AW139 Accident Brasil
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Malabo - show me your program of training for the seperation of tail rotor at high height and consequent c of g change, as opposed to loss of tail rotor drive? Perhaps that indicates a diference?
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Parnaiocas,
well done for the AW139 analysis, simply because few non-AW users knows about S/N logic for this particular rotorcraft line.
However,
if you had investigated a little bit more, you would know that:
- (new) fuselages are not manufactured separately, but they are rawly prepared in Poland and reworked in an Italian facility, while (new) blades are completely manufactured in Italy - while repair stations are located around the world.
- both in Vergiate and in Philadelphia final arrangements and test-flights are performed. If you look at the no. of helos released from Vergiate and Philly, you will notice that we are absolutely not around 50%/50%, but 80%/20%.
Therefore, in case of a mechanical/structural failure, assessing the historical data, I'd rather not look only at where the helicopter has been passed through a completion centre, but the whole history of a certain S/N and the components subject of a failure.
The first investigation criteria is to face the incident/accident scenario without pre-concepts, cleaning our mind from any possible mis-concept: in case of dynamic failure of a component, a manufacturer has to patch it, and patch it quickly,
but the stressing factors of an accident are multiple and have to be deeply assessed.
Providing uncomplete or misleading data creates only white noise.
well done for the AW139 analysis, simply because few non-AW users knows about S/N logic for this particular rotorcraft line.
However,
if you had investigated a little bit more, you would know that:
- (new) fuselages are not manufactured separately, but they are rawly prepared in Poland and reworked in an Italian facility, while (new) blades are completely manufactured in Italy - while repair stations are located around the world.
- both in Vergiate and in Philadelphia final arrangements and test-flights are performed. If you look at the no. of helos released from Vergiate and Philly, you will notice that we are absolutely not around 50%/50%, but 80%/20%.
Therefore, in case of a mechanical/structural failure, assessing the historical data, I'd rather not look only at where the helicopter has been passed through a completion centre, but the whole history of a certain S/N and the components subject of a failure.
The first investigation criteria is to face the incident/accident scenario without pre-concepts, cleaning our mind from any possible mis-concept: in case of dynamic failure of a component, a manufacturer has to patch it, and patch it quickly,
but the stressing factors of an accident are multiple and have to be deeply assessed.
Providing uncomplete or misleading data creates only white noise.
Thanks for your explanation Nightskywalker,
For the third time i repeat: It was just curiosity.
However, today left the Security Recomendation made by CENIPA, aeronautical authority of investigation and prevention of accidents in Brazil about crash AW-139 PR-SEK and what is in it certainly is not just white noise.
Contained in the report that the SEK lost paddle TR and box of the TR was found away from the ANV. CENIPA asks the European position on which the approval of that helicopter.
How do I do to insert a pdf file here?? Is it possible?
For the third time i repeat: It was just curiosity.
However, today left the Security Recomendation made by CENIPA, aeronautical authority of investigation and prevention of accidents in Brazil about crash AW-139 PR-SEK and what is in it certainly is not just white noise.
Contained in the report that the SEK lost paddle TR and box of the TR was found away from the ANV. CENIPA asks the European position on which the approval of that helicopter.
How do I do to insert a pdf file here?? Is it possible?
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I suppose that you can fill here the hyperlink.
Regarding HK, the TGB detachment could be consistent with an out-of-balance Tail Rotor due to the water impact, and in case of TR Blade detachment, it has never been declared that the one subject of failure is due to - despite debonding discrepancies which are subject of the Mandatory SB on them introducing a conservative preventive maintenance requirement,
Regarding TR Blades, it is necessary to assess if the failure has been occurred dynamically or statically: in HK the reason could be an out-of-balance condition for a bird strike, while in Qatar the TRB failure with the consequent TGB detachment could have been caused by a not removed rigging tool.
Regarding HK accident, please check the HK CAD interim statement:
http://www.cad.gov.hk/reports/Interi...B-MHJ_e%20.pdf
I absolutely don't want to defend AW139 from its debonding topics - I consider the TR Blades debonding a quality concern which AW should have already assessed in the past and with a reasonable time of resolution -
but as per my experience in aviation, frequently a suspicious accident driver is discovered, during the investigation assessment, a accident-driven failure (i.e. b MR/TR Blades breakage/major debonding consistent to a catastrophic unbalance of a rotor for external factors).
In other words, the smoking gun results only a component damaged or failed due to the energy released by the accident conditions.
The CVDR and HUMS data will contribute to clarify what sadly happened in Brasil to our Senior colleagues.
Regarding HK, the TGB detachment could be consistent with an out-of-balance Tail Rotor due to the water impact, and in case of TR Blade detachment, it has never been declared that the one subject of failure is due to - despite debonding discrepancies which are subject of the Mandatory SB on them introducing a conservative preventive maintenance requirement,
Regarding TR Blades, it is necessary to assess if the failure has been occurred dynamically or statically: in HK the reason could be an out-of-balance condition for a bird strike, while in Qatar the TRB failure with the consequent TGB detachment could have been caused by a not removed rigging tool.
Regarding HK accident, please check the HK CAD interim statement:
http://www.cad.gov.hk/reports/Interi...B-MHJ_e%20.pdf
I absolutely don't want to defend AW139 from its debonding topics - I consider the TR Blades debonding a quality concern which AW should have already assessed in the past and with a reasonable time of resolution -
but as per my experience in aviation, frequently a suspicious accident driver is discovered, during the investigation assessment, a accident-driven failure (i.e. b MR/TR Blades breakage/major debonding consistent to a catastrophic unbalance of a rotor for external factors).
In other words, the smoking gun results only a component damaged or failed due to the energy released by the accident conditions.
The CVDR and HUMS data will contribute to clarify what sadly happened in Brasil to our Senior colleagues.
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nightskywalker
If you read the HongKong CAA report you'll find that nowhere do they suggest that the White Tail rotor blade broke on impact with the water .
What it does imply in the report is the TR imbalance might have caused the tail pylon strike which would be in the air and not post water impact.
Also , if one sees the Gulf Helicopter ground incident (2nd one) , it appears that one TR blade has broken away causing similar damage .
That AW had issued ADs to inspect the TR blade for cracks in the past and now again on blades of much lesser hours puts the needle of suspicion on the TR manufacture and quality control !!
AW has to act fast and correctly this time else its really going to hurt both its credibility and its market share !!
If you read the HongKong CAA report you'll find that nowhere do they suggest that the White Tail rotor blade broke on impact with the water .
What it does imply in the report is the TR imbalance might have caused the tail pylon strike which would be in the air and not post water impact.
Also , if one sees the Gulf Helicopter ground incident (2nd one) , it appears that one TR blade has broken away causing similar damage .
That AW had issued ADs to inspect the TR blade for cracks in the past and now again on blades of much lesser hours puts the needle of suspicion on the TR manufacture and quality control !!
AW has to act fast and correctly this time else its really going to hurt both its credibility and its market share !!
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from nightskywalker
in HK the reason could be an out-of-balance condition for a bird strike,
in HK the reason could be an out-of-balance condition for a bird strike,
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The bird strike theory was not by Agusta initially, it was brought up by speculators in the HK press and by fellow ppruners (because there are birds in the HK harbour). Then it was conveniently taken over by Agusta as official response.
If my memory serves me right, the HK press made a video animation within hours to show how everything happened, including the bird flying in to the tail
If my memory serves me right, the HK press made a video animation within hours to show how everything happened, including the bird flying in to the tail
Last edited by Runway101; 30th Aug 2011 at 10:06.
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Aegir, Prehar, Runaway101,
I have not saying that HK accident has surely occurred due to a bird strike which has subsequently caused an unbalance of tail rotor,
I would like to stress anyway that a bonding failure of a blade can be - as occurred in many accidents in the pasts on helos - a consequence of a severe unbalance of a rotor which may lead to the accidents that we have seen so far (i.e. bird strike, water impact, maintenance poor quality, and so on).
It is more than fair to raise an Alert Mandatory SB/authority AD on such blades, simply because they are critical components of an helicopter and it is unacceptable to have such debondings on the fork:
however, in neither of the 3 accidents in subject there is any proof of a TRB failure as leading cause of the event - CAD report doesn't state that ("investigation is ongoing"), Qatari accident has not reported any evidence of this kind and the Brazil one is too recent for determining any preliminary cause.
Prehar, just a further comment for your (fair) observation: regarding the failure mode, I agree that it is the same, but we have to segregate the way how a component fails from the cause (static, dynamic failure) that has provoked.
I sustain your last point on which a manufactured should react quickly not only (...) for presumed accident causes, but also for quality concerns. If I were the owner and the maintainer of an AW139, I would simply not accept to fly being aware that TR Blades debonds in that area.
I have not saying that HK accident has surely occurred due to a bird strike which has subsequently caused an unbalance of tail rotor,
I would like to stress anyway that a bonding failure of a blade can be - as occurred in many accidents in the pasts on helos - a consequence of a severe unbalance of a rotor which may lead to the accidents that we have seen so far (i.e. bird strike, water impact, maintenance poor quality, and so on).
It is more than fair to raise an Alert Mandatory SB/authority AD on such blades, simply because they are critical components of an helicopter and it is unacceptable to have such debondings on the fork:
however, in neither of the 3 accidents in subject there is any proof of a TRB failure as leading cause of the event - CAD report doesn't state that ("investigation is ongoing"), Qatari accident has not reported any evidence of this kind and the Brazil one is too recent for determining any preliminary cause.
Prehar, just a further comment for your (fair) observation: regarding the failure mode, I agree that it is the same, but we have to segregate the way how a component fails from the cause (static, dynamic failure) that has provoked.
I sustain your last point on which a manufactured should react quickly not only (...) for presumed accident causes, but also for quality concerns. If I were the owner and the maintainer of an AW139, I would simply not accept to fly being aware that TR Blades debonds in that area.
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If my memory serves me right, the HK press made a video animation within hours to show how everything happened, including the bird flying in to the tail
I'm trying to find the video...
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Hello guys,
Following is the report issued yesterday the 29th by CENIPA as mentioned by parnaiocas above...
The link is for the original pdf file where we can see 3 pictures of the blades and the tail rotor. Below is the pdf file converted into txt so you can google the traductor (I found it easier that way so there is no miss interpretation from my side...)
Hope it helps...
http://www.abraphe.org.br/wp-content...A7a-de-Voo.pdf
COMANDO DA AERONÁUTICA
CENTRO DE INVESTIGACAO E PREVENCAO
DE ACIDENTES AERONÁUTICOS
RECOMENDACÓES DE SEGURANCA DE VOO
OCORRENCIA: ACIDENTE AERONÁUTICO
MATRíCULA: PR·5EK
MODELO AW-139
DATA 19 AGO 2011
..... - ACIDENTE AERONÁUTICO
SIPA~~
DATA: 19 AGO 2011 MATRÍCULA: PR-5EK 1. 1. LOCAL: Oceano Atliintico - Sacia MODELO: AW-139 Petrolífera de Campos - RJ
TIPO: OUTROS TIPOS OPERADOR: Senior Táxi Aéreo
COllforme a Lei 11" 7.565, de 19 de dezembro de 1986, Artigo 86, compete ao Sistema de
IlIvestigaráo e Prevenráo de Acidentes Aeronáuticos - SIPAER - planejar, orielltar, coordenar,
controlar e executar as atividades de investigaráo e de preven~áo de acidentes aeronáuticos.
A presente Recomendaráo de Seguranra de Voo (RSV) é o estabelecimento de uma aráo
que a Autoridade Aeronáutica 011 Elo-SIPAER emite para o seu ámbito de atllaráo, visando
eliminar ou mitigar o risco de uma Condiráo Latellte ou da conseqüellcia de uma Fallla Ativa.
Sob a ótica do SIPAER, tem o caráter essencial para a Seguranra de Voo, referindo-se a
um perigo especifico e develldo ser cumprida num determillado prazo.
A elahoraráo dessa RSV foi cOllduzida sem recorrer a qualquer procedimento de prova
para apuraráo de respolIsabilidade civil ou criminal; cOlIsequelltemente o uso que se fara dessa
recomellda~áo para qualquer propósito que lIáo o de prevellráo de futuros acidentes, poderá
illduzir a illterpretaroes e conclusoes errolleas.
1- FUNDAMENTACÁO
No dia 19 AGO 2011, o helicóptero de matricula PR-SEK decolou da plataforma
petrolífera P-65 com destino a Macaé, RJ. Cuando cruzava aproximadamente 1800 ft
durante a subida, declarou emergencia ao Controle de Aproxima~áo de Macaé (APP-ME)
e. em seguida, informou que estava com pane no sistema hidráulíco primário e
secundário.
A aeronave colidiu com o mar aproximadamente ás 19:48 UTC. O helicóptero
sofreu danos graves e os seus quatro ocupantes sofreram les6es fatais.
A investiga~áo está em andamento. Verificou-se que, em maio de 2011, a Agusta
Itália emitiu um boletim (8T 139-251, de 06 de maio de 2011) referente a inspe~6es em
duas áreas (BLADE ROOr e FORK) do punho de fixa~áo das pás do rotor de cauda (para
verifica~áo de sinais de trincas e descolamento do material composto).
A parte 1 do referido boletim estabeleceu que todas as pás com mais de 600 horas
(inclusive aquelas com mais de 1200 horas). a partir daquela data, deveriam ser
inspecionadas externamente a cada 25 horas de voo.
A parte 2 do referido 8T determinou que todas as pás com mais de 1200 horas
(totais) deveriam ser removidas para inspe~áo nas duas áreas do punho de fixa~áo. sendo
que aquelas que apresentassem evidencias de trincas ou descolamento deveriam ser
enviadas para reparo junto ao fabricante e substituidas por pás novas ou recondicionadas.
A parte 2 também estabeleceu que o procedimento dessa tarefa deveria ser
repetido a cada 600 horas após a última inspe~áo da pá.
A parte 3 do BT 139-251 estabeleceu que as pás estocadas no suprimento, com
mais de 600 horas totais, por já estarem removidas, deveriam ser submetidas a todos os
procedimentos da parte 2.
A aeronave PR-SEK foi adquirida diretamente do fabricante (nova) em 2007.
A pá SN Q 1018 foi o primeiro destro~o da aeronave na linha de proje~ao da
trajetória de voo, sendo encontrada a 240 metros do conjunto do rotor de cauda.
A referida pá sofreu ruptura entre a BLADE ROOT e o FORK, áreas estabelecidas
para inspe~ao estabelecida no BT 139 - 251, estando o restante da pe~a intacta.
O conjunto do rotor de cauda, segundo destro~o encontrado na Iinha de proje~ao da
trajetória de voo, foi encontrado a 560 metros da fuselagem.
As duas Iinhas dos sistemas hidráulicos 1 e 2 alimentam o conjunto do rotor de
cauda.
Urna separa~ao do conjunto do rotor de cauda da fuselagem implica no rompimento
das duas linhas hidráulicas, com alarmes visuais no painel, perda total do sistema 1 e
perda de 78 % do fluido hidráulico do sistema 2, quando urna válvula fecha a linha para o
rotor de cauda.
Com apenas 22% do fluido hidráulico, o sistema 2 alimenta apenas o rotor principal,
cuja atua~ao dos comandos fica deteriorada.
A fuselagem foi encontrada com danos severos em toda a parte dianteira e na
lateral direita.
O cone de cauda estava integro, afixado á fuselagem, sem o conjunto do rotor de
cauda.
No dia 17/08/2011, houve um acidente com esse modelo de aeronave, na China,
com evidencias de quebra de pá do rotor de cauda, seguida da separa~ao do conjunto do
rotor de cauda da fuselagem.
Os registros de manuten~ao da Senior Táxi Aéreo, verificados até este momento da
investiga~ao, demonstraram que todos os servi~os de manuten~ao da aeronave estavam
de acordo com o manual de manuten~ao do fabricante.
Os registros de manuten~ao demonstraram que a Senior Táxi Aéreo inspecionou
todas as pás das aeronaves de sua frota no dia 09/05/2011, aplicando os procedimentos
da parte 2 do BT 139-251 (retirada da pá e inspe~ao completa).
Nas referidas inspe~oes, urna pá com aproximadamente 1150 horas apresentou
trincas e duas pás com mais de 2000 horas nao apresentaram problemas.
Após as inspe~oes de todas as pás, a Senior Táxi Aéreo, de maneira conservativa,
vinha realizando as inspe~oes estabelecidas na parte 1 do BT 139-251 a cada intervalo
dos voos, enquanto que a parte 1 orientava para urna inspe~ao a cada 25 horas de voo.
A pá SN Q 1018, foi enviada para a Senior Táxi Aéreo em 10/01/2010, com 589,9
horas totais, após revisao na Agusta, na Itália.
Os servi~os realizados na revisao na Agusta Itália eliminaram corrosao e trincas
localizadas no punho de fixa~ao da pá, mas em áreas distintas dos pontos de ruptura. O
FORM 8130-3 AGU -2010-50674, datado de 09 de julho de 2010, detalha os servi~os de
reparos realizados nas regioes próximas á nervura da raiz da pá SN Q 1018 e também na
regiao do FORK da pá.
2
if'
Depois de instalada em outra aeronave da empresa, a pá SN Q 1018 foi removida e
instalada na aeronave PR-SEK, em 22104/2011, com 1280 horas totais.
A referida pá foi retirada em Sao Tomé e cumpriu a tarefa prevista na parte 2 do BT
139-251 no dia 09/05/2011, na Senior Jacarepaguá, na presenlfa e com supervisao de
representante da Agusta, com aproximadamente 1300 horas totais, quando nao foram
encontradas anormalidades.
Até o acidente, a referida pá passou por diversas inspelfoes diárias nos intervalos
dos voos, cumprindo os procedimentos de inspelfao visual estabelecidos na parte 1 do BT
139-251.
No acidente, a pá SN Q 1018 havia completado aproximadamente 290 horas após
a inspelf30 realizada no dia 09/05/2011, na Senior Jacarepaguá, faltando ainda
aproximadamente 310 horas para a próxima inspelf30 de 600 horas, estabelecida na parte
2 do BT 139-251.
A Agusta emitiu, em 25 AGO 2011, o Boletim Técnico n° 139-265, de caráter
mandatório. Na parte 1 do referido boletim, o fabricante determinou que, em até 25 horas
de voo a partir do recebimento do boletim e a cada 25 horas de voo a partir do seu
cumprimento, todas as pás sofressem inspelf30 visual externa.
Na parte 2, o fabricante determinou que, em até 5 horas de voo ou 30 dias a partir
do recebimento do boletim, o que ocorrer primeiro, todas as pás com mais de 600 horas
de voo ou mais de 1500 pousos, o que ocorrer primeiro, devem ser removidas e colocadas
em quarentena.
A European Aviation Safety Agency (EASA) emitiu, em 25 AGO 2011, a Diretriz de
Aeronavegabilidade de Emergencia (Emergency Airworthiness Directive) AD n° 20110156-
E, estabelecendo o cumprimento mandatório do Boletim Técnico n° 139-265.
Exames visuais realizados no conjunto do rotor de cauda indicaram o rompimento
da pá SN Q 1018 (fotos n01 e 2) na regiao da sua fixalfao e a ruptura do olhal do "Iead-Iag
damper assembly" (foto n03) correspondente a essa pá. Nao foram observadas marcas ou
danos na referida pá, que pudessem indicar que ela tenha sofrido algum impacto, que
pudesse ter colaborado para o seu arrancamento.
Foto n01: Aspecto geral da pá arrancada.
3
Foto n02: Aspecto da ruptura ocorrida, lado da pá,
Foto n03: Aspecto da fratura do olhal do "Iead-Iag damper assembly', A deforma~ao
sofrida indica um esfor~o de arrancamento longitudinal ao amortecedor.
A análise visual preliminar realizada indica que a ruptura ocorrida na regiao de
fixa~ao da pá SN Q 1018 ocorreu por um esfor~o longitudinal ao corpo da pá (radial em
rela~ao a sua rota~ao),
11 - RECOMENDACÓES DE SEGURANCA DE VOO
AANAC, recomenda-se:
RSV (A) 1B1 12011 - CENIPA Emitida em 25 108 12011
1) Tendo em vista a emissao do Boletim Técnico n° 139-265 pela Agusta, a
emissao da Diretriz de Aeronavegabilidade de Emergencia AD n° 2011-0156-E pela
EASA, os reportes de dificuldades em servi~o e os fatos conhecidos até o presente
momento em rela~ao as pás do rotor de cauda do helicóptero modelo AW139, avaliar junto
a Autoridade Primária de Certifica~ao (EASA) se as medidas mitigadoras adotadas sao
4
suficientes para assegurar um controle adequado das falhas nas referidas pás e permitem
que a aeronave seja operada no Brasil em conformidade com os requisitos de cerlificayao
de tipo aplicáveis.
111. DIVULGACAO
• ANAC
Brasilia, .¿5 I O íJ I 2011 .
Aprovo estas Recomendayoes de Seguranya de Voo
Chefe CENIPA
Following is the report issued yesterday the 29th by CENIPA as mentioned by parnaiocas above...
The link is for the original pdf file where we can see 3 pictures of the blades and the tail rotor. Below is the pdf file converted into txt so you can google the traductor (I found it easier that way so there is no miss interpretation from my side...)
Hope it helps...
http://www.abraphe.org.br/wp-content...A7a-de-Voo.pdf
COMANDO DA AERONÁUTICA
CENTRO DE INVESTIGACAO E PREVENCAO
DE ACIDENTES AERONÁUTICOS
RECOMENDACÓES DE SEGURANCA DE VOO
OCORRENCIA: ACIDENTE AERONÁUTICO
MATRíCULA: PR·5EK
MODELO AW-139
DATA 19 AGO 2011
..... - ACIDENTE AERONÁUTICO
SIPA~~
DATA: 19 AGO 2011 MATRÍCULA: PR-5EK 1. 1. LOCAL: Oceano Atliintico - Sacia MODELO: AW-139 Petrolífera de Campos - RJ
TIPO: OUTROS TIPOS OPERADOR: Senior Táxi Aéreo
COllforme a Lei 11" 7.565, de 19 de dezembro de 1986, Artigo 86, compete ao Sistema de
IlIvestigaráo e Prevenráo de Acidentes Aeronáuticos - SIPAER - planejar, orielltar, coordenar,
controlar e executar as atividades de investigaráo e de preven~áo de acidentes aeronáuticos.
A presente Recomendaráo de Seguranra de Voo (RSV) é o estabelecimento de uma aráo
que a Autoridade Aeronáutica 011 Elo-SIPAER emite para o seu ámbito de atllaráo, visando
eliminar ou mitigar o risco de uma Condiráo Latellte ou da conseqüellcia de uma Fallla Ativa.
Sob a ótica do SIPAER, tem o caráter essencial para a Seguranra de Voo, referindo-se a
um perigo especifico e develldo ser cumprida num determillado prazo.
A elahoraráo dessa RSV foi cOllduzida sem recorrer a qualquer procedimento de prova
para apuraráo de respolIsabilidade civil ou criminal; cOlIsequelltemente o uso que se fara dessa
recomellda~áo para qualquer propósito que lIáo o de prevellráo de futuros acidentes, poderá
illduzir a illterpretaroes e conclusoes errolleas.
1- FUNDAMENTACÁO
No dia 19 AGO 2011, o helicóptero de matricula PR-SEK decolou da plataforma
petrolífera P-65 com destino a Macaé, RJ. Cuando cruzava aproximadamente 1800 ft
durante a subida, declarou emergencia ao Controle de Aproxima~áo de Macaé (APP-ME)
e. em seguida, informou que estava com pane no sistema hidráulíco primário e
secundário.
A aeronave colidiu com o mar aproximadamente ás 19:48 UTC. O helicóptero
sofreu danos graves e os seus quatro ocupantes sofreram les6es fatais.
A investiga~áo está em andamento. Verificou-se que, em maio de 2011, a Agusta
Itália emitiu um boletim (8T 139-251, de 06 de maio de 2011) referente a inspe~6es em
duas áreas (BLADE ROOr e FORK) do punho de fixa~áo das pás do rotor de cauda (para
verifica~áo de sinais de trincas e descolamento do material composto).
A parte 1 do referido boletim estabeleceu que todas as pás com mais de 600 horas
(inclusive aquelas com mais de 1200 horas). a partir daquela data, deveriam ser
inspecionadas externamente a cada 25 horas de voo.
A parte 2 do referido 8T determinou que todas as pás com mais de 1200 horas
(totais) deveriam ser removidas para inspe~áo nas duas áreas do punho de fixa~áo. sendo
que aquelas que apresentassem evidencias de trincas ou descolamento deveriam ser
enviadas para reparo junto ao fabricante e substituidas por pás novas ou recondicionadas.
A parte 2 também estabeleceu que o procedimento dessa tarefa deveria ser
repetido a cada 600 horas após a última inspe~áo da pá.
A parte 3 do BT 139-251 estabeleceu que as pás estocadas no suprimento, com
mais de 600 horas totais, por já estarem removidas, deveriam ser submetidas a todos os
procedimentos da parte 2.
A aeronave PR-SEK foi adquirida diretamente do fabricante (nova) em 2007.
A pá SN Q 1018 foi o primeiro destro~o da aeronave na linha de proje~ao da
trajetória de voo, sendo encontrada a 240 metros do conjunto do rotor de cauda.
A referida pá sofreu ruptura entre a BLADE ROOT e o FORK, áreas estabelecidas
para inspe~ao estabelecida no BT 139 - 251, estando o restante da pe~a intacta.
O conjunto do rotor de cauda, segundo destro~o encontrado na Iinha de proje~ao da
trajetória de voo, foi encontrado a 560 metros da fuselagem.
As duas Iinhas dos sistemas hidráulicos 1 e 2 alimentam o conjunto do rotor de
cauda.
Urna separa~ao do conjunto do rotor de cauda da fuselagem implica no rompimento
das duas linhas hidráulicas, com alarmes visuais no painel, perda total do sistema 1 e
perda de 78 % do fluido hidráulico do sistema 2, quando urna válvula fecha a linha para o
rotor de cauda.
Com apenas 22% do fluido hidráulico, o sistema 2 alimenta apenas o rotor principal,
cuja atua~ao dos comandos fica deteriorada.
A fuselagem foi encontrada com danos severos em toda a parte dianteira e na
lateral direita.
O cone de cauda estava integro, afixado á fuselagem, sem o conjunto do rotor de
cauda.
No dia 17/08/2011, houve um acidente com esse modelo de aeronave, na China,
com evidencias de quebra de pá do rotor de cauda, seguida da separa~ao do conjunto do
rotor de cauda da fuselagem.
Os registros de manuten~ao da Senior Táxi Aéreo, verificados até este momento da
investiga~ao, demonstraram que todos os servi~os de manuten~ao da aeronave estavam
de acordo com o manual de manuten~ao do fabricante.
Os registros de manuten~ao demonstraram que a Senior Táxi Aéreo inspecionou
todas as pás das aeronaves de sua frota no dia 09/05/2011, aplicando os procedimentos
da parte 2 do BT 139-251 (retirada da pá e inspe~ao completa).
Nas referidas inspe~oes, urna pá com aproximadamente 1150 horas apresentou
trincas e duas pás com mais de 2000 horas nao apresentaram problemas.
Após as inspe~oes de todas as pás, a Senior Táxi Aéreo, de maneira conservativa,
vinha realizando as inspe~oes estabelecidas na parte 1 do BT 139-251 a cada intervalo
dos voos, enquanto que a parte 1 orientava para urna inspe~ao a cada 25 horas de voo.
A pá SN Q 1018, foi enviada para a Senior Táxi Aéreo em 10/01/2010, com 589,9
horas totais, após revisao na Agusta, na Itália.
Os servi~os realizados na revisao na Agusta Itália eliminaram corrosao e trincas
localizadas no punho de fixa~ao da pá, mas em áreas distintas dos pontos de ruptura. O
FORM 8130-3 AGU -2010-50674, datado de 09 de julho de 2010, detalha os servi~os de
reparos realizados nas regioes próximas á nervura da raiz da pá SN Q 1018 e também na
regiao do FORK da pá.
2
if'
Depois de instalada em outra aeronave da empresa, a pá SN Q 1018 foi removida e
instalada na aeronave PR-SEK, em 22104/2011, com 1280 horas totais.
A referida pá foi retirada em Sao Tomé e cumpriu a tarefa prevista na parte 2 do BT
139-251 no dia 09/05/2011, na Senior Jacarepaguá, na presenlfa e com supervisao de
representante da Agusta, com aproximadamente 1300 horas totais, quando nao foram
encontradas anormalidades.
Até o acidente, a referida pá passou por diversas inspelfoes diárias nos intervalos
dos voos, cumprindo os procedimentos de inspelfao visual estabelecidos na parte 1 do BT
139-251.
No acidente, a pá SN Q 1018 havia completado aproximadamente 290 horas após
a inspelf30 realizada no dia 09/05/2011, na Senior Jacarepaguá, faltando ainda
aproximadamente 310 horas para a próxima inspelf30 de 600 horas, estabelecida na parte
2 do BT 139-251.
A Agusta emitiu, em 25 AGO 2011, o Boletim Técnico n° 139-265, de caráter
mandatório. Na parte 1 do referido boletim, o fabricante determinou que, em até 25 horas
de voo a partir do recebimento do boletim e a cada 25 horas de voo a partir do seu
cumprimento, todas as pás sofressem inspelf30 visual externa.
Na parte 2, o fabricante determinou que, em até 5 horas de voo ou 30 dias a partir
do recebimento do boletim, o que ocorrer primeiro, todas as pás com mais de 600 horas
de voo ou mais de 1500 pousos, o que ocorrer primeiro, devem ser removidas e colocadas
em quarentena.
A European Aviation Safety Agency (EASA) emitiu, em 25 AGO 2011, a Diretriz de
Aeronavegabilidade de Emergencia (Emergency Airworthiness Directive) AD n° 20110156-
E, estabelecendo o cumprimento mandatório do Boletim Técnico n° 139-265.
Exames visuais realizados no conjunto do rotor de cauda indicaram o rompimento
da pá SN Q 1018 (fotos n01 e 2) na regiao da sua fixalfao e a ruptura do olhal do "Iead-Iag
damper assembly" (foto n03) correspondente a essa pá. Nao foram observadas marcas ou
danos na referida pá, que pudessem indicar que ela tenha sofrido algum impacto, que
pudesse ter colaborado para o seu arrancamento.
Foto n01: Aspecto geral da pá arrancada.
3
Foto n02: Aspecto da ruptura ocorrida, lado da pá,
Foto n03: Aspecto da fratura do olhal do "Iead-Iag damper assembly', A deforma~ao
sofrida indica um esfor~o de arrancamento longitudinal ao amortecedor.
A análise visual preliminar realizada indica que a ruptura ocorrida na regiao de
fixa~ao da pá SN Q 1018 ocorreu por um esfor~o longitudinal ao corpo da pá (radial em
rela~ao a sua rota~ao),
11 - RECOMENDACÓES DE SEGURANCA DE VOO
AANAC, recomenda-se:
RSV (A) 1B1 12011 - CENIPA Emitida em 25 108 12011
1) Tendo em vista a emissao do Boletim Técnico n° 139-265 pela Agusta, a
emissao da Diretriz de Aeronavegabilidade de Emergencia AD n° 2011-0156-E pela
EASA, os reportes de dificuldades em servi~o e os fatos conhecidos até o presente
momento em rela~ao as pás do rotor de cauda do helicóptero modelo AW139, avaliar junto
a Autoridade Primária de Certifica~ao (EASA) se as medidas mitigadoras adotadas sao
4
suficientes para assegurar um controle adequado das falhas nas referidas pás e permitem
que a aeronave seja operada no Brasil em conformidade com os requisitos de cerlificayao
de tipo aplicáveis.
111. DIVULGACAO
• ANAC
Brasilia, .¿5 I O íJ I 2011 .
Aprovo estas Recomendayoes de Seguranya de Voo
Chefe CENIPA
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Can one of our Portuguese speaking pilots translate this? I used Google, but as usual it is not easy to follow.
I'm confused on the time line of the events.
If Google has not lead me astray it looks like as they were climbing thru 1800ft they reported a hydraulic problem and asked for an emergency landing in Macae. Then stated that they were returning to the rig. There is mention of loss of both #1 and #2 hyd systems. There is also a mention of the shut-off valve being activated at 22% oil level (#2 sys)
OK, so if the tail rotor blade separated and a second later the whole TRG departs, I can see the hyd lines being severed and loss of all oil from #1 and all but 22% of #2.
But if this was the case, I can't imagine the crew reporting a hyd problem and asking to land another 50 miles away.
Finding the blade only 500 meters from the TRG seems strange as well, if again the TRG departing caused the loss of oil.
So, what came first, the hyd fluid loss or the blade departing?
I'm confused on the time line of the events.
If Google has not lead me astray it looks like as they were climbing thru 1800ft they reported a hydraulic problem and asked for an emergency landing in Macae. Then stated that they were returning to the rig. There is mention of loss of both #1 and #2 hyd systems. There is also a mention of the shut-off valve being activated at 22% oil level (#2 sys)
OK, so if the tail rotor blade separated and a second later the whole TRG departs, I can see the hyd lines being severed and loss of all oil from #1 and all but 22% of #2.
But if this was the case, I can't imagine the crew reporting a hyd problem and asking to land another 50 miles away.
Finding the blade only 500 meters from the TRG seems strange as well, if again the TRG departing caused the loss of oil.
So, what came first, the hyd fluid loss or the blade departing?
Out
Face it shucked a blade. The pictures show it. It is probable that one tang of the blade failed, took out the hydraulics due to vibration, and then failed completely later resulting in the ride down.
The evidence is conclusive and I think someone should relook at Malaysia. The pictures I saw clearly show one blade failed like Brazil. The opposite blade shows strike damage. So, how the f do the other two blades (opposite of each other) showed no substantial damage? Could the cause be an exact precursor to Brazil, except they were over a runway?
The Sultan
Face it shucked a blade. The pictures show it. It is probable that one tang of the blade failed, took out the hydraulics due to vibration, and then failed completely later resulting in the ride down.
The evidence is conclusive and I think someone should relook at Malaysia. The pictures I saw clearly show one blade failed like Brazil. The opposite blade shows strike damage. So, how the f do the other two blades (opposite of each other) showed no substantial damage? Could the cause be an exact precursor to Brazil, except they were over a runway?
The Sultan
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I don't deny it threw a blade. Just trying to figure out when. If the blade came partly off the vibration would be horrendous, and again, the crew would not be reporting a hyd problem and looking for a landing 50 miles away......something does not add up.
Malaysia was not caused by a TR blade.....
Malaysia was not caused by a TR blade.....
Last edited by Outwest; 31st Aug 2011 at 12:06.
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Sultan, there is quite enough misinformation here already without adding to it. As Outwest says the Malaysia accident was caused by incompetence - not a TR failure.