S76 crash Myanmar
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Yes I agree
you would not want to do like one oil company did after a S-76 crash
Like stop flying the aircraft all together without even a hint of the accident cause
Make unresonable demands as to the accident cause the day after accident.
Require 100's of hours of test on aircraft systems which were totally unrelated to the cause of the accident.
Made every attempt to smear two fine war veterans and professional pilots who were at the controls before the investigation was finished
create even more rules I mean "procedures" for the aircraft before the accident investigation was finished.
yes I agree it would be best to let the professionals work on finding the cause.
Unlike that one Oil company acted at the last S-76 crash.
I believe that those board room accident investigators their name started with a "S" or something
you would not want to do like one oil company did after a S-76 crash
Like stop flying the aircraft all together without even a hint of the accident cause
Make unresonable demands as to the accident cause the day after accident.
Require 100's of hours of test on aircraft systems which were totally unrelated to the cause of the accident.
Made every attempt to smear two fine war veterans and professional pilots who were at the controls before the investigation was finished
create even more rules I mean "procedures" for the aircraft before the accident investigation was finished.
yes I agree it would be best to let the professionals work on finding the cause.
Unlike that one Oil company acted at the last S-76 crash.
I believe that those board room accident investigators their name started with a "S" or something
Be patient, proper investigations take a long time!
They certainly do in the more backward areas of the world. A night medevac Bell 212/412? still lies at the bottom of the Bight of Benin c/w with crew & patient since 2003!
They certainly do in the more backward areas of the world. A night medevac Bell 212/412? still lies at the bottom of the Bight of Benin c/w with crew & patient since 2003!
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Great news, patience pays off
After a month the batteries on the sonar beacon would have failed making a search with active sonar essential. Just look at the time to find Af447.
After a month the batteries on the sonar beacon would have failed making a search with active sonar essential. Just look at the time to find Af447.
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I know COHC have ops in Myanmar, I believe they have a few S76 is their fleet.
EDIT: Google tells me it was a Heli-Union with a french captain.
..and please take everything I have written with a few grains of salt.
EDIT: Google tells me it was a Heli-Union with a french captain.
..and please take everything I have written with a few grains of salt.
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BEA Final Report
Here's the BEA Final Report concerning HU accident in Andaman Sea:
http://www.bea.aero/docspa/2011/f-cs...f-cs110711.pdf
http://www.bea.aero/docspa/2011/f-cs...f-cs110711.pdf
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Am I the only one who was intrigued by this report?
When this accident occurred, because it was a fatal, most of us were reluctant to comment - deciding instead to await the accident report. Having now examined the accident report including: the picture of the Yetagun FSO and platform; the traces; and the CVR commentary, I am somewhat surprised at the lack of comment in the report (and on PPRune) on the take-off procedure and direction.
Here are some questions:
(1) Why take off into a sector which appears to contain a crane and which limited the departure direction?
(2) Was the take-off direction effected by the direction of the Yetagun platform?
(3) Why accept a departure with a tail-wind component?
(4) Why take off to the port side of the FSO when the starboard side provided an obstacle-free into-wind departure?
(5) Why take-off with a starboard wind component which would draw more power from the tail-rotor?
(6) Why did the aircraft climb vertically at less than Delta power?
(7) Why wasn't the published TDP used?
In the CVR recording, the FO states "Yes, the take-off is PC1, 10870 pounds"; did that not signal that the published PC2e procedure should have been flown?
The S76C++ graphs appear to indicate that had this take-off been flown as published, a fly-away could have been achieved.
It is particularly noticeable that the vertical acceleration resembled more that published for the EC365 than that for the S76. Was that something to do with previous training, or habit, or was it a feature of the Heli-Union OM.
Have the Heli-Union procedures been amended since the accident?
Are we not intrigued that the accident investigator does not understand the nature of exposure? It covers a period when an engine failure will lead to a hazardous or catastrophic event. The only thing that can be done is to limit exposure by using minimising strategies.
If there is a real choice between operating to a CAT A (or PC2e) procedure or accepting exposure (even if the choice is marginal) shouldn't the consequences of that choice be emphasized in the OM.
Yes this has been written in hind-sight but isn't it true that there are lessons to be learnt here.
Mars
When this accident occurred, because it was a fatal, most of us were reluctant to comment - deciding instead to await the accident report. Having now examined the accident report including: the picture of the Yetagun FSO and platform; the traces; and the CVR commentary, I am somewhat surprised at the lack of comment in the report (and on PPRune) on the take-off procedure and direction.
Here are some questions:
(1) Why take off into a sector which appears to contain a crane and which limited the departure direction?
(2) Was the take-off direction effected by the direction of the Yetagun platform?
(3) Why accept a departure with a tail-wind component?
(4) Why take off to the port side of the FSO when the starboard side provided an obstacle-free into-wind departure?
(5) Why take-off with a starboard wind component which would draw more power from the tail-rotor?
(6) Why did the aircraft climb vertically at less than Delta power?
(7) Why wasn't the published TDP used?
In the CVR recording, the FO states "Yes, the take-off is PC1, 10870 pounds"; did that not signal that the published PC2e procedure should have been flown?
The S76C++ graphs appear to indicate that had this take-off been flown as published, a fly-away could have been achieved.
It is particularly noticeable that the vertical acceleration resembled more that published for the EC365 than that for the S76. Was that something to do with previous training, or habit, or was it a feature of the Heli-Union OM.
Have the Heli-Union procedures been amended since the accident?
Are we not intrigued that the accident investigator does not understand the nature of exposure? It covers a period when an engine failure will lead to a hazardous or catastrophic event. The only thing that can be done is to limit exposure by using minimising strategies.
If there is a real choice between operating to a CAT A (or PC2e) procedure or accepting exposure (even if the choice is marginal) shouldn't the consequences of that choice be emphasized in the OM.
Yes this has been written in hind-sight but isn't it true that there are lessons to be learnt here.
Mars
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Mars, at last someone commenting on this! I was surprised too that this final report not only went unnoticed but also only got a single Pprune comment describing it as a "good report"!
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I am also intrigued by the statement that all the occupants successfully got out of the aircraft and were rescued within an hour, but the copilot and 2 passengers "drowned to death".
The lack of detail in this account leaves me wondering:
1. Whether the survivors actually managed to board the life rafts.
2. Why no rescue boat was launched from the FSO.
3. How did the deceased come to drown?
There are surely lessons for everyone in the oil and gas industry to be learned here.
The contact with the sea was rather hard but the ditching took place without any problem. At that time the swell was approximately 2 meters and the wind resistance was approximately 90° right of the helicopter. Consequently after ditching, the helicopter capsized onto its left side. At that moment the roof windows were opened and water poured into the cockpit. The crew and passengers opened some jettison doors and got out within a few minutes by helping each other. All the life jackets and two life rafts were inflated and the PF managed to help his co-pilot and passengers. The person on the FSO threw life buoys and positioned a ladder. Approximately 30 minutes later, the field standby boat assigned to Yetagun field, which was
localised between FSO and the platform, arrived and continued the rescue
operations. After approximately 60 minutes, all crew and passengers were onboard. Co-pilot and two passengers drowned to death and other two passengers were seriously injured.
localised between FSO and the platform, arrived and continued the rescue
operations. After approximately 60 minutes, all crew and passengers were onboard. Co-pilot and two passengers drowned to death and other two passengers were seriously injured.
1. Whether the survivors actually managed to board the life rafts.
2. Why no rescue boat was launched from the FSO.
3. How did the deceased come to drown?
There are surely lessons for everyone in the oil and gas industry to be learned here.
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Mars,
Couple of points:
(1) Why take off into a sector which appears to contain a crane and which limited the departure direction?
Wind was from 215° @ 13kt according to the report, the Captain chose 125° as a departure direction (Port side of the FSO) which was 90° to the Yetagun FSO fuselage (Ship's heading was 215°) while keeping the obstacles on his side assuming he was seating on the right seat. The starboard side of the FSO might have indeed been a clearer departure path.
(2) Was the take-off direction effected by the direction of the Yetagun platform?
Most likely since they couldn't take off into the wind and had to accept some cross wind component. The decision to go for the port side of the FSO was probably in order to keep the obstacles on the PF side which was the commander at the time.
(3) Why accept a departure with a tail-wind component?
They had a right cross wind component since they departed on a 125° heading and wind was coming from 215°. Again had they chosen the Starboard side of the FSO they could probably have had less of a cross wind component.
(4) Why take off to the port side of the FSO when the starboard side provided an obstacle-free into-wind departure?
Quite agree on that one.
(7) Why wasn't the published TDP used?
Isn't that pretty common amongst Operators though? I believe CHC uses 20 feet for its Rotation Point on its Global Ops manual, HU was apparently using 25 feet. Is anyone using 30 feet which is the published RP?
Notice though on the Analysis part of the report : "The Héli Union operations manual, approved by the DGAC, makes no reference to the TDP nor to the rotation point in its description of the procedure for engine failure during takeoff from a helideck. However, the illustration indicates a height of 20 feet above the helideck. The references and values in the operations manual should not be lower than those certified by the manufacturer. The absence of any cohesion in the definition of the reference points and associated values leads to the development of erroneous procedures, source of confusion for crews."
On the pilot testimony part we can read 30 feet which is what Sikorsky has published on its Manual, the HU Ops Manual refers to 20 feet, the PNF announced 25 feet according to the CVR transcript.
It appears from the CVR transcript that there were some communications issues between the crew (Language barrier for both sides?) as well as unclear procedures (Lack of standardization?), the FO is not assertive and responds "Yes, Yes" most times, as you mentioned the take off should have been a PC2 procedure and the Captain responds "Go ahead no problem" to the FO "Yes, the take-off is PC1, 10870 pounds".
Heli-Union unclearly describes PC2 procedure where the Vy is designated as DPATO instead of Vtoss, the exposure time between the RP and the DPATO is not depicted on the manual graph.
The final conclusions section of the report is intriguing to say the least: "All crew members and passengers evacuated." followed by "Two passengers and the co-pilot drowned."
Now the HP turbine blade failure phenomenon had been identified since 2007, corrective action was current through the TU166 modification, shouldn't F-HJCS have been retrofitted by July 2011 or already retrofitted at the factory since it was built in 2008?
Also confusing: "The captain evacuated through the right pilot’s door while the passengers and the co-pilot evacuated through the window of the right sliding passenger door." I understand the helicopter tilted over 180° onto its left side according to the pilot's testimony but is the window of the right sliding door the fastest way out for a pilot on the left seat?
Couple of points:
(1) Why take off into a sector which appears to contain a crane and which limited the departure direction?
Wind was from 215° @ 13kt according to the report, the Captain chose 125° as a departure direction (Port side of the FSO) which was 90° to the Yetagun FSO fuselage (Ship's heading was 215°) while keeping the obstacles on his side assuming he was seating on the right seat. The starboard side of the FSO might have indeed been a clearer departure path.
(2) Was the take-off direction effected by the direction of the Yetagun platform?
Most likely since they couldn't take off into the wind and had to accept some cross wind component. The decision to go for the port side of the FSO was probably in order to keep the obstacles on the PF side which was the commander at the time.
(3) Why accept a departure with a tail-wind component?
They had a right cross wind component since they departed on a 125° heading and wind was coming from 215°. Again had they chosen the Starboard side of the FSO they could probably have had less of a cross wind component.
(4) Why take off to the port side of the FSO when the starboard side provided an obstacle-free into-wind departure?
Quite agree on that one.
(7) Why wasn't the published TDP used?
Isn't that pretty common amongst Operators though? I believe CHC uses 20 feet for its Rotation Point on its Global Ops manual, HU was apparently using 25 feet. Is anyone using 30 feet which is the published RP?
Notice though on the Analysis part of the report : "The Héli Union operations manual, approved by the DGAC, makes no reference to the TDP nor to the rotation point in its description of the procedure for engine failure during takeoff from a helideck. However, the illustration indicates a height of 20 feet above the helideck. The references and values in the operations manual should not be lower than those certified by the manufacturer. The absence of any cohesion in the definition of the reference points and associated values leads to the development of erroneous procedures, source of confusion for crews."
On the pilot testimony part we can read 30 feet which is what Sikorsky has published on its Manual, the HU Ops Manual refers to 20 feet, the PNF announced 25 feet according to the CVR transcript.
It appears from the CVR transcript that there were some communications issues between the crew (Language barrier for both sides?) as well as unclear procedures (Lack of standardization?), the FO is not assertive and responds "Yes, Yes" most times, as you mentioned the take off should have been a PC2 procedure and the Captain responds "Go ahead no problem" to the FO "Yes, the take-off is PC1, 10870 pounds".
Heli-Union unclearly describes PC2 procedure where the Vy is designated as DPATO instead of Vtoss, the exposure time between the RP and the DPATO is not depicted on the manual graph.
The final conclusions section of the report is intriguing to say the least: "All crew members and passengers evacuated." followed by "Two passengers and the co-pilot drowned."
Now the HP turbine blade failure phenomenon had been identified since 2007, corrective action was current through the TU166 modification, shouldn't F-HJCS have been retrofitted by July 2011 or already retrofitted at the factory since it was built in 2008?
Also confusing: "The captain evacuated through the right pilot’s door while the passengers and the co-pilot evacuated through the window of the right sliding passenger door." I understand the helicopter tilted over 180° onto its left side according to the pilot's testimony but is the window of the right sliding door the fastest way out for a pilot on the left seat?
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Wasted Payload
All those hours of carting around a spare engine, gearbox and fuel - and when the great day came it was pointless....
Report says engine failure cause known - 7 occurrences so far - if the other cases were not accidents (were some?) so that's at least 1in7 fatal...
Report says engine failure cause known - 7 occurrences so far - if the other cases were not accidents (were some?) so that's at least 1in7 fatal...
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Thanks Peter - my questions were rhetorical to highlight the decision to take one course of action when a safer one might have been called for.
ANFI,
This is a point that should be addressed at the operator.
In the Alert Bulletin that has been issued by SAFRAN it is stated that:
There is an implicit assumption in this message that twin-engine helicopters operate with engine-failure accountability. If that is not the case, and it was not in this accident, isn't there an obligation on the Operator to apply the modification as though it were a single or to ensure operations are flown in PC1 or PC2e?
There is a hint of this in the report when it questions why the Approval to operate with Exposure was not withdrawn when the failure rate showed an alarming trend (probably exceeding the 1:100 000 reliability rate). That would have been rendered unnecessary with the application of TU 166.
The engine failure was the main cause of this accident; however, there is a chain of human factor precursors that turned what should have been a heart-stopping moment for crew and passengers into a fatal accident (to crew and passengers).
When the IHST and EHEST started their work on re-analysing accidents, it confirmed the fact that the largest proportion of accidents were Human Factor related. That is the reason why EHEST integrated HFACS into their list of contributory causes.
I'm still astounded that this is a sleeping thread; is it because it is easier to comment on a R22 rescuing a radio controlled plane than read an accident report and question matters which are germane to continuing health in offshore operations.
Mars
ANFI,
This is a point that should be addressed at the operator.
In the Alert Bulletin that has been issued by SAFRAN it is stated that:
"Subject to Service Bulletins Mo. 292 73 2166 and No. 292 73 3166, modification TU 166 is currently applied to new engines and upon first return of module M03 to a Repair Center on all ARRIEL 2 variants.
Modification TU 166 (SB No. 292 73 2166) is applied to the ARRIEL 2 variant upon receipt of parts sent to the operator during replacement of the HP turbine and an approved technician or upon first return to a Repair or Maintenance Centre.
Application of modification TU 166 is mandatory on the ARRIEL 2 single-engined fleet. We remind you that modification TU 166 on single-engine helicopters is overseen by our NORIA teams and is subject to Mandatory SB No. 292 73 3166 which requires TY 166 to be applied before November 18, 2012..."
Modification TU 166 (SB No. 292 73 2166) is applied to the ARRIEL 2 variant upon receipt of parts sent to the operator during replacement of the HP turbine and an approved technician or upon first return to a Repair or Maintenance Centre.
Application of modification TU 166 is mandatory on the ARRIEL 2 single-engined fleet. We remind you that modification TU 166 on single-engine helicopters is overseen by our NORIA teams and is subject to Mandatory SB No. 292 73 3166 which requires TY 166 to be applied before November 18, 2012..."
There is a hint of this in the report when it questions why the Approval to operate with Exposure was not withdrawn when the failure rate showed an alarming trend (probably exceeding the 1:100 000 reliability rate). That would have been rendered unnecessary with the application of TU 166.
The engine failure was the main cause of this accident; however, there is a chain of human factor precursors that turned what should have been a heart-stopping moment for crew and passengers into a fatal accident (to crew and passengers).
When the IHST and EHEST started their work on re-analysing accidents, it confirmed the fact that the largest proportion of accidents were Human Factor related. That is the reason why EHEST integrated HFACS into their list of contributory causes.
I'm still astounded that this is a sleeping thread; is it because it is easier to comment on a R22 rescuing a radio controlled plane than read an accident report and question matters which are germane to continuing health in offshore operations.
Mars
Last edited by Mars; 14th Nov 2012 at 15:58.