HEMS Air Ambulance Landing Site Slide
HEMS Air Ambulance Landing Site Slide (BSAA H145 SE-JSS) On 12 February 2022 Airbus Helicopters H145 air ambulance helicopter SE-JSS, based at Mariehamn Airport, Åland island, Finland was deployed to the nearby island of Fiskö after a person fell on ice. After landing at a confined site near the casualty, power was reduced to idle, the helicopter slid backwards and struck adjacent obstacles. The Safety Investigation Authority Finland (SIAF) issued their safety investigation report on 28 January 2024. The Accident Flight A 112 emergency call was received at 15:33. Two roads with almost identical names are located in the municipality of Brändö, which caused confusion at first. At 15:50 it was decided to task the helicopter to attend. The helicopter had three occupants, pilot (1,725 total hours, 1,330 on type), Technical Crew Member (TCM) and nurse. Babcock Scandinavian Air Ambulance had provided ambulance helicopter services in Åland under a contract with Åland Health Care District from 2019 (but Babcock has since sold this business to Avincis). Shortly after becoming airborne the helicopter was passed coordinates for helipad on Korsö island, approximately 15 min flying time away. Only when halfway into the flight, were the helicopter crew informed that the casualty was on Fiskö and they were asked to proceed direct to the accident site (about 5 km northwest of the helipad). SIAF say: At 8 km from the accident site, the pilot descended to 500 ft (150 m) above ground level. During the approach, he reduced speed so he could identify the correct house among the buildings of the small community. They had been told that “someone would be outside waving a white cloth to help in identification”. The crew did not obtain visual contact with this person or the house during the first overflight, but during the second they spotted the house and agreed on the conduct of an off-airfield landing. Even though buildings, trees and a power line were observed in the area, the vicinity of the intended landing site and the approach path were clear of obstructions that could have jeopardized the landing. SIAF only mention this ’17 m danger zone’ in the caption of image above and don’t elaborate on landing site size requirements otherwise. AMC1.SPA.HEMS.125(b)(4) (performance requirements for HEMS operations) states a 2 D site is required by day (which for a H145 is 27.3 m). An approach was made… After the pilot had brought the helicopter to hover, the {technical] crew member [TCM] opened the door and scanned the area below and to the left for any obstructions that would be a factor during landing. He notified the pilot of a bush to the left of the helicopter’s tail about 6 m away but paid no particular attention to the fact that the ground was partially covered with ice. SIAF also comment on their being loose articles at the site. The pilot elected to land. Even though landing was uneventful, and the helicopter appeared stable…the pilot felt it was slightly tilted to the right. With the flight controls neutralized, the attitude indicator showed 2° to 3° right bank, well below the maximum permitted value of 8°. The pilot set the engines to idle. The crew’s attention was diverted to a person approaching the helicopter who was signalled by hand to wait. However, seconds after the engines were...
read moreUndetected Cross Connection Maintenance Error Resulted in a DA42 Hard Landing During a Maintenance Check Flight
Undetected Cross Connection Maintenance Error Resulted in Diamond DA42NG N591ER’s Hard Landing During a Maintenance Check Flight On 25 May 2022, Diamond DA42NG N591ER departed London International Airport, Ontario, on a maintenance check flight but suffered control difficulties and was forced to make a hard landing on the grass alongside the runway. The Transportation Safety Board of Canada (TSB) issued their safety investigation report on 5 January 2024. We examine the maintenance human factors involved. The Accident Flight The maintenance check flight followed a 2000-hour inspection (“including a mechanical and structural inspection, and general refurbishing”) that had been completed at the Diamond Aircraft Industries facilities at London International Airport. During the take-off, when the aircraft became airborne, the aircraft yawed abruptly to the left. The pilot attempted to correct for the unexpected yaw but had difficulty maintaining directional control of the aircraft. The pilot attempted to make an emergency landing on Runway 27; however, during the approach, the pilot continued to have difficulty controlling the aircraft and instead attempted to land on Taxiway A before ultimately landing on the grass between the runway and the taxiway. When the aircraft touched down hard on the grass, the rudder and the left-wing aileron mass balance weight broke off. The landing gear collapsed, and the aircraft slid to a stop approximately 265 feet from the initial impact point. The aircraft was substantially damaged but the pilot was uninjured. The Safety Investigation & Our Comments Upon initial examination it was discovered that the rudder moved in the opposite direction to the pilot input. Significantly, during the preceding maintenance the rudder guide tubes had been replaced. [The Aircraft] Maintenance Manual (AMM) explains that the “two fuselage cables go through Teflon tubes in the rear fuselage. The cables attach to the rudder lower mounting bracket. The cables cross over each other in the rear fuselage” Significantly: The rudder cable guide tubes are not normally replaced…during the course of regular maintenance because they are rarely found to be defective, and there is no specific requirement to change or inspect them at regular intervals. The AMM also provides some troubleshooting guidance, which suggests that rudder stiffness or catching may be caused by the rudder cables chaffing in the guide tubes. The AMM suggests to replace the rudder cables and guide tubes; however, there is no method or procedure in the AMM specific to replacing the guide tubes. The AMM system description does explain and illustrate that the cables cross over, but that is not referenced from AMM section for the task. The AMM contains instructions for the replacement of a single cable but makes no mention that it crosses from one side to the other (i.e. assumes the other cable is in place). TSB note that the only other information was in production drawings. These apparently could be requested, but wasn’t requested for this task. Clearly a maintenance organisation owned by the Type Certificate (TC) Holder has an advantage accessing production data, though if it is needed its a sign of an inadequacy in the AMM. Investigators determined the tube were therefore installed… …without the aid of specific procedures, guidance, or supervision. We discuss the supervision aspect further below. As noted above, the lack of procedures and guidance was not a ‘Failure to Follow (F2F) procedures’ by maintenance personnel (a...
read moreAir Ambulance EC135 Loss of Control & Main Rotor / Engine Overspeeds
Air Ambulance EC135P2+ Loss of Control & Main Rotor / Engine Overspeeds (Air Methods, N531LN) On 22 January 2022, an Airbus EC135P2+ air ambulance, N531LN (LifeNet 81), of Air Methods Corporation (AMC) was destroyed in an accident in Drexel Hill, Pennsylvania. The pilot was seriously injured but the two medical personnel and the patient (a child under the age of 5) aboard escaped injury. The US National Transportation Safety Board (NTSB) issued their safety investigation report on 4 January 2024. The Accident Flight The helicopter departed Chambersburg Hospital about 12:05 Local Time, destined for Children’s Hospital of Philadelphia. The helicopter established itself in cruise at an altitude of c 3,500 ft before descending as they approached Philadelphia. At 12:53:11, Automatic Dependent Surveillance – Broadcast (ADS-B) data revealed “a series of heading and altitude excursions” before the data was lost 6 seconds later. Doorbell cam recordings on the ground captured a “high-pitched whine…volume and pitch”. The NTSB report that: Surveillance video showed the helicopter in a near-vertical, nose-down, spiralling descent. The medical crew reported that the helicopter rolled inverted. No other evidence supported that. They however did manage to secure the patient and brace for impact. The injured pilot, who had 4,123 total hours, 185 on type) had no memory of the initiating event and limited recollection of the final seconds of the flight. However the NTSB established that the pilot…. …arrested the rotation and recovered the helicopter from the dive but was unable to climb or hover due to insufficient engine power, thereby resulting in a hard landing… The helicopter impacted the ground upright and came to rest on its left side adjacent to a church building. All wreckage was found in a compact area with no substantial debris trail. The main fuselage was whole but… the airframe was partially separated on the upper side of the frame between the cockpit and cabin. All occupant seats remained installed within the cockpit and cabin. The aft-left seat was partially bent in a downward direction near the front edge of the seat. Although not remarked upon by NTSB, it came to rest partly on a low wall. The pilot was extracted from underneath. The medical personnel egressed through the right cabin door, carrying the patient. NTSB Analysis The accident helicopter, manufactured in 2006, was not equipped with, nor perhaps surprisingly “was it required to be equipped with, a flight data recorder (FDR), a cockpit voice recorder (CVR), or any flight recorder system that records cockpit audio and image”. The FAA had changed Part 135 in 2017 so that helicopter air ambulance operators had to comply with a Flight Data Monitoring (FDM) System requirement, FAR 135.607: After April 23, 2018, no person may operate a helicopter in air ambulance operations unless it is equipped with an approved flight data monitoring system capable of recording flight performance data. Its not clear in the NTSB report how AMC were achieving that regulatory requirement. The NTSB investigators concluded that: Examination of the helicopter revealed no evidence of malfunction that would result in an abrupt departure from cruise flight. The investigators also note that: The accident helicopter was equipped an AFCS [Automatic Flight Control System] composed of a SAS [Stability Augmentation System] and autopilot systems that can control helicopter pitch, roll, and yaw through various actuators. The AFCS does not...
read morePolice Helicopter Unanticipated Yaw & Fatal Water Impact
Police Helicopter Unanticipated Yaw & Fatal Water Impact (Huntington Beach Police Department MD520N N521HB) On 19 February 2022 at 18:34 Local Time MD Helicopters 500N (MD520N) N521HB of Huntington Beach Police Department (HBPD) was destroyed when it impacted the water off Newport Beach, California in a Loss of Control – Inflight (LOC-I) accident. The police pilot escaped with minor injuries but the police Tactical Flight Officer (TFO) was fatally injured. The Huntington Beach Police Air Support Unit was formed in 1968, only the fifth in the US. In 1992 they introduced their first MD520N and became an all MD520N fleet in 2002. Instead of having a conventional tail rotor for anti-torque control the MD520N has a NOTAR (NO TAil Rotor) design with a variable thruster and ducted fan system. In 2023, the unit changed over to the tail rotor-equipped MD530F]. The Accident Flight The US National Transportation Safety Board (NTSB) issued their safety investigation report on 14 December 2023 into the Newport Beach accident. The law-enforcement helicopter was performing right turns at night over an waterfront peninsula supporting officers attending a street fight involving up to 10 people. The pilot estimated “that they were flying about 500-600 agl, which is standard practice” when the helicopter yawed aggressively to the right and he… …immediately applied full left foot pedal and forward cyclic to arrest the rotation, but there was no response. He then applied right pedal to see if the pedals had malfunctioned, and observing no change, he reverted to full left pedal. He continued to apply corrective control inputs, but the helicopter did not respond and began to progress into a spinning descent. The pilot stated that the rotation became more aggressive, and he began to modulate the throttle, collective, and cyclic controls to try to arrest the rotation rate. He stated that his efforts appeared to be partially effective, as the helicopter appeared to respond; however, because it was dark, he had no horizon or accurate external visual reference as the ground approached. The engine continued to operate, and he chose not to perform an autorotation because the area was heavily populated. He then had a sense that impact was imminent, so he pulled the collective control in an effort to bleed off airspeed. The helicopter impacted the water… …on the TFO’s side in a downward right rotation. The pilot recalled a sudden smash and saw water and glass coming toward him as the canopy shattered. He felt the rotor blades hitting the water, everything then stopped, and within a few seconds he was submerged. The Pilot’s Underwater Escape & the Attempted Rescue of the TFO The police department’s personnel… …fly with a full tactical vest, an inflatable “horse collar”, Submersible Systems “Spare Air” [Compressed Air – Emergency Breathing System] tank, gun, radio, magazines, and handcuffs, all carried on their chest. The pilot held on to the collective as a reference point. He recalled that: He waited for the helicopter to stop moving, grabbed the Spare Air mouthpiece, cleared it, and started to breath. Holding the collective with one hand he reached down and released his seat harness. His eyes were closed, and he was able to move by feel. He did not recall opening the door.. He exited the helicopter and was upside down. He tried to relax and...
read moreMulti-Tasking Managers & Deficient Operational Control: Low Viz AS350B3 Take-Off Accident
Multi-Tasking Managers & Deficient Operational Control: Low Viz Take-Off Accident (Midtnorsk Helikopterservice AS350B3 LN-OBP, Norway) On 1 November 2022 Airbus AS350B3 LN-OBP of Midtnorsk Helikopterservice crashed shortly after take-off at Slottelid (ENVS), Verdal, Trøndelag County, central Norway. The two passengers on board died. The pilot was seriously injured. A pet dog aboard also survived. The Norwegian Safety Investigation Authority (NSIA) published their safety investigation report on 5 December 2023. The Air Operator ad Pilot The operator was founded in 2002 and at the time of the accident operated one AS350BA, the AS350B3 and an EC120. They employed 8 people. The pilot had 6,115 hours total experience, 3,800 on type. He held 4 positions within the operator; Accountable Manager, Compliance Monitoring Manager, Safety Manager and Deputy Manager of Flight Operations. The later potion was necessary because the Manager of Flight Operations was a retired fixed wing pilot, with no flight experience on rotorcraft. The Manager of Flight Operations and Technical Manager were part time employees, the former running a human factors & CRM business. The Accident Flight The plan was to transport two passengers, a dog and cargo from the operator’s base Verdal to a mountain farm in Snåsa. Two days before the accident, the pilot had tried to fly the passengers to the farm, but had to abort due to fog in the mountains. The day before the accident there was fog in Verdal that prevented a flight. On the day of the accident the morning fog lay low in the terrain in Verdal, and followed the valley and river. The fog varied in density and two other company pilots had departed about 08:15 after a delay. The passengers due to travel on LN-OBP arrived at around 09:00. The pilot loaded their baggage / cargo and waited for the visibility to improve. The pilot told investigators “there was a calm atmosphere and that he did not feel any stress”. The pilot told investigators the fog had started to lift to the north east. He intended to take off in that direction, flying around a small cluster of trees near the landing site. The pilot to a photograph looking north east though the cabin at c 10:30. Also evident is a large amount of unrestrained cargo. CCTV evidence shows the helicopter lifted off at c 10:35 but crashed less than 20 seconds later, 450 m away, bouncing several times and coming to rest 540 m from the landing site. The pilot, who suffered several back fractures, regained consciousness, egressed the helicopter and raised the alarm. The Emergency Locator Transmitter [ELT] antenna had factored during the crash and the helicopter tracking system had not registered the short flight. Dense fog contributed to the problem of locating the aircraft. After 10–15 minutes, a doctor and rescue personnel arrived at the accident site. Both a rescue helicopter and an air ambulance helicopter were unable to land near the accident site due to fog. After a little while, the air ambulance helicopter was able to land in a field slightly higher up in the terrain about 2 km from the accident site. NSIA Safety Investigation & Analysis There are no indications of any pre-impact technical failures. NSIA concluded the helicopter was most likely overloaded by c 60-80 kg. A key issue for the NSIA...
read moreFire-fighting Bell 204B Underwater Escape
Fire-fighting B204B Underwater Escape (Forest Air Helicopters VH-EQW, Queensland) On 20 September 2023, Bell 204B VH‑EQW of Forest Air Helicopters crashed into a reservoir during fire-fighting operations for the Queensland Fire and Emergency Services (QFES) at the Southern Downs fire, near Cunninghams Gap. The pilot escaped from underwater and sustained minor injuries. The helicopter was destroyed. The Australian Transport Safety Bureau (ATSB) released a preliminary report on 7 December 2023. The Accident Flight The aircraft was tasked with fire-fighting operations near Tarome, Queensland, using a 1,200 l bucket and a short line. The single pilot (2,599 hours of total experience, 221 on type) was operating the helicopter from the left seat “for visibility” say ATSB. During their first water uplift, the pilot… …heard an unusual noise and that the helicopter ‘kicked’. Remaining in the hover, the pilot checked that all engine indications were normal and that the bucket and line were in the appropriate place. However, the pilot reported that something still did not feel right. As a result, they elected to dump the water from the bucket and initiate a climb out. Within about 10-15 seconds, as engine power was being applied, and the water was being released from the bucket, the pilot heard what they described as a ‘loud roaring’ sound and the helicopter pitched up, yawed, and subsequently had a reduction in power. The helicopter rolled left and impacted the water at low [forward] speed. The Pilot’s Escape Almost immediately after the impact, the helicopter inverted, started to fill with water, and sink rapidly. The pilot had previously undertaken practical HUET (helicopter underwater escape training) but does not appear to have been equipped with a Compressed Air – Emergency Breathing System (CA-EBS) or similar survival aid. However, he was able to take a breath before the cabin filled with water. The pilot removed their seatbelt and helmet, and attempted to open the front left door but could not open it with either the normal or emergency release handles. When the helicopter was almost fully submerged, the pilot swam to the rear of the cabin and tried to open the rear right door but could not open it either, making further attempts to get out by kicking the helicopter windows. Unlike a modern offshore helicopter, the cabin windows had not been modified into push out exits. The pilot then moved to the rear left door and, utilising considerable force, was able to successfully open it. The pilot noted in interview, that when they initially attempted to open the doors, they may have been trying to move the door handles in the incorrect (opposite) direction due to the helicopter being inverted. The pilot escaped and swam a few metres to the surface and then to the side of the dam. The ATSB Safety Investigation The helicopter was salvaged. To date, the ATSB has interviewed the pilot and witnesses, and conducted preliminary examination of the helicopter wreckage. The…rotor systems, flight controls, exits, and engine were visually examined. No pre‑accident damage was identified. The pilot’s left front door emergency jettison system was tested serviceable. ATSB say they intend to examine the pilot’s training and records, maintenance documentation, and certain key components of the helicopter. UPDATE 1 October 2024: ATSB final report: Firefighting helicopter accident due to snagged cables “The cables attaching...
read moreIn-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice
In-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice (N3688P, Falcon Executive Aviation) On 10 July 2021 Beech King Air C90 N3688P broke-up in flight and crashed near Wikieup, Arizona. The aircraft was operated Falcon Executive Aviation in support of firefighting for the Federal Bureau of Land Management (BLM), The pilot and the US Forest Service (USFS) Air Tactical Group Supervisor onboard were fatally injured. The US National Transportation Safety Board (NTSB) issued their safety investigation report on 23 August 2023. The Accident Flight The aircraft was on station for about 45 minutes, completing multiple orbits over the Cedar Basin wildfire. One witness saw the aircraft the descend in a steep dive. No distress call was heard and it impacted mountainous desert terrain. Another witness, a firefighter, observed the outboard left wing falling to the ground shortly after the aircraft had impacted the ground. The Safety Investigation Investigators found that: The main wreckage was mostly consumed by a post-crash fire. Debris was scattered over an area of several acres. The outboard left wing was found about 1250 m from the main wreckage. It had separated outboard of the engine nacelle. The C90 was manufactured in 1980. It had been flown as a aerial supervision / reconnaissance aircraft for firefighting since 2007. This involved operating in orbits at c 1000-3500 ft AGL. It was not used in the more demanding lead aircraft role (low level operation to lead in a larger firefighting aircraft for its drop). The aircraft had flown 17,262.6 hours and 15,475 cycles at the time of the accident. Since 2007, it had accumulated 3,507 hours and 1,877 cycles. The NTSB examined the maintenance history of the aircraft. Since 1990, FAA Airworthiness Directive (AD) 89-25-10, Wing Main Spar Inspection had been applicable. This required inspection of “the wing lower forward spar attach fittings, center section, and outboard wing spar caps adjacent to the attach fitting”. It stated: If any crack is found in a main spar lower cap or fitting, prior to further flight repair or replace the defective part using the instructions and limitations specified in the Beech SIRM or other FAA approved instructions provided by Beech Aircraft Corporation. On this aircraft… A total of 16 wing spar inspections were accomplished since the AD became effective and 6 times since the airplane went on contract to the USFS in 2007. Further, the annual spar cap visual inspection for cracks and corrosion [as specified in the Beech Structural Inspection and Repair Manual (SIRM) 57-13-01] was accomplished 16 times since 2007. However, in March 2021… During a scheduled [AD 89-25-10 and SIRM 57-13-01] maintenance inspection…eddy current (EC) non-destructive testing (NDT) of a left wing’s lower forward spar cap detected a crack in a fastener hole. The hole was then oversized/reamed to a larger size, but the EC reinspection still produced a crack indication. The operator then submitted a structural damage report and service request detailing the crack indication to the aircraft manufacturer. The manufacturer responded in April 2021 that this necessitated the replacement of “the center section forward spar cap, center section forward lower fittings and both outboard main spar assemblies.” The email response…to FAS also included the warning below from their published instructions for wing structure inspections in the SIRM 57-13-01, (in part [emphasis in...
read moreSouth Korean Night Black Hole Spatial Disorientation Fatal Helicopter Accident
South Korean Night Black Hole Spatial Disorientation Helicopter Fatal Accident (National 119 Rescue Airbus Helicopters H225 HL9619) On 31 October 2019 emergency service Airbus H225 HL9619 of National 119 Rescue crashed into the sea just 14 seconds after take off from the island of Dokdo during a patient transfer medevac flight. All 7 occupants died in the accident. The South Korean Aviation and Railway Accident Investigation Board (ARAIB) issued their safety investigation report (in Korean) on 6 November 2023. This accident summary is based on a translation of this report. Note: ambiguities after translation did made interpretation challenging but we are confident the content here represents the final report accurately. The Accident Flight National 119 Rescue is fire-fighting, air ambulance, mountain & maritime Search and Rescue (SAR) organisation, ultimately a part of the Korean National Fire Agency. The helicopter was tasked to fly east from Daegu on the mainland to Dokdo Heliport on an rocky offshore island, to retrieve a fisherman who was on the island after had suffering a severed finger on a fishing vessel. On board were 5 crew (two pilots, a flight engineer / hoist operator, a winchman and paramedic). The captain had 3,827 flying hours total experience, 444 on type. The first officer had 2,666 flying hours total experience, 307 on type. The flight crew had no prior experience landing at Dokdo and investigators state that during their flight planning the crew were unable to obtain “information about the terrain of the landing area or the heliport to the extent the crew desired”. The helicopter departed Daegu at 22:33 and refuelled successfully at Ulleungdo island en route. The captain complained of being tired during the flight. The captain was working an extended shift due to a business trip involving another pilot. The aircraft was fitted with a Night Vision Imaging System (NVIS). Investigators note that the… National Fire Agency does not have a clear basis for the operation of night vision equipment., Pilots selectively use night vision equipment depending on individual preference. Evidence from an Appareo Vision 1000 recording system confirmed the pilots were using their Night Vision Goggles (NVGs) when the aircraft departed, though the Vision 1000 video recording ceased during the flight. Cockpit Voice Recorder (CVR) evidence was that the NVG continued to be used intermittently as necessary during the flight. CVR data suggested that Automatic Flight Control System (AFCS) selections were not being verbalised and “there were cases where the first officer did not realize the captain’s intentions”. The 25 m square Dokdo heliport, at an elevation of 177 ft, was operated by the Gyeongbuk Provincial Police Agency, but they lacked specific heliport procedures and personnel with relevant competencies. This was the first night landing at the site in 3 years. Two of the four perimeter flood lights were unserviceable, though the green perimeter lights were serviceable. Visibility was good with no clouds or sea fog but little illumination form the waxing crescent moon. There was a crosswind at Dokdo, that was likely to have induced turbulence and no illuminated windsock. The helicopter landed at Dokdo at 23:24 after one missed approach (with a torque exceedance). The missed approach followed a miscommunication between aircraft and ground resulted in all lights at the site being briefly extinguished. During the second landing attempt a person...
read moreHelicopter Water Impact Accident: Safety of Airborne Geophysical Survey Operations
Helicopter Water Impact Accident: Safety of Airborne Geophysical Survey Operations (Synergy Aviation Guimbal Cabri G2 C-GSYN) On 8 October 2021, Guimbal Cabri G2 C-GSYN of Synergy Aviation impacted Wachigabau Lake, Quebec during a geophysical survey flight for survey company Novatem. The pilot sustained serious injuries, but egressed underwater and swam to shore. Context of the Flight The Transportation Board of Canada (TSB) issued their safety investigation report on 31 August 2023. TSB explain the helicopter was operating from Chapais, Quebec and that morning, the pilot (407 hours total, 235 on type and trained at the operator’s own flight school) was tasked with two low-level geophysical survey flights before ferrying the helicopter to Amos/Magny Airport (CYEY), Quebec, for maintenance. Synergy had started operating survey flights for Novatem in mid 2020, developing their Guimbal Aeromagnetic Survey Procedure (GASP). TSB explain that: Under the heading Safety, the GASP stated that “[h]azards to consider are wires, persons or livestock, trees, rising terrain, and water.” However the document did not offer mitigations on how to deal with these hazards. Rather, it referred readers to the Exercise 22 – Low Level Operations of the Helicopter Flight Training Manual on TC’s website. The GASP’s section on flight planning and hazard assessment listed 9 hazards to consider, including lakes, rising terrain, and tall standalone obstacles (e.g., trees), but it did not provide clear guidance on how to assess and mitigate those hazards within the context of aerial work, aeromagnetic survey work, low-level flying, or over-water operations. The helicopter was equipped with a nose boom, or ‘stinger’, containing a magnetometer. The Novatem aeromagnetic survey monitor, mounted to the right of the console directly in front of the pilot, displayed the survey blocks and flight tracks. It displayed height above sea level but did not display height above ground because the helicopter was not equipped with a radar altimeter. A conventional barometric altimeter was the only instrument on board that provided a useable indication of the helicopter’s altitude. Importantly: To obtain quality data, the helicopter must consistently maintain the optimal height (approximately 25 m [82 feet] over land and water) on all survey lines. This means that the helicopter is required to fly the contour of the terrain as much as possible. Novatem has stated that some variations in height due to obstacles and other safety concerns are acceptable, and data collected can be corrected with software calculations and extrapolation algorithms. However: While some pilots, including the occurrence pilot, had been briefed verbally by the chief pilot on the requirement to fly the contour of the terrain, the requirement to fly at and maintain the optimal height of 25 m (82 feet) was not clearly communicated. Neither the requirement to fly and maintain the optimal height of 25 m (82 feet) nor the requirement to fly the contour of the terrain was included in the GASP. As it was not part of the Operations Manual, the GASP was not reviewed by the regulator, Transport Canada. Without the integration of a precise height indication on board, the pilots were left to visually estimate and rely solely on feedback from Novatem to determine whether they had flown a proper flight profile at the correct height. This also left them to determine and maintain their height using visual cues only. In relation to training to prepare for this...
read moreInvestigation into B212 Accident off UAE 7 September 2023
Investigation into B212 Offshore Helicopter Accident off UAE 7 September 2023 (Aerogulf A6-ALD) On 7 September 2023 Aerogulf Services Bell 212 A6-ALD crashed into the Arabian Gulf of the UAE at c 20:06 Local Time during a night offshore training flight. Both pilots were fatally injured. The Accident Flight The Air Accident Investigation Sector (AAIS) of the United Arab Emirates GCAA, in a preliminary report, issued 6 October 2023, stated that the helicopter departed Al Maktoum International Airport (OMDW), Dubai, for the Aras Driller jack-up drilling rig located off the emirate of Umm Al Quwain at c 19:18 Local Time. The Aircraft Commander (9011 hours total time), the trainer, was in the left seat as pilot monitoring (PM), and the Co-pilot (7031 hours total time) was the pilot flying (PF) in the right seat. The intent was to make 5 offshore landings to maintain night recency. The Aerogulf Ops Manual Part D states… ..flight crew will keep their night recency using a FFS [Full Flight Simulator] or the real aircraft completing 3 night take off, each followed by a traffic pattern and a subsequent landings every 90 days. The training objective were: The helicopter climbed to 1100 ft and proceeded along the coast to the jack-up with an ETA of 19:40 Local Time. At 19:38 Local Time the radio operator on Aras Driller passed the latest weather data: “rvariable windspeed ranging from 7 to 9 knots coming from the 60°, visibility between 7 to 8 knots [sic – presumably nautical miles or km] and 1002 millibar air pressure”. At 19:46 Local Time the PM contacted the radio operator to inform him that they were 2 minutes away from landing. The radio operator confirmed they had a ‘green deck’ (i.e. the helideck was available). At 19:50 Local Time, the Bell 212 landed on helideck, heading southeast. It took off ay 19:52 Local Time and headed north east. Within 3minutes, it turned and descended for a second landing, again heading south east. After the second landing, it took off again at 19:59 Local Time and performed a second circuit landing for the third time at 20:03 Local Time. At 20:05 Local Time, the helicopter took off again. One minute later the Helideck Landing Officer (HLO) called the radio operator, reporting that the helicopter had crashed c 600 m away to the north west. The Search and Rescue (SAR) Activity At 20:08 Local Time, the radio operator notified the rig management and initiated a distress call for SAR. The rig launched a fast rescue craft. They were not able to locate any survivors but found an inflated liferaft with some debris attached The investigators say: The SAR rescue team reached the site in about 45 minutes after they were notified. The team swiftly initiated operation within the designated area. Its not clear what SAR asset this was, but it appears to have been a boat, as they go on to say: About 1 hour 20 minutes after the initial notification, a SAR helicopter arrived at the site. Equipped with powerful high beam focus lights fitted on it, the SAR helicopter conducted an intensive survey of the anticipated site. At the same time, the SAR rescue boat gathered all floating debris, which encompassed a small part of the helicopter. The following day after…the...
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