Brand new Bell 429 crash in Slovakia

[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.
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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.


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