The final report on the accident from the Armed forces accident investigation commission (SHF) was published recently.
It lists 12 safety recommendations and 8 measures that has already been implemented.
The complete report is available on their web page
here (Complete report in Norwegian only)
This is the published English summary:
On November 24th 2017, a Norwegian AW101-612 rescue helicopter rolled over during start-up. The helicopter was the first AW101 Norway had received and was operated by the unit OT&E AW101. Two pilots were seated in the helicopter when it rolled onto its right side outside an Air Force hangar at Sola air base. No one was injured in the incident, but the helicopter suffered comprehensive damage.
The incident happened during ground run of the helicopter’s engines following a compressor wash. The investigation has shown that the collective was in a higher position than usual when the rotor was accelerated. Thus, the rotor blades were at an angle of attack capable of producing a significant amount of lift. Because the rotor was accelerated using two engines rather than one, it achieved full rotational speed. The combined forces from the main rotor and the tail rotor, were sufficient to make the helicopter roll over.
Over time, ambitious timelines in the project for acquisition of new rescue helicopters, combined with delays in the development of the helicopter, had created a situation of persistent time pressure for all parties involved. The time pressure and the ongoing development of the helicopter, training aids and documentation, caused challenges in regards to the training that pilots and other personnel from OT&E AW101 received from the provider. Combined with the fact that several of the pilots did not have the experience and continuity that the training program was based on, this led to known and unknown shortcomings in the pilots’ skills and competencies after completing training. The constant demand for progress, negatively affected quality assurance in various parts of the organisation, and contributed to elevated and unidentified operational risk.
No sudden or unknown technical malfunction contributed to the incident. A number of human and organisational factors contributed to the incident developing without anyone identifying or correcting the deviations. Among these were shortcomings in the crew’s system knowledge and experience with the AW101-612, insufficient risk awareness, deviations from the checklist, shortcomings in the training received, and imprecise checklist wording.
After the incident, the Air Force cancelled operations with AW101 in Norway until further notice, and initiated an additional training program for OT&E AW101 personnel. Changes were made to how the unit was organised, including adding two new crews. Planned, complementary training was given by the helicopter provider to compensate for known training deltas. The Air Force took measures to clarify and strengthen the role of the Air Force part of the project organisation in shielding, supporting and supervising the activity of OT&E AW101. The Inspectorate of Air Operations gave increased priority to AW101 by increasing staffing in the helicopter department and performing inspections of OT&E AW101.
The accident investigation board has compiled a list of safety issues related to the incident and to the broader organisation involved in acquisition and operations of the AW101, and give recommendations that may help improve safety in the Armed Forces. Several of the recommendations have already been addressed by the measures listed in the previous paragraph. For some recommendations, there is still reason to consider additional measures. This includes, but is not limited to, quality assurance of the technical documentation of the helicopter, and the role of the defence sector in the project board.