ASN Wikibase Occurrence # 188812
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Date: | Sunday 17 July 2016 |
Time: | 19:42 LT |
Type: | PZL-Swidnik W-3AS Sokol |
Owner/operator: | Hispánica de Aviación - HASA |
Registration: | EC-LQA |
MSN: | 310306 |
Year of manufacture: | 1989 |
Fatalities: | Fatalities: 0 / Occupants: 12 |
Aircraft damage: | Destroyed |
Category: | Accident |
Location: | Villanueva de la Cañada -
Spain
|
Phase: | En route |
Nature: | Fire fighting |
Departure airport: | |
Destination airport: | Valdemorillo |
Investigating agency: | CIAIAC |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:On Sunday, 17 July 2016 at 19:42, helicopter EC-LQA, a PZL W3AS operated by Hispanica de Aviaci6n (HASA) with 12 people aboard, made an emergency landing on a crop field while flying back from a fire due to an emergency in engine 1 (left).
Engine 1 had been stopped by mistake after closing its fuel shutoff valve while executing a routine procedure. The investigation has determined that engine 1 stopped, but that 50 sec after the valve was closed, the engine was running at idle. It was not possible to determine what caused it to restart. The crew did not notice that the engine was running again and continued to believe that the engine had stopped.
Faced with this situation, and after trying an in-flight engine restart, the crew decided to make an off-field landing and start the engine. During the landing, the helicopter tipped over on its right side. The persons aboard, two pilots and 10 firefighters, exited the helicopter under their own power.
The investigation has determined that the accident of helicopter EC-LQA was likely caused by the incorrect execution of an emergency landing after making an approach maneuver in which proper speed, altitude and flight path values were not maintained.
The following potentially contributed to the accident:
- The failure to comply with the task allocation for "single-pilot operation with two pilots with procedures for one pilot.
- Inefficient crew training on technical skills (the helicopter's normal and emergency operating systems and procedures), as a result of which:
The nature of the emergency and the operational status of the engines were not identified.
Procedures were executed incorrectly, incompletely or not at all during the flight and the emergency.
Checklists were not used at any point during the operation.
- Inefficient crew training on non-technical skills (CRM) adapted to "single-pilot operation with two pilots with procedures for one pilot", which caused:
* Both crewmembers to focus on the TOT and on looking for a field.
* Basic night activities to be ignored, such as maintaining speed or monitoring parameters and gauges in the cockpit.
* A rush to land, affecting the choice of field.
* A lack of leadership by the captain during the emergency.
* The second pilot to supervise and instruct the captain during the emergency.
- Underestimation of the safety risk during the decisions made during the night, as a result of which:
* Safer landing areas were not evaluated.
* The emergency was not reported to the squad or to the CECOPS.
- The ambiguous definition, description and documentation of the fire fighting (FF) operation by HASA in its FF and SAR Operations Manual.
- The lack of supervision in the reality of FF operations in terms of the theoretical operation designed and described in its FF and SAR Operations Manual.
Accident investigation:
|
| |
Investigating agency: | CIAIAC |
Report number: | A-026/2016 |
Status: | Investigation completed |
Duration: | 2 years and 5 months |
Download report: | Final report |
|
Sources:
CIAIAC
Revision history:
Date/time | Contributor | Updates |
22-Jul-2016 10:26 |
harro |
Added |
22-Jul-2016 10:27 |
harro |
Updated [Aircraft type, Cn] |
31-May-2017 13:23 |
Piloto99 |
Updated [Phase, Nature, Damage, Narrative] |
19-Dec-2018 19:48 |
harro |
Updated [Time, Operator, Source, Narrative, Accident report, ] |
16-Mar-2019 12:32 |
harro |
Updated [Source, Accident report, ] |
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