Culture and CFIT in Côte d’Ivoire
Culture and CFIT in Côte d’Ivoire (ALAT SA342M Gazelle) On 10 July 2018, Airbus Helicopters (formerly Aérospatiale) SA342M Gazelle 3866 of the French Army 3rd Combat Helicopter Regiment (3e RHC) was completing an exercise with troops of the Armed Forces of Côte d’Ivoire (FACI) 20 km SE of Abidjan, Ivory Coast, when the crew made a loss pass over the troops. The French liaison officer on the ground requested the helicopter conduct a second mock strafing pass. History of the Flight The helicopter had first came from the east and passed the group on the ground at only c65-100 ft before climbing to make a tight turn and decent before a return pass. The aircraft however descended steeply and struck a power line and a pole before impacting the ground. One crew member died and the other was seriously injured in this controlled flight into terrain event (although this would strictly be coded as a Low Altitude [‘LALT’] event in the CAST/ICAO Common Taxonomy). BEA-E Safety Investigation and Analysis Investigators of the BEA-Etat (BEA-E) note in their safety investigation report (only available in French) that it is likely the manoeuvre to reverse direction was commenced at too low a speed and started at too low a height (100 kts and 165 ft is recommended). Furthermore it is likely that the right turn was tighter than recommended, which required more power to be diverted to the fenestron. There was also a 6 kt tailwind during the decent that may not have been considered by the crew. The crew may also have been surprised by reaching the servo reversibility threshold. The investigators also comment that in 2012 the strafing role was removed from the Gazelle fleet so there had been no recent training in the manoeuvre. The impromptu manoeuvre was labelled as both a ‘thrill-seeking’ and a ‘routine violation’ by the BEA-E investigators, who note that the exercise had been relatively unstimulating (the local troops had been practicing vectoring the helicopter to a target). Less sophisticated organisations might stop their analysis here or just focus on the culpability of the personnel directly involved. The BEA-E thankfully took a more sophisticated approach. First they consider the perception of risk. Both pilots were qualified in tactical flight (leading to a belief in their chances of success) and regularly carry out this type of flight training or operation. The pass below the minimum overflight height did not occur early but late in the session, or after over an hour of evolution of the work area with possibility to recognize and become familiar with the area (belief its ability to control the situation). Finally, it seems that this first pass at a height of less than 165 ft had resulted no comment by the present ground staff, including from the patrol leader on the ground (belief on the look of others). They comment that group decision-making, compared to individual decision-making tend to focus more on the potential positive benefits and that “young adults, particularly young men are known to be a population with an excess risk of accidents compared to other demographic groups as violation behaviours are more frequent”. Consequently, and entirely predictably: The group and its demographic and sociological characteristics favored the adoption of risky behaviour. Less obvious is that the detachment had only recently returned to full strength (3 Gazelles) after a “long period” with just one. This resulted in a increase in flying to clear the backlog of taskings. Working hours were consequently extended and...
read moreAS350B3 Rolls Over: Pilot Caught Out By Engine Control Differences
AS350B3 Rolls Over: Pilot Caught Out By Engine Control Differences (Helibravo AS350B3 D-HAUE) On 4 September 2019, Airbus Helicopters AS350B3 D-HAUE operated in Portugal by Helibravo – Aviação for fire-fighting rolled over on take off at Pampilhosa da Serra. One of the 6 persons on board received a minor injury. The Portuguese accident investigation agency, GPIAAF, say in their safety investigation report that: According to the pilot’s statements, the engine start-up and flight preparation procedures were normal with no relevant issues to record until the time the Flight Mode was selected, and a sudden increase in engine power was noticed. Immediately soon after, the aircraft begins a vertical movement with some oscillations. The aircraft rotated 90º clockwise, rose from the ground to a height of about one meter and the pilot could not counteract the low tail attitude and the descent aircraft movement. The aircraft touched hard on the back right of the skid and a tail rotor strike on the ground occurred. The aircraft returned to the air and rotated around its longitudinal axis until the main rotor also touched the ground. The aircraft fell on its right side, about 3 meters ahead of the initial contact point. From the readings taken from the engine data (VEMD [(Vehicle and Engine Monitoring Display]), it was possible to confirm two main rotor rotational speed peaks above the 448 rpm that is the maximum value recorded by the unit. (note: certification limit for AS350B3 ([Arriel] 2B) main rotor rpm is 390 +4/-5 rpm) The pilot had flown 1833.5 hours in total, including 1655.5 hours in the AS350B2 and B3 series. Of note is that he had very little experience with the Safran Arriel 2B powered AS350B3 (but more with the Arriel 2B1). The operator uses, mainly during the firefighting season, a mixed fleet of AS350 B3 helicopters equipped either with Arriel 2B and Arriel 2B1 engines (MOD 073254), that have different procedures for initiating the flight mode. The crashed aircraft was equipped with an Arriel 2B engine (pre-mod 073254) in which engine control is performed via a Digital Engine Control Unit (DECU) with single channel governor and mechanical redundant system. Differences in the operation of the various aircraft models are addressed by the operator in pre-season training… One of the main differences between aircraft versions (2B and 2B1), and relevant to the event, are the pre-engine start-up procedures and takeoff power selection for the FLIGHT mode. The AS350B3 helicopter equipped with an Arriel 2B engine has a single-channel engine governor and DECU back-up MANUALLY controlled using the mechanical system of the twist grip. As stated on the flight manual section 4.1, the twist grip must be in the “FLIGHT” detent before carrying out the starting procedure. The flight mode selection is done using the three-position selector (OFF-IDLE-FLT/AR-RAL-VOL). In contrast: …the AS350B3 helicopter equipped with an Arriel 2B1 engine has a dual-channel engine governor and an automatic backup control (EBCAU [Engine Back-Up Control Ancillary Unit]); the simplified twist grip must be in the “IDLE” detent before carrying out the starting procedure (section 4.3 of flight manual). The flight mode selection is done using the two-position selector (OFF-ON) And then rotate the twist grip to the FLIGHT/VOL position. On the accident aircraft with the older model (2B) the pilot needs to select the three position start-selector in the ceiling ([marked on the illustration below] 1) to Off/Idle/Flight,...
read moreAS350B3 Dynamic Rollover When Headset Cord Snags Unguarded Collective
AS350B3 LN-OTR Dynamic Rollover When Headset Cord Snags Unguarded Collective On 12 September 2017 Airbus Helicopters AS350B3 LN-OTR, operated by Helitrans, rolled over onto its side shortly after landing on slightly sloping ground at Laksefjordvidda in the northern district of Finnmark, Norway. All four occupants escaped uninjured. The helicopter sustained extensive damage but the seats and cabin floor structure were intact. The Accident Flight The Accident Investigation Board Norway (AIBN) investigation report (issued 12 May 2020 in Norwegian only), explains that the helicopter was chartered to support hunting inspections by three government agencies. This involved first searching to find hunters and then landing to check their weapons and licenses. The aircraft deployed from its base at Alta at 0800 and made the 1 hour 50 minute flight to the village of Skiippagurra with the pilot and a ‘task specialist’ / ‘loader’ on board. On arrival detail planning commenced with the customer’s inspectors. Due to the nature of the task, the pilot was only told in advance the general area to be searched. The search area could be adjusted if necessary so the flight could be conducted under Visual Flight Rules (VFR). Initially, the client had announced that two inspectors should be on the flight. This was changed to allow three people to participate and the pilot therefore carried out a new weight and balance calculation. Before departure, the helicopter’s fuel tanks were filled completely. The commander’s calculation showed that the total weight was well within the maximum allowable weight of the helicopter. It was decided the loader would not join the flight, though the logic for this decision is not discussed in the report. The controls on the left side of the cockpit were therefore dismantled. One passenger was seated in the front left seat and the other two passengers were seated in the back of the cabin. The pilot flew the helicopter from the front right seat. Before departure, the pilot briefed the passengers on how the helicopter’s doors could be opened and closed, as well as how the seat belts worked. After the passengers were taken on board and the pilot carried out an external inspection of the helicopter, the helicopter’s engine was started and at. In 1125, they took off to begin the task. All four wore headsets. Helmets were not usual for this type of tasking say AIBN. While south west of the village some All Terrain Vehicle (ATV) tracks were spotted, which the inspectors took some photographs of. The pilot tried to fly to a particular hunting cabin that the inspectors wanted to fly over, but that was curtailed due to fog so they headed to the west of the village. Shortly thereafter, they spotted some people, tents and three ATVs [34 km west of the village]. It was decided that the helicopter should land so that the inspectors could carry out a check. The pilot found a suitable landing site on gently sloping terrain covered with heather. As the hunters had lit a fire its smoke gave a clear indication of the wind direction. The helicopter landed into wind and sat softly against a slightly sloping surface, from right to left in the direction of travel of the helicopter. The right skid consequently touched the ground first and after the collective lever was further reduced, the left skid also came into contact with the ground. The pilot explained that the helicopter was steady after landing and that everything felt normal at this time. To be “absolutely sure” that the helicopter was stable, the pilot would habitually...
read moreEuropean Search and Rescue (SAR) Competition Bonanza: Northern Norway SAR, Netherlands SARHC, Ireland SAR Aviation and UK’s UKSAR2G
European Search and Rescue (SAR) Competition Bonanza (Northern Norway SAR, Netherlands SARHC, Ireland SAR Aviation and UK’s UKSAR2G) With the offshore oil and gas market depressed, offshore helicopter operators and other aviation service providers will be pleased by a surge in business opportunities for outsourced government SAR helicopter and aviation contracts. Norway, Netherlands, Ireland and the UK with UKSAR2G (listed in order of expected contract award) are commencing competitions for contract commencement from 2022-2024. In this article we collate what has been publicly announced so far for each competition and the current arrangements these will replace. Northern Norway SAR Helicopter Tender: Ministry of Justice and Public Security This tender, for ‘Procurement of Rescue Helicopter Services for Tromsø, Svalbard and for the Police’, was released in April 2020. It is for a new SAR helicopter in the northern city of Tromsø and the replacement of the current aircraft for the Arctic Ocean archipelago of Svalbard. Both helicopters are required in 2022, but they could be awarded in separate lots or together. The contract(s) will be for 6 years plus 2 x 2 year extensions. The Ministry of Justice and Public Security will manage the contract on behalf of the Governor of Svalbard (Sysselmannen) and the Norwegian Police. It will supplement the main SAR service provided by the Royal Norwegian Air Force (RNoAF), which is transitioning from Westland Sea Kings to 16 Leonardo AW101s. The SAR service in Svalbard is currently provided under contract let by the Governor by Lufttransport (a subsidiary of NHV) with two Airbus Helicopters AS332L1 Super Puma. Operations there include operating from the Governor’s support vessel, Polarsyssel. The procurement will involve a dialogue with bidders on their outline solutions this summer before best and final offers (BAFO) in August 2020 and contract award in September 2020, leaving plenty of time to mobilise during 2022. Video: https://youtu.be/JGb23RLbnbI Norwegian SAR Cooperation Plan Briefing video UPDATE 17 Febuary 2021: The agressive timeline was not achieved. The standtill period was only entered on 17 February 2021 with the annouvement that CHC were the presfrred bidder. The contract was valued at NOK 1860 million (EUR 188 million) for the initial 6 years. Netherlands SAR Helicopter Tender: Ministry of Defense / Netherlands Coastguard (NLCG / Kustwacht) The tender pre-selection for the ‘Search-and-Rescue Helicopter Capacity (SARHC) for the Netherlands Coastguard‘ was released in April 2020 by the Defence Materiel Organisation (DMO) of the Ministry of Defense of the Netherlands (MOD NL). This is for a 10 year contract that will replace the current service provided by NHV with two Airbus Helicopters AS365 helicopters in Den Helder and Pistoolhaven, Rotterdam. The service supports 6 different government ministries. The Dutch schedule leading to “starting preferably from 1 July 2022” consists of determining a shortlist of candidates in Q3 2020 before two rounds of bidding in late 2020 and contract award in Q2 2021: Video: https://youtu.be/YDzVu5Dzs84 NLCG have two Dornier (now RUAG) Do228 fixed wing aircraft too, which they looked to replace under a separate competition launched in 2019. Video: https://youtu.be/Mhoi0xbJkvU UPDATE 6 August 2010: PAL Aerospace is reported to have received notice of the preliminary contract award decision on the Do228 replacement: PAL Aerospace and its consortium member JetSupport, [will] modify and deliver two fully missionized Dash 8 aircraft, provide crew training on all systems and support the operation of the aircraft for an initial 10-year period with an option to extend for two additional one-year term Ireland SAR Aviation Tender: Irish Coast Guard (IRCG) The IRCG issued a Prior Information Notice (PIN) early in May 2020:...
read moreUngreased Japanese AS332L Tail Rotor Fatally Failed
Ungreased Japanese AS332L Tail Rotor Fatally Failed (Toho Air Sevices JA9672) On 8 November 2017, Airbus Helicopters AS332L Super Puma JA9672 of Toho Air Service crashed in Gunma prefecture after the tail rotor separated from the aircraft as the crew prepared to make an emergency landing. There were four people on board, who all died. There was a post crash fire. The Japan Transport Safety Board (JTSB) concluded in their safety investigation report (published in Japanese on 23 April 2020) that: It is highly probable that the crash occurred because the tail rotor separated from the aircraft when it tried to make an emergency landing due to abnormal vibration that occurred during the flight… The tail rotor separated from the fuselage because the spindle bolt of the white tail rotor blade flapping hinge broke and the tail rotor became unbalanced… It is presumed that the spindle bolt broke because the bearing of the flapping hinge was damaged [which] was not detected by inspection. The following JTSB presentation slides that we have translated show the accident sequence: These graphics illustrate how lucky the 17 occupants of Bond AS332L G-PUMH were in 1995 when a tail rotor flapping hinge retainer had failed due to a fatigue crack emanating from a grease nipple hole while returning from a North Sea offshore installation. G-PUMH was able to make a safe landing at Longside, near Peterhead. Background Toho use their AS332Ls for construction projects. Early in the history of the of the AS332L, the manufacturer had noticed that using Shell Aeroshell 14 grease in tail rotor pitch change hinge bearings had increased the tendency for false brinelling to occur. In 1991 Exxon Mobil MOBILPLEX 47 grease was introduced as an alternative. This was a great success but in February 2008 production of MOBILPLEX 47 was abandoned. Subsequently the manufacturer noticed that on the return to the inferior Shell grease a… …reduction in the reliability of the tail rotor hub bearing [occured], especially within the helicopter operating range under hot and humid conditions. Coincidentally, before this accident occurred on 6 December 2016, Aerossurance spoke at a breakout session organised by EASA at their 10th Rotorcraft Symposium in Cologne on rotor and rotor drive system safety. One of the points made in that session was that a crucial contribution that the oil industry can make to helicopter safety is the production of optimised lubricants, even though they may have a small market. The continued airworthiness of the five AS332L tail rotor flapping hinges were reliant on greasing every 10 flying hours (or daily if parked in hot and humid conditions), as well as 50 and 250 hour inspection. The newer four bladed AS332L2 and EC225 tail rotors feature an improved design. JTSB could not find evidence of a seal replacement on that blade since June 2014 and postulate the seal had been deteriorating by 2017. As the aircraft was parked outside in high humidity during summer 2017 that would have allowed moisture ingress into the grease. Unfortunately it appears the maintenance personnel were not aware that they should have re-greased the tail rotor due to the humid environment each day either. Inspections from July 2017 started to show the grease in the white blade’s hub starting to turn increasingly black and by September 2017 “movement of the white blade was not smooth”. JTSB believe these were indications of bearing deterioration. However, no corrective maintenance action was taken...
read moreCFM56 HPC Titanium Fire Due to VSV Maintenance Assembly Error
CFM56-7 HPC Titanium Fire Due to VSV Maintenance Assembly Error (United Boeing 737-924 N30401) On 21 February 2019 United Airlines Boeing 737-924 N30401, powered by two CFM International CFM56-7B26 turbofan engines, experienced a No. 2 engine failure after a titanium fire during initial climb from Orlando International Airport (MCO), Florida. The US National Transportation Safety Board (NTSB) reported on 27 April 2020 that: At about 7,000 feet altitude, the flight crew reported an “abrupt loud grinding noise and instantaneous boom,” followed by a loss of No. 2 engine power and subsequent uncommanded engine shutdown. The crew initiated quick reference handbook procedures, closed the No. 2 engine fuel shutoff valve, declared an emergency, and returned to MCO, where they made an uneventful overweight single engine landing. A preliminary visual inspection of the No. 2 engine…reported high pressure compressor (HPC) case burn through. The engine was shipped to an overhaul facility for strip: HPC case burn through was observed…to have affected approximately 60% of the circumference. The case surfaces and accessories/lines in proximity to the burn through holes were discolored, sooted and coated in metal spray. The forward sump magnetic chip detector (MCD) plug had metal debris (“fuzz”) accumulation on the magnet and in the filter screen. See VIDEO. A visual examination of the HPC stator cases was performed after removal of the external engine components, and in addition to the case burn through, one HPC stage 1 variable stator vane (VSV) trunnion stem was missing a washer and retaining nut at the 1:30 position. The VSV alignment mark, located on the top of the trunnion stem was positioned (clocked) at a different angle relative to the rest of the vanes in the stage. The HPC rotor was badly damaged During engine disassembly, eight HPC stage 2 rotor blades, including the blade dovetails, were found separated and missing. The HPC stage 2 disk blade slots for each of the eight missing blades had one or more separated disk post corners. There was secondary impact damage observed throughout the gas path aft of HPC inlet guide vanes. The HPT stage 1 blades and the LPT stage 1 nozzle vanes exhibited thermal damage. Metal flakes and debris were collected in the aft sump, adjacent to the No. 4 bearing. …examination of the HPC stage 1 VSV (identified as VSV #33) trunnion stem confirmed that the missing washer and retaining nut identified during the engine teardown resulted in disengagement of the lever arm…allowing the vane to go off-schedule approximately 31 degrees relative to the other HPC stage 1 VSVs. The HPC VSV #33 trunnion stem had a uniform coating of dirt/debris along the full length of the stem consistent with engine operation over an extended period of time without the washer and retaining nut. The laboratory analysis also identified witness marks on HPC VSV #33 indicating that a washer and retaining nut were present at some point, but it could not be determined when the parts were removed or separated. NTSB examined the engine’s maintenance history: The last…shop visit was an engine overhaul at the GE Aviation-Celma maintenance, repair, and overhaul (MRO) facility in Petrópolis, Brazil in July 2014. According to the shop records, 22 of the 82 HPC S1 VSVs were replaced and the remaining VSVs were overhauled. Installation position of the replaced and overhauled S1 VSVs were not...
read moreSécurité 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...
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