ASN Wikibase Occurrence # 173191
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Date: | Wednesday 21 January 2015 |
Time: | 12:31 LT |
Type: | Eurocopter AS 350B2 Ecureuil |
Owner/operator: | Airspan Helicopters |
Registration: | C-GJPW |
MSN: | 4738 |
Year of manufacture: | 2009 |
Engine model: | Turbomeca ARRIEL 1D1 |
Fatalities: | Fatalities: 0 / Occupants: 1 |
Aircraft damage: | Substantial |
Category: | Accident |
Location: | 11nm SE of Key Lake -
Canada
|
Phase: | Manoeuvring (airshow, firefighting, ag.ops.) |
Nature: | Cargo |
Departure airport: | |
Destination airport: | |
Investigating agency: | TSB |
Confidence Rating: | Information verified through data from accident investigation authorities |
Narrative:The helicopter impacted the ground after an uncommanded roll and rotation to the left and descended while being used to string steel feeder cable through a row of 14 steel hydro power transmission towers. The pilot sustained serious injuries and the helicopter substantial damage.
A tool called a “needle” is used to guide the feeder cable through the centre phase below the insulator string.
Findings as to causes and contributing factors
The needle suddenly lunged and abruptly stopped, possibly as a result of the needle contacting the tower steel or the feeder cable catching on a ground obstacle, such as cut trees, deadwood, and large boulders.
The aircraft's continued lateral movement with the impeded feeder cable led to the onset of a dynamic rollover, resulting in loss of control and impact with the ground.
The abrupt stop and skid contact with the grapple line, combined with the additional weight of ballast and the crosswind from the right, contributed to the onset of the dynamic rollover.
Findings as to risk
If training does not adequately prepare pilots for abnormal flight conditions, there is a risk that pilots may not recognize and correct an unsafe condition in a timely manner.
If approved flight manual supplements are not complete and clear, there is a risk that operators will unknowingly conduct operations that are not approved.
If pilots do not use available shoulder restraints, there is an increased risk of injury in the event of an accident.
If ground observers cannot adequately monitor Class C loads along the ground, there is a risk that a load may inadvertently snag and compromise safety of operations.
If pilots do not follow normal checks and procedures, there is a risk that the defences that these provide will not be available.
Airspan did not have a fully implemented safety management system in place, but it was not required to by regulation. The TSB has identified safety management and oversight as a Watchlist issue. As this occurrence demonstrates, some transportation companies are not effectively managing their safety risks. The Board has been calling on Transport Canada (TC) to implement regulations requiring all operators in the aviation industry to have formal safety management processes and for TC to oversee these companies' safety management processes.
Following the occurrence, Airspan suspended AS350 helicopter stringing operations until further notice. They reviewed and amended their standard operating procedures, including amendments to pre-flight checks, stringing operations, and feeder cable–pulling procedures. The operator also hired third-party consultants to audit the company's safety management system.
Accident investigation:
|
| |
Investigating agency: | TSB |
Report number: | A15C0005 |
Status: | Investigation completed |
Duration: | 1 year and 4 months |
Download report: | Final report |
|
Sources:
https://saskatoon.ctvnews.ca/helicopter-pilot-injured-in-crash-near-key-lake-1.2200632 http://www.cbc.ca/news/canada/saskatoon/helicopter-crashes-near-key-lake-1.2927992 http://www.tsb.gc.ca/eng/rapports-reports/aviation/2015/A15C0005/A15C0005.asp Revision history:
Date/time | Contributor | Updates |
22-Jan-2015 18:46 |
gerard57 |
Added |
22-Jan-2015 19:06 |
gerard57 |
Updated [Operator, Source] |
22-Jan-2015 19:51 |
Aerossurance |
Updated [Time, Nature, Narrative] |
22-Jan-2015 20:59 |
Aerossurance |
Updated [Source, Narrative] |
22-Jan-2015 22:08 |
Black Typhoon |
Updated [Aircraft type, Registration, Source, Narrative] |
23-Jan-2015 01:53 |
Geno |
Updated [Aircraft type, Registration, Cn, Operator, Location, Source] |
23-Jan-2015 07:57 |
Aerossurance |
Updated [Aircraft type, Registration, Cn, Operator, Location, Source] |
23-Jan-2015 08:22 |
Aerossurance |
Updated [Aircraft type, Registration, Cn] |
04-Apr-2015 09:55 |
Aerossurance |
Updated [Source] |
05-Oct-2015 16:30 |
Aerossurance |
Updated [Aircraft type] |
02-Jun-2016 17:24 |
Aerossurance |
Updated [Time, Location, Source, Narrative] |
02-Jun-2016 17:29 |
Aerossurance |
Updated [Narrative] |
23-Sep-2016 10:03 |
Aerossurance |
Updated [Aircraft type] |
02-Jan-2019 19:28 |
Aerossurance |
Updated [Source] |
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