile during most of the descent) and shutdown the aircraft without further issues. There were no injuries to the four occupants. The pilot and medical crew began to look over the aircraft for any noticeable damage. Initially, they could see a bent pitch change link on the rotorhead as well as a bird wing lodged in the upper wire strike prevent system. Upon further inspection, the swashplate drive link was bent as well near the bent pitch change link. The upper left corner of the pilot’s windscreen was also cracked. The US National Transportation Safety Board (NTSB) safety investigation report, issued on 18 July 2024 added nothing further, nor was the bird debris identified. Just a few weeks earlier, on 5 March 2024, Airbus AS350B3e (H125) N853MB of Med-Trans Corp, suffered a double bird strike near its destination at Fort Morgan, Colorado, that we previously discussed.  In that case the windscreen was penetrated, the pilot’s visors shattered and helmet knocked off. 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: Med Trans Air Ambulance Pilot’s Visor Smashed in Double Bird Strike HEMS H145 Bird Strike Safety Lessons from a Fatal Helicopter Bird Strike: A fatal accident occurred on 4 Jan 2009 involving Sikorsky S-76C++  N748P of PHI that highlighted a range safety lessons.  We also discuss current activity on enhancing bird strike requirements. USAF HH-60G Downed by Geese in Norfolk, 7 January 2014 Swedish Military NOE Helicopter Bird Strike Power of Prediction: Foresight and Flocking Birds looks at how a double engine loss due to striking Canada Geese had been predicted 8 years before the US Airways Flight 1549 ditching in the Hudson (which was just days after the Louisiana helicopter accident). Final Report Issued on 2008 B737 Bird Strike Accident in Rome NTSB Recommendations on JT15D Failure to Meet Certification Bird Strike Requirements USAF T-38C Downed by Bird Strike AS350B3/H125 Bird Strike with Red Kite  Big Bustard Busts Blade: Propeller Blade Failure After Bird Strike AW169...

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