Brand new Bell 429 crash in Slovakia

[Pali]

Bell 429 – the newest helicopter of the rescue fleet entered service just few days ago on 25th of August.

http://t2.aimg.sk/magaziny/BLl9a6sETPSUP5Z8ArWGYg~Nov-vrtu-n-k-Vrtu-n-kovej-z-chrannej-zdravotnej-slu-by-Air-Transport-Europe-Bell-429.jpg?t=LzB4MTc0OjI3NDR4MTcxNi8xNjAweDkwMC9zbWFydA%3D%3D&h=VR7CVTEorDamNAff3ONK3A&e=2145916800&v=3

Yesterday at around 11 PM crashed in the mountains around this area (http://mapy.hiking.sk/?x=19.41895&y=48.69827&ref=permalink), 3 crew and rescued patient were found dead.

http://static.dnes24.sk/images/photoarchive/sized/700/2016/09/08/ate-zachranari.jpg

Helicopter crashed shortly after take off, per reports debris covered larger area in a forrest in a rough terrain (gorge). Per the TV cameraman who witnessed the rescue it took less than a minute after take off when he heard a loud thump.

50 years old pilot had 4640 hours and worked as a rescue pilot since 1995.

In Slovakia we had a clear and dark night yesterday.

[9Aplus]

Sad, sad news, my sincere condolences to all related and involved
RIP :(

[arica]

does anyone know, if the helicopter was operated under NVIS?

condolences to all involved

[Pali]

Very little data so far, in this link (http://www.aktuality.sk/clanok/371101/video-posadka-vrtulnika-nalozila-zraneneho-potom-s-nou-stratili-kontakt/) you can find the video filmed during rescue. Hiker has fallen from a cliff, rescue teams arrived by 4x4 vehicles and brought him by foot to the landing spot. I know the area as I've been hiking the same place maybe 2 years ago.

Landing and take off is filmed. At the very end there is large rescue action due helicopter missing – they didn't respond to ATC calls after they left the scene. I've heard the army helicopter helped to locate wreckage but this is not certain.

Rescue community is heartbroken, there was earlier loss of a complete helicopter crew back in July 2015 in an attempt to salvage 10 yrs old boy.

A friend of mine – a climber who called rescue to an injured mountaineer in High Tatras on 5th of September – showed me an SMS in his phone when the helicopter crew sent him message "We are inbound". It was the very same crew which died yesterday. I hardly keep myself from tears.

In between there is new information about machine, it was not completely new, entered service in 2014 but ATE received it just 2 weeks ago.

Per recent briefing they identified 2 bodies.


http://img.topky.sk/900px/1828967.jpg/trosky-vrtulnik--Strelniky.jpg

http://img.topky.sk/900px/1828971.jpg/trosky-vrtulnik--Strelniky.jpg

http://img.topky.sk/900px/1828977.jpg/trosky-vrtulnik--Strelniky.jpg

[SansAnhedral]

Any more news on this since last week?

[Pali]

So far only speculations, FDR and CVR are still in the lab abroad (I am not sure what equipment of this kind is available at Bell 429).

In the media there were additional reports that pilot had night vision equipment and there was unexplained U-turn in the path of this flight – the original destination was a hospital in Banská Bystrica.

http://t3.aimg.sk/magaziny/NiJgYelyQq_aAg2rjfV2ZA.jpg?t=L2ZpdC1pbi8xNjAweDA%3D&h=fvj4B1l-ubIH0e4Ax10AOg&e=2145916800&v=2

But I would be very cautious regarding informations of the media before official report but I will post here once something important will be known.

[Pali]

Just seen the news in TV. In nutshell:

Investigation not completed yet. There are hints that there was some malfunction of engines and that could be the main cause of crash, however no specifics mentioned.

Unfortunately the CVR was heavily damaged and all attempts to read it were futile.

[Pali]

Final report has been published today, haven't seen English version yet.

Link to final reports (see the SKA2016008, 24.09.2016, OM-H153) (http://www.telecom.gov.sk/index/index.php?ids=191242)

Pilot took off in utter darkness, gained height and made a left descending curve (lost 96m during flight). If he would continue in level flight helicopter would pass the mountain safely. It is unclear why he lost altitude, however it was pointed out that he had only 1 hour 53 minutes on the type at night (4640 during career). CVR recording was destroyed in post crash fire.

Landing on the patch to load the injured hiker was very stressful as it has barely the minimum allowed size (I've been there during a hike, it is quite rough former volcanic terrain).

Engines delivered power to the very end. Per the report it was a CFIT accident. It must be tough for the family of the pilot to read the conclusions.

I added English titles to some photos:

https://lh3.googleusercontent.com/e1KE4vbc2GMHXPVWevROmpURui8lOL02CNRpIGpFAuMDCHA0TWkoi3YPWiBk WAWbLv7vBjb6D4YJ_tK-dOsF7z9jSaannIC-WqRtZe48_B4LPgLULljb_wcWpKvdjCLit4OPJblx_yzlDSCu44do2Udw85tJ IyNxEBDMIlkWRjhbYv9xBCuTk10JFkrIgHBWE8fotCagpXmFUvbc5Y1vKEJ6 YHBIM6Je9j9a-CzJbVbcN-9LNfz2nIlyE2gHu8Wk19zcaXxcnhgwnvHjWFXj2ACxxWbKgAX-BcJ61XoVA3eioienFZmJ9yM1ndHznd6zk4uLp-xxV5aJRqMmMwHABjW_HPo9LGMol5pAcQpg2Iz-YuUTKSHiQyH6KSHW3N4XVN8_uiG8D7gmPc9wLyJfwWdDhhpijIrNxqqj2rRT Pcnpe7U8BAIXIEkMUjRA9wfMFcRb13WYG2XSyFzD2wNtoA3HXVT8ehiCWXb6 HIj0DrLB9n7H-3yfsnK2GI7sgnJ6gtk3DZZmrtpWtW5_E9QdGmnVZbI0gQQ1gHCE5puriivhm kPuR6c7StZwnaeZkzFtTqW4rtQRzqzr4qJNVUvZNPikn3yjOkyvDMR-_WT7gwt0Jo3TG7js=w622-h302-no

https://lh3.googleusercontent.com/YchuZ2ZijqHi494PlscisAWGryTIrKFp8WwFFGVx6Ue-Qr5pcC_Ev3CBzGcffUgLcy6L2XfT5Ic4AeoyHVOI_7OdFLWOUs4CmWFn-ZGJlU2QYDlK0PoNJCcTI1gCcx0MPk2mVfeVEN5pR0BR4-EePUDOfpx5x5kLpCx8e4Zqq42csVZB6QFi5QfOWkYb7sHvXzhxNEGDdnJfSs 2NUaBoR2dZpUvQmV54_ywNvgi6yf3XO2394ciN0j7fakrZ3enhZM7xl7RE9I 73NZiv5JjIThM9oFR9Q4ezdnS2qFq7IO9SpxMmG5x5cPPhND1o1jK3kTGhz9 z0biXuGKGRpRfyq4VLSqnz3pboAs2un2cjiU9UaRfiphi0c1PrUJEmgkS8do 1O-tQulL_kzly1zWpT1NfkExLy68kULybUvLi8bw-IqFINiFyaCLAYl037Oa3h0y1-ZJjVoFJsl-Nys8iprmmpz6yH_w5DG-wVw-f4aef_EuDUOcHXt_qz3xYwf7aJqtYHdIKMmHdBuRLQCyMZdoru4swJG8hO0N 3xmvJxxaZ1u8AUx7n_bfO49EbAmrllb47fMIQN0gjlmfWdY4TpUSSODr6oWK fTIq5s-hBIQowEOTfZxTdd=w481-h323-no

https://lh3.googleusercontent.com/1Gqc26KuxBEngvlEANEk8jJzNeiZ3ufUtB7Qu4VdCgy0xv53igArmEvzvOr3 3o0FIYhWbvaeUfAPOBrstAWNfzHzxw9LgFqryjzDUuVltl-XA31vkl6mesobHmY8kJp3VC9NV8zAQDbHdaoDM6w7vMeUiPiXS2lys3UdlLN 8NcoQ9FLawhavnpiegvjhazD1dAbDQ5kMua8aZyfduFgUVI80MQk_gdq95Kx MCsYUIJxlim971p6LEqxY5Ixh14rh_r_SDMuQHO_f1BbUySMNoqLzmExbHtv PlDimK6oWatnDg418Yipt71UfPZxFnln7FAgVLcU9OW2lrJo8M0wVYgzqmlC ArZwGUnsR6f3jPRuE0XqLKf8jJUzXApyS5XSh0V9JaxwWoztXIIXrGiZ5ZKH TPfPmVjV5rP43YYCI4EON-D4ZDhokCsRL-GseqqEZkNCkZlthVRzbZG_cq1Ml0XQH8_DiBx2r7M7V2GUtnbEizQxhSy-FX2heTPmf9QGmMQ98zGUTWHN5WKuqJ5SBcxiWR1ELZGQVjD5IaptCrYR4owb eqzuVse6k5dMqY4Hpc_iehlwl8RQWeu4uEwoR3pUCLMQdlyQaxG8S8Swc8dJ osAnRfRiC=w1956-h822-no

https://lh3.googleusercontent.com/2x8u0bFR7wad6KxOKSWsA44UPTA_3TkPwKoQub3OLQbRf6H4FBC9Yd4iZYjC V8L4ABnqM9W3MTjQifO1JVCfV_XPJbowImUzwiYZ16VVl4Bmfe2HG8dobv91 ne8JkpXkRFptRZ-WiQWbMZ4j-_SmtmUakqvj2FjOMow1QTD9pc2fx_aKAeMLth9czq7qwFYg9NS8EnbAyh1dh wrRxZw7QLLkkRgwjZjaLzgnAS-XYlT3AT4iJjZicn3-KgGKUwLDncosQXSfUbPxvdOXOS0PlkHTYYZCHmaA6ApqvKvTUkCICvBZ4kkq _YhsO5GdGXr0y3cw1Giq7bJfJgWxkjhI3m6sdNzYwiY-ySI0hOnr8KDQl5wF7R04-9wCzCtAZuo9_9yPttWnNtCsGNatIPGYDTc7Oekg7R1jsqqQhmD96RQ8Sr26_ B4jCSC155mIBQ9XXp33XVWbKtC3WIv3oLiYacJGS-m5My3PPCxTIVE-74WqqNq5FcEdKBgrFFpet9gCL_8mA7IoxhBWrMipDxg-nwYPRnpRs-kR81ftt_m5CADMNMGTVsZknzuZMwDr22czwDm389J20WAJ-in_PgqbqeeT0CspwWUG9nf0PAiFcHV8h-FjObe0=w1968-h540-no

Note: English is not my native language.

[SilsoeSid]

Thanks Pali,

Very sad, RiP
:(

The report is the one above the H-153 Report.
Direct link;
http://www.telecom.gov.sk/index/open_file.php?file=doprava/uvlni/ZS_SKA2016007_web.pdf

S ECO / Cause of occurrence of an accident
3.1 Findings
Crew
 Pilot and crew members have valid qualifications to carry out the flight in question, according to the submitted documentation for the execution of rescue flights,
 The pilot did not suffer from medical changes that might be causal to the aviation incident in question.
helicopter
 had valid documentation and showed no malfunction before and during flight,
 before the critical flight, he / she fulfilled the conditions of airworthiness,
 The CVR / FDR device has been exposed to large fire and radiant heat, which has seriously damaged memory chips,
 The SANAV did not record the whole record after the take-off - it does not include the whole route from take-off to the crash moment but only about 40 seconds of flight, and the Security Commission could not assess the next flight until the helicopter fell,
 there were no signs of any mechanical anomalies or impacts on the engine components,
 Examining the KEU's research suggests that the technical condition of the helicopter before the accident and during the flight was not the cause of the occurrence of an airplane event. Both engines had normal operation until the event.
3.2 Air Accident Cause
 a helicopter helicopter stretch during a flight in a downtrend at ground level,
 the pilot did not have a safe height above the surrounding terrain after taking off.
3.3 Matching Causes
Performing rescue flights on demanding mountain terrain under specific conditions (astronomical night).


SAFETY RECOMMENDATIONS
Based on a safety investigation of the causes of the occurrence of an air accident
Bell 429 helicopter
OM-ATR
Which occurred on 07.09.2016
We recommend taking action:
ATE
 During the investigation, the "operator" determined an increase in the dimensions of the HEMS landing areas overnight above the dimensions required by Commission Regulation (EU) 965/2012 of 5.October 2012,
 Perform additional pilot training to address emergency situations at night in a dedicated workplace designed to simulate changes in global and weather conditions for flights without NVG and NVG.

[Same again]

I'd think twice about landing there with NVG. It is criminal that crews are expected to undertake this kind of tasking without them.

[gulliBell]

Why make a left turn on a dark night so soon after take-off? Was weather an issue? The terrain directly ahead in the take-off direction doesn't appear to warrant an early turn immediately after take-off. Surely, dark night = climb on departure heading to 1000' AGL before turning?

[ersa]

The leans - black night very easy done

[hoistop]

Excerpt from report Googletranslated:
ANALYSIS
Crew activity
The crew in the landing maneuver in the unknown mountain terrain under the weather conditions was subjected to an extremely high psychological burden. The pilot decided to perform an intervention based on information that the HEMS operating area was 100 x 100 meters in size, with the actual dimensions of the area being within the allowed dimensions. Nevertheless, the pilot made the landing on the unknown terrain without any problems.The pilot, after loading the patient, made a helicopter take-off from the 1 065 m MSL with vertical climb to the height of the trees. The take-off was oriented east (in the direction of the helicopter landing). Subsequently, the helicopter began to run-accelerate over the trees at a prescribed flight speed of 55-60 kt.Upon helicopter climb, a technical crew member / rescuer monitors obstacles and at this stage should report to the pilot a continuous flight speed and altitude up to V = 100 kt or H 500 ft AGL. Torque on the pilot track safely over obstacles until a safe height of min. 500 ft AGL.The pilot should set the height H min = 500 ft or higher before the take-off to warn of possible approaches to a field obstacle below it. After the take off, he should rise to a safe height and carry out "instrument check" in a horizontal flight. After 40 seconds from take-off, the helicopter reached a speed of 76.6 kt according to the data recorded in the SANAV and the undefined height of the flight above the top of the trees.The pilot from this time probably did not continue to climb to a safety height of 300 meters above the mountainous terrain at night. Based on witness testimony, the trajectory of the last phase of the flight continued in the dark, clear night hidden from the witnesses of the witnesses / firefighters and rescuers / behind the high forest by a left-hand turn westward towards the town of Banská Bystrica.

The average steady turn in the 360 ​​° horizon at the estimated 80 kt flight speed was set at 640 meters after the map was calculated. Based on the average, the total circumference of the fictitious curve was determined to 1 396 m.The Commission recalculated flight time from the point of closure to the point of last record on the SANAV using a predicted 50 kt / 25 ms-1 flight speed and a 257-meter trajectory for the calculation, was set for 10 seconds, which is the same as the SANAV.The flight time from the point of the last SANAV record to the tree-lined trajectory was calculated as ¾ of the expected flight trajectory of 360 ° (1,139 m) minus the 244 m traveled flight at the assumed 80 kt flight speed was set for 27 seconds. The total time since the end of the blind was 37 seconds.The Commission has recalculated the helicopter's heeling angle for a steady horizontal turn at an estimated 80 kt flight speed at a known 320 m radius and was set at 28 ° (the heeling angle during the flight could vary with the speed and height of the flight).Based on the assumed tilt angle of 28 ° and at a distance of 964 m, a speed of 80 kt, and the height difference the helicopter dropped during a bend (95 m), the helicopter descending angle from the last SANAV record point to the 5 ° 38 '. At this descending angle and assumed velocity, the vertical helicopter descending velocity was set to 4 ms -1 At this time, the helicopter did not show any system failures or engines during the flight, and the crew did not report any problems to the FIC.The likely take-off relief and deployment of the course with the left-hand turn on the track became a disposition factor for disrupting routine crew activity and projected into their next activity. The result was probably a failure in piloting, which led to an inexplicable flight regime change.The established procedures do not deprive the pilot of responsibility for knowing the actual position and condition of the helicopter at each phase of the flight. When deviating / changing from the agreed procedure, crew members must inform each other.The transition from "with NVG" to "without NVG" must be mutually agreed. It is important for the crew that all its members understand the meaning of the two-way communication, respectively. Information when using NVG. During the flight, the pilot must at regular intervals observe the helicopter space outside the NVG. Tracking is also performed by a member of the technical crew as instructed by the pilot. It is likely that searchlight on the take-off and climb fixed on the obstacles present in the departure sector caused short or complete loss of the natural horizon and could create a short-term illusion in flight.The pilot's physiological mileage during the summer during the dark could have an effect on night traffic.The crew did not pay attention to the altimeter radio during the descent, which had to alert the crew to the approaching terrain beneath it. The small flight experience of the Bell 429 helicopter pilot at night flight (1 h 53 min) and the associated stereotype / habits gained from years of experience on the Agusta helicopter could lead to pilots' fatigue after a major psychological burden. At 20:30, a rotor hit a high spruce tree in the left tilt. The tree at a diameter of about 20 cm was torn at an angle of 60 °, with destruction of all four of its blades, with a subsequent impact of the helicopter on the ground in the forested mountainous terrain. After a collision with the terrain a fire occurred, resulting in the helicopter cabin, including the crew (except the pilot who was thrown out of the cabin in the crash), practically completely burned. The distance from the point of first contact with the trees from the last record on the SANAV is 964 m at the estimated 80 kt flight, and after doing the left-hand turn, it probably took 37 seconds to reach the helicopter. The Commission has not been able to prove the reason for the helicopter's drop in the mountainous terrain. If the pilot, for unknown reasons, did not descend with the helicopter and stayed at the height he had reached after taking off from the landing zone and would not rise again, there would be no crash with terrain at the given flight course and the mountainous terrain towards the medical facility would fly.
- - -
SAFETY RECOMMENDATIONSBased on a safety investigation of the causes of the occurrence of an air accidentBell 429 helicopterOM-ATRWhich occurred on 07.09.2016We recommend taking action:
ATE During the investigation, the "operator" determined an increase in the dimensions of the HEMS landing areas overnight above the dimensions required by Commission Regulation (EU) 965/2012 of 5.October 2012,
Perform additional pilot training to address emergency situations at night in a dedicated workplace designed to simulate changes in global and weather conditions for flights without NVG and NVG.


End of report






I am somewhat disappointed on safety reccomendations. Increasing the LZ minimums above those prescribed by EASA OPS regulations is a side effect and has not much to do with the cause of this accident. Second recommendation is ambigious to me (something lost in translation, I suppose)


My five cents:
Taking off/flying in pitch dark night VFR manually (single pilot) is outright dangerous. NVG will not help much if there is not enough natural and/or manmade background light - unfortunately, I did not find anything about that in the report (estimation of lighting and NVG performance) From experience I can assure you that even best non-military (and military grade) NVGs cannot "see" with inadequate lighting. Add an NVG incompatible light source into view, and you are effectivelly blind, as goggles will close gain level and minute details will dissapear.


I am sure that the only real prevention to such crashes is: mimic the commercial, passenger carrying ,IFR flying world as much as possible.
Take off should be designed and executed similar to a SID, and autopilot used as much as prudent. Yes, even big commercial jets take off manually, but autopilot is engaged seconds after leaving runway. This helicopter was very well equipped, but it seems its capabilities were not used to full extent.
But going that way means change of culture, not just a few procedures. And EASA is of no help not seeing this, and even tolerating non-compliant operations well beyond 965 regulation implementation deadline.


Now I am taking flak.


hoistop

[jeepys]

You are quite right, it's a change in culture and cannot be taught in a flight.
The NVG's I use however are very good and with full cloud cover and very little light they are still good enough to give obstacle clearance but I am with you that they are not the answer.
The aircraft automatics are there to make the trip safer, more efficient and reduce fatigue but if one is not fully conversant with the use of them they can have the opposite effect.
There is a time and place to use them and night is one of them especially in mountainous regions.
Moving from non complex to complex should address these issues and a thorough line training syllabus should target culture change if required. Unfortunately not all operations have the money available to allow for such training.
The change needs to come from the top down as let's face it we as pilots are just the drivers.

Very sad incident and one which will happen again I am sure especially with the new breed of light to medium twin helicopters like the 429/169/145 coming out the factory spifr or as near damn it.

[rotorspeed]

Was the aircraft IFR equipped and the pilot IR?

[[email protected]]

Night VFR flying in sparsely populated areas with little cultural lighting is essentially IFR flight with a tiny bit of lookout and needs to be given the same respect a full IFR flight would have.

That means properly equipped aircraft and trained crews with good currency/recency.

It also means having good SOPs for rad alt setting, CRM and cross cockpit monitoring.

Even if you have NVGs, the same criteria apply.