ASN Wikibase Occurrence # 367962
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| Date: | Saturday 23 February 2019 |
| Time: | |
| Type: |  Eurocopter EC 175B |
| Owner/operator: | Dancopter |
| Registration: | OY-HHV |
| MSN: | 5006 |
| Engine model: | Pratt & Whitney (Canada) PT-6C-67E |
| Fatalities: | Fatalities: 0 / Occupants: 18 |
| Aircraft damage: | Minor |
| Category: | Serious incident |
| Location: | Esbjerg Airport -
 Denmark
|
| Phase: | Standing |
| Nature: | Offshore |
| Departure airport: | Esbjerg Airport (EBJ/EKEB) |
| Tyra E Helideck (EKTE) | |
| Investigating agency: | HCLJ |
| Confidence Rating: |  Information is only available from news, social media or unofficial sources |
After starting up engine number one, engine number two was started, and after a few seconds a loud bang was heard, followed by vibrations in the aircraft. The starting sequence was aborted and both engines shut down. After shutdown aircraft was inspected and a piece of tooling was observed to have been lodged into the leading edge of one of the main rotor blades. Tool stickout was estimated to be a top nut wrench, about 20cm long.
Contributing factors
The AIB safety investigation did not reveal any systemic safety issues, but the below listed safety factors likely contributed to the sequence of events:
The organisation and management:
- scheduled a maintenance production, which at times led to a lack of defined roles on a shift
- proposed a future work shift structure in a manner that produced unwanted human factor effects
- did not consistently follow up on irregular use of tool rack tool control checklists
- did not provide an updated handover sheet for the shift
- implemented mitigating actions for tool control procedures compliance that did not accomplish the desired effect.
The engineers:
- felt detached from the Belgian Part-145 organisation
- did not perceive the group/management structure as fully transparent
- showed complacency on complying with procedures
- introduced a workaround during the shift that decreased or removed the effects of the tool control safety barriers
- felt some group tool control procedures were not especially suited for the maintenance performed at the operator
- did not fully comprehend the intended process of the tool control procedures.
The maintenance procedures/equipment:
- The tool rack markings were less than optimum.
Despite of the above, procedures were in place, valid, mandatory to follow and the engineers had the necessary training to apply them properly.
Therefore, in the view of the AIB, adherence to procedures would most likely have revealed the missing breaker bar and socket, and thereby avoided the serious incident from happening.
Accident investigation:
 |
|
Sources:
https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-airbus-ec175-registered-oy-hhv-on-23-02-2019-at-esbjerg-investigation-led-by-aaib---denmark/
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 22-Mar-2024 20:44 | ASN | Added |
| 22-Mar-2024 20:44 | ASN | Updated [Departure airport, Destination airport] |
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