ASN Wikibase Occurrence # 224247
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| Date: | Monday 22 April 2019 |
| Time: | c. 19:37 |
| Type: |  Kawasaki BK 117C-1 |
| Owner/operator: | Southern Lakes Helicopters |
| Registration: | ZK-IMX |
| MSN: | 1108 |
| Year of manufacture: | 1996 |
| Total airframe hrs: | 6558 hours |
| Engine model: | Turbomeca Arriel 1E2 |
| Fatalities: | Fatalities: 0 / Occupants: 3 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | off Enderby Island, Auckland Islands -
 New Zealand
|
| Phase: | Approach |
| Nature: | Ambulance |
| Departure airport: | Invercargill Airport (IVC/NZNV) |
| Enderby Island | |
| Investigating agency: | TAIC |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Kawasaki BK 117C-1 helicopter crashed into the sea at night at the Auckland Islands. The three occupants survived the crash.
The operator was conducting a medical evacuation flight under visual flight rules (VFR). On board was the pilot, a paramedic in the front left-hand seat, and a winch operator in the rear cabin. The helicopter was to position south of New Zealand at Auckland Islands that day (the positioning flight). After camping overnight on Enderby Island, the helicopter crew would rendezvous with a fishing ship next day to heli winch and evacuate a sick crew member back to New Zealand.
The positioning flight was intended to arrive during daylight, but unexpected delays to the departure time resulted in them arriving after dark. The crew carried night vision goggles (NVGs) and donned them during the positioning flight to continue under VFR using NVGs.
The hills and coastline around Port Ross and part of Enderby Island were visible through NVGs, but the pilot believed that the landing area was covered in cloud. The pilot planned an alternative approach to descend in the clear area to below the cloud and then follow the coastline back to the landing area.
The pilot descended and was turning back towards the landing area when the crew member (paramedic in front left-hand seat) alerted them to cliffs rising immediately ahead. The pilot reacted, but the helicopter impacted the sea.
The crew were able to escape while the helicopter was partly submerged, but it sank soon after. They were all wearing immersion suits that kept them afloat and enabled them to make their way to shore. After sheltering under cover overnight, they were spotted the next day by one of the rescue helicopters and brought back to Invercargill to be checked in the hospital.
The winch operator in the rear cabin was knocked unconscious during the impact, but was able to be evacuated by another crew member. They regained consciousness during the swim to shore. Otherwise, the crew only suffered minor injuries.
The helicopter was recovered about three weeks later.
TAIC found that the pilot had misinterpreted the image seen through the NVGs as cloud covering the landing area when it was very likely to have been fog near the sea surface and downwind of the shore. The planned descent and approach in the clear area was made using visual reference outside and to the global positioning system (GPS) map display. However, the helicopter’s descent rate became high as the pilot, relying primarily on visual depth perception, believed the helicopter was further from the surface of the sea than it was. When the crew did see an image through the NVGs it was the 20-metre high cliffs several hundred metres ahead and above them. During the manoeuvre to avoid the cliffs, the helicopter impacted the sea.
The Commission found that the operator’s exposition for single pilot VFR operations into the Southern Ocean was inadequate at the time to manage the risks associated with such operations. The operator has since made significant improvements, including engaging an external auditor and introducing a new standard operating procedure for Sub Antarctic Island flights. Therefore, the Commission considered that no safety recommendations to the operator were necessary.
The Commission also identified regulatory gaps in the New Zealand Civil Aviation Rules (CARs) regarding minimum safety requirements for helicopters operating under Part 119 and Part 135 air operator certificates (AOCs). The gaps related to:
• Helicopter air ambulance (HAA) operations.
• Night vision imaging systems (NVIS) and operations.
• Crew resource management (CRM) for operations conducted with multi-pilot or a single pilot with a non-pilot crew.
• Pilot logging of NVG flight time.
Accident investigation:
 |
|
Sources:
https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12224398&fbclid=IwAR2daLxFHfLEylOddtXoICYbwfYnqWPLvEfWgmk7DZpkmiTNxu4nY6WbLO0
https://www.radionz.co.nz/news/national/387562/helicopter-crash-in-auckland-islands-three-crew-members-found-alive
https://www.stuff.co.nz/national/112219979/auckland-islands-helicopter-crash-survivors-swam-to-shore-in-darkness-after-southern-ocean-crash
https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12224813
https://www.odt.co.nz/regions/southland/pilot-out-hospital-inquiry-begins
https://aerossurance.com/helicopters/bk117-offshore-medevac-cfit-survivability-issues/
_______________________________
https://taic.org.nz/news/taic-opens-inquiry-accident-involving-rescue-helicopter-auckland-islands
https://www.bea.aero/en/investigation-reports/notified-events/detail/event/accident-du-kawasaki-bk117-immatricule-zk-imx-et-exploite-par-southern-lakes-helicopters-survenu-le/
Images:
Photo: TAIC
Media:
TAIC report: BK117 helicopter, controlled flight into terrain (sea). Lucky no fatalities. Safety issues - NZ CAA to resolve: NVIS requirements & standards; crew resource management training & quals, guidance for crew members assisting pilot during NVIS ops https://t.co/CjtguzG9gB pic.twitter.com/Ch4opho0qh
— NZ TAIC 🚢✈️🚞 (@NZTAIC) April 19, 2023
An offshore medevac accident highlights considering the changing risk of an individual flight, flight path management in degrading conditions and offshore survivability in a 'regulatory void'.https://t.co/xSQWly2dHD #sar #helicopter #flightsafety #aviationsafety #survivability pic.twitter.com/pUbEcH1s4q
— Aerossurance (@Aerossurance) July 8, 2023
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 23-Apr-2019 05:22 | gerard57 | Added |
| 23-Apr-2019 07:12 | gerard57 | Updated [Source] |
| 23-Apr-2019 10:25 | Aerossurance | Updated [Aircraft type, Narrative] |
| 23-Apr-2019 10:39 | Aerossurance | Updated [Source, Narrative] |
| 23-Apr-2019 20:50 | Aerossurance | Updated [Source, Narrative] |
| 24-Apr-2019 11:15 | Aerossurance | Updated [Time, Source, Narrative] |
| 29-Apr-2019 09:29 | Iceman 29 | Updated [Source, Embed code] |
| 13-May-2019 06:35 | Iceman 29 | Updated [Embed code] |
| 04-May-2020 08:18 | harro | Updated [Aircraft type, Registration, Cn, Source, Embed code] |
| 30-Jul-2020 00:29 | Ron Averes | Updated [Location, Narrative] |
| 22-Sep-2021 01:51 | Ron Averes | Updated [Location] |
| 27-May-2023 14:29 | Aerossurance | Updated [[Location]] |
| 08-Jul-2023 11:56 | Aerossurance | Updated [[[Location]]] |
| 04-Dec-2023 14:38 | harro | Updated [Other fatalities, Embed code] |
| 05-Dec-2023 20:42 | harro | Updated [Other fatalities] |
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