News & Comment

Heli-Expo 2016 Photo Report

Posted by on 12:14 pm in Accidents & Incidents, Business Aviation, Design & Certification, FDM / Data Recorders, Helicopters, Military / Defence, Mining / Resource Sector, News, Offshore, Oil & Gas / IOGP / Energy, Special Mission Aircraft, Survivability / Ditching

Heli-Expo 2016 Photo Report News from HAI Heli-Expo 2016 in Louisville, Kentucky (1-3 March 2016): Airbus Helicopters H215 Airbus Helicopters had on show the newly designated H215, formerly the AS332C1e (i.e. an enhanced, short fuselage Super Puma) and AS332L1e (the long fuselage version), to be built in Romania and aimed at aerial work, disaster relief and other missions.  The replacement of elderly SA330Js, S-61s and Mil Mi-8s being distinct targets. The Finnish Border Guard recently took delivery of its first H215, OH-HVP, with the second to follow in Apri 2016l.  It has been suggested that a major current sales target is California’s Department of Forestry and Fire Protection (CAL FIRE), which has issued a tender for 15 helicopters. Airbus Helicopters AS350 / H125 Probably one of the oddest special mission modifications on show was this AS350B3 fitted for environmental research. The so called Helicopter Observation Platform (HOP), N350UM, is owned by the University of Miami Rosenstiel School of Marine and Atmospheric Science and operated by Helicopter Express.  The aircraft was exhibited by Donaldson Aerospace & Defense as it is  equipped with a Donaldson Inlet Barrier Filtration (IBF) system. Meanwhile Vector Aerospace and Robertson Fuel Systems were exhibiting their soon to be certified (by FAA and EASA) Crash Resistant Fuel System (CRFS) for the AS350 AStar and EC130B4. This direct replacement tank features a number of safety enhancements, including the introduction of modern fuel retention technology and the relocation of certain critical components to further enhance safety and ease of maintenance. Vector worked closely with Onboard Systems to ensure that the tank remained compatible with Onboard’s cargo swing options. For more on the value of this modification see our article: Crashworthiness and a Fiery Frisco US HEMS Accident Airbus Helicopters H130 Canadian operator Phoenix Heli-Flight took delivery of a spectacularly painted H130 at the show. Airbus Helicopters H160 and H175 While Airbus did not exhibit aircraft or mock-ups of the H160 and H175 this year they did offer attendees a virtual reality experience with both. Meanwhile it has been reported that Airbus Helicopters are planning a new lean production philosophy for the H160.  ‘Major Component Assemblies’ will be produced in different locations before final assembly and flight test at Marignane in France. Production aircraft will have their tail booms produced Albacete, Spain, and main rotor blades would be produced at La Courneuve, near Paris. The central and front fuselages will be produced and pre-equipped by Airbus at its Donauworth facility in southern Germany. They will be mated together in Marignane with the main dynamic components that are also produced there. This could see the 36 week assembly process for the AS365 drop to 18 weeks for the H160, when the production line opens in 2017. UPDATE 10 October 2016: The H160 has now achieved 250 hours in flight test. Bell 505 Jet Ranger X Two Bell B505s were on display. The B505 first flew with a single, right hand side, horizontal stabiliser. The type has now a rather less elegant solution. The Bell 505 features a Garmin G1000H avionic suite. Bell 525 Relentless Bell also brought B525 Flight Test Vehicle 2 (FTV2) to the show.  The second aircraft first flew on 21 Dec 2015.  The 525 utilises fly-by-wire (FBW) controls. A third aircraft is due to join the flight test programme in the coming month, to be followed by two...

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Misrouted Engine Fuel Control Cable Hawker 800XP

Posted by on 12:01 am in Accidents & Incidents, Business Aviation, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

Misrouted Engine Fuel Control Cable Hawker 800XP In Issue 4/2015 of TP 6980 – Canadian Aviation Service Difficulty Reports – Feedback an maintenance error involving a Hawker 800XP fuel control cable is reported: During a planned major structural inspection, the technician noticed that the no.1 engine high-pressure fuel lever cable was trapped under the cover of the electrical junction box. The box straddles the area beneath the floor. Luckily the cable was still able to move and function normally as there was only a slight cable deflection under a flexible plastic cover. The cable was inspected, found to be serviceable with no apparent damage. The cable was properly re-routed above the junction box as per the maintenance manual requirements. Transport Canada say: The mis-routing of this control cable was done at either its last replacement or re-installation from a past maintenance check or snag rectification. As it is with any primary flight or engine control, an independent inspection and dual sign-off would have been required as stated in CAR standard 571.10, maintenance release. Transport Canada Civil Aviation would like to advise all maintenance personnel that the inspection criteria includes an operational check and confirmation for correct assembly of the complete affected system. Our readers will know Aerossurance has previously discussed independent inspections several times, including: Critical Maintenance Tasks: EASA Part-M & -145 Change EC130B4 Accident: Incorrect TRDS Bearing Installation You may also find these earlier articles of interest: James Reason’s 12 Principles of Error Management Maintenance Human Factors: The Next Generation Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements: Aerossurance can provide practice guidance and specialist support to successfully implement a MOP. Aerossurance has extensive air safety, airworthiness, human factors and safety analysis experience.  For 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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Pitot Punctures Floats in Icelandic SAR Ditching

Posted by on 11:18 pm in Accidents & Incidents, Design & Certification, Helicopters, Maintenance / Continuing Airworthiness / CAMOs, Offshore, Safety Management, Special Mission Aircraft, Survivability / Ditching

Pitot Punctures Floats in Icelandic SAR Ditching The ditching of Icelandic Coast Guard Aérospatiale SA365N Dauphin TF-SIF in the Atlantic off Reykjavik on 16 July 2007 highlights the importance of avoiding protuberances that can puncture emergency flotation systems, careful configuration management and establishing emergency drills. The Icelandic Transportation Safety Board (ITSB), the RNF, issued their report in December 2010. The Accident Flight The aircraft was on a winch training mission to hoist people from the Slysavarnarfélagið Landsbjörg (ICE-SAR) 16m Arun Class lifeboat BS Einar Sigurjónsson, a life raft and from the water at a training area about 8 minutes from their base at Reykjavik’s domestic airport. The RNF say that: …arriving at the training area, the aircraft was flown in a standard pattern at 200 feet and 60 knots IAS and then descended to 100 feet and 20 knots IAS. When the training session began, the aircraft was hovered at 45-50 feet and 0-5 knots GS. At this time a power check was made and the pre-hoist checklist was completed. According to the commander’s statement, all parameters were normal and the torque was approximately 85%. The commander announced to the crew that the aircraft was in Class 3 performance and the aircraft would be ditched in case of an engine or tail rotor failure. The aircraft was operating in a light wind (10 knots) and at ISA-1 (14°C).  Being Performance Class 3 (PC3) highlights the risk of conducting live winching on an aircraft with limited One Engine Inoperative (OEI) performance. While in the hover at 45 feet, the crew commenced an operation to winch a rescue litter down to the lifeboat. About 3 seconds after the line was free from the litter the low Nr [main rotor speed] horn started to sound… [and]…the crew noticed a power loss followed by a reduction of Nr. The PF [Pilot Flying] directed the aircraft away from the ship and scanned the caution warning panel for warning lights but saw none lit. The PNF [Pilot Not Flying] looked at the Nr indicator and determined it to show Nr between 300 and 330 (Normal Nr is 355) rpm and the aircraft was losing altitude. About 10 seconds after the horn first sound, the crew deployed the floats and 7 seconds after that made a controlled ditching in water estimated to be Sea State 2-3. …the crew retarded the fuel flow control lever (FFCL) in order to shut off the engines. The pilot reported that when shutting off the right hand engine the engine seemed to be already on low rotation speed. The crew then stopped the main rotor by applying the rotor brake and then cut the hoist wire. After a short briefing the crew shut the battery off as well as the gyros.  The crew then evacuated the aircraft through the right hand sliding door and swam to a boat from BS Einar Sigurjónsson. The RNF note the evacuation was a surprisingly unhurried 4 minutes after ditching.  The floats had inflated correctly however the crew noticed when they evacuated that that the front floats were rubbing against the pitot tubes and shortly after the forward chamber of the right hand front float deflated. The aircraft capsized approximately 18 minutes after ditching. The Safety Investigation The helicopter was fitted with a Cockpit Voice Recorder (CVR), though not a Flight Data Recorder (FDR).  Acoustic analysis of he CVR showed that one...

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Falcon 7X LOC-I Due To Solder Defect

Posted by on 1:49 pm in Accidents & Incidents, Business Aviation, Design & Certification, Safety Management

Falcon 7X LOC-I Due To Solder Defect On 25 May 2011, Dassault Falcon 7X business jet, HB-JFN, operated by Jet-Link, suffered a pitch trim runaway that caused a 40° pitch up, rapid climb and temporary Loss of Control Inflight (LOC-I) over Malaysia. First flown in 2005 and certified in April 2007, after a 590 flight, 1600 flying hour test programme, the 7X features a fly-by-wire (FBW) control system.  This Digital Flight Control System (DFCS) and the Falcon family’s EASY (Enhanced Avionics SYstem) flight deck design draw on Dassault’s 30 years of military fighter experience, especially its Rafale and Mirage 2000. The type had accumulated 75000 flying hours at the time of the incident. The French Bureau d’Enquêtes et d’Analyses (BEA), to whom the investigation was delegated, has now reported (in French) on this serious incident (commenting that the long duration was necessary to examine the organisational factors). The Incident Flight While descending through 13000 feet at the end of a positioning flight to Kuala Lumpur, over 15 seconds the elevator pitch trim began to move from neutral to the full nose-up position. The First Officer (Pilot Flying), a former military pilot with experience on Mirage IV and Mirage 2000, put the aircraft into a steep right-hand bank to aid recovery partially replicating the ‘palier-ressource’ military manoeuvre (which involves approaching a target in level flight before pulling up at 30° pitch to release the weapon, and then banking to 90° to reduce pitch and escape). At two points (for 9 and 12 seconds) both the Commander (Pilot Non-Flying) and the First Officer were simultaneously using their side stick.  The First Officer used the priority button to override the Commander’s inputs and asked him to stop.  The pitch subsequently decreased, as did the load factor (from a maximum of 4.6 g to less than 1.5 g). After about 2.5 minutes the crew regained control and landed safely. The aircraft had however climbed to 22500 feet. Immediate Response The incident prompted such concern that the next day that the European Aviation Safety Agency (EASA) published an Emergency Airworthiness Directive (EAD), prohibiting further flights by the Falcon 7X fleet until further notice.  A further Airworthiness Directive (AD), in two stages, permitted operations to resume with modifications and operational limitations.  A third AD with modifications and operational tests followed. The Safety Investigation The BEA found that a defective ‘cold’ solder joint at a pin of a component of the Horizontal Stabilizer Electronic Control Unit (HSECU) led this computer to sending erroneous signal to the actuator driving the horizontal stabiliser trim (HRT) and a simultaneous failures of monitoring channel which were not detected. The solder had not reached an adequate temperature because the board had acted as a heat sink, resulting in micro-cracking.  They highlight a similar, but unconnected case in 2007 (Airbus A321 I-BIXK that suffered a braking failure after similar solder defects in its Brakes and Steering Control Unit). A number of contributory factors are identified by the BEA.  One is the non-detection of the production fault.  They also comment on the HSECU supplier’s Failure Modes and Effects Analysis (FMEA) which was not suitably comprehensive.  They note that this FMEA was not subject to detailed review by the aircraft Type Certificate (TC) Holder.  The TC Holder’s System Safety Assessment (SSA) in accordance with 25.1309, being partly based on that FMEA, was therefore incomplete. The BEA also reference safety assessment lessons from an Australian Transport Safety Bureau (ATSB) report into an upset involving a A330 VH-QPA in 2008 (in that case not...

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UK CAA CAP1145 North Sea Helicopter Safety Two Years On

Posted by on 12:01 am in Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Survivability / Ditching

UK CAA CAP1145 North Sea Helicopter Safety Two Years On Not long after the fatal loss of Eurocopter AS332L2 G-WNSB of Sumburgh Airport, Shetland Islands on 23 August 2013 with 4 fatalities (AAIB Special Bulletin), the UK Civil Aviation Authority (CAA) launched an rapid review on offshore helicopter safety. That CAA Review resulted in the CAP1145 report (‘Safety review of offshore public transport helicopter operations in support of the exploitation of oil and gas’), issued two years ago on 20 February 2014. Last year the CAA issued CAP 1243, the Offshore Helicopter Review Progress Report, which provides an update on the 10 months to 31 Dec 2014.  The minutes of the 16 October 2015 meeting of the Offshore Helicopter Safety Action Group (OHSAG) suggest the next CAP1145 progress report is due in April 2016. When they refreshed their website in late 2015 the UK CAA introduced a blog section with the opportunity for public comment and questions.  This includes one on offshore helicopter operations, which has had the most interaction to date (on two topics we have previously written about certified sea states limits and CA-EBS training). UPDATE 24 September 2016: The UKCAA has issued CAP1386, their second update on CAP1145.  We have summarised that report. UPDATE 1 February 2017: An update of BARSOHO (Version 3), fully aligned with the HeliOffshore SPM, is now available. Aerossurance is pleased to be supporting both HeliOffshore and the Flight Safety Foundation in their work to improve offshore helicopter safety. UPDATE 6 March 2017: HSS3b is issued (initially in Norwegian, with an English Exec Summary).  It features comment on CAP 1145 and survivability matters. UPDATE 23 January 2020: Without fanfare UK CAA publish CAP 1877: Safety Review of Offshore Public Transport Helicopter Operations in Support of the Exploitation of Oil and Gas Aerossurance is an Aberdeen based aviation consultancy.  For expert advice you can trust on offshore helicopter safety, survivability, safety assurance, safety culture and contracting matters, contact us at enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...

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US Helicopter Accident Rate Analysis

Posted by on 12:01 am in Accidents & Incidents, Helicopters, Safety Management

US Helicopter Accident Rate Analysis Aerossurance recently looked at US Helicopter Emergency Medical Service (HEMS) accident data for the last 10 years and has also examined accident rates in Gulf of Mexico (GOM) oil and gas operations.  We thought we would also look at published accident rates for all US helicopters and demonstrate the effects of choosing different start dates and different trending methods. To look, initially, at performance during the 21st century we choose to use data from the International Helicopter Safety Team’s (IHST‘s) US regional team, the US Helicopter Safety Team (USHST).  This is topical as this data has recently been discussed in a magazine article: What We Don’t Know Has Hurt Us.  We then take a take a longer historic perspective back to 1970. US Helicopter Fatal Accident Rates  2001-2015 In October 2015 the USHST published data for 2001-2015 (with the latter being a part year estimate) for fatal helicopter accidents per 100,000 flying hours. We’ve plotted this data (excluded the partial 2015 results) and added a linear trend line (i.e. a best-fit straight line): This shows an impressive improvement over the period.  But what if we apply a rolling (or moving) average?  A rolling average smoothes fluctuations to show a pattern or trend more clearly.  If we choose a three year rolling average (i.e. we plot data based on the average of the last 3 years) then the results look very different: Here the poor start to the data set in 2001-2003 dominates the early rolling averages but in more recent years the data, while fluctuating, has essentially plateaued.  Similar results are evident in 2 or 5 year rolling averages are selected. If we were to choose a different start point, say 2006, the first year after the IHST was created, and revert to a linear trendline the results are even more dramatic: Almost no change in fatal accident rate over 9 years is evident. If we use a 3 year rolling average: Here the rolling average has risen in recent years, very different to the liner trend. US Helicopter Accident Rates  2001-2015 In October 2015 the USHST also published data for 2001-2015 for helicopter accidents (fatal and non-fatal) per 100,ooo flying hours.  Unfortunately 2001-2005 is presented only as an average: You will note that the USHST compare 2015 performance with the baseline 5 year average for 2001-20o5 (a 55% improvement).  The 2015 data is however only 20% better than 2006. We can plot average data for 2001-2005 and annual data for 2006-2014 (again ignoring the partial data for 2015) with a linear trend: This shows a dramatic (over 50%) improvement.  However, if we use a 3 year rolling average: Here, although the trend reduces during the middle part of the last decade, in recent years the rate has again essentially plateaued. If we focus just on 2006 onwards and apply a linear trend: A modest improvement is evident over the period. If we apply a 3 year rolling average: Very little improvement is now evident. US Helicopter Accident Rates  1970-2013 To take a more historic perspective we have take data from the Helicopter Association International (HAI).  There website contains data from 2001 to 2013 (we have taken the most recent record for each year to allow for any revisions as any new, mostly usage data, has emerged).  In the Aerossurance achieves we have HAI published data back to 1970. This data is generally...

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First Eleven: Guidance for Designers on Maintenance Human Performance

Posted by on 10:59 pm in Design & Certification, Fixed Wing, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

First Eleven: RAeS Guidance for Design Organisations on Maintenance Human Performance The Royal Aeronautical Society (RAeS) Human Factors Group: Engineering (HFG:E) has published a short guidance document on 11 steps an aviation Design Organisation (DO) can take to “deliver safer, more effective and reliable aircraft through improved design for maintenance”. The RAeS say: Aircraft safety and in‐service maintenance performance can be significantly improved through integrating maintenance Human Factors (HF) principles into aircraft design… Research shows that many aircraft incidents and accidents are caused or contributed to by maintenance errors that are induced or aggravated by aircraft design and technical documentation. Improved, user‐centred design and documentation reduces maintenance error and its consequences. Many DOs already recognise…their products can be improved through applying HF principles to reduce in the probability and consequences of maintenance errors, reduce lifecycle costs and improve operational reliability / availability. However, research by the HFG:E suggests that identifying practical steps to realise these benefits remains a significant challenge for many DOs. Consequently, the ‘First Eleven’ guidance was developed over several years of engagement with DOs, air accident investigators and regulators to be a practical series of steps for a DO to fully integrate the best practices for maintainer-centric design. A First Eleven gap analysis is a practical way to identify opportunities for improvement.  The RAeS say: These are the ‘First’ Eleven because striving for enhanced maintenance human performance should be a continuously evolving process. The full guidance document can be found here. Aerossurance is pleased to have sponsored the RAeS HFG:E conference on 12 May 2015 at Cranfield University on Human Factors in Engineering – the Next Generation (as well as its staff actively participating in the HFG:E since 2005). We see the First Eleven as one way that DOs can contribute to next generation solutions that enhance maintenance human performance. Aerossurance is pleased to support the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 7-8 November 2016.  Our presentation will discuss the importance of HCD. UPDATE 2 March 2018: An excellent initiative to create more HCD by use of a Human Hazard Analysis (HHA) is described in Designing out human error HeliOffshore, the global safety-focused organisation for the offshore helicopter industry, is exploring a fresh approach to reducing safety risk from aircraft maintenance. Recent trials with Airbus Helicopters and HeliOne show that this new direction has promise. The approach is based on an analysis of the aircraft design to identify where ‘error proofing’ features or other mitigations are most needed to support the maintenance engineer during critical maintenance tasks. The trial identified the opportunity for some process improvements, and discussions facilitated by HeliOffshore are planned for early 2018. A systems approach in healthcare: UPDATE 24 October 2022: The Royal Aeronautical Society (RAeS) has launched the Development of a Strategy to Enhance Human-Centred Design for Maintenance.  Aerossurance‘s Andy Evans  is pleased to have had the chance to participate in this initiative. Aerossurance has extensive airworthiness, design assurance, certification, maintenance error management and human factors experience.  For professional design / maintenance HF support you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...

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Safety Data Silo Danger – Data Analytics Opportunity

Posted by on 12:01 am in Accidents & Incidents, Safety Management

Safety Data Silo Danger – Data Analytics Opportunity We recently enjoyed reading The Silo Effect by Gillian Tett.  Tett, who has a PhD in social anthropology, is a journalist and senior editor for the Financial Times.  Some organisations are, often by design, divided into silos (by project or by functional specialism).  Silos however can restrict who we talk to and how we share information.   Such ‘structural secrecy’ was noted by sociologist Prof Diane Vaughan in her examination of the disastrous NASA Space Shuttle Challenger launch decision. Tett (who discusses her work in this podcast) argues that the observational discipline of anthropology can also identify the unspoken silos within a organisation (as well as society as a whole).  From a safety perspective the most interesting case study comes in the book’s introduction, a case study that is less about anthropological observations and more about data collation and analysis. Fighting Fire with Data On 25 April 2011 a fire a 2321 Prospect Avenue in the Bronx claimed three lives.  The property had been “illegally subdivided, leading city officials to pledge a crackdown on a practice that can impede fire-fighters and imperil lives” in the resulting furore. New York City had a team of building inspectors and they were not short of complaints to investigate.  Each year they received 20,000 complaints on the nearly 1 million buildings and 4 million properties in their remit via the city’s 311 phone line (which receives 30,000 calls on a host of topics every day).  However, only 13% of those complaints when investigated wre valid, wasting time and limited resources. Another city department, the fiercely independent New York Fire Department (NYFD) had overlapping duties and its own data, effectively an inaccessible silo, but key data turned out to be split between many city departments and databases. In May 2011 New York City Mayor Michael Bloomberg appointed Mike Flowers to head a new Mayor’s Office of Data Analytics (MODA) and create what some have called ‘The Mayor’s Geek Squad’ of data analysts.  They started to develop a way to use data from multiple sources (not just Dept of Buildings and NYFD data) to prioritise attention on the most probable reports of illegal conversions.    Flowers said: Before we started, we didn’t know what we knew. The analysts did more than look at data.  They spent time with building inspectors and fire-fighters to understand more about illegal conversions and fires. Flower’s explains that what they then did was: …come up with a way to prioritize those [complaints] which represent the greatest catastrophic risk… In doing that, we built a basic flat file of all 900,000 structures in the city of New York and populated them with data from about 19 agencies, ranging from whether or not an owner was in arrears on property taxes, if a property was in foreclosure, the age of the structure, et cetera. Then, we cross-tabulated that with about five years of historical fire data of all of the properties that had structural fires in the city, ranging in severity. After we had some findings and saw certain things pop as being highly correlative to a fire, we went back to the inspectors at the individual agencies, the Department of Buildings, and the fire department, and just asked their people on the ground, “Are these the kinds of conditions that you see when you go in post-hoc, after this catastrophic event? Is this the kind of place that has...

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EC130B4 Accident: Incorrect TRDS Bearing Installation

Posted by on 12:01 am in Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

EC130B4 Accident: Incorrect TRDS Bearing Installation The Accident Investigation Board Norway (AIBN) has recently reported on a serious incident involving Airbus Helicopters EC130B4 LN-ORR, operated by Helicopter Utleie (now trading as Fjord Helikopter) on 12 August 2014 when arriving at Rørvik Airport for refuelling. The Incident As the helicopter passed over the runway threshold at about 15-30 feet the helicopter started to yaw to the left: The commander quickly understood that he had no directional control, and chose to land the helicopter without engine power. The helicopter rotated twice around its own axis before it was landed on the runway. No injuries or damage occurred. AIBN say: The reason it did not have more serious consequences was because the commander quickly figured out that the tail rotor was not functioning, and he made the right decisions. …it was decisive for the outcome that the incident occurred over a flat surface. Had the tail rotor shaft fracture occurred at a less favourable moment, and over rugged terrain, the outcome of the incident could have been fatal. The Technical Investigation and Analysis An examination revealed that the riveted joint just behind the tail rotor drive shaft (TRDS) no. 1 bearing had fractured. The bearings on the TRDS had been replaced during scheduled maintenance 98 flying hours prior to the incident.  AIBN say: It became evident that the position of the bearing in relation to the shaft did not comply with the Aircraft Maintenance Manual (AMM) requirements. The measured discrepancy was approximately 1 millimetre, whereas the maximum permitted value in the AMM is 0.1 millimetre. Lab examination showed the rivet holes had deformed and the six rivets had become worn over time. When the rivets came loose gradually, the load increased to such a point that fatigue fractures occurred in some of the rivet holes on the shaft. There were also signs of a ductile fracture in one of the rivet holes. Lab examination of the bearing “showed that the bearings balls had made an abnormal track in the outer race”. AIBN asked the technician who installed the bearing to demonstrate the measurement method for verifying the bearing’s position in “Bearing drive/Bearing flange”. The measurement demonstrated to AIBN did not comply with the method described in the helicopter’s AMM. The aircraft technician had worked alone on Helikopter Utleie’s helicopters for many years. Without having a community of colleagues for support, there may be a risk of developing sub-standard working methods. The technician, from a contracted Part 145 (see below), had incorrectly used the tailboom structure as the reference not the TRDS itself.  The AIBN state the specific AMM task was “was fully understandable”.  With condor and proactivity: Airbus Helicopters… concluded that the measuring method and adapter to attach the dial gauge to the tail rotor shaft should be emphasised more clearly in AMM, so there is a greater degree of reproducibility of the measurement results when replacing bearing no. 1. AIBN established that the bearing installation had not been subject to an Independent Inspection by a second person. The work on LN-ORR was carried out at the helicopter company base in Stryn. The technician carried out this work alone. In a best case scenario, he would have inspected his own work. This would have been an inspection based on his personal understanding of the procedure in AMM, which was incorrect as regards installation of bearing...

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Troublesome Tiedowns

Posted by on 12:01 am in Accidents & Incidents, Airfields / Heliports / Helidecks, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Safety Management

Troublesome Tiedowns The US National Transportation Safety Board (NTSB) has recently reported on two cases in October 2015 were helicopters offshore suffered accidents after the tie-downs were not fully removed: Fish Spotting Helicopter, Pacific Ocean (B206, N1060C) On 21 October 2015 Bell 206B N1060C was being prepared for take-off from the 74m Fishing Vessel Majestic Sun off Christmas Island, Kiribati in the Pacific for a fish spotting flight.  The NTSB say: The pilot of the helicopter reported that he entered the helicopter for takeoff while the mechanic removed the tie downs from the helicopter. The pilot reported that when he tried to takeoff, one of the [four] tie downs was still attached to the helicopter and the helicopter rolled to the right and impacted the helipad. The helicopter sustained substantial damage to the main rotor, mast, and tail boom. In this case it appears that the tie downs were applied to the floats and were removed after the pilot boarded the helicopter (not unreasonable for operation on a small moving deck). Oil and Gas Helicopter, Gulf of Mexico (PHI B407 N420PH) On 30 October 2015, N420PH, a Bell 407 of PHI, lost most of one rotor blade in an accident on an offshore installation in the Gulf of Mexico (WC167). The operator reported that: …the pilot and aircraft began the operational day at High Island A 264, an offshore platform located in the Gulf of Mexico. The pilot began his duty day at 06:25 CST. At 08:07 the aircraft departed the platform with the pilot and one passenger onboard destined for another offshore location, West Cameron 149 arriving at 08:41. The pilot dropped off his passenger and flew the aircraft with no passengers to another offshore location; West Cameron 167 arriving at 08:51 . The pilot shut down the aircraft and secured the main rotor system by attaching a rope to the forward left main rotor blade and tying the rope end to the left front skid cross tube. He then went inside the platform facility for slightly over 3 hours while waiting for a call to return to West Cameron 149 to pick  up the passenger. The pilot received a call at approximately 12:15 instruction him to return to West Cameron 149 to pick up the passenger for further transportation as directed. The pilot went to the platform helideck were the aircraft was located and proceeded directly to the right-rear cabin door and placed his personnel bag in the aircraft. He then moved to the right-front cockpit door and placed additional personnel items in the aircraft in preparation for flight, then entered the aircraft using the same door and sat in the right-front pilot seat. He then proceed to start the aircraft and noted a few seconds after initiating the engine start the aircraft make an “unusual noise” and began to shake. He immediately secured the engine and completed aircraft shutdown. Upon exiting the aircraft he found one main rotor blade damaged by the rotation of the main rotor system with the tie down attached during the engine start. The NTSB comment: The Bell Helicopter 407 Rotorcraft Flight Manual lists the preflight check areas in Section 2 Normal Procedures. Regarding the exterior check, this manual states in part; 2-3-B-1. Fuselage – Cabin Right Side 1. All main rotor blades – tiedowns removed, condition. There is also a warning in this section that states, “Failure to remove...

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