CA 12-12a 23 FEBRUARY 2006 Page 1 of 35 Section/division Accident & Incident Investigation Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY Reference: CA18/2/3/8362 Aircraft Registration ZS-RWW Date of Accident 9 September 2007 Time of Accident 1000Z Type of Aircraft Robinson R44 Raven II Type of Operation Training Flight Pilot-in-command Licence Type Commercial Age 25 Licence Valid Yes Pilot-in-command Flying Experience Total Flying Hours 668.8 Hours on Type Unknown Last point of departure Port Alfred Aerodrome (FAPA) Next point of intended landing Port Alfred Aerodrome (FAPA) Location of the accident site with reference to easily defined geographical points (GPS readings if possible) Farms Welgevind and Hopedale, Cove Ridge area near East London (GPS: South 33°04.210’ East 027°47.212’) Meteorological Information Surface wind; 070°/9kt, Temperature; 18°C, Cloud cover; BKN 1000ft, BKN at 2100ft and OVC at 3000ft. Top of cloud between 6000 and 7000ft AGL. Number of people on board 2 + 0 No. of people injured 0 No. of people killed 2 + 0 Synopsis The helicopter, with two pilots on board, departed from Port Alfred Aerodrome on an instrument training flight (IF). The intention was to fly to East London and perform the VOR/DME instrument approach for Runway 11 at East London Aerodrome (FAEL). The pilot flying (PF) occupied the right front seat and the instructor pilot occupied the left front seat. The helicopter was equipped with dual flight controls, and was certified for operation in compliance with Visual Flight Rules (VFR) by day and night only. The pilot flying was wearing “foggels” for the duration of the flight. On the approach approximately 5 nm to the west of FAEL, the helicopter entered Instrument Meteorological Conditions (IMC). According to several residents that were residing in the vicinity of the accident site, they could hear the helicopter flying overhead in the direction of the aerodrome, but were unable to see it due to the overcast weather conditions that prevailed. An unusual noise was heard, whereupon the helicopter went silent and the next thing the eyewitnesses observed was the helicopter and associated parts/components falling from the sky, through the clouds. Both occupants that were on board were fatally injured in the accident. There was no damage to people and property on the ground. Probable Cause Incorrect recovery technique following a low-G push over condition in-flight, resulting in main rotor blade contact with the cockpit/cabin area, and subsequent loss of control. IARC Date Release Date
35
Embed
Section/division Accident & Incident Investigation Form ... and Incidents Reports/8362.pdf · Section/division Accident & Incident Investigation Form ... Section/division Accident
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
CA 12-12a 23 FEBRUARY 2006 Page 1 of 35
Section/division Accident & Incident Investigation Form Number: CA 12-12a
AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY
Reference: CA18/2/3/8362
Aircraft Registration ZS-RWW Date of Accident 9 September 2007 Time of Accident 1000Z
Type of Aircraft Robinson R44 Raven II Type of Operation Training Flight
Pilot-in-command Licence Type Commercial Age 25 Licence Valid Yes
Pilot-in-command Flying Experience Total Flying Hours 668.8 Hours on Type Unknown
Last point of departure Port Alfred Aerodrome (FAPA)
Next point of intended landing Port Alfred Aerodrome (FAPA)
Location of the accident site with reference to easily defined geographical points (GPS readings if possible)
Farms Welgevind and Hopedale, Cove Ridge area near East London (GPS: South 33°04.210’ East 027°47.212’)
Meteorological Information Surface wind; 070°/9kt, Temperature; 18°C, Cloud cover; BKN 1000ft, BKN at 2100ft and OVC at 3000ft. Top of cloud between 6000 and 7000ft AGL.
Number of people on board 2 + 0 No. of people injured 0 No. of people killed 2 + 0
Synopsis
The helicopter, with two pilots on board, departed from Port Alfred Aerodrome on an instrument training
flight (IF). The intention was to fly to East London and perform the VOR/DME instrument approach for
Runway 11 at East London Aerodrome (FAEL). The pilot flying (PF) occupied the right front seat and
the instructor pilot occupied the left front seat. The helicopter was equipped with dual flight controls,
and was certified for operation in compliance with Visual Flight Rules (VFR) by day and night only. The
pilot flying was wearing “foggels” for the duration of the flight. On the approach approximately 5 nm to
the west of FAEL, the helicopter entered Instrument Meteorological Conditions (IMC). According to
several residents that were residing in the vicinity of the accident site, they could hear the helicopter
flying overhead in the direction of the aerodrome, but were unable to see it due to the overcast weather
conditions that prevailed. An unusual noise was heard, whereupon the helicopter went silent and the
next thing the eyewitnesses observed was the helicopter and associated parts/components falling from
the sky, through the clouds. Both occupants that were on board were fatally injured in the accident.
There was no damage to people and property on the ground.
Probable Cause
Incorrect recovery technique following a low-G push over condition in-flight, resulting in main rotor blade contact with the cockpit/cabin area, and subsequent loss of control.
IARC Date Release Date
CA 12-12a 23 FEBRUARY 2006 Page 2 of 35
Section/division Accident & Incident Investigation Form Number: CA 12-12a
AIRCRAFT ACCIDENT REPORT
Name of Owner : Activest 23 (Pty) Ltd
Name of the Operator : 43 Air School
Manufacturer : Robinson Helicopter Company
Model : R44 Raven II
Nationality : South African
Registration Marks : ZS-RWW
Place : Cove Ridge near East London
Date : 9 September 2007
Time : 1000Z
All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South
African Standard Time is UTC plus 2 hours.
Purpose of the Investigation:
In terms of Regulation 12.03.1 of the Civil Aviation Regulations (1997) this report was compiled in the
interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and
not to establish legal liability.
Disclaimer:
This report is produce without prejudice to the rights of the CAA, which are reserved.
1. FACTUAL INFORMATION 1.1 History of Flight:
1.1.1 The helicopter, occupied by two crew members, departed from Port Alfred
Aerodrome on an Instrument Flight Rules (IFR) training flight to East London. An
IFR flight plan was filed and the helicopter was refuelled to capacity, with 130 litres
of 100LL Avgas being uplifted prior to their departure.
1.1.2 The flight was conducted under the call sign of Prima 442 (PIU442). The pilot flying
occupied the right front seat and the instructor pilot occupied the left front seat.
The helicopter was equipped with dual flight controls. The pilot flying (PF) was
wearing “foggels” for the duration of the flight. These “foggels” are special glasses
CA 12-12a 23 FEBRUARY 2006 Page 3 of 35
that are worn by flight crew members during IF training in order to obscure/limit their
outside visibility, however, allowing adequate visibility to view the instrument panel,
which would be the primary function of the pilot while engaged in instrument flight
training.
Photo 1. A view of the foggel-type glasses, referred to in the paragraph 1.1.2.
1.1.3 The initial phase of the flight was conducted at 1 500 feet Above Mean Sea Level
(AMSL) until they were abeam Hamburg, as they approached East London
Aerodrome from the west. Radio communication was established with the East
London control tower on the VHF frequency 118.3 MHz and the aircraft was cleared
to climb to the Minimum Sector Altitude (MSA) of 4 500 feet AMSL. The Air Traffic
Controller (ATC) on duty was able to track the approaching aircraft via radar on a
monitor at his workstation. Radio communication between the ATC and the aircraft
was limited to this once-off clearance.
1.1.4 According to the radar footage, the aircraft climbed from 1 500 feet to 4 500 feet
AMSL where it levelled off and maintained its airspeed between 80 and 100 knots.
The height of the aircraft was noted as fluctuating between 4 400 feet and 4 600
feet AMSL. At no time had the ATC alerted the crew of this deviation, as they
managed to maintain their altitude within the 300 feet safety margin either way.
1.1.5 With the aircraft on the approach for the VOR/DME Runway 11 at East London
Aerodrome (approach plate included for reference on page 5 of report) the following
observations were noted from the radar footage. At the time the aircraft was
approximately 5 nm from the aerodrome. The values indicated below were as the
sequence of events followed.
CA 12-12a 23 FEBRUARY 2006 Page 4 of 35
Height indicated at 4 500 feet, airspeed 100 knots.
Height indicated at 4 400 feet, airspeed 110 knots.
Height indicated at 4 400 feet, airspeed 80 knots.
Height indicated at 4 300 feet, airspeed 40 knots.
Height indicated at 4 300 feet, airspeed 20 knots.
The aircraft (target) then disappeared from the radar screen. The sequence of
events occurred within a time frame of between 30 to 40 seconds.
Photo 2. A view of the radar screen with the helicopter (PIU442) approaching FAEL.
1.1.6 According to a witness who was standing in his garden at the time, he heard the
helicopter flying but was unable to see it due to obscure cloud cover. He then
heard what sounded to him like the rotor blades slowing down, followed by a loud
noise (bang), where after everything went quiet. He then observed the wreckage
falling through the clouds towards the ground in a nose-down attitude. The
cockpit/cabin area was broken up. He also saw the body of one of the occupants in
amongst the wreckage falling towards the ground.
He immediately contacted the emergency services, whereupon he rushed to the
scene of the accident. The main wreckage was located in dense bush-type terrain.
Once the emergency services arrived at the accident site, he withdrew from the
area.
East London Aerodrome
Helicopter climbing through 4000 feet on approach for FAEL.
CA 12-12a 23 FEBRUARY 2006 Page 5 of 35
1.1.7. The accident occurred during daylight conditions, and the main wreckage was
located at a geographical position determined as South 33°04.210’ East 027°
47.212’, which was 5 km (2.7 nm) from the aerodrome on a heading of 250°M at an
elevation of 300 feet AMSL. Both occupants on board the helicopter were fatally
injured in the accident. There was no damage or injury to people or property on the
ground.
Figure 1. Approach plate for the VOR/DME approach Runway 11 at East London.
1.2 Injuries to Persons:
Injuries Pilots Crew Pass Other
Fatal 2 - - -
Serious - - - -
Minor - - - -
CA 12-12a 23 FEBRUARY 2006 Page 6 of 35
None - - - -
1.3 Damage to Aircraft:
1.3.1 The helicopter was destroyed when the main rotor blades contacted and penetrated
the cockpit/cabin area in-flight and it crashed to the ground in a nose-down attitude.
Photo 3. A view of the main wreckage, which crashed in dense bush-type terrain.
1.4 Other Damage:
1.4.1 Although the wreckage was scattered over a large area consisting of two farms, no
damage or injury was caused to property or people on the ground.
1.5 Personnel Information:
1.5.1 Pilot-in-command:
Nationality Botswana Gender Male Age 25
Licence Number **************** Licence Type Private (Aeroplane)
Commercial (Helicopter)
Licence valid Yes Type Endorsed Yes
Ratings Instructor’s Rating Grade III, Instrument Rating, Undersling/
winch Rating. (The ratings are all applicable to helicopter
CA 12-12a 23 FEBRUARY 2006 Page 7 of 35
operations)
Medical Expiry Date 30 April 2008
Restrictions None
Previous Accidents None
Flying Experience:
Total Hours 668.8
Hours as Instructor on Helicopters 433.2
*NOTE: The pilot’s flying hours reflected above were obtained from his SACAA
pilot’s file. The last entry in the file prior to the accident was dated 31 July 2007,
when he submitted the form CA61-01.08 (Application for Renewal of Flight Crew
Member’s Licence). The hours flown during the Past 90 days prior to the accident
could not be concluded due to the unavailability of the pilot’s flying logbook, which
could not be located.
Flying Experience Aeroplane and Helicopter
Total Hours Aeroplane 224.2
Total Hours Helicopter 444.6
Total Hours 668.8
The pilot applied for a student pilot’s licence (aeroplane) to the SACAA on 11
February 2003. On 25 June 2003 he applied for a private pilot’s licence
(aeroplane), which was issued following compliance with the regulations pertaining
to the issue of a flight crew licence.
On 1 April 2004 the SACAA received an application from the pilot for a student
pilot’s licence (helicopter). On 13 May 2004 he applied for a private pilot’s licence
(helicopter), which was issued to him following compliance to the requirements as
stipulated in the regulations.
On 8 July 2004 the SACAA received a conversion application from the pilot for the
Robinson R44 helicopter after obtaining 7.1 hours of dual flight training onto the
type in question. The pilot obtained a conversion onto the Bell 206 series helicopter
on 2 June 2005 after 13.0 hours of dual flight instruction.
CA 12-12a 23 FEBRUARY 2006 Page 8 of 35
On 30 June 2005 the SACAA received an application form from the pilot for a
commercial helicopter pilot’s licence, which was issued to him following compliance
to the requirements as stipulated in the regulations.
On 23 September 2005 the SACAA received an application from the pilot for an
endorsement of a flight instructor’s rating on helicopters, which was approved.
On 31 March 2006 the pilot again applied for a student pilot’s licence (aeroplane)
and on 6 April 2006 he applied for a private pilot’s licence (aeroplane), which was
approved.
On 31 July 2007 the SACAA received a renewal form for the pilot’s commercial
helicopter pilot’s licence, which included an IF (Instrument Flying) proficiency test
that was conducted on 21 July 2007 by a CAA approved designated examiner.
*NOTE: According to the SACAA pilot’s file, on 9 May 2005 the pilot wrote one of
his Flight Instructor Rating (helicopter) examinations, with the subject being
‘Principles of Flight’, which he passed. One of the questions in the examination was
to explain the phenomenon know as Mast Bumping, which is explained in
paragraph 1.18.2 of this report, as it had a direct effect on this accident. The
question was correctly answered by the incumbent.
1.5.2 Pilot Flying:
Nationality Nigerian Gender Male Age 26
Licence Number ***************** Licence Type Commercial (Aeroplane)
Private (Helicopter)
Licence valid Yes Type Endorsed Yes
Ratings Instrument Rating (on aeroplane, expired on 24 July 2007)
The pilot did not hold any rating/s on helicopters.
Medical Expiry Date 30 April 2008
Restrictions None
Previous Accidents None
Flying Experience:
Total Hours 363.1
Total Past 90 Days 52.0
Total on Type Past 90 Days 13.0
CA 12-12a 23 FEBRUARY 2006 Page 9 of 35
Total on Type 13.0
Flying Experience Aeroplane and Helicopter
Total Hours Aeroplane 226.3
Total Hours Helicopter 136.8
Grand Total 363.1
The pilot applied for a student pilot’s licence (aeroplane) to the SACAA on 12 May
2004. On 15 July 2004 he applied for a private pilot’s licence (aeroplane), which
was issued following compliance with the regulations pertaining to the issue of a
flight crew’s licence. On 14 November 2005 the SACAA received an application for
a night rating, which was granted. On 25 July 2006 the SACAA received an
application for an instrument rating. Following the required commercial pilot’s
examinations and practical flight test, the pilot was issued with a commercial pilot’s
licence aeroplane on the date.
On 22 January 2007 the SACAA received an application from the pilot for a student
pilot’s licence (helicopter). On 17 May 2007 he applied for a private pilot’s licence
(helicopter), which was issued to him following the requirements as stipulated in the
regulations.
It was noted that the application form for a student pilot’s licence (helicopter)
contained both the Robinson R22 and R44 models. According to the pilot’s logbook
he had never flown a Robinson R44 during his training period as a private pilot,
although the aircraft type was endorsed onto his student pilot’s licence by the
SACAA.
According to the pilot’s logbook, the first time that he flew a Robinson R44
helicopter was on 2 August 2007, some time after he had already obtained his
helicopter private pilot’s licence. His conversion onto the Robinson R44 helicopter
was not endorsed by the flight school/flight instructor in his pilot’s logbook, but was
simply entered as a conversion. The conversion was conducted over a period of
seven days and comprised 6.0 hours of dual flying training, according to the pilot’s
logbook. The conversion onto the Robinson R44 was not performed in compliance
with the Air Navigation Regulations (ANR) of 1976, Chapter 2, paragraph 2.3
(3)(a)(i), which state the following:
CA 12-12a 23 FEBRUARY 2006 Page 10 of 35
(3) In the case of a piston-engined aeroplane having a maximum certified mass
of 5 700kg or less-
(a) the flight instructor or designated pilot shall on satisfactory completion of the
training for a type rating-
(i) make an endorsement to this effect in the logbook of the pilot who
received the training, whereupon that pilot shall be entitled to exercise
the privilege of such rating.
1.6 Aircraft Information:
1.6.1 The Robinson R44 Raven II is a four-seat, single reciprocating engine helicopter equipped with a skid landing gear. It is certified for Visual Flight Rules (VFR) operations by day. VFR operation at night is permitted only when landing, and navigation, instrument, and anti-collision lights are operational. Operation during night flight must be maintained by visual reference to ground objects illuminated solely by lights on the ground or adequate celestial illumination. NOTE: There may be additional requirements in countries outside the United States.
1.6.2 Airframe:
Type Robinson R44 Raven II
Serial Number 10217
Manufacturer Robinson Helicopter Company
Year of Manufacture 2003
Total Airframe Hours (At time of Accident) 1 315.8
Last MPI (Hours & Date) 1 304.9 30 August 2007
Hours since Last MPI 10.9
C of A (Issue Date) 13 February 2004
C of A (Currency Fee Expiry Date) 12 February 2008
C of R (Issue Date) (Present owner) 23 March 2007
Operating Categories Standard
SB’s and AD’s status Complied with
Type acceptance in RSA Yes
*NOTE: The airframe hours reflected in the table above at the time of the accident
CA 12-12a 23 FEBRUARY 2006 Page 11 of 35
was obtained from the aircraft’s Flight Folio and reflected the hours prior to the
accident flight. Due to the destruction of the airframe it was not possible to locate
the hobbs meter reading.
1.6.3 Engine:
Type Lycoming IO-540-AE1A5
Serial Number L-29017-48A
Hours since New 1 315.8
Hours since Overhaul T.B.O. not yet reached
1.6.4 Weight & Balance:
At the time of the accident there were only two occupants on board the four-seater
helicopter. They had been airborne for approximately 30 to 40 minutes when the
accident occurred. The maximum certified take-off weight for the helicopter
according to the Pilot’s Operating Handbook (POH), Section 2, page 2-3 was not
allowed to exceed 2 500 pounds (1134 kg). According to the post-mortem report
received, the two occupants weighed 70kg and 75kg respectively. The helicopter
was operated at the time of the accident within its maximum certified take-off weight
limitations.
1.6.5 Instrument Panel ZS-RWW
The photo below was obtained from one of the flight instructors at the training
school and had been inserted for illustration purposes, to reflect the instrument
panel layout of the helicopter in question.
Photo 4. An archive photo of the instrument panel of the accident helicopter ZS-RWW.
CA 12-12a 23 FEBRUARY 2006 Page 12 of 35
1.7 Meteorological Information:
1.7.1 An official meteorological report was obtained from the South African Weather
Services following the accident.
(i) Weather conditions at time of accident. (Surface analysis)
A trough of low pressure was present over the southern part of the country
with a weak cold front south-east of the country. Another weak cold front
was just west of Cape Town. Cloudy conditions were present on the Cape
east coast.
(ii) Satellite Image:
The satellite image (below) taken on 9 September 2007 at 1000Z, shows
cloudy conditions in the East London area.
Photo 5. Satellite image of the southern part of the country on 9 September 2007 at 1000Z.
(iii) Weather conditions in the vicinity of the incident.
No official observations were available at the time and place of the accident.
The East London Weather office issued the following Meteorological
Aeronautical Report/s (METARs) at 1000Z and 1030Z: