FINAL INVESTIGATION REPORT ON ACCIDENT TO Bell 212 HELICOPTER  AT (TUKAWADE) THANE ON 29/09/2013

FINAL INVESTIGATION REPORT ON ACCIDENT TO Bell 212 HELICOPTER  AT (TUKAWADE) THANE ON 29/09/2013

 The helicopter departed from Juhu airport for Aurangabad at 07:47 IST with 05 persons on board.  The flight plan was filed to fly the route under VFR conditions at 2000 feet AGL with endurance of 02:30 hours. As per ATC, the helicopter changed over the frequency from Juhu to approach control at 05 NM. Juhu ATC passed the ETA 09:30 IST to the control tower. At 09:18 IST, Juhu ATC received call from FIC stating, Helicopter is not in contact. Later WSO, Mumbai informed to Juhu ATC that the helicopter had crashed near Murbad and the same information was passed to Operator at 1010 hrs. IST. At the same time, message was received that the helicopter crashed at 0820 hrs. IST. The location of accident was at around 49 NM from Juhu airport and 104 NM prior to Aurangabad.

 

All the occupants received fatal injuries. The accident occurred in day light conditions.

PIC -52 Years old-Total Experience-Helicopters -3700 Hrs. Total Experience Bell 212-1432 Hrs-PIC on Bell 212-406 Hrs.

Co Pilot-30 Years Old- Total Flying Experience-1727 Hrs. Total Experience on Bell 212-451 Hrs-PIC –Nil.

The CEO of the company is from finance background. The Chief Pilot of the Company is a non-flying pilot though he has got very good experience of helicopter flying.

The Company did not have any permanent contract for the leasing of helicopters from April, 2013. The flying was very limited. There was limited flying and as per the company there was no DGCA approved examiner available on type of helicopter. Bell 212 has been accepted as a variant of the Bell 412 by DGCA and the recurrent checks were carried out at HATSOFF, Bangalore whenever an external examiner was not available.

The helicopter was under flyable storage since 29.5.2013. De-preservation of flyable storage was carried out on 8.8.2013 followed by 90 days/ 100 hrs. Flyable storage inspection was again carried out on 14.8.2013 at 23575:30 hrs. And was repeated periodically till 28.09.2013.

No flight check was conducted prior to releasing the helicopter for the positioning flight as this was not required as per the Company’s approved maintenance schedule.

The CVR readout has the following transmissions by the crew to the engineer on board:

o “Radar should give us something where are we entering.” o “It is not painting yar.” o “…… your radar is not working weather radar.” o “From start it was not working.” o “It was not painting. It is not painting at all.”

The CVR readout of the flight reveals that the Weather Radar was not working during the flight.

The following are the relevant portion of the CVR transcript indicating that the crew was aware of poor visibility conditions immediately after take-off.

“How is the weather?” “Give me wiper yar shortly.” “Because here the clouding is there.” “Now I can’t really make out where are we are. Where are we are.”

The following portion of CVR transcript

PF OK now concentrate on instruments ha. I am on instruments, PNF OK Reduce speed. Right is clear, Now can we descent down a little?  PF No, I will not. PNF Just fly orbit……. You want to turn back? PF No, PNF your rate of descent … rate of descent … rate of descent. PF Mine is OK,I have controls, PNF We are going down We are going down. PF We are not going down.. Hold on. Leave the controls.

Almost immediately thereafter, as Spatial Disorientation had set in, it resulted in the crash.

Further the following CVR transcript indicates that the PIC was

not very much familiar with the track/ terrain.

“Am I steering correctly?”

“Is this my track?”

“What am I supposed to track now?”

“Have we crossed Thane now?”

From the CVR read out it is clear that:

 They experienced poor visibility right from the beginning.

 The pilot was not very familiar with the terrain.

 The radar was unserviceable.

The flight was continued in poor visibility and without adequate terrain clearance. The pilot tried to maintain ground contact, resulting in not having safe ground clearance. The last contact with the helicopter was at 0243 UTC  (25mins 32secs after take-off).

The pilot encountered IMC conditions at 0245 UTC (approximately 27mins after take-off) and decided to fly on instruments.

At approximately 0248 UTC, complete Spatial Disorientation set in, resulting in the fatal crash.

ELT functional check was carried out on 28.9.2013. The ELT antenna got detached during the accident from the ELT therefore, though the ELT was functional (blinking) but the signal was not transmitted /captured by the designated organizations.

 

 

Analysis by ASMSI

The analysis of the accident by ASMSI is based on the Inquiry Report of the Accident placed on DGCA website. In order not to burden the readers with too much of material, only the relevant portion from the report has been included as covered above.

The Operator was the only operator of Bell 212 in the country. No type examiner was available on Bell 212.The PC, other tests and Recurrent Training were being done on the Bell 412 Simulator as approved by DGCA. This has a bearing on the skill levels of the Pilots since there is considerable difference between the handling and operating the Helicopters under different flying conditions.

The Operator is headed by a CEO with financial background and obviously has very little knowledge about the Operating environments of the Helicopter Operations. The Chief Pilot of the Company, though highly experienced helicopter Pilot, was not flying any type of helicopter in the Company and as such was not in an authoritative position to assert himself in a professional manner, in ensuring conducive flying and safety environments in the Company. This has a bearing on the safety and efficiency of the operations being conducted by Company.

The Operator had 3 helicopters and 8 Pilots but no contracts for generating revenue for the Company for quite some time. Flying was very limited and the Operator must be going through financial stress. The stress on the Pilots, AME’s, Technicians and in fact on all the Company personnel including CEO must be tremendous. The Operator must have pulled out all the stops to ensure positioning of the Bell 212 to Nagpur where they had received a contract for 30 days.

Since there was no flying in the Company, Bell 212 which was on preservation for a long period of time, with of course regular maintenance, must have been hurriedly prepared and made ready for the ferry. Even a Flight check to ensure that the helicopter was fully serviceable was not carried out before departing for the positioning. The Pilots in their exuberance to undertake the task, seem to have overlooked the need for a thorough inspection and Flight Check to ascertain the airworthiness of the Helicopter.

Both the Pilots were well experienced. However due to large difference in their age, experience and status (Power Distance/Cockpit Gradient/Authority Gradient), the Co Pilot was inhibited to give inputs and assert himself when the situation demanded. Hence even after noticing the confusion in the mind of the Pilot (CVR Readings), the Co Pilot was not able to assert himself to advise the Captain to return or find a suitable place to land.

The Weather Radar was found to be unserviceable during flight as is evident from the CVR readings. It appears that the Pilots never checked the serviceability of the Radar during ground run. If they had checked the Radar during ground run, its unserviceability would have come to their notice and necessary rectification of the Radar would have been undertaken. It also highlights the importance of a Flight Check if the helicopter has been released for flying after long period of preservation.

The Pilots were not familiar with the terrain most of which is hilly, high ground and likely adverse weather conditions in their route. The Pilots did not take the weather clues of degraded visibility and low clouds into consideration and continued the flight hoping for better weather conditions. The Captain was forced to fly with ground contact since he had non-functional Radar and may be not confident to fly through clouds or undercast.

The low cloud base and poor visibility must have forced the Pilots to fly at lower heights close to the ground so as to remain in contact with ground. The terrain and ground was undulating and the pilots must have been changing their height and direction frequently to avoid high features and weather. Under such conditions, the Pilots seem to have panicked, got disorientated and crashed.

There appears to be lack of Planning and Preparation of the Flight, Knowledge about the Terrain, Weather, Spatial Disorientation, Controlled Flight into Terrain, Situational Awareness, Crew Resource Management, Decision Making, Supervision and Monitoring.

Lessons Learnt

  • Planning and Preparation for the Flight is absolutely essential for the safe and efficient conduct of the Flight. During planning and preparation, the Pilots must have very good knowledge of the Terrain (including knowledge of the Electric, Telephone Cables, Pylons, Towers, Trolley cables particularly in the hills and other obstructions, Minimum Safe Altitude, Enroute Altitude, Minimum Descent Altitude, Minimum off Route Altitude and obstructions around and in the approach path of the Airfield/Helipad.
  • The next important consideration is weather. It is essential that the Pilots are well informed about weather conditions at the departure and arrival airport/helipad and enroute, the season in which they are operating and the likelihood of generally rough weather in the hilly terrain. The Pilots must learn to respect the weather and should remain alert and vigilant to monitor the weather cues and take decision in time to return, divert or land before the return route/passage closes.
  • Low clouds, rain, fog, poor visibility and hilly/high ground terrain are deadly combination. Keep this aspect in mind, always.
  • Please do not succumb to any kind of pressure whether it is Company pressure, Commercial pressure, VIP or passenger pressure or self-imposed pressure. Unfortunately most of us tend to take wrong decision under pressure. Pressures will always be there. Pilots must learn to handle pressure without succumbing to it. Remember most of the fatal accidents are caused due to wrong decision making by the Pilots under pressure. Always carry out proper risk assessment and undertake the flight in a professional manner.
  • The Co Pilots have to be fully prepared for the Flight, carry out thorough Pre Flight Planning, Preparation, have good knowledge, be alert, vigilant, situationally aware, fully involved with the progress of the flight and assertive if the situation demands to caution the Pilot. They should be an asset in the cockpit and not a dead weight or liability.
  • Pre Flight briefing must be carried out by the Captain covering all the aspects of the flight, likely threat to the safety and efficiency of the flight and role of each crew member in normal as well as emergency situation.
  • Regardless of the pressures, no compromise should be made on the full airworthiness of the Helicopter. Short cuts can lead to catastrophic consequences.

If the Helicopter has not flown for a long period, a proper ground run and Flight Check are essential requirements to ascertain the Airworthiness of the Helicopter and should not be overlooked. Pre Flight Checks must be carried out meticulously and all the equipment should be checked for its proper functioning. If unserviceability of any critical equipment for the safety of the flight over particular terrain or weather conditions is observed, the Pilots should not hesitate to abandon the mission and return/divert or land.

  • The CEO of the Company should be appointed with due care since he has an important role in promoting safety and efficiency of the conduct of operations in the Company. If CEO is not from Aviation background than the Company should have an Accountable Executive who is knowledgeable about the Aviation and is accountable to DGCA for ensuring safe flying environments in his Company. He should be fully involved in the conduct of flying operations of the Company and should conduct close monitoring and supervision through Chief Pilot or Chief Operating Officer.
  • There is no place for ego, overconfidence, unprofessional attitude, resigning to fate and show off to impress others. Self-styled Rambos are a serious threat to safety, reputation and survival of the company. Always be a thorough professional, carry out proper Risk Assessment and always err on the positive side.
  • Mind Set, get theiritis, homeitis and mission accomplishment at all cost are serious threat to safety. All the Pilots must keep these aspects in mind to remain safe.

 

 

 

 

2 Comments

  • Mahadev

    This CFIT accident was in the making. The aircraft was not flown for nearly 6 months before this flight indicating the crew was not current on type. Although DGCA recognizes Bell 212/412 as variant of a type, there are distinct differences. There was no supervisor qualified on Bell 212 to oversee and brief the crew. They were independent and left to themselves, who lacked maturity in understanding the seriousness of the mission. The crew was operating as co-pilots on 412 previous to this flight, with the crew having experience only on offshore and recency was with another company before proceeding on-off period.The crew moreover had just returned from the off period the previous evening, with the result the aviation scenario and associated seriousness had not sunk into them, with a lingering holiday hangover. The operation was lackadaisical. The date of the flight was in the closing stages of monsoon and obviously, the crew was not current on recent instrument flying. The captain was instrument-rated whilst the co-pilot was not. The chief pilot with no operational experience on Bell 212 , could not give specific brief other than the requirement of the company, to position the helicopter at the destination no matter what the intervening challenges it posed. There was no distinct brief to return in the event of encountering IMC conditions.
    The crew did not plan, prepare, practice what they intended to do, with least self-preservation instinct, and what would their action be in the event of inadvertent IMC, which they encountered. Their intent was to push the operation no matter what the circumstances they would encounter.The captain indulged in a Hazardous attitude of impulsivity, Anti authority, Invulnerability, and macho instinct. The cardinal principle of controls with one pilot was not followed where in the co-pilot lost confidence in Captain’s ability to fly on instruments and hence overrode the control input. There was confusion in the cockpit, Captain lacked interpretation of instruments and he was oscillating between VFR and IFR and continuing to hunt for Contact with the ground despite being in clouds.
    The final moments leave a lot to be desired. The helicopter was loaded to its limit carrying maintenance eqpt and personnel for the outstation requirement. The pilot appears to have run into a wall of hills with low clouds covering the tops and decided to turn back, and in the circumstances, a panic maneuver of return was executed. The heavily loaded h/c could not sustain a level turn with the excess bank and experienced height loss during the turn that brought the h/c’s tail in contact with a tree and separating it . The subsequent maneuver by the helicopter was akin to tail rotor failure with the crew experiencing high “G” forces of a 360-degree turn in 1 .75 seconds. The crew were ejected out , receiving fatal injuries whilst the helicopter rolled down the mountain slope before coming to a stop in a ball of fire.

    • Aviation Safety India

      Very well analysed and covered by Capt Mahadev. Number of lessons can be learnt from this accident. Unfortunately most of the Pilots are indifferent to learning and history keeps repeating itself.

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