Thanks JimJim for uploading the report, and to Arnie's for their good summary. A few points that come to mind, in no particular order:
- The entire 40-page report is well worth the read.
- Fly the aircraft to the site of the accident. The mishap pilot had time to kill the engine (in an attempt to 'diagnose' the excessive vibration problem) but lost RRPM in the process. Thereby was unable to even attempt an autorotation. So basically crashed with zero engine and zero rotor RPM.
- Despite a similar high profile accident in the same area just three month ago where due to nil flight following or sat tracker (compounded by the usual ELT failure) it took seven days to locate the aircraft, this occurrence flight took off without flight following, no sat tracker and faulty ELT.
- The pilot's medical had expired over a year before the accident (indicates attitudinal problems). Technically speaking, the pilot was not licensed.
- Given the known design problems of earlier RHC blade, the a/c was still equipped with dash-2 blades (current blades are dash-7).
- Blade delamination would have been visible before the accident flight and was big enough that it should have been detected by the pilot, had the mandatory daily visual inspection been carried out. The report found that that the pilot - despite knowing that they flew with old to-be-phased-out blades - didn't conduct this mandatory daily inspection.
- Because the daily visual inspections were not done or recorded, the aircraft's airworthiness certificate was invalidated (indicates attitudinal attitude problem No 2).
- The ELT Arm switch (at the ELT unit itself, not the remote test/activation switch in the cockpit), was found to be damaged. To prevent inadvertent change of that (typically rather inaccessible) switch, this switch has a locking mechanism. In order to move the switch, the switch normally has to be moved up (pulled out) to set it to another position. This also prevents the switch to move to the OFF position by the decelerating forces during a crash. Some ham-fisted person may have just forced the switch thereby breaking the locking mechanism. Since then the ELT Arm switch was free to move between its positions. A CT scan of the broken switch proved that it was moved several times between the OFF and the ARM position over time, after the locking mechanism had been broken. The broken switch problem was not detected or repaired during the periodic ELT maintenance. It was found that in its current state, the broken switch could be moved from the ARM to the OFF position by an acceleration force of just 1.8G (which is below the activation force that should activate the ELT's the G-switch - around 6G - and well below the over 16G forces that occurred during this crash).
- The (initially) surviving pax activated the ELT with the remote switch in the cabin. But because the ELT was switched off at the unit itself, it didn't work. Anyway, we know that ELTs fail (for this or other reasons) in 2 out of 3 accidents.
- The report describes over many pages how the lack of good crash position estimates can frustrate the SAR efforts, but fails to mention that carrying a (monitored) sat tracker would therefore be recommended.