Customs Training Loss of Control While Climbing Away from a Quick Stop
Customs Training LOC-I While Climbing Away from a Quick Stop (CBP Airbus AS350B2 N841BP) On 13 May 2021 Airbus AS350B2 N841BP of US Customs and Border Protection (CBP) Air and Marine Operations (AMO) was destroyed in a training Loss of Control – Inflight (LOC-I) accident at Yukon, Oklahoma. Both pilots escaped injury but the aircraft was consumed by a post crash fire. The Accident Flight According to the US National Transportation Safety Board (NTSB), who issued their safety investigation report 19 January 2023 the pilot under instruction had been enrolled on CBP’s Initial Pilot Certification course for the AS350B2 at the CBP National Air Training Center (NATC) in Oklahoma City. The student was aged 45, held a CPL and had 1,200 hours total, 620 hours on type. The instructor was 40 and had 6,000 hours total, 1,000 on type. The instructor reported for duty at c11:30 Local Time and started preparing with the student at 12:30 for 2 flights. The aircraft departed at 14:45. The pilot under instruction was in the right hand seat, The flight departed the Will Rogers International Airport (KOKC) and proceeded to the Clarence Page Municipal Airport (KRCE) to conduct training maneuvers. After arrival at KRCE, the flight crew conducted several approaches to the airport including confined area and pinnacle approaches. They then conducted several simulated emergencies, each of which required the helicopter’s hydraulic system to be turned off and then turned back on at the conclusion of the procedure. Readers should note that: The hydraulic system was turned off and on using the hydraulic cut-off switch, an unguarded push-button switch mounted on the end of the pilot’s collective stick. Next… …the flight crew proceeded to conduct a series of “quick stops.” After the third quick stop, the pilot heard a radio call indicating an airplane was on final approach to land on the runway they were using, and the flight instructor indicated that they would clear the runway. The pilot [under instruction] added that he completed a final quick stop and immediately entered a climbing left turn. At this point the pilot under instruction noticed the helicopter was yawing to the left. He was unable to correct that with a pedal input. When the pilot [under instruction] adjusted his grip on the collective, he felt the hydraulic cut-off button with his thumb as he prepared to reduce collective. As he tightened his grip on the collective, “the hydraulics came offline aggravating the left yaw into a hard left spin.” The controls were stiff, and the flight instructor told him to turn the hydraulics back on. The pilot “intentionally pressed the [hydraulic cut-off] button but felt no effect.” He pressed the button a second time, but the hydraulic light on the caution warning panel remained illuminated, so he pressed the button a third time. However the flight instructor stated that during the last quick stop “the helicopter slowed normally but then started a left yaw about 25 ft above ground level”. As the helicopter yawed to c 30° left the instructor “pushed forward on the cyclic to gain airspeed”. Its not clear from the NTSB report if he verbalised that intervention. He stated that “as the aircraft was recovering, the control loads instantly became excessive” and “noticed the hydraulic light on the caution warning panel...
read moreDusk Duck: Birdstrike During Air Ambulance Flight
Dusk Duck: Birdstrike During Air Ambulance Flight (Reach H130 N415RX) On 12 December 2022 air ambulance Airbus H130 / EC130T2 N415RX of Reach Air Medical Services was damaged in a birdstrike north west of Yuba City, California. According to the US National Transportation Safety Board (NTSB), who issued their safety investigation report uncharacteristically quickly on 9 February 2023: The pilot in the helicopter reported that, during cruise flight [at 1,500 ft AGL] at dusk with night vision goggles on, he encountered a flock of birds at 1,500 ft above ground level. As the pilot initiated a climbing left turn to avoid the birds, he heard a loud bang accompanied by a pain in his left leg. The helicopter then began to vibrate, and the pilot initiated a precautionary landing in a nearby field without further incident. Bird remains were located throughout the pilot side of the cockpit. The helicopter sustained substantial damage to the windshield. Fortuitously the bird struck low on the windscreen rather than at head height and only one bird of the flock struck the helicopter. Neither the pilot nor the two other occupants were injured. Even though part of the bird was recovered, disappointingly the bird species and therefore its likely size, was not recorded by NTSB (other than a photo caption saying ‘duck’). Safety Resources EASA have issued Safety Information Bulletin SIB 2021-07 on Bird Strike Risk Mitigation in Rotorcraft Operations and accompanying safety promotion material. In a presentation on behalf of the Rotorcraft Bird Strike Working Group (RBSWG) to the 11th EASA Rotorcraft Symposium in December 2017 it was revealed that in the US 94% of the current helicopter fleet is made up of types that never needed to meet a bird strike requirement. A helicopter accident (discussed below) and the Hudson A320 ditching, both in January 2009, were likely causes of a big increase in all wildlife strikes reporting across the US helicopter fleet.While fixed wing aircraft predominantly strike birds during take-off and landing, two thirds of rotorcraft strikes occurred during the en route phase (where kinetic energy is highest). Only 8-9% occurred during approach and 9-10% during climb. The presentation went on: The largest single component struck by birds is the windshield with 47% on Part 27 and 40% on Part 29. 84-85% of all bird strikes occurred on components forward of the main rotor mast. This includes the main rotor which experienced 30%-33% of the strikes reported. Not one single record exists for windshield penetration on Part 29 rotorcraft certified to the FAA bird strike airworthiness standard established over 21 years ago. This is statistically significant. For newly manufactured and existing rotorcraft, the RBSWG proposed to use a Risk-Based Safety-Tiered approach that scales the bird strike regulation based on the maximum number of occupants onboard. As the number of occupants increases, so does the risk exposure. They also recommend: Reduce airspeed when practical Increase altitude as quickly as possible and practical Use taxi and landing lights They also say: The location of bird concentrations during seasonal migrations and the local bird nesting and roosting habitats, should be made available to the rotorcraft operator/pilot for preflight planning to minimize the potential for bird strikes. Air carriers and general aviation operators working with the Flight Safety Programs and Flight Service Briefing should identify and publish the known locations and probability of bird concentrations. This information on...
read moreUrgent Exit Required: A Helideck Incident
Urgent Exit Required: A Helideck Incident (Omni Sikorsky S-76C+ PR-SEC) Vessels and mobile installations in the UKCS are currently completing a long anticipated helideck upgrade to introduce the latest Rev 9b of the Helideck Certification Agency (HCA) standard of Helideck Monitoring System (HMS) with deck repeater lights. This serious incident in Brazil is a reminder of why this HMS upgrade is essential. On 28 June 2015, Omni Taxi Aero Sikorsky S-76C+ PR-SEC, under contract to Petrobras, had to make a sudden departure from the deck of pipelaying vessel Kommandor 3000, almost colliding with the vessel’s superstructure, after the vessel had changed heading. The aircraft was undamaged and the occupants unharmed. The helicopter damaged the helideck net. The Incident Brazilian accident investigation agency, the Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA), explain in their safety investigation report (avaible in Portuguese only) that the offshore helicopter had departed from Macaé Airfield (SBME), RJ at 10:30UTC with two pilots and four passengers onboard. Before landing, the [Kommandor 3000’s] radio operator informed [the helicopter crew of] the wind conditions (080°/17kt), the ship’s heading (351°) and the values of pitch, roll and heave. On that occasion, the first consultation was made on the possibility of changing the bow of the vessel after landing. The aircraft landed at 11:40UTC. The Aircraft Commander was Pilot Flying (PF) and remained at the controls while rotors running on the helideck. The four outbound passengers disembarked and four inbound passengers boarded. During this time, the ship’s radio operator again questioned the crew about the 096° turn to heading, and the [aircraft] captain agreed with the manoeuvre. With the passengers on board, the maneuver was carried out as requested. Thus, the wind, which before landing was incident laterally on the vessel, became a bow relative to the ship, and abeam relative to the aircraft. During the vessel’s turn CENIPA say the wind was 29 knots and the vessel was “struck by a wave”, which caused an “aggressive…pitch-up, propelling the aircraft upward and to the right”. The aircraft skidded across and damaged the deck net. The Aircraft Commander perceived the motion as the start of a dynamic rollover towards the superstructure and so wisely initiated an immediate take off. After losing contact with the helideck surface, the aircraft banked and moved dangerously to the right, passing very close to the main structure of the ship, indicating a risk of collision. Safety Investigation The investigation was hampered because the Honeywell Cockpit Voice and Flight Data Recorder (CVFDR) was not functioning during the incident flight, for reasons that were not determined. The investigators did however discover that 10 minutes prior to the landing, the earlier generation HMS was already displaying a red warning on the vessel’s bridge that at least one motion parameter was outside of limits. Other Occurrences We have previously discussed an accident from February 2014 in Brazil where another Petrobras chartered S-76C+ was damaged landing on a vessel without being warned that the HMS was showing exceedance: Helideck Heave Ho! (BHS Sikorsky S-76C++ PR-CHI). That prior investigation was only released 16 November 2021 (in Portuguese only), far too late to have helped prevent the 2015 near miss. CHC AS332L G-BKZE suffered a rollover on the helideck of drillship West Navion in the North Sea on 10 November 2001. In that...
read moreCHC S-92A Offshore Landing Obstacle Strike: CENIPA Report
S-92A Offshore Landing Obstacle Strike: CENIPA Report (CHC / BHS S-92A PR-CHR on Sevan Brasil) On 15 April 2017, Sikorsky S-92A PR-CHR of CHC‘s Brazilian Helicopter Services (BHS), under contract to Petrobras, suffered an obstacle strike and hard landing on the Sevan Brasil (SS-86), a Mobile Offshore Drilling Unit (MODU) off Brazil. None of the 21 occupants were injured in this accident, which was dramatically caught on video: Brazilian accident investigation agency CENPIA published their safety investigation report, in Portuguese only, on 3 November 2022, a disappointing 5½ years later. The Accident Flight The offshore helicopter had departed Cabo Frio for the Sevan Brasil under VFR, with two pilots, a cabin attendant and 18 passengers. CENIPA explain that the Aircraft Commander, who had flown 21,307 hours (3.294 on type) was sat in the left hand seat as an instructor & ‘Accredited Examiner’, and Pilot Monitoring (PM). In the right seat was a Pilot in Command Under Instruction (PICUS) who had 5,500 flying hours experience (253 on type) was Pilot Flying (PF). This was the flight crew’s third flight of the day. The Aircraft Commander had been PF for the first two offshore landings as the wind, and therefore the approach direction, favoured an approach best made by the left hand pilot. In fact the Aircraft Commander had made all landings in the previous three days they had flown together too. Sevan Brasil is a relatively novel circular hull MODU with a D23, t15.6 helideck, adequate for helicopters up to the size of the AW101, mounted at c 150 ft above sea level. The octagonal helideck is not mounted tangentially. CENPIA note the chevron marking that indicates the 210° Obstacle Free Sector (OFS) was incorrectly positioned. Though this is not relevant to this accident due to the chosen approach direction. More significantly, the helideck plate for the Sevan Brasil, which the crew consulted before departure, had… …no information regarding the positioning of the chevron, 150º and 210º sector orientations, helideck bow, wind limitations, relative wind, etc. This deficiency is of note because CENIPA also reveal that the flight was due to have been flown by another helicopter company, implying the crew would be less familiar with the installation and more dependent of the plate for their orientation. The investigators highlight that UK CAA CAP 437: Standards for offshore helicopter landing areas, probably the most widely referenced helideck standard, is far more explicit of the data that should be included. CENPA also highlight whip antennas and structure near the helideck were not marked in accordance with guidance in NORMAM 27 (the Brazilian helideck standard). However, CENPIA also commented that the guidance was not explicit about how far from the helideck these markings were necessary. The operator’s Operations Manual states that: The Aircraft Commander should use his judgment and experience in selecting what he considers to be the best profile. Factors such as: aircraft weight; wind speed; turbulence; size of helideck; elevation and orientation helideck; obstructions; available power margins; platform gas burner flames; etc., will influence the takeoff and landing decision-making. The Ops Manual goes on to list factors to consider such as Landing area location and wind direction; Wind strength; Experience level of each pilot; and Missed approach (go-around) profile. In this case it was decided that the PICUS, sat in...
read moreAfter Landing this HEMS Helicopter Suddenly Started to Slide Towards it’s Hangar…
After Landing this HEMS Helicopter Suddenly Started to Slide Towards it’s Hangar… (ADAC Airbus EC135P2+ at University Hospital Augsburg) On 5 June 2022, shortly after an ADAC Airbus EC135P2+ HEMS helicopter, callsign Christoph 40, landed at its base, an elevated helipad at the University Hospital Augsburg, in Bavaria, the pilot was surprised by the sudden uncommanded movement of the helicopter. The Incident According to the German safety investigation agency, the BFU, who published their report in German only the rooftop hospital landing site has a… …18 m x 18 m final approach and take off area (FATO) / touch down and take off area (TLOF), a helicopter parking area and a 5.24 m x 7.5 m mobile helicopter platform for landing and exiting the helicopter. The site is at an elevation of 58 m. After the landing approach to the marked landing area, [the pilot] manoeuvred the helicopter to the mobile platform to land. The platform was in the outboard position and the hangar doors were closed. The helicopter touched down on the platform with the nose of the fuselage pointing towards the hangar. Before the engine power was reduced, the pilot noticed the platform rolling away in the direction of the closed hangar doors, picked up the helicopter again immediately and then hovered to the parking position. Investigators found the brakes to the mobile helicopter transport platform were not applied. But why?… The Platform This unit had been in use since the heliport opened in 2014 but the BFU report it had proved troublesome in service. It is battery-operated and runs on rails. In its the outer position, the distance from the centre of the turntable on the platform to the hangar doors was about 16 m. The D-value of an EC135 is 12 m, so when centred there is c 10 m of clearance from the doors. The 28 V DC motor has an integral brake. When powered up the brake is released and when power is removed it activates. The brake can also be disengaged to allow the unit to be moved by hand but the brake then should be manually reengaged. Investigators found was that while the helicopter had been airborne on an operational tasking, a hospital technician had been conducting repairs. While they don’t elaborate it appears the unit was left with power disengaged and the brake disengaged. Such platforms are not subject to aviation regulations but fall within health and safety regulations for work equipment. The BFU have expressed concern that ICAO Annex 14 Volume II (Heliports) does not address the safety of these units. Other Similar Incidents The BFU note three prior incidents with mobile helicopter transport platforms: BFU 3X449-96 on 10/11/1996: The platform on which the helicopter was standing began to move after the engines had been started, without the operating speed having been reached. The helicopter collided with a building. BFU 3X012-0/05 on 03/11/2005: When taking off from the transport platform, the helicopter got caught on a protruding wheel, rolled to the left and touched the ground with the main rotor and tail boom. The helicopter remained on the left side, badly damaged. BFU 7X010-0/07 on 08/23/2007: During take-off from the transport platform, the cable from the external power connection briefly got caught on the right skid of the helicopter....
read moreFatal GOM B407 Offshore Take Off Accident: Safety, Helideck & SAR / Emergency Response Questions
Fatal Gulf of Mexico Bell 407 Offshore Take Off Accident: Safety, Helideck & SAR / Emergency Response Questions (RLC N595RL, Walters/IOC WD-106 Installation) – Updated After NTSB Final Report Issued 16 Jan 2025 In 29 December 2022 Bell 407 N595RL of Rotorcraft Leasing (RLC) crashed on take off from the West Delta 106 (WD106) offshore installation in the Gulf of Mexico (GOM). The pilot and 3 passengers died. On Friday 13 January 2023, the US National Transportation Safety Board (NTSB) issued their preliminary report into this offshore helicopter accident. UPDATE 22 January 2025: The NTSB issued their final report on 16 January 2025, prior to the renaming of the GOM, and we have updated this article. The Pilot The NTSB final report reveals the pilot was hired by RLC on 12 September 2022, just 3.5 months before the accident. His resume reported the following experience, including working for 5 onshore operators (the S-60 time should be S-70/H-60): On 28 September 2022, the pilot completed RLC’s initial ground and flight training (which included 16.8 flying hours, 7 offshore), and became a pilot-in-command (PIC) in the Bell 407 helicopter. RLC evaluated the pilot as satisfactory for the ‘Dynamic Rollover (Oral)’ and ‘Pinnacles or Platform’ requirements. The pilot’s total flight experience in helicopters, including the 155.8 flight hours flown with RLC, was 1,667.8 hours, of which 1,343.8 hours were flown as PIC at the time of the accident. The pilot had operated to and from WD106 a total of 23 times (GOM pilots are frequently assigned to contracts with specific customers serving a small number of installations). The pilot was on a 14 day on, 14 day off roster. He had been in Brazil during his most recent time off and travelled back on the day before the accident. That would involve a 9:20 hour international flight, a 1:50 hour domestic flight, plus a drive of c 2:40 hours. The NTSB did not determine their exact schedule. Based on current flight options this journey either involved leaving late on 27th with an overnight international flight and arriving early afternoon the day before the accident or worse, arriving after midnight on the day of the accident. The lead pilot stated that the pilot arrived for work at 05:30 on the day of the accident. The Accident Flight The helicopter departed South Lafourche Leonard Miller Jr. Airport (KGAO), Galliano, Louisiana with 4 passengers for WD106 on a VFR flight, 51.6 nm to the SE, at 07:48 Local Time. The outbound flight appears to have been uneventful. WD106 is owned by Houston based Walter Oil & Gas Corporation, and was constructed in 1994. On its SE corner WD106 has a 24×24 ft square helideck, which gives a 7.3 m D-value. The B407 has a 13 m D-value so this is a small, 0.56D, sub-D deck. The RLC Ops Manuals treats such decks as “a restricted category helideck” and states that “the pilot may have to reduce load to operate safely”. The WD106 Touch Down / Position Marker (TDPM aka Aiming Circle) is 10 ft diameter according to the NTSB, but as evident in images and deck drawings its actually 20 ft diameter. The NTSB report the deck, which was at an elevation of 100 ft, had recently been repainted and the stairwell painted red. It...
read moreBlinded by Light, Spanish Customs AS365 Crashed During Night-time Hot Pursuit
Blinded by Light, Spanish Customs AS365 Crashed During Night-time Hot Pursuit (Eliance/SVA Airbus AS365N3 EC-JDQ) On 11 July 2021 Airbus AS365N3 EC-JDQ, operated by Eliance for the Spanish Customs Surveillance Service (Servicio de Vigilancia Aduanera [SVA]) impacted the sea while manoeuvring in pursuit of a smuggler’s boat. The two Fight Crew survived but a Customs Agent was died, having been trapped in the capsized helicopter. The Accident In the safety investigation by the Spanish the Civil Aviation Accident and Incident Investigation Commission (CIAIAC), issued in Spanish in December 2022, the investigators explain that the helicopter left its base at Algeciras, Cadiz at 01:20 for a routine patrol. The Straits of Gibraltar are notorious route for drug smuggling from North Africa. The Aircraft Commander (9,347 hours experience, 4,005 on type and c7,000 hours flying customs flights) was the Pilot Flying (PF). The Co-Pilot (5,935 hours, though only 14.5 on type having joined the operator 2 months earlier with a SAR & HEMS background) was the Pilot Monitoring (PM). The Customs Agent was in the cabin, in the front left seat, at a FLIR equipped work station. The aircraft was operating Night VFR rules. The investigation report makes no mention of Night Vision Imaging Systems (NVIS) googles being used. When they took off, the pilot at the controls the PF set their radalt bug to 300 ft and the other PM had theirs set to 500 ft. When descending below 500 ft the PM would re-set theirs to 100 ft. When they had been flying for approximately five minutes, they heard on the radio that an SVA vessel (Patrol Boat Águila 4 [a 17 m, 50 knot, Rodman 55]), based in the Port of Algeciras, was pursuing a boat and the Customs Agent offered to support them from the air in the chase. The crew of the Patrol Boat answered in the affirmative and provided them with their coordinates. The helicopter crew verified that the Patrol Boat was at a distance of approximately 35 NM to the east and began to move towards the area where the pursuit was taking place. The smugglers were taking a longer route to Spain. Which also meant operating further from cultural (i.e. man-made) lighting ashore. When they were south of Europa Point [site of the Trinity House lighthouse at the southern tip of Gibraltar], heading towards the coordinate point they had been given, they gradually descended from an altitude of 3,500 ft, until they reached the vicinity of the vessels, flying with 70% torque and a speed of 130 kt… When in pursuit of a vessel, the flight crew would turn on the landing lights. These were deployed but not turned on at this point. When slowing below 80 knots the PM armed the emergency flotation system. Crucially: There was a lot of humidity and scattered banks of fog…according to a statement from the PF. When the Customs Agent located the two vessels, using the FLIR surveillance system, he guided the crew with more precision until they positioned themselves close to them. When positioned to the left of the SVA patrol boat they descended “very rapidly” from an altitude of 500 ft to below 100 ft. There is no discussion on the use of any automation, the implication being that the descent was conducted manually. It can be presumed...
read moreHESLO EC135 LOC-I & Water Impact: Hook Confusion after Personnel Change
HESLO EC135 LOC-I & Water Impact: Hook Confusion after Personnel Change (DAP Helicopteros Airbus EC135T1 CC-CCA) On 22 December 2018 Airbus EC135T1 CC-CCA of DAP Helicopteros impacted the water of the Beagle Channel off Chile’s Picton Island after a Loss of Control – Inflight (LOC-I) while conducting Helicopter External Sling Load Operations (HESLO) from a ship. The aircraft sank 165 m from shore. The pilot, the sole occupant, was seriously injured but successfully egressed, swam to the remains of a pier and was recovered by boat. The Accident The accident was investigated by the Dirección General de Aeronáutica Civil (DGAC) Accident Prevention Department. Their safety investigation report was issued in Spanish only. They explain that the pilot (5,215 flying hours of experience, 651 on type) had conducted a number of HESLO cycles to transport loads to the ship. A large extra 25 kg hook was fitted as a safety weight to keep the 6.1 m sling vertical below the helicopter. Briefings were conducted with the ground parties ashore and on the ship and the need for this extra hook was emphasised. A maintenance technician from the helicopter operator had been on board the ship until c17:15 when he travelled ashore to prepare for refuelling. the helicopter. At 18:04 Local Time, having deposited a further load he pilot commenced manoeuvring away. Upon reaching a speed of 30 knots he heard a noise from the rear of the helicopter. The pilot of CC-CCA identified he no longer had any yaw control through the pedals. He slowed the aircraft to c 30 knots, descended towards 50 ft and commenced a turn to the right. As the helicopter slowed and the aerodynamical side load on the vertical stabiliser reduced the loss of yaw control became aggravated. Ultimately the pilot completely lowered the collective and the aircraft impacted the water, inverted and sank. The DGAC Safety Investigation Divers identified that was damage to the right hand side of the fenestron fairing and blades. However the large extra hook was not found with the helicopter but attached to the last container positioned on the ship. The pilot stated that while the helicopter was equipped with mirrors he was not able to always readily observe the hook. Investigators confirmed that the smaller sling load hook could reach the area of damage. Examination of GPS data confirmed the aircraft stayed below 69 knots (80 knots is the limit for HESLO). The helicopter was equipped with an emergency flotation system. It did not deploy. The investigation report does not discuss whether its activation had been commanded by the pilot but had failed or whether the system was not activated. DGAC Conclusions Cause: Loss of directional control of the helicopter during the flight, due to the impact of the hook of the load line against the tail rotor. Contributory Factors: Ship’s personnel unhooked the container from the permanent cargo, leaving the load line without its safety weight [the extra hook] The person in charge of giving the signal of conformity to the pilot did not realize that the line was left without its safety weight. The pilot did not realize that the permanent charge was not installed in the sling, because the mirror allowed him to partially see the line. The speed reached by the helicopter would have contributed to...
read moreDornier 328-100 Crossed Apron During Runway Excursion
Dornier 328-100 Crossed Apron During Runway Excursion (DANA 5N-DOX at Port Harcourt NAF Base) On 23 January 2019 Dornier 328-100 turboprop 5N-DOX of DANA (Dornier Aviation Nigeria AIEP Limited) suffered a significant runway excursion at the Port Harcourt NAF Base, crossing the airport apron and stopping just 3 m from the boundary fence. Nigeria’s Accident Investigation Bureau (AIB) released their safety investigation report on 30 December 2022. The aircraft was operating an oil and gas industry chartered flight from Bonny with 16 persons on board (2 Flight Crew, 1 Cabin Crew, 12 passengers, and 1 Aircraft Maintenance Engineer). The Co-Pilot (3,900 hours experience, 3,650 on type) was the Pilot Flying (PF) and the Aircraft Commander (18,400 hours, 6,500 on type) was the Pilot Monitoring (PM). On approach to PH NAF Base: According to the crew at 6.2 NM they noticed that number 1 engine was producing torque higher than the recommended 20% for final approach and landing. At flight idle, it was indicating 24%, whereas the number 2 engine was indicating the normal 20% torque at flight idle. At 10:00 h, [flight nember] DAV462 landed right of centreline runway 22. The crew also stated that, on idling the power lever during the landing roll, torque from number 1 engine increased to 27% instead of decrease below 10% causing a differential torque between the engines. It showed a maximum value of 34%. The torque from number 2 engine decreased below 10% (normal indication). The aircraft veered off the runway to the right…and was uncontrollable despite rudder application. BETA light were sighted and speed was higher than normal taxi speed. Emergency park brake was engaged. Specifically: [T]he aircraft exited the runway at a distance of 1,190 m from the threshold of runway 22. It further travelled on the runway shoulder for a distance of about 105 m. At a distance of approximately 98 m of its movement on the runway shoulder, the No. 4 right main tyre broke a runway edge light. The aircraft further veered off the runway shoulder and continued on the grass verge. It covered a distance of about 262 m on the grass verge. The aircraft travelled an additional distance of 259 m on the apron and came to a complete stop at about 3 m to the perimeter fence by the Aero Contractors ramp. The aircraft was slightly damaged. The occupants were all uninjured. Luckily there were no aircraft or vehicles on the apron in the path of the Dornier. The AIB Safety Investigation The AIB found the CVR data had been overwritten. The FDR showed a torque disparity of 20% (78/58) when at 6,000 ft 23 minutes prior to landing. There was an initial rudder displacement of 26° immediately after touchdown. The disparity in the left and right propeller torque values is an indication of failure of the propeller control unit (PCU) of the number 1 engine. Maintenance was conducted before investigators arrive: The aircraft technical logbook entry of 23rd January 2019 (post-occurrence) indicated: “L/H engine propeller will not come out of feather. L/H PCU [model D-1192-2] replaced IAW DO328 MM 61-21-04. OPS, Rig Check, Leak Check, OK”. Tyres were also replaced. The PCU responds to commands from the pilot’s “power and condition levers and controls and actuates the propeller hydraulically using oil from the...
read moreNight Mountain Rescue Hoist Training Fatal CFIT
Night Mountain Rescue Hoist Training Fatal CFIT (SAF Hélicoptères Airbus EC135T1 F-HJAF) On 8 December 2020 Airbus EC135T1 F-HJAF of SAF Hélicoptères suffered a Controlled Flight into Terrain (CFIT) at c 5,900 ft altitude in mountainous terrain in the French Alps during mountain rescue training. The helicopter was destroyed, 5 occupants died and the pilot was rescued with serious injuries. The Accident Flight The Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA) explain in their 109-page safety investigation report, issued 14 December 2022, that six training flights were planned, namely two morning, two afternoon and two night flights. These were conducted under an EASA Part-SPA.HHO specific approval for hoist operations. The operator’s SPA.HHO training approval had been issued by regulator the previous Friday, 4 December 2020. The operator had however previously been conducting rescue hoisting under a national approval and the trainees therefore had prior mountain hoisting experience. The exercises followed a day of classroom training on Monday 7 December 2020 and were… …designed for the trainees to obtain the SPA.HHO “Initial” and “Advanced Mountain” approvals taking into account their [prior] experience. The instructor pilot (who was also the NPCT [Nominated Person for Crew Training, appointed just 4 months earlier]) and the instructor hoist operator (who was also the NPFO [Nominated Person for Flight Ops]) were the only two people trained to deliver the training they had set up. There was a potential time pressure as the mountain rescue season was set to start on 12 December 2020 and two trained crews were contractually required. At the end of the afternoon, the two crews held a briefing before the two night flights. The review of the weather forecast had revealed that there would be a disturbance bringing snow in the evening. For the night flights, the crew was to consist an instructor pilot [the NPCT], a pilot under instruction, an instructor hoist operator [the NPFO), a hoist operator under instruction and two rescuers who were to be hoisted. After the first night flight a second pair of trainees were to replace the first. Given the arrival of this [weather] disturbance, the very short exercise programme (three hoist operations) and the proximity of the exercise site (situated 3.2 NM SE [of Albertville aerodrome] at an altitude of 6,000 ft), all the persons concerned took the decision to carry out the two flights one after the other and to switch crews with the rotor turning at the end of the first night flight.’ It was a moonless night. The aeronautical night (30 min after sunset) started at 16:22 at [near-by] Chambéry. The second night flight commenced at 17:00. The instructor pilot had 6,200 hours experience, 1,513 on type. The pilot under instruction had 5,493 hours experience, 663 on type. EC135T1 F-HJAF, manufactured in 1998, was equipped with traditional analogue avionics and didn’t have an autopilot. It did have a HELIMAP moving map display connected to a Trimble GNSS. On the way to the site, the instructor [pilot] identified fog banks on the northern slope of the mountain located to the north-east of the exercise site. On arrival the same three approaches and hoist exercises as conducted during the first night flight were repeated. Although the town lights in the distance were visible, they were only sufficient for choosing...
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