Sécurité Civile EC145 SAR Wirestrike
Sécurité Civile EC145 SAR Wirestrike (F-ZBQK, Martinique): BEA-Etat Safety Investigation Report During a SAR mission to rescue a jet-skier in difficulty in the sea off Martinique in the Caribbean, the crew of base BH972’s Airbus Helicopters EC145 (BK117C2) F-ZBQK suffered a wire strike on 3 April 2019, spectacularly captured on video. The Accident Flight Investigators of the BEA-Etat (BEA-E) note in their safety investigation report (only available in French), issued on 29 April 2020, that the crew (pilot, winch operator and winchman) were airborne from Martinique Aimé Césaire International Airport within 4 mins of being tasked by the Antilles Guyane Regional Operational Surveillance and Rescue Centre (CROSS AG). BH972 has a single helicopter on call 0700-1900 each day. They are a busy unit, conducting around 800 taskings per annum. The crew located the survivor 260 m from the beach at Fond Bellemare cove near Case-Pilote just 4 mins later. They came into a hover above, at around 100 ft due to the mast of an adjacent anchored yacht. The winchman was lowered and once they had placed the survivor in the strop, gave the signal to be hoisted up. The pilot determined they would transit to the beach to disembark the survivor and so the winch operator stopped their ascent with 15 to 20 ft below the aircraft. The winch operator did start to challenge that plan until interrupted by the pilot. This choice may have been partially influenced by the limited space due to the fitment of a stretcher in the cabin (usual at that time of year when onshore tasks were most prevalent). The pilot commenced a slow translation (<20 kt) towards the east part of the beach but due to members of the public in that area, changed direction to the left for the west part of the beach (note both the pilot and winch operator were seated to the right hand side of the aircraft). This is when the helicopter hit three wires of a medium-voltage (20 kV) power line, which they had previously not spotted, which spanned around 400 m over the cove. Although a Wire Strike Protection System (WSPS) is fitted this is designed to deflect and cut a cable encountered while moving forwards at speed. The winch cable failed and both survivor and winchman fell into the sea from 45-60 ft. They were able to swim to shore and the helicopter landed safely at the airport. The Safety Investigation and Analysis The employee of a beachfront restaurant who raised the alarm about the jet-skier being in difficulties claims to have mentioned the presence of the power line to CROSS AG. The BEA-E interviews at CROSS AG proved “to be contradictory”. The recording of those particular phone calls had not been retained either. It is undisputed however that the helicopter crew did not receive any warning about the presence of the power line. Damage was evident on several parts of the airframe. Laboratory examination showed that the hoist cable failed due to arc burn damage. From 3 videos and CVFDR data, the BEA-E created reconstruction below: The crew were not familiar with the small cove. The power cables were unmarked and had a diameter of just 7.82 mm. They were dark in colour, with little contrast with the landscape beyond. They were the only power lines on the island to cross water. These medium voltage cables were neither marked on local maps or aeronautical charts (though high and very high voltage cables...
read moreBeech 99A MLG Collapse
Beech 99A MLG Collapse (N326CA, Alpine Air) On 19 January 2017 Beech 99A N326CA of Alpine Air experienced a landing gear collapse on landing at the Billings Logan International Airport (BIL), Montana while making a Part 135 cargo flight. The pilot was uninjured. According to the US National Transportation Safety Board (NTSB) safety investigation report (released 13 April 2020), after take off from BIL the pilot retracted the landing gear and heard a ‘thud’. The Main Landing Gear (MLG) ‘unsafe’ light illuminated, and the left MLG light remained green, indicating that it was still extended. The pilot returned to BIL and just before touch down, feathered the propellers and decreased the airspeed. During touchdown, the right MLG collapsed. This caused substantial damage to the right aileron and right wing spar. The NTSB say: During the post-accident examination of the landing gear, the left MLG actuator’s piston rod was found fractured. Metallurgical examination of the piston rod revealed that the rod had failed in its threaded section due to fatigue cracking over about 60% of the cross-section. Contact wear was observed on the faying surface of the retaining nut and piston head and the shoulder of the piston rod. These signatures were consistent with the nut not being tight enough to mitigate sliding of the piston head relative to the piston rod and retaining nut. Surprisingly: It could not be determined if the manufacturer required a specific torque to be applied to the nut during assembly. The 1970 made aircraft had accumulated 46,416.3 flying hours. The left actuator was last overhauled in November 2001, at which time the piston rod was replaced. The part had 7,445.2 hours and 8,267 cycles since overhaul. The landing gear hydraulic actuators need to be overhauled or replaced every 10,000 hours. The NTSB concluded: Based on the evidence, it is likely that inadequate torque on the nut reduced the preload on the threaded section of the piston rod and contributed to premature fatigue crack propagation in the rod and its eventual failure. The failure of the piston rod allowed hydraulic fluid to pass freely from the down-side to the up-side of the piston, which prevented the hydraulic system from producing pressure to control the MLG’s position. Safety Resources Eclipse 500 Landing Gear Production Defect Significant Twin Otter NLG Crack “Shoulda gone around”: B727 Landing with NLG Retracted Poor Painting Prevents Proper Performance: Shorts Sherpa NLG Collapse B1900D Emergency Landing: Maintenance Standards & Practices A Lufthansa MD-11F Nose Wheel Detached after Maintenance Error ATR72 VH-FVR Missed Damage: Maintenance Lessons B747 Landing Gear Failure Due to Omission of Rig Pin During Maintenance When Down Is Up: 747 Actuator Installation Incident Lost in Translation: Misrigged Main Landing Gear Maintenance Human Factors in Finnish F406 Landing Gear Collapse S-92A Nose Landing Gear Incidents UPDATE 3 June 2020: Beechcraft 1900C Landing Gear Collapse at San Antonio, TX UPDATE 12 October 2020: Frozen Dash 8-100 Landing Gear After ‘Improper Maintenance Practices’ Say NTSB Aerossurance has extensive air safety, operations, 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 moreFatal R44 Loss of Control Accident: “Overweight and Out of Balance” Say NTSB
Fatal R44 Loss of Control Accident: “Overweight and Out of Balance” Say NTSB (N7530R, Newport Beach, CA) On 30 January 2018 a privately operated Robinson R44, N7530R, was destroyed on impact houses near Newport Beach, California about a minute after takeoff from John Wayne-Orange County Airport (SNA), Santa Ana, California. The private pilot and two passengers were fatal injured, one passenger sustained serious injuries and one person on the ground received minor injuries. The Accident Flight According to the US National Transportation Board (NTSB) safety investigation report (issued 8 April 2020): The surviving passenger reported that the pilot and all of the passengers met at the pilot’s office and planned to fly to Catalina Island for lunch. Following a brief conversation, the pilot drove the passengers to the airport. The passenger stated that, during the drive, the pilot received a phone call during which he appeared to be frustrated. The passenger asked if everything was ok, and the pilot responded everything was fine and he just wanted a different helicopter. NTSB don’t elaborate on what that might have meant and whether that frustration could have been a distraction. They don’t seem to have interviewed whoever the call was with either, which is surprising. Upon arriving at the airport, they all walked to the helicopter and the pilot appeared to conduct a preflight inspection. The passenger recalled that the pilot never asked any of the passengers about their weights, nor did he assign them seats. The pilot had flown only 195 hours in total. Surveillance video footage of the takeoff showed the helicopter slightly move forward in a nose low attitude, lift off, rotate left, increase in a nose-low attitude, and yaw to the right. As the helicopter briefly transitioned into a level attitude, it moved momentarily out of view behind a parked airplane. The tailboom of the helicopter became visible shortly after, in an elevated attitude consistent with a nose-low pitch attitude. As the rest of the helicopter became visible, it appeared to be in a slight climbing left turn, remaining in a nose-low attitude. The helicopter briefly descended and appeared to transition into a level attitude before it began a climb. The helicopter continued the climb while transitioning to a nose-low pitch attitude as it traveled out of frame. A…witness reported that they observed the helicopter flying on an easterly heading and descending until it impacted two residential houses. A review of archived Federal Aviation Administration (FAA) radar data…showed that the helicopter climbed to a maximum altitude of 500 ft mean sea level (msl) and traveled along a southeasterly heading for about 13 seconds. The data showed that the helicopter then descended from 500 ft msl to the last recorded target, at 200 ft msl, in 11 seconds…almost directly above the initial impact area. The helicopter impacted multiple residential structures and a residential street about 0.95 nm miles south-southeast of the departure end of runway 20R at SNA. https://youtu.be/qHQ2pwTKw80 The surviving passenger, who was making their first helicopter flight, said: I remember looking straight down between my legs through the glass at the ground rushing toward us and saying “God no! God no! No God! No God!” and instinctively preparing for impact. It is so complicated to explain the feeling at impact because it was so hard, loud and really indescribable if...
read morePoor Painting Prevents Proper Performance: Shorts Sherpa NLG Collapse
Poor Painting Prevents Proper Performance: Shorts Sherpa NLG Collapse On 13 October 2016, a Shorts C-23C SD3-60 Sherpa, N148Z, sustained minor damage following a Nose Landing Gear (NLG) collapse on landing, at the Missoula International Airport (MSO), Montana. The aircraft was operated by the US Department of Agriculture (USDA), as a public aircraft in support of the US Forest Service (USFS). The flight was a ferry flight after being re-painted in Kingman, Arizona prior to this ex-US Army 360 Sherpa conversion entering service as a smokejumper drop aircraft. In their safety investigation report, released in November 2019, the US National Transportation Safety Board (NTSB) say: The pilots reported that prior to landing, they had an unsafe nose gear indication. After multiple unsuccessful attempts to get the nose gear to extend and indicate that it was down and locked, they decided to come in for a landing. During the landing roll, as the airplane’s nose was lowered, the nose gear collapsed… Post incident examination of the nose gear down-lock actuator piston (plunger), revealed that its chrome surface had been painted, which resulted in the locking piston not engaging, and prevented the locking of the nose gear during landing gear extension. The painting of the nose gear down-lock actuator piston was not observed by maintenance personnel or the flight crew on their pre-flight exterior checks. Shorts issued a SD3-60 Sherpa Service Information Letter (SIL) Sherpa L-23, in April 2007, titled: Servicing/Painting – Removal of masking material/paint from nose landing gear down-lock actuator piston after cleaning/painting operations. The SIL described a similar incident where the nose gear failed to lock in the down position, on the first flight after the airplane had been re-painted. The subsequent investigation revealed paint spray on the exposed chrome piston of the nose landing gear down-lock actuator. The SIL stated “to ensure that all masking material has been removed from the exposed piston after cleaning/painting, and that the piston is free from any paint or cleaning materials.” The Maintenance Manual is clear. NTSB don’t provide any further detail on the painting. NTSB Probable Cause The failure of the nose landing gear down-lock piston to engage due to paint accumulation, which resulted in a nose landing gear collapse during landing. Also causal was the failure of the facility that performed the painting to comply with manufacturer guidance regarding painting of the airplane. Safety Resources Human error is not itself a cause, but merely the start of a human factors investigation, as explained by Sidney Dekker in The Field Guide to Understanding Human Error – A Review (discussed in this book review The Field Guide to Understanding Human Error to the RAeS). Maintenance Human Factors: The Next Generation Airworthiness Matters: Next Generation Maintenance Human Factors Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law? B1900D Emergency Landing: Maintenance Standards & Practices A Lufthansa MD-11F Nose Wheel Detached after Maintenance Error ATR72 VH-FVR Missed Damage: Maintenance Lessons B747 Landing Gear Failure Due to Omission of Rig Pin During Maintenance When Down Is Up: 747 Actuator Installation Incident Lost in Translation: Misrigged Main Landing Gear Maintenance Human Factors in Finnish F406 Landing Gear Collapse Significant Twin Otter NLG Crack UPDATE 28 April 2020: Beech 99A MLG Collapse UPDATE 3 June 2020: Beechcraft 1900C Landing Gear Collapse at San Antonio, TX UPDATE 16 June 2020: CRJ-200 Landing Incident Highlighted US Maintenance Competency Inadequacies UPDATE 28 June 2020: Maintenance...
read moreSAR Helicopter Loss of Control at Night: ATSB Report
SAR Helicopter Loss of Control at Night: ATSB Report (Careflight AW139 VH-YHF near Darwin, NT) On 13 May 2018 Leonardo Helicopters AW139 VH-YHF of HEMS operator Careflight, while descending during a nighttime search, the aircraft entered a degraded visual environment, developed a high rate of descent, an autohover mode was inappropriately selected and came within 31 ft of impacting the ground. The aircraft was also then flown on for one more flight after the related 159.5% over-torque. We look at the Australian Transport Safety Bureau (ATSB) safety investigation report issued 16 April 2020. The SAR Tasking, Aircraft Equipment and Preparations On the evening of 13 May 2018 the Australian Maritime Safety Authority (AMSA) Rescue Coordination Centre (RCC) tasked the crew of VH-YHF, to locate an active Emergency Position-Indicating Radio Beacon (EPIRB) 21 nm north-east of Darwin International Airport, Northern Territory in the vicinity of a waterway called Salt Water Arm, popular with recreational anglers. The aircraft was operated single pilot (front right seat), an ‘ Aircrew Officer (ACO)’, a dual qualified winch op and winchman (right hand cabin doorway) and a ‘Flight Nurse’ (rear of the cabin), who was “not expected to be involved in the operation of the aircraft in flight”. The Pilot and ACO were equipped with AN/AVS-9 green phosphor Night Vision Goggles (NVGs). The ATSB explain that the rest of the Night Vision Imaging System (NVIS): • NVG-compatible cockpit lighting • NVG-compatible cabin lighting • 2 x 450 W incandescent forward facing steerable search lights • 1 x 450 W incandescent steerable search light by winch • White flood lights at the front and back of the aircraft. The operator required the use of NVIS for all visual flight rules (VFR) flights at night. The Civil Aviation Safety Authority (CASA) provided the Operator with an exemption to Supplement 60 of the AW139 rotorcraft flight manual. The exemption allowed the ACO to operate from the rear cabin of the aircraft during flight below 300ft and for landing at unimproved sites. The Operator listed the responsibilities of an ACO in their operations manual as “Under direction of the pilot assist with the operation of all aircraft equipment and systems during the conduct of VFR, NVG and IFR operations” and “operate the winch, dispatch, and recovery of personnel and assist the pilot in maintaining clearance from obstacles by lookout and reporting over the intercom”. The ACO was expected to work from both cockpit and cabin. CASA’s position was that “they supported the role of the ACO in the front left seat” and “preferred operators to land” for the ACO to transfer positions, but ‘climb-throughs’ did occur. The operator seems to have recognised this risky manoeuvre was unusual as everyone had to be reported. ATSB state that the crew believed the tasking would “most likely” need use of the hoist, and so with a nearby search area with limited landing opportunities the ACO was in the cabin. ATSB note that: The helicopter’s autopilot was a 4-axis system with enhanced 3-cue flight director (FD). The FD is capable of controlling the helicopter’s movement in the pitch, roll, yaw, and vertical axis. The installed version of the FD had auto-hover functionality (HOV) mode, yet did not offer SAR modes that can mark, return, and transition down to a selected target. Engaging the system instructs the autopilot to make control inputs to bring...
read moreJest11 is Dead: Hawker Hunter Downed by F-35A Jet Wash
Jest11 is Dead: ATAC Hawker Hunter F Mk 58 N338AX Downed by USAF F-35A Jet Wash On 22 August 2017 Hawker Hunter F Mk 58 N338AX, operated by Airborne Tactical Advantage Company (ATAC) under contract to the US Navy as a Public Aircraft, was destroyed when it impacted open water about 80 nm southwest of San Diego, California. It was one of a pair of Hunters supporting an exercise with aircraft carrier USS Theodore Roosevelt and two USAF Lockheed Martin F-35As. The pilot ejected using a Martin Baker Mk3 ejection seat and received only minor injuries. The US National Transportation Safety Board (NTSB) say in their safety investigation report, published 13 April 2020, that: While flying at 14,000 ft mean sea level (msl), one of the F-35s flew alongside and about 1,500 ft from the accident pilot’s right wing. Moments later, the F-35 accelerated ahead of the [Hunter] pilot and crossed in front of his flight path from the accident pilot’s right side to his left side. The pilot attempted to follow the F-35, but the airplane then initiated a right turn and passed in front of the pilot’s flight path again, this time to the right. As the pilot started to turn right to follow the F-35, he heard a “thump”, which he dismissed as jet wash. He continued his maneuver and rotated to the right into an approximate 60° angle of bank and began to apply back pressure, but the airplane immediately rolled into a left bank, at which time the F-35 disappeared from his view. Critically: The pilot briefly terminated the left-hand roll by applying right aileron but was unable to move the flight controls more than one inch to the right of its center position. He remarked that the right aileron flight control movement felt “jammed” as he can normally move the flight controls to his right knee. The airplane then entered an approximate 35° nose down attitude, at which time the pilot applied back pressure on the flight controls, but the airplane repeated its previous movement and entered a left-hand roll. After about 2 full 360° rotations, the pilot stopped the movement with some right aileron, but the flight controls still would not advance to the right more than one inch beyond its center position. As he was passing through 4,000 ft mean sea level, the pilot notified his wingman that he was ejecting. He did not observe any unusual sounds or harmonics from the engine during the accident flight. The airplane impacted open water about 2 nm from its final radar data point. ATAC reported that the debris field was comprised of an oil slick, and no physical remnants of the aircraft. The airplane wreckage was not recovered. Radar data was provided by the Southern California Offshore Range (SCORE) at Naval Air Station North Island, California. The F-35’s relayed altimeter data at a 1 hz sampling rate along with its geographic positioning system (GPS) data. Large Area Tracking Range (LATR) pods were mounted to both [Hunter] Mk 58s, which reported multiple parameters, including position and altimeter data. The radar displayed data points for “Jest11” (the accident airplane) and “Jest12” (the accident pilot’s wingman). The radar data for Jest11 and Jest12 began at 1530:00 at a radar altitude of about 15,800 ft. Both airplanes turned to a southern heading at 1534:42,...
read moreInadequately Secured Pallets Penetrate the Rear Pressure Bulkhead of a Cargo B737
Inadequately Secured Pallets Penetrate the Rear Pressure Bulkhead of a Cargo Boeing 737 (Aloha, B737-300, N301KH) On 16 October 2014 Aloha Air Cargo Boeing 737-330, N301KH flew a cargo to Lanai Airport (LNY), Lanai City, Hawaii. The aircraft was turned around but shortly after rotation on the return flight the aircraft experienced a load shift that caused substantial damage to the aft pressure bulkhead, preventing pressurisation. the aircraft landed safely with no injuries to the three occupants. The Accident Flight The US National Transportation Safety Board (NTSB) explain in their safety investigation report issued on 6 April 2020 (nearly 5.5 years later): Aloha Air Cargo was chartered, by Hawaii Island Air, to fly round trip from [Daniel K Inouye International Airport (HNL), Honolulu, Hawaii] to LNY to deliver lumber for an impeding hurricane. LNY was not a station Aloha Air Cargo normally flew to, nor did they have employees there. The decision was made to limit the number of Additional Crew Members (ACMs) due to concerns about the return flight’s weight and balance. With the choice of taking the load planner or the mechanic, Aloha Air Cargo made the decision to take the mechanic, which was against the company loading procedures since the mechanic was not trained on cargo securing nor were there any approved personnel at the destination to assist with loading and securing the empty pallets. Aloha Air Cargo used various unit load devices (ULDs) in its freighter operation. The LD7 cargo pallet “cookie sheets” consisted of a single skinned pallet with four edge rails, four corner castings and a center sheet section. Since the load planner would not be making the flight, he discussed with the mechanic on how to load the empty pallets for the return flight, which was to load and lock each empty pallet in their original loaded location. The aircraft landed at LNY and the lumber was safely offloaded. The investigators explain that: …while in LNY, Aloha Air Cargo dispatch recommended that all the pallets be placed in position 9 due to concerns about weight and balance. The decision was made to secure the stacked pallets with a cargo strap… The NTSB note this “was insufficient to keep the pallets from moving”. The mechanic, first officer (FO), and Island Air employees helped to load the aircraft and verified that the locks were up and locked in all positions. There were a total of 8 empty pallet cookie sheets. Of these sheets 7 were strapped down and secured to the 8th sheet. The 8th sheet was then locked down in position 9 (the aircraft was equipped with 9 cargo positions on the main deck with the ninth position being the most aft and turned lengthwise). This was done per dispatch’s request for center of gravity (CG) consideration… On rotation the load came loose. Post event examination revealed that the aft pressure bulkhead had substantial damage, left aft (L2) door panel was damaged, and the right hand forward and aft pop up locking mechanism “claws” were detached/torn from their seat tracks. The first indication of a problem to the crew was…. …upon reaching 10,000 ft. the altitude alert horn came on so the crew leveled at 10,000 ft. No emergency was declared. The aircraft landed uneventfully. Upon arrival the flight crew notified dispatch of the pressurization issue [and] made a...
read moreBear Paws Claw Reindeer Herding Bell 206
Bear Paws Claw Reindeer Herding Bell 206 (SE-HPM) A single pilot was conducting reindeer herding using Bell 206L1 SE-HPM for Alpine Helicopter Sweden in the Alajaure National Park, 30 nm north of Kiruna on 8 October 2019. The helicopter was equipped with ‘bear paws‘ to allow landing on soft surfaces. The pilot needed land to pick up a one passenger. According to the Swedish Accident Investigation Board (the Statens Haverikommission [SHK]) in their safety investigation report (issued 16 March 2020): After setting down the helicopter, the pilot felt that it was unsteady due to a turf under the left [skid]. He therefore decided to lift up in order to move the helicopter slightly to the right. In connection with that, he experienced a sudden roll movement to the right. Although the collective pitch lever was lowered immediately, the helicopter continued to roll to the right with the main rotor hitting the ground and the helicopter resting on the right side. The damage were extensive but the pilot was uninjured. During the site investigation it was found that the bear paw plate on the right skid had been turned slightly clockwise. Marks were found in the turf indicating that the plate had dug in. When the bear paw installation was examined more closely, the investigation team found that the plate was mounted so that it could be forced to rotate about 20 degrees clockwise and about 80 degrees counterclockwise from its normal position. The SHK say that: When lifting from soft marshland, it can be difficult to determine if the landing gear is stuck on an obstacle or if it has “sucked” into the wet marshland… When operating from uneven ground, it is important that toch down and lifting are done slowly and carefully in order to detect any obstacles and tendency to roll. They also asked Transport Canada “to initiate a discussion with the manufacturer of the plates, Dart Aerospace, about the possibility of a more secure installation of the plates”. SHK Conclusion The investigator concluded this was a dynamic rollover: The accident was caused by the plate mounted on the right rear part of the helicopter’s landing gear getting stuck in a turf under the helicopter in connection with hovering, and by the pilot not being able to stop the roll tendency. Safety Resources This EHEST leaflet covers the following subjects: – Degraded Visual Environment (DVE), – Vortex Ring State (VRS), – Loss of Tail Rotor Effectiveness (LTE), – Static & Dynamic Rollover, and – Pre-flight planning Checklist. Be Careful If You Step Outside!: Unoccupied Rotors Running AS350 Takes Off US Police Helicopter Night CFIT: Is Your Journey Really Necessary? When Habits Kill – Canadian MD500 Accident UPDATE 16 May 2020: AS350B3 Dynamic Rollover When Headset Cord Snags Unguarded Collective UPDATE 16 May 2020: AS350B3 Rolls Over: Pilot Caught Out By Engine Control Differences UPDATE 26 July 2020: Impromptu Landing – Unseen Cable Aerossurance has extensive air safety, operations, 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 moreNTSB Confirms United Airlines Maintenance Error After 12 Years
NTSB Confirms United Airlines Maintenance Error After 12 Years (Airbus A320 N442UA at Jackson Hole 2008) On 25 February 2008 United Airlines Airbus A320 N442UA left the right side of Runway 19 during landing at Jackson Hole Airport (JAC), Wyoming. The NTSB determined in 2020(!) this serious incident was due to “inadequate maintenance” during a prior landing gear tachometer installation. This was the third United Airlines tachometer cross-connection maintenance error to emerge between October 2007 and March 2008. Incident Flight The US National Transportation Safety Board (NTSB) reported on 30 March 2020 that… ..the takeoff [from Denver International Airport (DEN), Colorado], climb, cruise and descent to JAC was normal. The captain was the flying pilot. During the approach briefing it was noted that the Mu readings indicated “good” breaking and that if the airplane did not touchdown in the first 2,000 feet of runway, they would perform a go-around. The captain stated that the touchdown was “firm” and the speedbrakes auto-deployed quickly; he believed that the airplane touched down in the first 2,000 feet of runway. The deceleration was normal until the airplane reached about 80 knots and 2,000 feet from the end of the runway when it started to slide. At that time, the captain stated that he applied maximum manual braking and the airplane started to slide toward the right side of the runway. The captain applied maximum left rudder, maximum braking, and reverse thrust as the airplane exited the right side of the end of the runway. The airplane came to rest against snow banks. The first officer said that the engines “flamed out” when they ingested snow. As the flight crew was shutting off the engine fuel levers and were getting out of their seats, they heard a passenger yell “fire” and the passengers began a self-initiated evacuation of the airplane. The 119 passengers and 6 crew members evacuated the aircraft via the emergency slides. One passenger received minor injuries during the evacuation. Examination of the runway revealed distinct rubber transfer marks leading to an area of disturbed snow on the right side of the runway. The Left MLG inboard tire exhibited a large flat spot with a rupture through the aft end from sidewall to sidewall. Maintenance History According to United Airlines, both MLG and the nose landing gear were replaced on the airplane on February 2, 2008 due to approaching overhaul time limits. The left-hand main landing gear was an “enhanced” landing gear and the right-hand landing gear was a standard or “pre-enhanced” landing gear. According to Airbus, the Service Bulletin to retrofit an airplane with the “enhanced” gear required they only be replaced as a set and that installation of a “mixed” configuration would only be approved on a case-by-case basis. United Airlines was unaware that two different types of landing gear were installed on the airplane and there were no records indicating that a request was made to install a “mixed” set of gear on the incident airplane. United Airlines contracted with Hawker Pacific Aerospace to overhaul its A320/A319 landing gears. Review of records and interviews of United and Hawker Pacific personnel revealed…all work was accomplished using United Airlines Joint Documents and Messier-Dowty Component Maintenance Manuals. The wiring harnesses of the landing gear are overhauled at this time and installed into the overhauled Hawker Pacific gear components. During the landing gear installation,...
read moreHEMS AW109S Collided With Radio Mast During Night Flight
HEMS AW109S Collided With Radio Mast During Night Flight (Babcock MCS Portugal I-EITC) On 15 December 2018 Leonardo AW109S I-EITC of Babcock MCS Portugal flew into a radio mast at night near Serra de Santa Justa, Valongo, Portugal. The HEMS air ambulance helicopter was operated under a 5 year, 4 base 24/7 contract for the the National Institute of Medical Emergency (INEM), awarded in June 2018. It was en route, returning from an urgent inter-hospital patient transfer that afternoon. On board were two pilots and two medical passengers. All died in the accident. The Accident Flight In their safety investigation report, issued 6 March 2020, the Portuguese accident investigators GPIAAF (Gabinete de Prevenção e Investigação de Acidentes com Aeronaves e Acidentes Ferroviários / Office for the Prevention and Investigation of Accidents in Civil Aviation and Rail) explain that after the successful inter-hospital transfer the crew initially retired to a coffee shop to wait out the poor local weather (rain and low cloud). The crew made several phone calls related to the weather. Witness testimony was the Commander was comfortable with an IFR diversion and night-stop at Porto International Airport if required. Subsequently the helicopter departed Massarelos heliport, at 18:35 UTC, heading to refuel at Paredes-Baltar heliport before returning to its base at Macedo de Cavaleiros heliport. None of these sites had navigation aids or meteorological data. Although not used, Porto International Airport’s navaids were operational. At 18:38:03, the crew informed the ATC that they will maintain an altitude of 1500 ft to Baltar. According to secondary radar data provided by the air navigation service provider, after take-off, the aircraft proceeded with a direct heading to the Paredes-Baltar heliport, flying at a cruising speed of around 130 kt and at altitudes oscillating between 1400 ft and 1500 ft. At 18:40 the helicopter collided at 371 m (1217 ft) AMSL just 2.2 m (7 ft) from the top of a 66 m (216 ft) guyed steel lattice radio broadcast tower. It was not possible to confirm if this beacon was operating on the accident night. [Note a lower adjacent deactivated mast was unlit.] This tower (marked ‘1’ below) was actually one of 10 obstacles along the ridge line. However only those 200 ft (60 m) above ground level were marked, with only those over 328 ft (100 m) listed in the AIP. The investigation subsequently identified that some of the obstacles were unlit. In relation to emergency response: After the aircraft hit the ground, the Emergency Locator Transmitter (ELT) signal was activated, however, it was not received by the COSPAS/SARSAT satellites, as the system lost the antenna. In accordance with the existing contract for the HEMS service provision…the operator should have installed an aircraft tracking system that would allow the contractor to follow up the performed missions in real time. This system was not installed on the aircraft by the operator or verified by the contract [holder]. Consequently, lacking an accurate fix on the aircraft an extensive search was required. Safety Investigation GPIAAF note that: A risk analysis of the HEMS operation service in Portugal and its limitations was not [produced] by the operator or required by the [customer], especially in the northern part of the country and on the usual routes, where evidence suggests that it is followed a typical low altitude flight profile, in some cases below the minimum altitude values imposed by the regulation, and frequently in adverse weather conditions. The operator, by accepting the...
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