News & Comment

King Air 100 Stalls on Take Off After Exposed to 14 Minutes of Snowfall: No De-Icing Applied

Posted by on 5:27 pm in Accidents & Incidents, Business Aviation, Fixed Wing, Human Factors / Performance, Regulation, Safety Management, Survivability / Ditching

King Air 100 Stalls on Take Off After Exposed to 14 Minutes of Snowfall: No De-Icing Applied (Island Air Express, C-GIAE) On 23 February 2018, an Island Express Air, Beechcraft King Air B100, C-GIAE, departed Abbotsford, British Columbia on a day Instrument Flight Rules (IFR) flight to San Bernardino, California with a single pilot (the owner of the operator) and 9 passengers. According to the Transportation Safety Board of Canada (TSB) safety investigation report (issued 14 August 2019) snow had been falling during the flight planning and the aircraft had been kept within a hangar to protect it from the snow.  TSB explain that: The pilot and passengers boarded the aircraft and, at 1150, the hangar door was opened and the aircraft was towed outside. At 1154, both engines were running. No de‑icing or anti-icing fluid was applied to the aircraft. At 1159, the pilot informed the controller that the aircraft was holding short for Runway 07. While the aircraft was waiting for takeoff clearance, no contamination was observed adhering to the wings. Two minutes later…the occurrence aircraft was cleared for takeoff. …the amount of snow estimated to have fallen on the aircraft from the time it exited the hangar until it entered the runway was about 4 to 5 mm. At 1203, the aircraft taxied onto the snow-covered Runway 07 and continued with an immediate takeoff. Approximately 4 to 5 seconds after takeoff, the pilot selected the landing gear control to the up position. As the gear retracted, the aircraft rolled approximately 30° to the left. To correct the uncommanded left bank, the pilot applied right aileron, and the aircraft returned to a near wings-level attitude. In order to make an immediate off-field emergency landing, the pilot retarded the power levers and then applied forward pressure on the control column to land the aircraft. The aircraft struck terrain between Runway 07 and Taxiway C. The aircraft slid across the snow-covered ground for approximately 760 feet before coming to rest in a raspberry patch located on the airport property. Five passengers and the pilot were seriously injured. The other 4 passengers received minor injuries. Both occupants of the crew seats received serious head injuries (i.e., facial fractures and lacerations) and compression injuries (i.e., spinal fractures). The passenger seated in the right-hand crew seat was rendered unconscious and had to be carried out of the aircraft. The passengers seated in the cabin received a variety of injuries… Two of the adult passengers seated in the cabin had compression injuries and spinal fractures. Otherwise, the injuries received by the adults and children seated in the cabin were the result of being hit by loose articles, detached seats, and other passengers. Safety Investigation: Flightpath and Icing The flight path was reconstructed as follows: It is likely the aircraft stalled during the initial climb after the aircraft lost the benefit ground effect. The aircraft was equipped with an ice protection systems and it had been activated.  Type I de-icing fluid was available but not used.  Type I fluids do not however offer any significant anti-icing holdover protection and so are  commonly used as part of a two-step de/anti-icing procedure when the final application of a Type II or Type IV fluid provides the required hold-over time. According to the aviation weather report current at the time of the occurrence, the aircraft departed in moderate snowfall. However, according to internationally recognized de-icing and...

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Drone Operation Injury

Posted by on 8:35 pm in Accidents & Incidents, Helicopters, Human Factors / Performance, Regulation, Safety Management, Unmanned (Drone / RPAS / UAS / UAV)

Drone Operation Injury (DJI Phantom 4 UAS at Virginia Tech) On 14 August 2018 a DJI Phantom 4 Unmanned Air System (UAS) / drone flight was planned as demonstration for students of the Virginia Tech (VT) College of Natural Resources and Environment under the provisions of 14 Code of Federal Regulations (CFR) Part 107. The Accident Flight The Phantom 4 is a 1.4 kg quad-copter.  The VT Conservation Management Institute (CMI) has two UAS pilots and focuses on natural resource related UAS uses (e.g. habitat mapping, wildlife monitoring and woodland burn monitoring).  The US National Transportation Safety Board (NTSB) report that: The Mountain Lake Biological Station was University of Virginia property. The CMI chief pilot explained that they had been conducting demos there for 3 years with departmental approval and the Station management. It was not specified what the clearance entailed, and there were no records of any flight operations clearances or requests for the Biological Station site. The drone pilot held a Federal Aviation Administration (FAA) Part 107 Remote Pilot Certificate and had logged a total of 3.7 hours as Remote Pilot in Command (RPIC), most of which was on the senseFly eBee fixed-wing drone and the 3D Robotics (3DR) Solo quadcopter. He had logged 8 minutes RPIC on the Phantom 4 but reported about 2 hours of experience with it as a hobbyist. His training on the Phantom 4 consisted of performing some basic maneuvers at a practice field using various DJI GO 4 functions, and practicing using the DroneDeploy flight control app. While CMI could furnish the NTSB with an Operating Guide and Checklists for the eBee and Solo, significantly it did not have these for the Phantom 4. On the day of the incident, the pilot conducted a mapping flight prior to the demo. The pilot reported that, during the mapping flight, he attempted an automatic landing but the drone “missed its homepoint,” and the Director of CMI  hand-caught the drone. The pilot reported that he “used the manual shutdown procedure, which worked correctly.” According to the pilot, the demonstration was intended to consist of a short, automated flight over a pond using the DroneDeploy control application (app) to show how mapping surveys were conducted, followed by a manual flight to view wildlife in the pond…at the Mountain Lake Biological Station, Blacksburg, Virginia. The six students who were observing the demo flight were located less than 10 feet from the pilot. There was no visual observer or other assistant to the pilot for this flight. He started the demo in manual flight mode, and took off from a plastic picnic table on the berm of the pond. The pilot reported that he was controlling the aircraft via a Samsung Galaxy J7 smartphone using the DJI GO 4 app and that he normally conducted mapping flights using the DroneDeploy app. All obstacle avoidance and vision positioning systems were turned on. He reported the flight was normal, although the wind picked up a little bit during the flight. He flew the drone back to the picnic table for landing but reported that it would not touch down onto the table. The pilot reported that he made numerous attempts to land and attempted “the shutdown procedure,” but the drone flew off to the side. He then reported that he climbed the drone back up and attempted an automatic landing and a landing in the grass, again using the “shutdown procedure,”...

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Remote Landing Site Blade Strike

Posted by on 1:55 pm in Accidents & Incidents, Airfields / Heliports / Helidecks, Helicopters, Safety Management

Remote Landing Site Blade Strike The Accident Investigation Board Norway (AIBN) have released their safety investigation report (available in Norwegian only) into a serious incident to Airbus Helicopters AS350B3 LN-OWE, operated by Nord Helikopter.  It occurred 24 February 2018 at Kvamsdal, Masfjorden Municipality, Norway during operations supporting the construction of a new power line. While manoeuvring at a temporary worksite with four persons on board (the pilot, a loadmaster and two passengers), the main rotor blades came in contact with a container that was located next to the landing site. The commander manouvered the helicopter away from the container. There were insignificant vibrations in the helicopter. The helicopter was controllable and therefore the commander decided to return to the departing site one to two minutes flight time away. The AIBN did not concur with that decision. After shutdown, it was found that the outermost part of all three main rotor blades was damaged. None of the persons sustained any injuries. The site layout had changed considerably since the pilot’s last visit there and obstacles had been sited too close. The AIBN believes that…the commander should not have accepted the reduced safety margins, and consequently refrained from landing. 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...

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AS350 Tail Rotor Control Incident, Grand Cayman

Posted by on 3:31 am in Accidents & Incidents, Design & Certification, Helicopters, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

AS350 Tail Rotor Control Incident, Grand Cayman An Airbus AS350BA helicopter, VP-CIH, suffered tail rotor control problems during a sightseeing tour flight from Owen Roberts International Airport, Grand Cayman, 30 August 2018.  In their safety investigation report the UK Air Accidents Investigation Branch (AAIB) describe how… Whilst descending through 500 ft and turning onto final approach for George Town Aerodrome, the pilot felt that the tail rotor pedals were not producing the correct yaw response, so he aborted the approach and informed ATC he would be returning to Owen Roberts International Airport. On the approach to the latter he tested the directional control, which did not respond correctly, so he informed ATC that he planned to conduct a run-on landing… The pilot carried out a successful run-on landing on Runway 26, having rejected the grass alongside as too soft for a safe run-on landing.  None of the 5 persons on board were injured. Safety Investigation During examination of the helicopter it was found that the TGB [tail gearbox] actuating rod (part number 350A27191003) had ruptured at the aft end. [This rupture] was associated with the uncoupling of the steel sleeve inside the external aluminium alloy tube. An anomaly in the internal structure of the material of the rod was identified, along with the presence of cracks in a cold worked area. The manufacturer reported that this was the first such event on the AS350 that they were aware of. Safety Action As a result of these findings, on 20 March 2019 the EASA issued Airworthiness Directive 2019-0060, mandating [sic] dye penetrant crack checks of TGB actuating rods on affected AS350 and AS355 helicopters. Other Safety Resources Engine Failure after Inadvertently Being Put Back into Service Incomplete (and excellent autorotation in mountainous terrain) EC135P2+ Loss of NR Control During N2 Adjustment Flight Dim, Negative Transfer Double Flameout BK117B2 Air Ambulance Flameout: Fuel Transfer Pumps OFF, Caution Lights Invisible in NVG Modified Cockpit AAIB Report on Glasgow Police EC135T2+ Clutha Helicopter Accident US HEMS EC135 Dual Engine Failure: 7 July 2018 Accident Report: Fatal Police Helicopter Double Engine Flameout Over City Centre HF Lessons from an AS365N3+ Gear Up Landing Austrian Police EC135P2+ Impacted Glassy Lake UPDATE 2 January 2020: EC130B4 Destroyed After Ice Ingestion – Engine Intake Left Uncovered UPDATE 27 December 2020: Fire-Fighting AS350 Hydraulics Accident: Dormant Miswiring 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...

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Severe Propeller Vibrations on ATR 72-212A: BEA Report

Posted by on 12:04 pm in Accidents & Incidents, Design & Certification, Fixed Wing, HUMS / VHM / UMS / IVHM, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

Severe Propeller Vibrations on ATR 72-212A: BEA Report The Bureau d’Enquêtes et d’Analyses (BEA), the French Safety Investigation Authority, released their report in July 2019 (in French, UPDATE 10 Sept 2019: and now also in English) on a series of propeller incidents that occurred due to a vibratory phenomena that was not uncovered in certification testing. Caribbean In Service Event Caribbean Airlines ATR 72-212A 9Y-TTC was operating from Tobago to Port of Spain, Trinidad and Tobago on 4 May 2014.  It was at top of descent, 6000 feet and 220 KIAS, with both Hamilton Sundstrand / UTAS  568F-1 propellers at 82% Np, when the flight crew commenced a 1500 fpm descent. The airspeed began to increase and so the crew reduced power.  The airspeed did not decrease however.  When the aircraft reached 246 KIAS, 4 knots below Vmo (max operating velocity), the crew reduced power to idle.  The crew felt strong vibrations which was shortly followed by No 2 Propeller Electronic Control (PEC) warnings.  Airspeed did now decrease, so the flight crew increased power slightly and the PEC fault indications disappeared.  However, shortly after a No 2 ACW GEN fault message was displayed. After further propeller fluctuations the crew managed to balance the power, albeit at c4.5º difference in blade angles and subsequently made a safe landing. After this flight, the drive shaft of the No 2 engine’s AC generator was found broken and was replaced. Ground runs revealed no abnormalities so the aircraft was released to service.  The next flight was normal until loud vibration was reported during taxi after landing when the flight crew moved the power levers from the flight idle to ground idle. Further maintenance fault finding was conducted.  When the power levers were positioned in reverse thrust, vibration occurred.  After shutdown, blades 1, 2, 5 and 6 of the No 2 propeller were feathered but blades 3 and 4 appeared to remain in the reverse thrust position. Upon disassembly of the No 2 propeller, the trunnion pin of  blade 4 and the propeller blade actuator plate were found damaged. The Safety Investigation The BEA investigated this occurrence under the delegation of Trinidad and Tobago.  In their report the BEA note that: The circumstances and damage observed were similar to that which had been observed in an investigation into a serious incident on 18 September 2013 in Indonesia, involving an ATR 72-212A registered PK-WFV. An investigation was opened by the Indonesian investigation authority, the NTSC, who issued an immediate safety recommendation to the operator of the aircraft concerning the verification of the condition of the propeller blade trunnion pins and the search for crack indications on part of the fleet. On 30 November 2014, a new similar incident occurred in Sweden to an ATR 72-212A registered SE-MDB, for which an investigation was opened by the Swedish investigation authority, SHK.  In fact there was also one other occurrence in 2007 in Spain and three more identified between 2012 and 2014 in Tanzania and Brazil.  BEA comment that: In almost all of the [7] cases, the rupture of a trunnion pin of one of the blades and damage to the propeller blade actuator forward plate were observed. They also only involved on No 2 propellers.  The BEA noted that as both propellers turn in the same direction, but are located differently relative to the fuselage, they see different aerodynamic loads.  Extensive in-flight and ground vibration testing was conducted in 2014 and 2016 on a...

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Hurried Door Inspection Results in Fall From Aircraft

Posted by on 3:37 pm in Accidents & Incidents, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

Hurried Door Inspection Results in Fall From Aircraft On 15 June 2016, Air Europa Embraer ERJ190-200LR EC-LKX, had an aft-door open warning while cruising at 31,000 ft en route to Madrid-Barajas Airport.  The crew carried out the relevant procedure and the aircraft landed safely.  After disembarking the passengers the flight crew contacted maintenance to inspect the door.   While conducting the maintenance, one of the technicians fell from the aircraft, suffering serious injuries.  According to the safety investigation report of the Spanish accident investigation agency, the CIAIAC: Two maintenance technicians proceeded to inspect the problem with the aft door while the captain and first officer remained in the cockpit to prepare for the flight to La Coruña, at which time they were called by one of the maintenance technicians to report that his colleague had fallen… The 44 year old male maintenance technician who fell couldn’t recall the events clearly, but did recall that: …a coworker asked him for help, since he had a B1.1 license and is certified on that airplane type, unlike said coworker. So as not to delay the flight, since the airplane was ready for boarding, he interrupted the maintenance activities he was performing on another airplane and went to assist his coworker. His coworker told him that the door was open.  To prevent falls when the door is open, the airplane features a safety strap. This strap is more to warn of the danger than to protect against it, since it is not capable of supporting a person.  He was also holding on to a safety handle, which also did not keep him from falling. He thought that to identify the fault, he must have opened and closed the door while visually inspecting the sensor from the inside. During the visual inspection, he must have placed his leg outside the airplane and fallen. This is consistent with statement of the second technician. The accident occurred during the maintenance technician’s 6th hour of his shift, which had started at 07:00 and ended at 15:00. It was his fourth task since commencing his shift. In the time period when the accident took place, the workload was usually high [he said].  He was in a hurry, since he had to do maintenance on other airplanes, and this was a routine visual inspection, so he did not consider calling for a platform. As a safety measure to avoid a repeat occurrence, however, he would recommend the use of a platform any time a door is open. The CIAIAC also comment that: …the safety strap, as it does not prevent falls, cannot replace a work platform installed outside the door as a safety barrier. Further Safety Resources Airbus have published an article on preventing falls from height.  On the door strap they say: It should only be used for a limited time pending the closure of the door. A safety strap does not prevent from a fall. The Cabin Crew Operating Manual (CCOM), states that whenever a cabin door is open with no stairs or no gateway in position, the safety strap should be installed and the door should not be left unattended. When a door remains open and unattended for a long period of time, Airbus recommends the installation of a safety barrier in absence of stairs or gateway. This same recommendation is made in IATA’s Airport...

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Usage Related Ex-Military Helicopter Accident

Posted by on 9:09 am in Accidents & Incidents, Design & Certification, Helicopters, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Management, Special Mission Aircraft

Usage Related Ex-Military Helicopter Accident (UH-1H, N175SF) On 5 October 2016 Tamarack Helicopters (Bell) UH-1H N175SF, operated on a Part 137 agricultural aerial application flight by Farm AG Enterprises under a restricted certificate of airworthiness, rolled over during a forced landing near Gila Bend, Arizona, after the 90° tail gearbox (TGB) separated. The pilot, the sole person, onboard sustained minor injuries. The US National Transportation Safety Board (NTSB) say in their safety investigation report that: The pilot reported that he had just completed a series of passes over a cotton field, and was maneuvering the helicopter for a return to the fuel truck. The helicopter was moving at about 20 knots and climbing, when after reaching about 100 ft above ground level he heard a loud bang. The helicopter then began to spin to the right, and would not respond to foot pedal inputs, so he lowered the collective and initiated an autorotation. The helicopter was still spinning as it descended, and as it approached the ground the skids made contact with cotton bushes, and the helicopter rolled onto its left side. The tail rotor assembly and TGB was found 30ft from the wreckage. The input quill and sleeve assembly remained attached to the vertical fin. Safety Investigation The TGB was installed about 300 flying hours earlier on 19 August 2014. A representative from Tamarack Helicopters stated that the 90° gearbox is typically removed and overhauled after 1,200 flight hours, or if grey material indicative of fretting is observed at any of the gearbox mating surfaces. In this case: Examination revealed that the six studs which attached the gearbox case to the input quill sleeve assembly on the fin had fractured at the gearbox housing joint line. The threaded portion of the fractured studs remained within the gearbox case. All six stud fracture surfaces displayed topographies and arrest lines indicating bending fatigue cracking. In each case, the fatigue initiated in the thread root radii on the same side of each stud relative and perpendicular to the center of the bolt hole radius. The fatigue cracks propagated diametrically across each stud terminating in small overstress regions, with a small area of secondary reversed bending fatigue cracking at the opposite side of each stud. Magnified examinations of the corresponding stud sections from the vertical fin revealed fracture areas with fatigue cracks that had initiated at either the first, second or third full thread from the grip portion of the stud. The thread roots were smooth and typical of rolled thread roots, and yellow paste material consistent with zinc chromate paste was present in all thread roots. The fatigue cracks penetrated between 89% and 98% of each stud cross section. They then failed in overload. Fatigue is typically the result of insufficient preload in the fastener often due to insufficient torque during installation or by the loss of preload after installation. Fretting wear on the studs and in the holes indicated that there were small amounts of relative movement between these components and thereby also indicated insufficient preload. However, the interface between the input quill housing and the vertical fin showed no significant fretting or wear. The locations of the main fatigue origins in the studs and the fretting location between the studs and fin holes were both consistent with normal torsional loads in the tail rotor drive system. The studs exhibited a large percentage of...

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Twin Otter Nose Wheel Steering Misused in Runway Excursion

Posted by on 2:23 pm in Accidents & Incidents, Fixed Wing, Human Factors / Performance, Safety Management

Twin Otter Nose Wheel Steering Misused in Runway Excursion On 23 April 2018, Daily Air‘s flight DA7012, a Viking DHC-6-400 Twin Otter, B-55573, departed Qimei Airport for Kaohsiung International Airport.  According to the Taiwan Aviation Safety Council (ASC) safety investigation report (only available in full in Chinese) the aircraft landed at Kaohsiung: …in a right crosswind. After touchdown, the pilot flying (PF) attempted to correct the lateral deviation but misused the nose wheel steering lever which caused the aircraft veered-off the runway from its left hand side with a 35 degrees drift angle. The aircraft turned 180 degrees left and stopped on the grass area. The aircraft commander was PF. ASC Safety Analysis The ASC made 10 findings related to risk, 8 of which are reproduced below in full: At the time of the occurrence, the DHC-6-400 level D flight simulator was not yet available in the aviation industry. The Daily Air could only carry out pilot training and check in a real aircraft. However, it is not only impossible to simulate various scenarios and weather conditions in a real aircraft, but also contained higher risks, thus restricted the effectiveness of pilot training and check. Daily Air did not specify standard call-outs in relevant manuals for pilot monitoring (PM) to remind lateral deviation during landing roll. Thus the flight crew acted on their own style and it weakened the effectiveness and accuracy of the communication. Daily Air did not specify the timing or speed limit in relevant manuals for the use of “nose wheel steering”. It may result in divergence of views and actions toward this issue and adverse effect on standardization in the DHC-6-400 fleet. Daily Air did not have a clear policy regarding the usage of asymmetric thrust to assist directional control during landing roll. There were divergences in opinions between management, instructor pilots, check airmen and flight crew in the DHC-6-400 fleet. The captain of this occurrence had already carried out all flying tasks, including take-off and landing operations manually for 8 legs, and his flight duty period had exceeded 10 hours. The captain’s decayed physical and mental conditions due to his accumulated workload could weaken his alertness and ability to perform tasks safely. Although flight crew schedules of Daily Air was in compliance with the CAA regulations, a bio-mathematical model analysis of pilot fatigue showed that the eastern Taiwan routes with 12 legs a day may exist a high risk of fatigue, the Taiwan eastern routes with 10 legs a day may exist a moderate-to-high risk of fatigue; the western Taiwan routes with 8 legs a day may exist a moderate risk of fatigue. Shortage of pilots in Daily Air DHC-6-400 fleet has existed at least for a year before the occurrence happened, especially in the case of a shortage of captains, which may result in high risk of fatigue on the pilot flight schedule. The cockpit of DHC-6-400 aircraft owned by Daily Air was not equipped with effective air-conditioning, which may result in unpleasant mental situation or fatigue of flight crew members due to potentially heat stress environment. There were also two rather vague findings on the airline’s “internal evaluation program” (IEP).  One that the IEP was spread across the Safety Management Manual and the other that flight crew recurrent checks were included in the IEP.  While both might be symptoms of weaknesses in...

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Helicopter Wirestrike During Powerline Inspection

Posted by on 12:56 pm in Accidents & Incidents, Helicopters, Mining / Resource Sector, Regulation, Safety Management, Special Mission Aircraft

Helicopter Wirestrike During Powerline Inspection (HU369D, OH-HNX, Norway) On 21 June 2018 OH-HNX, a Hughes 369D (500D) helicopter of Heliwest hit a crossing power line 10 km NW of Grimstad, Norway while laser scanning a powerline.  It cut all three conductors but was able to land safely with only minor damage. The Accident Investigation Board Norway (AIBN) say in their safety investigation report this was “very close to a total loss”. History of the Accident Flight Heliwest was contracted by Agder Energi Nett to inspect the condition of the power lines in the company’s 22 kV distribution network and the proximity of surrounding vegetation in the surrounding area. The company provides electricity to 199,000 customers and have 20,600 km of lines.  Agder Energi Nett has a framework contract with two helicopter companies (assessed on a 50% cost / 50% other factor basis). The survey was to be conducted photographically and using laser scanning (LIDAR) with a crew of two (a pilot and a systems operator).  The mapping equipment on board was calibrated with focus at a 45 m distance which necessitated long duration, high risk, low altitude operations. Heliwest specialises in supplying helicopter for the energy sector under EASA SPO rules and have extensive experience with this type of task. They were familiar with the conditions in Norway and had previously flown for both TrønderEnergi Nett and Hafslund Nett. OH-HNX arrived in Norway on 6 June 2018 and made its first inspection flight from Arendal Airport Gullknapp (ENGK) two days later. According to the AIBN: The evening before the accident occurred [20 June 2019], the crew planned the flight by e.g. drawing the power lines to be inspected the next day on a paper map. Due to a lapse, the crossing line in question with which the helicopter later collided, had not been registered or drawn on the map. The crew had only planned to fly one sortie on 21 June 2019 because they were going to fly back to their main base at Helsinki-Malmi that afternoon in connection with Midsummer’s Eve celebrations that evening. The crew were accommodated in Mandal, and on the morning of 21 June 2018: …they ate breakfast before driving approx. one hour and 20 minutes to Gullknapp, where they arrived at approx. 07:20. They then completed a pre-flight check on the helicopter, prepared the equipment and signed a dedicated checklist for line inspection flights prepared by Heliwest. This checklist contained multiple safety-related items, including the item “Daily risk analysis”. The helicopter took off at 08:45. It was flown by the commander in the left seat. Apart from the helicopter’s instruments, he used an iPad with the application Air Navigation Pro for general navigation. The systems operator was in the right seat. There was a navigation display in front of him to the left. The display used the software Vimap and showed a map with the power lines to be inspected. There was a large screen (main screen) in front and to the right of the systems operator which showed the results from the photography and scanning. When the accident occurred, there was a problem with the Vimap software to the effect that it was not possible to enter digital map information about crossing power lines. They also [therefore] had the paper map the crew had prepared the evening before. On this map they e.g. marked the lines they had documented. They...

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Fatal B206L3 Cell Phone Discount Distracted CFIT

Posted by on 10:14 pm in Accidents & Incidents, Business Aviation, Helicopters, Human Factors / Performance, Safety Management

Fatal B206L3 Cell Phone Discount Distracted CFIT The US National Transportation Safety Board (NTSB) has reported on a Controlled Flight Into Terrain (CFIT) accident involving Bell 206L3 N213TV, operated by what NTSB call WQRE TV 13 (but was actually KRQE) on 16 September 2017.  The helicopter impacted open ranch land, near Ancho, New Mexico.  There was a post impact fire.  The pilot, the sole occupant, was fatally injured, and the helicopter destroyed. The helicopter had departed from Roswell International Air Center Airport (ROW), New Mexico at c1554 local time for Albuquerque International Sunport (ABQ), New Mexico. The NTSB say in a report released 8 July 2019: The pilot was conducting a return cross-country business flight in a helicopter. The reported winds at the time of the accident were light, and visibility was at least 10 miles. A Garmin Aera 796 GPS unit was found at the accident site. A review of the flight track from the GPS unit, revealed that the helicopter departure and northwest heading towards Albuquerque. The flight track was a straight line and started at a GPS altitude of 3,681 ft. For about the last 5 minutes of the flight track, the helicopter’s GPS altitude varied between 6,200 and 6,456 ft, the last recorded altitude. The ground elevation and surrounding terrain near the accident site varied between 6,000 and 6,400 ft; the elevation at the initial impact point was 6,330 ft. The last recorded data showed the helicopter about 1.5 nm from the accident site. The pilot’s mobile phone (US: cell phone) was recovered in the wreckage. A review of the [cell phone] records revealed that the pilot placed a call at 1607; the call lasted only 3 seconds. About 1612, the pilot repeated the telephone call, which was to a car rental agency, this time the call lasted for 1 minute and 47 seconds. The clerk reported that she remembered the call well, and that she knew the pilot, because he often rented a car from the agency. The reason for the call was [the pilot] wanted to insure he was going to get a special rate for his rental that day. They had a special deal…if he put less than 75 miles on a car. He also called to let her know [where] the car was parked… She added that she could not tell that he was in a helicopter but that he seemed “busy or distracted.” She added that, as they were talking about a future rental and was in “mid-sentence,” when the call was disconnected. NTSB Probable Cause The pilot’s distraction by a cell phone during a low-altitude flight, which resulted in controlled flight into terrain. Similar Occurrence The Irish Accident Investigation Unit (AAIU) reported on a non-fatal accident involving Enstrom 280FX N531TJ on 16 July 2018. Whilst carrying out practice exercises near Carrahane Strand, Co. Kerry, the Pilot, who was the sole occupant of the Enstrom 280FX helicopter, landed briefly for a break. The landing surface was soft, wet, sand. The skids of the helicopter had touched down lightly prior to it rolling over on to its left-hand side. The helicopter was substantially damaged. The Pilot was uninjured. While the helicopter was touching down, the Pilot’s mobile telephone had rung.  The phone contained software for navigation and flight planning but the pilot told the AAIU he would never use it...

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