A319 Double Cowling Loss and Fire – AAIB Report
A319 Double Cowling Loss and Fire – AAIB Report The UK Air Accidents Investigation Branch (AAIB) has published their report into an Airbus A319 that lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow in 2013. We look at the circumstances of the previous evening’s maintenance on this aircraft, which has lessons for other operators and maintenance organisations. In particular, we look at the maintenance human factors that resulted in the cowlings being left unlatched, including an aircraft ‘swap-error’ and maintainer fatigue / alertness. We had previous discussed the series of incidents with the A320 family cowlings and planned design improvements, in this article: Maintenance Human Factors: The Next Generation. The Accident At 07:16Z on 24 May 2013, British Airways A319 G-EUOE, powered by IAE V2500s, departed runway 27L at London Heathrow. At rotation, the fan cowl doors from both engines detached, damaging the airframe and puncturing a fuel pipe on the right-hand (or Number 2) engine. The flight crew observed: engine thrust control degradation, the loss of the yellow hydraulic system, and a significant fuel leak. They declared a PAN, with the intention of returning to Heathrow once they had fully assessed the situation using the T-DODAR (Time, Diagnose, Options, Decide, Act/Assign, Review) philosophy. During the approach to land on runway 27R, a fire developed on the right-hand engine and the crew declared a MAYDAY. Both engine fire extinguisher bottles were discharged and the right-hand engine was shut down (albeit without the normal crew cross-check). The intensity of the fire reduced but it did not abate. The other engine continued to perform normally. The aircraft landed safely at 07:45Z, coming to rest on the runway where the airport fire service extinguished a small fire on the right-hand engine. The 80 persons on board evacuated in 64 seconds without injury using the left-hand escape slides. There had been a short delay to evacuation however as the left-hand engines had been left running. The Investigation The AAIB determined that both engine fan cowlings had been left unlatched after maintenance the previous evening and this that was not spotted prior to take-off. The investigation identified the following causal factors: The technicians responsible for servicing the aircraft’s [Integrated Drive generators] IDGs did not comply with the applicable [Aircraft Maintenance Manual] AMM procedures, with the result that the fan cowl doors were left in an unlatched and unsafe condition following overnight maintenance. The pre-departure walk-around inspections by both the pushback tug driver and the co-pilot did not identify that the fan cowl doors on both engines were unlatched. The investigation identified the following contributory factors: The design of the fan cowl door latching system, in which the latches are positioned at the bottom of the engine nacelle in close proximity to the ground, increased the probability that unfastened latches would not be seen during the pre‑departure inspections. The lack of the majority of the high-visibility paint finish on the latch handles reduced the conspicuity of the unfastened latches. The decision by the technicians to engage the latch handle hooks prevented the latch handles from hanging down beneath the fan cowl doors as intended, further reducing the conspicuity of the unfastened latches. Maintenance Aspects – Introduction The AAIB report (both in the main body and Appendix 6, written by...
read moreUK CAA Helideck Developments
UK CAA Helideck Developments The UK Civil Aviation Authority (CAA) are considering changing how offshore helidecks are approved and assessing the fire-fighting provision on Normally Unattended Installations (NUIs). The former activity is subject to a public consultation and that latter is being examined by a Offshore Helicopter Safety Action Group (OHSAG) working group. Helideck Qualified Entities In the UK CAA’s review of offshore helicopter operations, CAP 1145, issued in February 2014, Action A13 in Chapter 14 was raised as the CAA had the intention to assume responsibility for the certification of UK helidecks (originally with a target of ‘delivery in Q1/2015’). The helidecks are currently inspected against CAP437 by the Helideck Certification Agency (HCA) who is contracted to do this by the UK operators. A consultation (based around proposals in CAP1295) is currently being undertaken. This consultation is open for public comments until 24 July 2015. CAP1295 describes how CAA could empower one or more Qualified Entities to act on behalf: The proposal would be for CAA to underwrite a qualified entity’s approvals system by issuing an operational directive under article 15 of the [Air Navigation Order] ANO (and article 6(4) of the Air Operations Regulation 965/2012) requiring helicopters operating to offshore installations and vessels on the UKCS only to do so if facilities have been approved /certificated by a Qualified Entity (or Entities) acting on behalf of the NAA (UK CAA). We predicted the CAA would consider the Qualified Entity approach, as used in the Unmanned Air System sector, a year ago. The CAA believe their proposals address ‘the perceived weaknesses of the present system’. In particular, by also providing a mechanism for grading non-compliances, which they describe as a ‘Helideck MEL’, backed by a: …legal directive whereby CAA (and their agent(s)) is [sic] empowered to prevent an operation should, in the opinion of the CAA and / or the qualified entity, the helideck fail to achieve a minimum level of compliance i.e. if it is deemed unsafe to continue operations. UPDATE 5 October 2015: The CAA have stated they received 20 responses: These responses are being used to assist in the determination of the next steps to address CAP 1145 Action item A13. It is anticipated that an update on progress will be communicated by the end of 2015. NUI Fire-fighting In April 2015, after the last OHSAG meeting, UK CAA also announced a set of proposals aimed at improving the safety of helicopter operations to the 116 NUIs on the UK Continental Shelf (UKCS). The CAA say they build upon an independent report commissioned by CAA in mid-2014 from Cranfield University, but not as yet made public by CAA. These CAA proposals effectively supersede Recommendations R8 and R9 in Chapter 10 of CAP1145 (which originally had a target of ‘delivery in Q3/2014’). The CAA say: These proposals will be taken forward on a very short timescale by a joint industry working group, featuring the CAA, helicopter operators, offshore industry and pilot union representatives. Health and Safety Executive has also been invited to participate. The work will focus on addressing the risk posed by fire following any incident involving a helicopter on the helideck of a normally unattended installation, where there may be no one on the rig to assist in fire suppression. The CAA say their proposals “either individually, or collectively, will meet the requirement to increase safety and survivability” and...
read moreDuPont Reputational Explosion
DuPont Reputational Explosion Chemical company DuPont (E.I. DuPont de Nemours & Co Inc.) has been feted for its safety performance for many years (for example winning the National Safety Council‘s 2013 Robert W. Campbell Award). Its reputation in the field of safety stretches back to the founding of the company as a gunpowder manufacturer in 1802. This is one that the company also exploits through a consultancy division selling safety and operational excellence services to other organisations. However, that reputation has been blasted by federal agencies after a series of fatal accidents. La Porte Accident On 15 November 2014, a worker was overcome at a DuPont chemical manufacturing facility in La Porte, Texas when a supply line unexpectedly released around 20 tonnes of methyl mercaptan. Three colleagues came to the worker’s aid but all four were asphyxiated by the flammable and highly toxic gas. The independent investigation into that accident is still on-going by the US Chemical Safety Board, but in February 2015 the CSB made an interim statement that identified serious process safety shortcomings: The process included several interconnections between the methyl mercaptan supply line and a chemical vent system, which allowed a toxic leak into an unexpected location… The chemical vent system…had a design shortcoming that allowed liquid to accumulate inside…The liquid needed to be manually drained by operators to prevent safety issues from interconnected equipment, such as reactors. …workers were exposed to whatever chemicals were drained from the vent system. The building was designed in such a way that even had ventilation fans been working on the day of the accident, it would likely not have effectively protected workers from chemical exposure. …those ventilation fans were not, in fact, working at the time of the accident. The Regulator’s Response Last week it was reported that: Just weeks after blasting DuPont for safety violations following a deadly chemical plant incident last November, federal regulators now say the chemical manufacturing giant’s problems reach even further than they originally thought. The U.S. Occupational Safety and Health Administration [OSHA] on Thursday slapped DuPont with a $273,000 fine for safety violations at its plant in La Porte. That’s on top of fines issued in May stemming from last year’s tragedy, when a toxic chemical leak killed four workers. OSHA issued citations to DuPont for what they claimed were: …three willful, one repeat and four serious violations at their chemical manufacturing plant in La Porte. The agency has proposed penalties of $273,000 for these new violations. The issues cited included lack of procedures, inadequate inspections and weak hazard analysis. DuPont was previously cited at their Darrow, Louisiana facility in November 2014 and Deepwater, New Jersey facility in December 2014 for similar process safety management violations. OSHA has also placed the company in its Severe Violator Enforcement Program. DuPont’s website contains no reaction to the OSHA fines, although they do have 15 days to contest them. The last DuPont press release on the La Porte accident was issued two days afterwards, on 17 November 2014, promising further (yet to materialise) updates. One newspaper reported that DuPont has said “it has not had the chance to fully review the latest findings” but is “disappointed with OSHA’s classification”. Comments by CSB on this and Two Previous Fatal Accidents Rafael Moure-Eraso, Chairperson of the CSB said in February 2015: This is my fifth and final year serving...
read moreHelicopter Underslung Load: TV Transmitter
Helicopter Underslung Load: TV Transmitter HESLO In 2014, RF communication infrastructure specialists, The Bridge Network North (now merged into Virtua), undertook a major engineering project at Arqiva’s Croydon TV Transmitter in South London, UK. Arqiva operate much of the UK TV and radio broadcast infrastructure. The project included the replacement of the 10 tonne, 16m, top antenna section on the 153m tower by as a Helicopter External Sling Load Operation (HESLO). A series of lifts were conducted on one day using an Airbus Helicopters AS332C helicopter of HeliSwiss in association with UK company Helirig. This fascinating 3 minute video gives an overview of the project. Also see our articles: What the HEC?! – Human External Cargo, Keep Your Eyes on the Hook! Underslung External Load Safety and French Skyscraper: Helicopter Underslung Load UPDATE 2 July 2020: Erickson videos: Aerossurance has extensive HESLO, helicopter flight operation, safety and contracting experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreMetro III Low-energy Rejected Landing and CFIT
Metro III Low-energy Rejected Landing and CFIT The Transportation Safety Board of Canada (TSB) has issued a report on a fatal accident to Fairchild SA227-AC Metro III, C-GFWX, operated by Perimeter Aviation at Sanikiluaq, Nunavut, on the coast of Hudson Bay on 22 December 2012. The route from Winnipeg is normally operated by sister company Keewatin Air, but Perimeter were chartered to help catch-up a backlog due to poor weather. According to the TSB: Following an attempted visual approach to Runway 09, a non-precision non-directional beacon (NDB) Runway 27 approach was conducted. Visual contact with the runway environment was made and a circling for Runway 09 initiated. Visual contact with the Runway 09 environment was lost and a return to the Sanikiluaq NDB was executed. A second NDB Runway 27 approach was conducted with the intent to land on Runway 27. Visual contact with the runway environment was made after passing the missed approach point. Following a steep descent, a rejected landing was initiated at 20 to 50 feet above the runway. The final, tailwind, approach had been unstable. The TSB determined: …that the aircraft came in too high, too steep, and too fast, striking the ground 525 feet past the end of the runway after an unsuccessful attempt to reject the landing. The 2 crew and 6 adult passengers, secured by their seatbelts, suffered injuries ranging from minor to serious. A lap-held infant, not restrained by any device or seatbelt, was fatally injured. At a news conference on release of the report, investigators said inclement weather, poor visibility, fatigue and a departure from established protocols all played a part in the accident. As the company did not normally fly this route there had been problems obtaining approach plates and survival kits (which were to be borrowed from their sister company). These problems and a defective cargo door indication delayed departure. The TSB commented: The captain felt frustrated as a result of the pre-flight preparation issues, and it is evident from analysis of his speech that signs of frustration persisted after takeoff. The captain’s use of 43 expletives in conversation with the first officer (FO) during the non emergency, non stressful, 2-hour period preceding the occurrence, showed a rate of approximately 21.5 swear words per hour. This type of behaviour was seen as being out of character for the captain. They added that circadian rhythm, the long day and a 1.5 hours wake period in his previous nights sleep mean… …acute sleep disruption may have played a role in the captain’s behaviour during the flight by increasing the risk for fatigue and its associated performance decrements. Two recommendations were issued in relation to the carriage of infants. The airline issued a statement on their actions after the accident. TSB Causes and Contributory Factors The lack of required flight documents, such as instrument approach charts [NOTE: they had been inadvertently forgotten], compromised thoroughness and placed pressure on the captain to find a work-around solution during flight planning. It also negatively affected the crew’s situational awareness during the approaches at CYSK (Sanikiluaq). Weather conditions below published landing minima for the approach at the alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL (La Grande Rivière) eliminated any favourable diversion options. The possibility of a successful landing at CYGW was considered unlikely and put pressure on the crew to land at CYSK (Sanikiluaq). Frustration, fatigue, and an increase in workload and...
read moreCHC FY2015 Results & Restructuring
CHC FY2015 Results & Restructuring On 29 June 2015 CHC Group (NYSE: HELI), the parent company of CHC Helicopter, reported on Fiscal Year 2015 (to end April 2015). The headlines are: Full-year revenue down 3% to $1.7 billion with a net loss of $795 million (compared to $1.78 billion and a net loss of $171 million in FY2014). Q4 revenue of $374 million and a net loss of $119 million (compared to $453 million and a net loss of $26 million in Q4 FY2014). Restructuring charge of $77 million booked in Q4 in response to the oil and gas industry downturn. Adjusted EBITDAR excluding special items down 2%. $320 million of long-term debt retired in FY2015; annualized interest expense reduced about $30 million. New $145 million asset-backed loan facility which it was stated will provide additional financial flexibility. Full year GAAP net loss per share of $11.17; adjusted EPS loss of $1.82. On 30 June 2015 the company staged an investor webcast with new CEO Karl Fessenden and outgoing CFO Joan Hooper and an accompanying presentation. The annual filing to the Securities and Exchange Commission (SEC), the 10K, is due later this week. Safety The 5 year rolling accident rate is 0.38 per 100k flying hours, unchanged since last year (see presentation page 4). A footnote states this data includes G-CHCN in 2012 and G-WNSB in 2013. While total flying hours in the period are not disclosed, based on recent SEC filings, CHC has been flying an average of about 160k FH per annum, so 0.38 equates to 3 accidents. There was also a ramp accident to VH-LAG in 2011. CHC has made what would, traditionally, have been a sensible choice and compared their performance to the last IOGP (formerly known as OGP) aviation report (1.8 per 100k FH for all offshore helicopters and 0.8 per 100k FH for twins). Unfortunately, while for many years IOGP produced annual reports on aviation accident rates in the oil and gas sector, the last IOGP report was published in 2009, and covers data up to the end of 2007. So their 5 year average covers the truly dreadful year of 2003 through to 2007 but nothing more recent. It is disappointing that current safety benchmark data is not currently available in the public domain. There is other data that could be used in comparison. For example from the Helicopter Safety Advisory Conference (HSAC) for the Gulf of Mexico, which we have discussed recently, where the accident rate for 2010-2014 was 1.22 per 100k FH and the dreadful UK performance of 1.62 per 100k FH from the Feb 2014 UK CAA CAP1145 report for 2008-2012 (combining flight hours from Annex C Table C6 and the 6 accidents from Appendix 1 to Annex C). However, neither is an ideal comparison baseline for a global helicopter company. CHC was a founder member of industry safety organisation HeliOffshore, along with Babcock, Bristow, ERA and PHI. HeliOffshore held their inaugural conference in May. Operational and Financial Data Aircraft availability (of operational aircraft not undergoing scheduled maintenance) has improved (page 8). In FY2014 it slowly increased from a poor 82% up to 90% and has been pretty consistent at around 94% in FY2015. CHC do not state what proportion of their fleet is operational. In early remarks there was positivity about the Operations Control Centre in Dallas and IT standardisation initiatives but also for a change so that...
read moreHelicopter Ops and Safety – Gulf Of Mexico 2014
Helicopter Ops and Safety – Gulf of Mexico 2014 The Helicopter Safety Advisory Conference (HSAC) has been publishing data on the Gulf of Mexico (‘GOM’) offshore helicopter fleet and its safety since 1995. Helicopter Operations: GOM Fleet Data They report that flying activity has remained “relatively constant” for the last several years, with just under 300k flying hours, using 415 helicopters, operated by 13 companies in 2014 (the big three are Bristow, ERA and PHI, with RLC strong in the single engine sector). However, flying hours, passenger numbers and flights have dropped by 11-12% over the last 5 years. The drop is even more significant since the peak of 2008 (30%, 28% and 40% respectively). The number of single engine helicopters continues a “slow decline”, down 14% since 2010, 26% since 2008 and 37% since 2005. In fact, in 2005, the single engine fleet was 424, more than the total for all types in the current GOM fleet. This perhaps is indicative of the economic decline in the small ageing coastal fields. The number of heavy twins (mainly Sikorsky S-92As and with a few Airbus Helicopters H225s) however has doubled in the last 5 years, trebled in the last 10 and increased 8.6 fold since 1997, as more deepwater exploration and production has occurred (as demonstrated by the last few seconds of the animated map below, a 2008 MMS report and a deepwater field status listing). Between 2013 and 2014 there was also a noticeable 21% drop in the number of medium twins. However flying hours dropped by just 3%, suggesting the GOM operators have retired many of the older aircraft, Sikorsky S-76As in particular, and are now achieving higher utilisation. In fact in 2014 the average utilisation was: Single engine – 590 flying hours (average 20 minute sector length) Light twin – 441 flying hours (average 17 minute sector length) Medium twin – 794 flying hours (average 38 minute sector length) Heavy twin – 805 flying hours (average 36 minute sector length) The medium / heavy twin usage per aircraft is approximately 20% less that the average for the UK North Sea fleet. Helicopter Safety GOM There were just two accidents in 2014 using NTSB data (one fatal, with two fatalities). There were however also two ditchings in 2014, both due to loss of engine power. These were not recorded as accidents by the NTSB (as would have been the case in most other countries). Consequently, according to HSAC: The 2014 accident rate was 0.68 per 100k flying hours (or more correctly 1.35 counting all four occurrences) compared to a 31-year annual average accident rate of 1.74. The 2014 fatal accident rate was 0.34 per 100k flying hours compared to a 31-year annual average accident rate of 0.44. We covered the fatal accident last year in more detail. UPDATE 17 February 2016: Having completed a study of the US HEMS safety record we have also plotted HSAC data (including all ditchings as accidents), first back to the start of the start of the International Helicopter Safety Team (IHST) in 2006: Although there is year on year variability, no long term improvement is evident (and while the 3 year rolling average accident rate has dropped in recent years, the 3 year rolling average fatal accident rate has climbed). If we look over the full span that HSAC published data: Here a rise of accidents (but not fatal accidents) from the mid 1990s is evident, peaking in 2003, before...
read moreB767 Engine Fire – Ignition from Misrouted / Chaffed Cables
B767 Engine Fire – Ignition from Misrouted / Chaffed Cables The National Transportation Safety Board (NTSB) have reported on an engine fire that occurred on 11 July 2014 when: …Boeing B-767-332, registration number N139DL, operated by Delta Air Lines (DAL)… powered by two General Electric (GE) CF6-80A2 turbofan engines, experienced a left engine (No. 1) fire during climb at about flight level (FL) 190 (19,000 feet) from Los Angeles International Airport (LAX), Los Angles, California. The crew performed the appropriate fire drills and made a successful overweight landing at LAX. The Investigation Examination of the engine revealed that the fire damage was concentrated under the engine heatshield from about the 6:00 o’clock position to the 8:30 o’clock position (aft looking forward) and forward of the accessory gearbox. The fire and thermal distress included melted and consumed electric wire insulation, melted and consumed accessory gearbox fire loop isolators, melted and consumed tubing P-clamps, exposed electric wire conductors, and soot deposits. A fuel leak was detected from the integrated drive generator (IDG) fuel/oil heat exchanger main housing, which is located below the engine heatshield. Cracks were identified where the inner core was brazed to the main housing. Additionally: Removal of the IDG power feeder cables revealed evidence of chaffing and arc burn; this damage was not related to the fire damage that was observed overall as a result of the actual fire. .. the accessory drive lube and scavenge pump pressure (supply) line support bracket…exhibited evidence of melted material consistent with an arc burn. The location of the arc burn on the bracket was in-line with the arc burn observed in the IDG power feeder cables. The NTSB also note: …the IDG power feeder cables (below the engine heatshield) were not tight and straight along their support bracket but exhibited slack and dangling below the support bracket. …there should be no slack in the IDG cables; instead the cables should run straight and tight along its support bracket and gently bend upward towards the cutout hole in the engine heatshield. …the IDG power feeder cables also exhibited a considerable amount of orange tape to bundle all the cables together. This excessive slack in the IDG power feeder cables created the situation where the cables could get pinched/wedged between the inside of the thrust reverse cowl and the accessory drive lube and scavenge pump pressure (supply) line support bracket when the thrust cowl is closed and latched creating the environment for the IDG power feeder cables to chaff against the support bracket. They also observed that: The excessive amount of tape used on the IDG power feeder cables suggests that maintenance personnel may have noticed this chaffing and added extra tape without realizing that the chaffing was caused from the thrust reverser pressing the IDG power feeder cables against the bracket or that the slack was contributing to the chaffing. Conclusions The NTSB determined the Probable Cause was: The combination of fuel leaking from the integrated drive generator (IDG) fuel/oil heat exchanger and the coincident arcing of the IDG power feeder cables that ignited the leaking fuel. Contributing to the ignition of the fuel was the misrouting of the IDG power feeder cables, which resulted in chaffed cables that exposed the electrical wire that contacted a metal bracket, creating an arc. Safety Action Based...
read moreBristow 60
Bristow Celebrates 60 Years On 24 June 2015 Bristow celebrated being 60 years old. That was the anniversary of the incorporation of Bristow Helicopters Limited in 1955 by its founder Alan Bristow. The company has picked out some highlights of the company history: Alan Bristow formed Bristow Helicopters in 1955 after securing a contract to supply helicopter crews for Shell Oil Co. in the Persian Gulf. Bristow, a renowned aviator, led the company until 1985 and stayed involved until his death in 2009 at the age of 85. Bristow was on the scene from the first days of oil production in the North Sea. It was a pioneer on many aircraft types and an early advocate of safety and helicopter pilot training, establishing a major training facility at Redhill, England in 1960. Bristow began operations in Aberdeen, Scotland in 1967. Bristow began operations in Africa began operations in Africa in 1960 by acquiring Fison-Airwork, a crop-spraying company that also supported some of the first oil exploration work in Nigeria. Bristow continues to maintain a strong business presence in Nigeria, operating from six bases that mostly serve the offshore energy industry. Operations in the U.S. can be traced back to the launch of Offshore Logistics in 1969. As it grew over the decades, the company eventually purchased a 49-percent stake in Bristow Aviation Holdings Ltd. in 1996 to expand its operations into the North Sea. Offshore Logistics moved its headquarters to Houston in 2005 and took on the Bristow name in 2006. In 1971, Bristow began civilian search and rescue (SAR) services in the U.K. After a hiatus, it resumed serving the Maritime and Coastguard Agency in 1983 and most recently won a 10-year contract to provide SAR service across the country from 10 bases. Bristow also has SAR operations in Australia, Canada, Norway, Russia and Trinidad. In 2006, under the direction of then-President and CEO William Chiles, the company was rebranded as Bristow Group, creating a single brand under which the entire company would operate. The company also established its Core Values of safety, quality and excellence, integrity and teamwork, and its Code of Business Integrity, both of which remain in force today. Bristow launched its industry-leading Target Zero safety program in 2007. Target Zero is a long-term strategy to develop a culture of safety at all levels of the company and it remains the underpinning of Bristow’s successful safety culture today. Also in 2007, Bristow acquired Florida-based Helicopter Adventures Inc. and renamed it Bristow Academy with the mission to fulfil the company’s need for top-quality pilots as well as train pilots for other applications. The Bristow Group fleet is now over 500 aircraft worldwide. Flight International covered the company’s 25 anniversary with a special feature and interview with ‘the old man’. Perhaps unsurprisingly, as Bristow was known for having robust views, Flight International nervously felt obliged to offer a right to reply to a number of other organisations! Many other stories can be found in Alan Bristow – Helicopter Pioneer, completed just a week before he passed away. Bristow had previously formed his first company, Air Whaling in 1953 (not earlier as suggested in his Daily Telegraph obituary). This explains why, perhaps confusingly, the 50th anniversary was celebrated in 2003! See also Leading from the Front Bristow Helicopters: The First 50 Years. Trivia The company...
read moreScottish Court Orders Release of Sumburgh Helicopter CVFDR
Scottish Court Orders Release of Sumburgh Helicopter CVFDR A Scottish Court has ordered that the UK Air Accidents Investigation Branch (AAIB) release the combined Cockpit Voice and Flight Data Recorder (CVFDR) from a fatal 2013 AS332L2 Super Puma offshore helicopter accident at Sumburgh to prosecutors, who will use the Civil Aviation Authority (CAA) to “provide an expert opinion on the performance of the flight crew…during the accident flight”. In his judgement in the Court of Sessions in Edinburgh, Lord Jones stated that this would not form a precedent but that: …there is no doubt that the Lord Advocate’s investigation into the circumstances of the death of each of those who perished in this case is both in the public interest and in the interests of justice. The Accident On 23 August 2013 AS332L2 Super Puma G-WNSB impacted the sea on approach to Sumburgh Airport in the Shetland Islands. The CHC helicopter, chartered by Total, was making a 2 sector flight to Aberdeen from the Borgsten Dolphin drilling rig. The helicopter capsized and four passengers died, the first fatalities in a survivable water impact of a helicopter on the UK Continental Shelf since the Cormorant Alpha accident in 1992. This accident was at least partially responsible for triggered a number of initiatives and reports including: The Joint Operators Review (JOR) review and the formation of HeliOffshore. A CAA Review, which resulted in the CAP1145 report (‘Safety review of offshore public transport helicopter operations in support of the exploitation of oil and gas’). A House of Commons Transport Committee report on offshore helicopter safety. The AAIB have yet to issue their final report but they have issued three Special Bulletins: S6/2013 dated 5 Sept 2013 (basic initial information) S7/2013 dated 18 Oct 2013 (covered an overview of the evidence gathered, including an FDR trace, plus a recommendation on airport sea rescue capability) S1/2014 dated 23 Jan 2014 (contained a recommendation related to passenger briefing on emergency breathing systems) Legal Background Although part of the United Kingdom, Scotland has its own legal system, with distinct legal and organisational differences to the other UK jurisdictions. The Crown Office and Procurator Fiscal Service (COPFS), headed by the Lord Advocate, are the Scottish prosecution service. In Scotland, the local Procurator Fiscal can direct police investigations, though normally this only occurs in large and complex cases. They are also “responsible for the investigation of the circumstances of a death in Scotland which is sudden, suspicious or unexplained, has occurred in circumstances such as to give rise to serious public concern, or has resulted from an accident while the person who has died was in the course of his or her employment” (in accordance with the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976). In April 2013 all the regional Scottish police services were merged into one national service, Police Scotland, second only to London’s Metropolitan Police in size in the UK. A fatal accident involving a helicopter operated on charter to Police Scotland is currently under investigation by the AAIB. That aircraft was not fitted with either a CVR or FDR, nor was it required to be by regulation or contract. Both COPFS and Police Scotland report to the Scottish Government. The AAIB investigate aviation accidents to improve aviation and not to apportion blame or liability. A Memorandum of Understanding exists between the AAIB, the Marine Accidents Investigation Branch (MAIB), the COPFS and the Association of Chief Police Officers in Scotland (which ceased to exist...
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