Author: Aviation Safety India

It is reported that India’s Airport Security is unprepared for dangerous enemies in the sky. In the age when drones across the border can unleash terror, India’s Airport security is not equipped. The Bureau of Civil Aviation Security had issued an order earlier for a time-bound deployment of drone interception technology at all the airports across the country. After nine months, not a single airport in India is equipped with the technology. In the year 2019, an on Annual Anti-Terror Conference of the National Investigation Agency with all the stakeholders including the law enforcement agencies of states, the issue of criminal drones, or the drones that can be deployed for any kind of criminal activity was discussed.

Our Civil Airports are a soft target and attacks using Drones is a serious threat. China is almost a Drone Super Power and can indulge in some kind of Drone attacks or interference through Drones in connivance with Pakistan. Hence, it is essential that immediate steps are taken to neutralise such threats before they reach anywhere close to striking distance.

Another Major threat which is looming large is the Cyber Attack on the communication and Navigation system at the airports by our adversaries or rogue elements. We are hopeful  that this threat has been analysed and appreciated by Cyber Security Agencies of the country  and they must be working overtime to face this challenge.

 Introduction

Incorrect altimeter setting and lack of awareness among Pilots about the importance of correct altimeter setting has caused many accidents or near accidents.

The aircraft/Helicopter altimeter barometric sub-scale must be set to the appropriate setting for the phase of flight. Failure to set the appropriate barometric sub-scale pressure setting may result in a significant deviation from the cleared altitude or Flight Level

Flight level. Standard pressure setting (1013 hPa) is set when flying by reference to flight levels above the transition altitude;

Altitude. Regional or airfield pressure setting (QNH) is set when flying by reference to altitude above mean sea level below the transition level;

Height. Altimeter pressure setting indicating height above airfield or touchdown (QFE) is set when approaching to land at airfield where this procedure is in use.

Types of Altimeter Setting Error

The pilot mishears the transmitted pressure setting and sets an incorrect figure.

The pilot hears the transmitted pressure setting correctly but fails to set it or mis-sets it.

The pilot fails to change the pressure setting at the appropriate point in a departure, climb, descent or approach.

Effects

Failure to set the appropriate pressure setting can result in deviation from the cleared altitude or flight level leading to level bust, loss of separation from other traffic, and even collision with other aircraft or with the ground (CFIT).

Loss of situational awareness due to failure to appreciate the significance of a pressure setting (especially QFE as opposed to QNH). This can result in incorrect appreciation of the closeness of the ground possibly leading to an unstabilised approach or collision with the ground (CFIT).

Defences

Effective SOPs contained in company flight operations manuals which specify appropriate procedures for the setting and cross-checking of altimeter barometric sub scales.

Strict adherence to the verification of pressure-altitude-derived level procedure by ATC. This should be done at least once by each suitably equipped ATC unit. The check is performed by comparing the level received from surveillance sources with a voice report by the pilot.

System support – the Transponder always transmits the level information as flight level, regardless of the pressure setting. The ground system then converts this information to altitude/height.

Pilot Errors

A pilot fails to ensure that standard pressure is set when passing the transition altitude in the climb, and levels the aircraft at a flight level which differs from the cleared level by an amount dependent on the difference between the QNH and 1013 hPa.

A pilot fails to set QNH when passing the transition level in the descent and levels the aircraft at an altitude which differs from the cleared altitude by an amount dependent on the difference between QNH and 1013 hPa.

A pilot un-used to landing with QFE set, does not remember that the altimeter now indicates height above airfield elevation or touch-down zone.

Solutions

The existence of appropriate SOPs for the setting and cross-checking of altimeter sub scales and their strict observance is the only universal primary solution to eliminate incorrect altimeter setting.

Use of the aircraft radio altimeter to monitor the aircraft proximity with the ground can help to improve situational awareness provided that the flight crew are generally familiar with the terrain over which they are flying;

GPWS/GPWS/TAWS provide a safety net against CFIT and, in the case of TAWS Class ‘A’ with its option of a simple terrain mapping display, it can also be used to directly improve routine situational awareness.

Radio-altimeter Callouts

Radio-altimeter callouts can be either:

Announced (verbalized) by the PNF or the Flight Engineer.

Automatically generated by a synthesized voice (e.g., smart callouts).

Callouts should be tailored to the operating policy of the Operator and to the type of approach.

To enhance the flight crew’s terrain awareness, a callout “Radio altimeter alive”, should be announced by the first crewmember observing the radio altimeter activation at 2500 ft height AGL.

The radio altimeter reading should then be included in the instrument scanning for the remainder of the approach.

Radio altimeter readings (i.e., feet’s AGL) below the Minimum Obstacle Clearance (MOC) values listed below, should alert the flight crew

Initial approach segment (i.e., from IAF to IF) : 1000 ft;

Intermediate approach segment (i.e., from IF to FAF): 500 ft.

Final approach segment (i.e., after FAF, for non-precision approaches with a defined FAF, until visual references or reaching MAP) : 250 ft.

Unless the airport features high close-in terrain, the radio-altimeter reading (i.e., height

AGL) should reasonably agree with the height above airfield elevation (i.e., height AFE),

Obtained by:

Direct reading of the altimeter, if using QFE; or,

By subtracting the airport elevation from the altitude reading, if using QNH.

Operational and Human Factors Involved in Altimeter-setting Errors

The incorrect setting of the altimeter reference often is the result of one or more of

the following factors:

High workload;

Deviation from normal task sharing.

Interruptions and distractions.

Absence of effective cross-check and backup between crewmembers.

The analysis of incident / accident reports identify the following operational and human factors as causes of or contributing factors to altimeter-setting errors.

Incomplete briefings (i.e., failure to discuss the applicable altimeter-setting unit and the country practice for fixed or variable transitions altitudes / levels);

Workload during descent / approach.

Distraction / interruption;

Language difficulties (unfamiliar accents, speaking pace, unclear contraction of words, mixed English / local language communications)

Failure to cross-check altimeter-setting information (e.g., ATIS versus TWR messages, PF / PNF cross-check).

Fatigue;

Confusion between altimeter-setting units (i.e., in.Hg or hPa);

Excessive number of instructions given by ATC in a single message.

Confusion between numbers such as 5 and 9 (i.e., if 9 is pronounced as nine

instead of niner); and/or, Incorrect listening associated with ineffective read back / hear back loop (.

Flight Operations Briefing Note on Effective Pilot / Controller Communications).

 

 

Prevention Strategies and Personal Lines-of-Defence

Adherence to the defined task sharing (for normal or abnormal / emergency conditions) and the use of normal checklists are the most effective lines-of-defences against altimeter-setting errors.

Altimeter-setting errors often result in a lack of vertical situational awareness;

The following key points should be considered by pilots to minimize altimeter-setting

errors and to optimize the setting of the barometric-altimeter MDA(H) / DA(H) or radio-altimeter DH:

Awareness of the altimeter setting unit in use at the destination airport.

Awareness of rapid QNH / QFE changes due to prevailing weather conditions (i.e., extreme cold or warm fronts, steep frontal surfaces, semi-permanent or seasonal low pressure areas).

Awareness of the anticipated altimeter setting, using two independent sources for cross-check (e.g., METAR and ATIS messages).

Effective PF/PNF crosscheck and backup.

Adherence to SOPs for Sterile-cockpit rule during taxi, take off and descent-approach phases;

Change of barometric-altimeters setting in climb and descent:-

• In climb: at the transition altitude; and,
• In descent: when approaching the transition level and when cleared to an altitude.
• Use of standby-altimeter to cross-check main altimeters.

Altitude callouts (e.g., approach-fix crossing altitudes) including the radio-altimeter in the instrument scan, when the radio-altimeter is “alive” (i.e., below 2500 ft RA) radio-altimeter callouts.

Setting the barometric-altimeter MDA (H) or DA (H) or the radio-altimeter DH.

Exercising extra vigilance and cross-check if QFE is used for approach and landing.

The following prevention strategies should be considered by air traffic controllers:

Limiting the number of instructions transmitted in a given message.

Indicating all the numbers and the unit defining the altimeter setting.

Adhering to the standard phraseology and pronunciation.

Adopting the accepted terminology “Low” before a 28.XX in.Hg altimeter setting and

“High” before a 30.XX in.Hg altimeter setting.

 

Airports Authority of India (AAI) is extensively working towards the holistic development of the Surat Airport with a project cost of Rs 353 crore. The building will have five aerobridges.

New Delhi: Surat, the financial capital of Gujarat and hub for diamond and textile business in India attracts air travellers in large numbers from across the world and India. In fact, Surat Airport has witnessed one of the highest passenger traffic growth in the recent past. Surat Airport’s air traffic has grown around 600% from 2016-17 to 2018-19.

Considering the significant rise in passenger traffic in the last few years, Airports Authority of India (AAI) is extensively working towards the holistic development of the Surat Airport with a project cost of Rs 353 crore. This development project includes the extension of the existing terminal building from 8,474 sqm to 25,520 sqm.

Salient features of the developed terminal building:

Equipped with all modern passenger amenities, the developed terminal building will have 20 check-in counters.

The building will have five aerobridges, In-Line baggage handling system, five conveyor belts for arriving passengers

There will be car parking for 475 cars.

In addition to the extension of the current terminal building, the expansion of Apron from five parking bays to 23 Parking bays and construction of parallel taxi track (2,905 m X 30 m) work has also commenced. After completion of the project next year in December, the new state-of-the-art extended terminal building will be capable of handling 1,200 domestic and 600 international passengers’ during peak hours taking the annual passenger capacity to 2.6 million.

The modernized airport terminal will be 4-Star GRIHA rated energy-efficient building and the interiors will reflect the art and culture of Gujarat. The Foundation Stone for the extension of Terminal Building of Surat Airport was laid by Prime Minister Modi on 30th January 2019. The new world-class terminal building of the airport will give impetus to the growth of the region.

Worth mentioning that last year, the Cabinet gave its approval for the development of a new Greenfield Airport at Hirasar, Rajkot in Gujarat at an estimated cost of Rs 1,405 crore. The existing airport at Rajkot is severely land constrained having only 236 acres (approx.) of land and situated in the heart of the city. The government has already identified the  equired land for the new airport and has also requested Airports Authority of India to develop, operate and maintain the new airport.

 

 

Accidents and Incidents involving Helicopters/Rotary Wing Aircraft

• A109, vicinity London Heliport London UK, 2013 (On 16 January 2013, an Augusta 109E helicopter positioning by day on an implied (due to adverse weather conditions) SVFR clearance collided with a crane attached to a tall building under construction. It and associated debris fell to street level and the pilot and a pedestrian were killed and several others on the ground injured. It was concluded that the pilot had not seen the crane or seen it too late to avoid whilst flying by visual reference in conditions which had become increasingly challenging. The Investigation recommended improvements in the regulatory context in which the accident had occurred.)
• A139 / A30B, Ottawa Canada, 2014 (On 5 June 2014, an AW139 about to depart from its Ottawa home base on a positioning flight exceeded its clearance limit and began to hover taxi towards the main runway as an A300 was about to touch down on it. The TWR controller immediately instructed the helicopter to stop which it did, just clear of the runway. The A300 reached taxi speed just prior to the intersection. The Investigation attributed the error to a combination of distraction and expectancy and noted that the AW139 pilot had not checked actual or imminent runway occupancy prior to passing his clearance limit.)
• A139, vicinity Sky Shuttle Heliport Hong Kong China, 2010 (On 3 July 2010, an AW139 helicopter was climbing through 350 feet over Victoria Harbour Hong Kong just after takeoff when the tail rotor detached. A transition to autorotation was accomplished and a controlled ditching followed. All occupants were rescued but some sustained minor injuries. The failure was attributed entirely to manufacturing defects but no corrective manufacturer or regulatory action was taken until two similar accidents had occurred in Qatar (non-fatal) and Brazil (fatal) the following year and two interim Safety Recommendations were issued from this Investigation after which a comprehensive review of the manufacturing process led to numerous changes.)
• A169, Leicester UK, 2018 (On 27 October 2018, a single pilot Augusta Westland AW169 lifted off from within the Leicester City Football Club Stadium, but after a failure of the tail rotor control system, a loss of yaw control occurred a few hundred feet above ground. The helicopter began to descend with a high rotation rate and soon afterward impacted the ground and almost immediately caught fire, which prevented those onboard surviving. An Investigation is being conducted by the UK AAIB.)
• A319 / AS32, vicinity Marseille France, 2016 (On 27 June 2016, an Airbus A319 narrowly avoided a mid-air collision with an AS532 Cougar helicopter whose single transponder had failed earlier whilst conducting a local pre-delivery test flight whilst both were positioning visually as cleared to land at Marseille and after the helicopter had also temporarily disappeared from primary radar. Neither aircraft crew had detected the other prior to their tracks crossing at a similar altitude. The Investigation attributed the conflict to an inappropriate ATC response to the temporary loss of radar contact with the helicopter aggravated by inaccurate position reports and non-compliance with the aerodrome circuit altitude by the helicopter crew.)
• A320 / A139 vicinity Zurich Switzerland, 2012 (On 29 May 2012, a British Airways Airbus A320 departing Zürich and in accordance with its SID in a climbing turn received and promptly and correctly actioned a TCAS RA ‘CLIMB’. The conflict which caused this was with an AW 139 also departing Zürich IFR in accordance with a SID but, as this aircraft was only equipped with a TAS to TCAS 1 standard, the crew independently determined from their TA that they should descend and did so. The conflict, in Class ‘C’ airspace, was attributed to inappropriate clearance issue by the TWR controller and their inappropriate separation monitoring thereafter.)
• AS32 / B734, Aberdeen UK, 2000 (For reasons that were not established, a Super Puma helicopter being air tested and in the hover at about 30 feet agl near the active runway at Aberdeen assumed that the departure clearance given by GND was a take off clearance and moved into the hover over the opposite end of the runway at the same time as a Boeing 737 was taking off. The 737 saw the helicopter ahead and made a high speed rejected take off, stopping approximately 100 metres before reaching the position of the helicopter which had by then moved off the runway still hovering.)
• AS32, en-route, North Sea Norway, 1998 (On 20 October 1998, in the North Sea, an Eurocopter AS332L Super Puma operated by Norsk HeliKopter AS, experienced engine failure with autorotation and subsequent lost of height. The crew misidentified the malfunctioning engine and reduced the power of the remaining serviceable engine. However, the mistake was realised quickly enough for the crew to recover control of the helicopter.)
• AS32, en-route, North Sea UK, 2002 (On 28th February 2002, an Aerospatiale AS332L Super Puma helicopter en route approximately 70 nm northeast of Scatsa, Shetland Islands was in the vicinity of a storm cell when a waterspout was observed about a mile abeam. Soon afterwards, violent pitch, roll and yaw with significant negative and positive ‘g’ occurred. Recovery to normal flight was achieved after 15 seconds and after a control check, the flight was completed. After flight, all five tail rotor blades and tail pylon damage were discovered. It was established that this serious damage was the result of contact between the blades and the pylon.)
• AS32, en-route, near Peterhead Scotland UK, 2009 (On 1 April 2009, the flight crew of a Bond Helicopters’ Eurocopter AS332 L2 Super Puma en route from the Miller Offshore Platform to Aberdeen at an altitude of 2000 feet lost control of their helicopter when a sudden and catastrophic failure of the main rotor gearbox occurred and, within less than 20 seconds, the hub with the main rotor blades attached separated from the helicopter causing it to fall into the sea at a high vertical speed The impact destroyed the helicopter and all 16 occupants were killed. Seventeen Safety Recommendations were made as a result of the investigation.)
• AS3B, en-route, northern North Sea UK, 2008 (On 22 February 2008, a Eurocopter AS332 L2 Super Puma flying from an offshore oil platform to Aberdeen was struck by lightning. There was no apparent consequence and so, although this event required a landing as soon as possible, the commander decided to continue the remaining 165nm to the planned destination which was achieved uneventfully. Main rotor blade damage including some beyond repairable limits was subsequently discovered. The Investigation noted evidence indicating that this helicopter type had a relatively high propensity to sustain lightning strikes but noted that, despite the risk of damage, there was currently no adverse safety trend.)
• AS3B, vicinity Den Helder Netherlands, 2006 (On 21 November 2006, the crew of a Bristow Eurocopter AS332 L2 making an unscheduled passenger flight from an offshore platform to Den Helder in night VMC decided to ditch their aircraft after apparent malfunction of an engine and the flight controls were perceived as rendering it unable to safely complete the flight. All 17 occupants survived but the evacuation was disorganised and both oversight of the operation by and the actions of the crew were considered to have been inappropriate in various respects. Despite extensive investigation, no technical fault which would have rendered it unflyable could be confirmed.)
• AS3B, vicinity Sumburgh Airport Shetland Islands UK, 2013 (On 23 August 2013, the crew of a Eurocopter AS332 L2 Super Puma helicopter making a non-precision approach to runway 09 at Sumburgh with the AP engaged in 3-axes mode descended below MDA without visual reference and after exposing the helicopter to vortex ring conditions were unable to prevent a sudden onset high rate of descent followed by sea surface impact and rapid inversion of the floating helicopter. Four of the 18 occupants died and three were seriously injured. The Investigation found no evidence of contributory technical failure and attributed the accident to inappropriate flight path control by the crew.)
• AS50 / PA32, en-route, Hudson River NJ USA, 2009 (On August 8, 2009 a privately operated PA32 and a Eurocopter AS350BA helicopter being operated by Liberty Helicopters on a public transport sightseeing flight collided in VMC over the Hudson River near Hoboken, New Jersey whilst both operating under VFR. The three occupants of the PA32, which was en route from Wings Field PA to Ocean City NJ, and the six occupants of the helicopter, which had just left the West 30th Street Heliport, were killed and both aircraft received substantially damaged.)
• AS50, Dalamot Norway, 2011 (On 4 July 2011, an Airlift Eurocopter AS 350 making a passenger charter flight to a mountain cabin in day VMC appeared to suddenly depart controlled flight whilst making a tight right turn during positioning to land at the destination landing site and impacted terrain soon afterwards. The helicopter was destroyed by the impact and ensuing fire and all five occupants were fatally injured. The subsequent investigation came to the conclusion that the apparently abrupt manoeuvring may have led to an encounter with ‘servo transparency’ at a height from which the pilot was unable to recover before impact occurred.)
• AS50, en-route, Hawaii USA, 2005 (On 23 September 2005, an AS350 helicopter, operated by Heli USA Airways, crashed into the sea off Hawaii following loss of control associated with flight into adverse weather conditions.)
• AS50, manoeuvring, East River New York USA, 2018 (On 11 March 2018, an Airbus AS350 engine failed during a commercial sightseeing flight and autorotation was initiated. The pilot then noticed that the floor-mounted fuel cut-off had been operated by part of the tether system of one of the five passengers but there was insufficient time to restore power. On water contact, the automatic floatation system operated asymmetrically and the helicopter submerged before the occupants could evacuate. Only the pilot was able to release his harness and escape because the unapproved adapted passenger harnesses had no quick release mechanism. The Investigation found systemic inadequacy of the operator’s safety management system.)
• AS55, vicinity Fairview Alberta Canada, 1999 (On 28th April 1999, an AS-355 helicopter suffered an in-flight fire attributed to an electrical fault which had originated from a prior maintenance error undetected during incomplete pre-flight inspections. The aircraft carried out an immediate landing allowing evacuation before the aircraft was destroyed by an intense fire.)
• AS65, vicinity North Morecambe Platform Irish Sea UK, 2006 (On 27 December 2006, an AS365 Dauphin 2, operated by CHC Scotia, crashed into the sea adjacent to a gas platform in Morecambe Bay, UK, at night, following loss of control.)
• B412, vicinity Karlsborg Sweden, 2003 (On 25 March 2003, the crew of a Bell 412 lost control of the aircraft as a result of pilot mishandling associated with the development of a Vortex Ring State.)
• D150 / H500, London UK, 2007 (On 5 October 2007, a loss of separation occurred between a Hughes 369 helicopter and a Jodel D150. The incident occurred outside controlled airspace, in VMC, and the estimated vertical separation as the Jodel took avoiding action by descending, was assessed by both pilots to be less than 50 feet.)
• D328 / R44, Bern Switzerland, 2012 (On 2 June 2012, a Dornier 328 and a commercially-operated Robinson R44 helicopter came into close proximity within the airport perimeter whilst both were departing from Bern in VMC as cleared. The Investigation attributed the conflict to inappropriate issue of clearances by the controller in a context of an absence of both a defined final approach and take off area and fixed departure routes to the three designated departure points.)
• EC25, en-route, 20nm east of Aberdeen UK, 2012 (On 10 May 2012, the crew of a Eurocopter EC225 LP on a flight from Aberdeen to an offshore platform received an indication that the main gearbox (MGB) lubrication system had failed. Shortly after selecting the emergency lubrication system, that also indicated failure and the crew responded in accordance with the QRH drill to “land immediately” by carrying out a successful controlled ditching. The ongoing investigation has found that there had been a mechanical failure of the MGB but that the emergency lubrication system had, contrary to indications, been functioning normally.)
• EC25, en-route, 32nm southwest of Sumburgh UK, 2012 (On 22 October 2012, the crew of a Eurocopter EC225 LP on a flight from Aberdeen to an offshore platform received an indication that the main gearbox (MGB) lubrication system had failed. Shortly after selecting the emergency lubrication system, that system also indicated failure and the crew responded in accordance with the QRH drill to “land immediately” by carrying out a successful controlled ditching. The ongoing investigation has found that there had been a mechanical failure within the MGB but that the emergency lubrication system had, contrary to indications, been functioning normally.)
• EC25, vicinity Bergen Norway, 2016 (On 29 April 2016, an Airbus EC225 Super Puma main rotor detached without warning en-route to Bergen. Control was lost and it crashed and was destroyed. Rotor detachment was attributed to undetected development of metal fatigue in the same gearbox component which caused an identical 2009 accident to a variant of the same helicopter type. Despite this previous accident, the failure mode involved had not been properly understood or anticipated. The investigation identifies significant lessons to be learned related to gearbox design, risk assessment, fatigue evaluation, gearbox condition monitoring, type certification and continued airworthiness, which may also be valid for other helicopter types.)
• EC25, vicinity ETAP Central offshore platform, North Sea UK (On 18 February 2009, the crew of Eurocopter EC225 LP Super Puma attempting to make an approach to a North Sea offshore platform in poor visibility at night lost meaningful visual reference and a sea impact followed. All occupants escaped from the helicopter and were subsequently rescued. The investigation concluded that the accident probably occurred because of the effects of oculogravic and somatogravic illusions combined with both pilots being focused on the platform and not monitoring the flight instruments.)
• EC25, Åsgård B Platform North Sea, 2012 (On 12 January 2012, the crew of an EC 225LP helicopter were unable to prevent it almost departing the helideck at the offshore platform where it had just made a normal touch down at night after an en route diversion prompted by a partial hydraulic failure. An emergency evacuation was ordered and ground crew intervention prevented further helicopter movement. A component in the left main landing gear brake unit was found to have failed due to a manufacturing fault. Emergency Regulatory action for the helicopter type followed in respect of both the airworthiness and operational issues highlighted by the Investigation.)
• EC35, Sollihøgda Norway, 2014 (On 14 January 2014, the experienced pilot of an EC 135 HEMS aircraft lost control as a result of a collision with unseen and difficult to visually detect power lines as it neared the site of a road accident at Sollihøgda to which it was responding which damaged the main rotor and led to it falling rapidly from about 80 feet agl. The helicopter was destroyed by the impact which killed two of the three occupants and seriously injured the third. The Investigation identified opportunities to improve both obstacle documentation / pilot proactive obstacle awareness and on site emergency communications.)
• EC35, vicinity Glasgow City Heliport UK, 2013 (On 29 November 2013, control of an Airbus Helicopters EC135 undertaking a night VMC night for policing purposes was lost after both engines flamed out following fuel starvation. The subsequent crash killed the three occupants and seven on the ground, seriously injuring eleven others. The Investigation found that although the pilot had acknowledged low fuel warnings after both fuel transfer pumps had been switched off, the helicopter had not then been landed within 10 minutes as required. No evidence of any relevant airworthiness defects was found and without FDR/CVR data, a full explanation of the accident circumstances was not possible.)
• EC55, en-route, Hong Kong China, 2003 (On 26 August 2003, at night, a Eurocopter EC155, operated by Hong Kong Government Flight Service (GFS), performing a casualty evacuation mission (casevac), impacted the elevated terrain in Tung Chung Gap near Hong Kong International airport.)
• F100 / EC45, vicinity Bern Switzerland, 2012 (On 24 May 2012, a Fokker 100 descending visual downwind to land at Berne and an EC145 helicopter transiting the Bern CTR (Class ‘D’ airspace) VFR came within 0.7 nm horizontally and 75 ft vertically despite early traffic advice having been given to both aircraft. The Investigation attributed the conflict to the failure of the F100 crew to follow either their initial TCAS RA or a subsequent revised one and noted that although STCA was installed at Berne it had been disabled “many years before”.)
• H500 / D150, en-route, North of London UK, 2007 (On 5 October 2007, a loss of separation occurred between a Hughes 369 helicopter and a Jodel D150. The incident occurred outside controlled airspace, in VMC, and the estimated vertical separation as the Jodel took avoiding action by descending, was assessed by both pilots to be less than 50 feet.)
• NIM / AS32, vicinity RAF Kinloss UK, 2006 (On 17 October 2006, at night, in low cloud and poor visibility conditions in the vicinity of Kinloss Airfield UK, a loss of separation event occurred between an RAF Nimrod MR2 aircraft and a civilian AS332L Puma helicopter.)
• P28A / S76, Humberside UK 2009 (On 26 September 2009, a Piper PA28-140 flown by an experienced pilot was about to touch down after a day VMC approach about a mile behind an S76 helicopter which was also categorised as ‘Light’ for Wake Vortex purposes rolled uncontrollably to the right in the flare and struck the ground inverted seriously injuring the pilot. The Investigation noted existing informal National Regulatory Authority guidance material already suggested that light aircraft pilots might treat ‘Light’ helicopters as one category higher when on approach and recommended that this advice be more widely promulgated.)
• S61, vicinity Bournemouth UK, 2002 (On 15 July 2002, a Sikorsky S-61 helicopter operated by Bristow suffered a catastrophic engine failure and fire. After an emergency landing and evacuation, the aircraft was destroyed by an intense fire.)
• S61, vicinity Bødo Norway, 2008 (On 24 February 2008, a Sikorsky S-61N being operated by British International Helicopters on a passenger flight from Værøy to Bødo attempted a visual approach at destination in day IMC and came close to unseen terrain before accepting an offer of assistance from ATC to achieve an ILS approach to runway 07 without further event. None of the 18 occupants were injured.)
• S76, Peasmarsh East Sussex UK, 2012 (On 3 May 2012, a Sikorsky S76C operating a passenger flight to a private landing site at night discontinued an initial approach because of lack of visual reference in an unlit environment and began to position for another. The commander became spatially disorientated and despite a number of EGPWS Warnings, continued manoeuvring until ground impact was only narrowly avoided – the minimum recorded height was 2 feet +/- 2 feet. An uneventful diversion followed. The Investigation recommended a review of the regulations that allowed descent below MSA for landing when flying in IMC but not on a published approach procedure.)
• S76, en-route, southeast of Lagos Nigeria, 2016 (On 3 February 2016, a Sikorsky S76C crew on a flight from an offshore platform to Lagos was ditched when the crew believed that it was no longer possible to complete their intended flight to Lagos. After recovering the helicopter from the seabed, the Investigation concluded that the crew had failed to perform a routine standard procedure after takeoff – resetting the compass to ‘slave rather than ‘free’ mode – and had then failed to recognise that this was the cause of the flight path control issues which they were experiencing or disconnect the autopilot and fly the aircraft manually.)
• S76, vicinity Lagos Nigeria, 2015 (On 12 August 2015, a Sikorsky S76C crew on a flight from an offshore platform to Lagos lost control of their aircraft after a sudden uncommanded pitch up, yaw and roll began and 12 seconds later it crashed into water in a suburb of Lagos killing both pilots and four of the 10 passengers. The Investigation concluded that the upset had been caused by a critical separation within the main rotor cyclic control system resulting from undetected wear at a point where there was no secondary mechanical locking system such as a locking pin or a wire lock to maintain system integrity.)
• S76, vicinity Moosonee ON Canada, 2013 (On 31 May 2013 the crew of an S76A helicopter positioning for a HEMS detail took off VFR into a dark night environment and lost control as a low level turn was initiated and did not recover. The helicopter was destroyed and the four occupants killed. The Investigation found that the crew had little relevant experience and were not “operationally ready” to conduct a night VFR take off into an area of total darkness. Significant deficiencies at the Operator and in respect of the effectiveness of its Regulatory oversight were identified as having been a significant context for the accident.)
• S92, West Franklin Wellhead Platform North Sea, 2016 (On 28 December 2016, yaw control was lost during touchdown of a Sikorsky S92A landing on a North Sea offshore platform and it almost fell into the sea. The Investigation found that the loss of control was attributable to the failure of the Tail Rotor Pitch Change Shaft bearing which precipitated damage to the associated control servo. It was also found that despite HUMS monitoring being in place, it had been ineffective in proactively alerting the operator to the earlier stages of progressive bearing deterioration which could have ensured the helicopter was grounded for rectification before the accident occurred.)
• S92, en-route, east of St John’s Newfoundland Canada, 2009 (On 12 March 2009, a Sikorsky S-92A crew heading offshore from St. John’s, Newfoundland declared an emergency and began a return after total loss of main gear box oil pressure but lost control during an attempted ditching. The Investigation found that all oil had been lost after two main gear box securing bolts had sheared. It was noted that ambiguity had contributed to crew misdiagnosis the cause and that the ditching had been mishandled. Sea States beyond the capability of Emergency Flotation Systems and the limited usefulness of personal Supplemental Breathing Systems in cold water were identified as Safety Issues.)
• S92, northeast of Aberdeen UK, 2018 (On 23 August 2018, a low experience Sikorsky S92 First Officer undergoing line training made a visual transit between two North Sea offshore platforms but completed an approach to the wrong one. The platform radio operator alerted the crew to their error and the helicopter then flew to the correct platform. The Investigation attributed the error primarily to the inadequate performance of both pilots on what should have been a straightforward short visual flight but particularly highlighted the apparent failure of the Training Captain to fully recognise the challenges of the flight involved when training and acting as Pilot Monitoring.)