Analysis of Helicopter Accident on 24 Nov 15 – Muleri, Nagaland
On 24 Nov 15, a Helicopter belonging to Pawan Hans, flying for Govt of Nagaland ,met with an accident at Meluri helipad injuring two crew members and four passenger.
The helicopter was on a scheduled task Dimapur-Kohima-Mon-Meluri-Kohima. The flight was uneventful up to Mon. The helicopter took off from Mon to Meluri at 0455 Z. The flight up to Meluri approach was uneventful. On Meluri approach, pilot approached for beginning of the helipad. As he entered area around helipad at about 5-6 feet a huge dust bowl engulfed the helicopter. The visibility of the pilots reduced to zero due to dust bowl, pilots got disoriented and initiated a go around. After about 5 sec of initiating go around first Main rotor and then nose hit the 30 feet hillock, the helicopter toppled to the left. The helicopter caught fire in aft cabin, engine and front tail boom. All six occupants (two pilots and four passenger were rescued by local people and taken to hospital at Kohima. Both pilots sustained serious injuries while all four passengers received minor injuries.
The Inquiry Team during their investigation observed the following which may have contributed directly or indirectly to the occurrence of this accident:-
The PIC had a total flying experience of 6000 hers and the co-pilot had a total flying experience of around 6600 hrs.
Pilots were qualified to operate the flight.
Nagaland state transport (NST) had informed the Pawan Hans and yard master at Meluri in writing about flight schedule on 24 Nov 2015.
The flight was under VFR and the weather was Ok for the flight.
On 24.11.2015 flight was uneventful up to approach at Meluri.
‘H’ mark was clearly visible to the pilots.
Pilots observed that on normal approach direction of 110/290 deg vehicles were parked on road leading to the helipad, also people had gathered around the vehicles.
Therefore, pilots decided to carry out an approach in 150-160 direction. The approach was free from obstructions. Pilots had sufficient reserve of power and helipad was clearly visible.
At about 25-30 feet from the helipad, a small intensity dust from helipad was observed. Pilots decided to continue with the approach as helipad was clearly visible.
As helicopter entered the helipad for hover at about 5-6 feet, due to rotor downwash, a huge dust bowl engulfed the helicopter. This was due to loose mud and gravel on the helipad. The visibility reduced to zero and pilot lost all visual contact with ground and obstruction.
The PIC got disoriented and decided to initiate a go around, after about 5 sec of go around action MR blade and subsequently nose hit the 30 feet high hillock in ‘S’ direction, which was about 45 meters from the ‘H’.
Helicopter toppled to the left and caught fire. The pilos and the passengers were evacuated by locals and taken to Kohima hospital.
Pilots sustained serious injuries and passenger received minor injuries.
Cockpit was totally damaged, control column amd control rods were broken, tail boom was detached and all support of MGB were broken. Helicopter sustained substantial damage.
Additional Points by Inquiry Team
All maintenance was done as per schedule. Helicopter was ‘S’
Weather was fair with vis 2500 mtrs.
Temp helipad at Meluri was the responsibility of NST. NST were supposed to ensure security, ambulance/first aid, fire fighting, no unauthorised personnel at the helipad. Well aware of these duties NST did not inspect the helipad, did not ensure helipad free from loose gravel/dust/unauthorised personnel. Which is a contributory factor to the accident.
Both pilots discussed the approach in 150-160 direction with hillock as obstruction ahead, instead of 110/290, decision to continue approach (at 25-30 feet from helipad when small dust kicked up) aggravated the situation.
Pilots disoriented, engulfed by dust bowl with no visual contact with ground and obstruction decided to go around.
Crew did not follow SOP of approach in 110/290 dir. Crew did not appreciate the situation of go around, when initially dust kicked up at 25-30 fet away from helipad.
Even NST had prior knowledge of flight, dusty helipad was not watered. No arrangement for first aid and fire fighting made.
Last operation at the Meluri helipad by Pawan Hans helicopter was done on 28.06.2018.
Contributory Factors include
Helipad condition and management as per CAR
Pilot did not follow SOP of 110/290 approach with clear go around area.
From the Committee of Inquiry report, it becomes abundantly clear that the Operations by the Operator were being carried out without adequate supervision by operation department and ensuring that helipad condition at destination is as per CAR on the subject. This shows lack of involvement of Operation personnel towards safety.
Though, the pilots were highly experienced and qualified, did not ensure from authorities that helipad is fit for landing with all required facilities. Also, on reaching overhead did not carry out any recce, as helipad was not used for a very long time. This showed lack of safety culture and complacency on part of the crew.
Lack of situational awareness on part of crew, to go round when obstruction was in front and no visual contact with ground/obstruction.
Lessons which can be learnt from this accident are covered in succeeding paragraphs.
- Operation Risk Assessment must be carried out before undertaking any operations particularly going to a temporary helipad after a long time by both the crew and operations department team.
- Thorough Planning, preparation of the flight, pre-flight briefing, comprehensive helipad condition awareness. This can be achieved by obtaining inputs from the NST and district authorities responsible for maintenance of helipad, is of paramount importance and should not be neglected.
- Adherence to laid down SOPs saves the day.
- If a helipad not used for long time a recce is essential to know the obstructions, helipad condition, winds etc.
- Hazard identification and risk mitigation by discussing all the contingencies which could arise in use of a temporary helipad not used for a long time.
- Management of Change principle should be applied and safety should have been at top of agenda and ‘core value’ of company. Therefore all resources available should ensure and give proactive input to the crew that all arrangement and facilities at the destination required as per CAR are available. Any deficiency should be brought to the notice of crew.
- ERP for helipads should be prepared in consultation with responsible authorities and practiced.
- The CRM, SMS, Specific Ground Training, Safety and Emergency Procedures Training of the Pilots and other crew members need to be result oriented rather than tick the box syndrome to meet regulatory requirements.
- During simulator training go around should be practiced.
- All aircrew must be counselled that any amount of experience is no guaranty that accident will not happen to you, if you do not follow SOP
- The SOP’s must be reviewed, updated, approved and followed meticulously. Violation of SOP’s must be taken seriously.
- There is a definite need to learn lessons from past accidents/Incidents and the recommendations of Inquiry Committee must be implemented with the seriousness it deserves.
- Safety Management System is a proven process of managing safety through identification of hazards, Safety Risk Management and Safety Assurance to ensure that risk control measures introduced are effective.
- It is the moral duty of the Top Management to implement Safety Management System in letter and spirit and create safety culture in the organisation. Any lapse on the part of the Management on this subject must be viewed seriously.