Helicopter down in East River, NYC
When I think about being tethered to an aircraft with a harness that is secured BEHIND me with a screw-type carabiner...I mean, it just gives me the willies. Or heebie-jeebies, one or the other. Because off the top of my balding head I can come up with a couple of very valid reasons that I might want to un-ass an aircraft tout de suite! And then I think about trying to reach *BEHIND* me to unscrew the carabiner. If such a scenario doesn't make your skin crawl, then buddy, you have less fear than I do.
And that poor pilot; sheesh, he must have known that those harnesses were a literal death sentence for his pax. I mean, just suppose he couldn't have made the river? Suppose he ended up landing in Manhattan somewhere and...let's be honest for a moment - botched the auto and it rolled onto its side and burned. Astars have been known to do that. Those pax would still be dead. I mean, come on. To all you real pilots out there I ask: Would YOU take off in a helicopter in which the pax could not quickly and easily release their own restraints and get the heck out if it were on fire...or under water? HECK NO, you wouldn't! Part of every pre-takeoff safety briefing I've ever given includes instruction about releasing the seatbelts, which have a different release motion than the cars with which we're all familiar. How did that pilot handle that bit?
I'm wondering...I mean, I'm really at a loss for words as to why NOBODY in either company (FlyNYON or Liberty) took a look at those harnesses and said, "Uhhhhhh...hold on. This ain't great." When the lawsuits come - and you know they will - there's going to be a *BUNCH* of people on the hot-seat, including, unfortunately, that PIC.
And that poor pilot; sheesh, he must have known that those harnesses were a literal death sentence for his pax. I mean, just suppose he couldn't have made the river? Suppose he ended up landing in Manhattan somewhere and...let's be honest for a moment - botched the auto and it rolled onto its side and burned. Astars have been known to do that. Those pax would still be dead. I mean, come on. To all you real pilots out there I ask: Would YOU take off in a helicopter in which the pax could not quickly and easily release their own restraints and get the heck out if it were on fire...or under water? HECK NO, you wouldn't! Part of every pre-takeoff safety briefing I've ever given includes instruction about releasing the seatbelts, which have a different release motion than the cars with which we're all familiar. How did that pilot handle that bit?
I'm wondering...I mean, I'm really at a loss for words as to why NOBODY in either company (FlyNYON or Liberty) took a look at those harnesses and said, "Uhhhhhh...hold on. This ain't great." When the lawsuits come - and you know they will - there's going to be a *BUNCH* of people on the hot-seat, including, unfortunately, that PIC.
Last edited by 212man; 25th Sep 2019 at 16:18.
When I think about being tethered to an aircraft with a harness that is secured BEHIND me with a screw-type carabiner...I mean, it just gives me the willies. Or heebie-jeebies, one or the other. Because off the top of my balding head I can come up with a couple of very valid reasons that I might want to un-ass an aircraft tout de suite! And then I think about trying to reach *BEHIND* me to unscrew the carabiner. If such a scenario doesn't make your skin crawl, then buddy, you have less fear than I do.
And that poor pilot; sheesh, he must have known that those harnesses were a literal death sentence for his pax. I mean, just suppose he couldn't have made the river? Suppose he ended up landing in Manhattan somewhere and...let's be honest for a moment - botched the auto and it rolled onto its side and burned. Astars have been known to do that. Those pax would still be dead. I mean, come on. To all you real pilots out there I ask: Would YOU take off in a helicopter in which the pax could not quickly and easily release their own restraints and get the heck out if it were on fire...or under water? HECK NO, you wouldn't! Part of every pre-takeoff safety briefing I've ever given includes instruction about releasing the seatbelts, which have a different release motion than the cars with which we're all familiar. How did that pilot handle that bit?
I'm wondering...I mean, I'm really at a loss for words as to why NOBODY in either company (FlyNYON or Liberty) took a look at those harnesses and said, "Uhhhhhh...hold on. This ain't great." When the lawsuits come - and you know they will - there's going to be a *BUNCH* of people on the hot-seat, including, unfortunately, that PIC.
And that poor pilot; sheesh, he must have known that those harnesses were a literal death sentence for his pax. I mean, just suppose he couldn't have made the river? Suppose he ended up landing in Manhattan somewhere and...let's be honest for a moment - botched the auto and it rolled onto its side and burned. Astars have been known to do that. Those pax would still be dead. I mean, come on. To all you real pilots out there I ask: Would YOU take off in a helicopter in which the pax could not quickly and easily release their own restraints and get the heck out if it were on fire...or under water? HECK NO, you wouldn't! Part of every pre-takeoff safety briefing I've ever given includes instruction about releasing the seatbelts, which have a different release motion than the cars with which we're all familiar. How did that pilot handle that bit?
I'm wondering...I mean, I'm really at a loss for words as to why NOBODY in either company (FlyNYON or Liberty) took a look at those harnesses and said, "Uhhhhhh...hold on. This ain't great." When the lawsuits come - and you know they will - there's going to be a *BUNCH* of people on the hot-seat, including, unfortunately, that PIC.
the counter argument to above is that a quick release system puts the passengers at danger because they are inexperienced and might use it by accident and fall out. This doesn’t hold water because if the pax can’t be trusted to operate the equipment properly then they shouldn’t be there in the first place.
I flew with Liberty in 2011 and certainly did not have that belt arrangement, might have been a different set up as there were only 2 of us as pax and single pilot in an AS350......as we all know any kind of sight seeing tours, boat, small plane, coaches and helicopters has accidents that make headlines because of numbers involved. Many business owners moan about regulations, but in this day and age maybe it’s time for standards and compliance? I’m aware that standards exist....who is enforcing compliance?
I flew with Liberty in 2011 and certainly did not have that belt arrangement, might have been a different set up as there were only 2 of us as pax and single pilot in an AS350......as we all know any kind of sight seeing tours, boat, small plane, coaches and helicopters has accidents that make headlines because of numbers involved. Many business owners moan about regulations, but in this day and age maybe it’s time for standards and compliance? I’m aware that standards exist....who is enforcing compliance?
To keep unsecured passengers from doing a swan dive into the Hudson River from 2,500 feet, Liberty and FlyNYON devised the supplemental restraint with that goofy behind-the-back, screw-type carabiner thing. In somebody's mind, they thought they were being "extra safe" and were going beyond the regulations. Sadly, as we've come to find out, they were wrong. Very, very wrong. I mean, it's indisputable. (Heck, maybe their local FAA guy encouraged them to come up with some "extra" restraint system for the shoe-selfie flights, who knows.)
But now the FAA must feel that they have egg on their face. They certainly don't want to come out and publicly admit the uncomfortable truth. ...Which is that what FlyNYON was doing wasn't illegal, per se. I've done dozens of door-off photo flights in my career, and the photographer-passenger didn't have to have any special credentials or training. We'd put a little strip of duct tape around the seat belt latch to keep it from inadvertently releasing, and we'd pretty much leave it up to the passenger to not fall out. In fact we'd even say to him, "Don't fall out." Personally, I've never lost a passenger.
There is no doubt that the FAA is in the process of creating regulations which would cover these so-called shoe-selfie flights. But since they won't be able to prohibit them completely (in my opinion, anyway), they will instead focus on passenger restraints. They will surely prohibit the use of any restraint that cannot be quickly and easily released by the passenger. Because THAT is what killed those passengers.
We used a photo harness with a quick release on the front chest. Under a velcro patch, lift the flap and pull the handle. Took a positive effort, and like 1100 says, we never lost anybody overboard.
Shoe selfies is a ferkin stupid thing to do, but mad milennials will do anything to upstage their friends on Napchat or bookface.
Shoe selfies is a ferkin stupid thing to do, but mad milennials will do anything to upstage their friends on Napchat or bookface.
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- Leaving the ground in the first place is dumb.
- Doing it in a helicopter is even more dangerous.
- Doing it to take photos is even more dangerous, there are alternatives that are safer for humans (drones).
- Letting the great unwashed--er--untrained up in a helicopter to do this, even more dangerous.
- Taking the door off to get better photos: more dangerous still.
- Flying over water to do it, even more dangerous.
We do these things all of the time and don't even bat an eye. Par for the course. Standard stuff. And it could just as easily happened otherwise. Somebody moves their purse, or bag, or camera, and a strap snags the fuel control. Float doesn't inflate. People could still drown.
- Letting people stick their feet out of the door while all of the above happens: seems like not that much greater a leap. Unnecessary, yes, but so is all of the above.
It's the sh*tty harness rigging that should be focused on, not the shoe selfies themselves. If these folks had properly rigged harnesses the results would have been little different than a "regular" photo/sightseeing flight gone similarly awry.
Is it? Where do you want to draw the line?
- Leaving the ground in the first place is dumb.
- Doing it in a helicopter is even more dangerous.
- Doing it to take photos is even more dangerous, there are alternatives that are safer for humans (drones).
- Letting the great unwashed--er--untrained up in a helicopter to do this, even more dangerous.
- Taking the door off to get better photos: more dangerous still.
- Flying over water to do it, even more dangerous.
We do these things all of the time and don't even bat an eye. Par for the course. Standard stuff. And it could just as easily happened otherwise.
Somebody moves their purse, or bag, or camera, and a strap snags the fuel control. Float doesn't inflate. People could still drown.
- Letting people stick their feet out of the door while all of the above happens: seems like not that much greater a leap. Unnecessary, yes, but so is all of the above.
It's the sh*tty harness rigging that should be focused on, not the shoe selfies themselves. If these folks had properly rigged harnesses the results would have been little different than a "regular" photo/sightseeing flight gone similarly awry.
- Leaving the ground in the first place is dumb.
- Doing it in a helicopter is even more dangerous.
- Doing it to take photos is even more dangerous, there are alternatives that are safer for humans (drones).
- Letting the great unwashed--er--untrained up in a helicopter to do this, even more dangerous.
- Taking the door off to get better photos: more dangerous still.
- Flying over water to do it, even more dangerous.
We do these things all of the time and don't even bat an eye. Par for the course. Standard stuff. And it could just as easily happened otherwise.
Somebody moves their purse, or bag, or camera, and a strap snags the fuel control. Float doesn't inflate. People could still drown.
- Letting people stick their feet out of the door while all of the above happens: seems like not that much greater a leap. Unnecessary, yes, but so is all of the above.
It's the sh*tty harness rigging that should be focused on, not the shoe selfies themselves. If these folks had properly rigged harnesses the results would have been little different than a "regular" photo/sightseeing flight gone similarly awry.
You want to take people up to do ridiculously stupid things. Fine, just have your clients sign a waiver stating that what they are about to do is incredibly stupid and if they die while doing it they (the clients) take full responsibility.
Vertical released another article today:
Full disclosure: I was aboard a FlyNYON-operated companion flight that departed at the same time as the accident aircraft, as a photographer taking advantage of the pristine conditions to capture sunset views of the city. Because I witnessed the safety briefing and passenger-related pre-flight procedures, observed certain key details about the victims, and have a background in aviation journalism — and thus a degree of knowledge about the subject — I was interviewed by the NTSB in the aftermath of the crash, as well as by multiple media outlets. Notes from my NTSB interview are among the documents released yesterday, and they include key details that I withheld from my media interviews and my own coverageuntil the evidence could confirm them and validate their discussion.
https://www.verticalmag.com/news/pas...-photo-flight/
Full disclosure: I was aboard a FlyNYON-operated companion flight that departed at the same time as the accident aircraft, as a photographer taking advantage of the pristine conditions to capture sunset views of the city. Because I witnessed the safety briefing and passenger-related pre-flight procedures, observed certain key details about the victims, and have a background in aviation journalism — and thus a degree of knowledge about the subject — I was interviewed by the NTSB in the aftermath of the crash, as well as by multiple media outlets. Notes from my NTSB interview are among the documents released yesterday, and they include key details that I withheld from my media interviews and my own coverageuntil the evidence could confirm them and validate their discussion.
https://www.verticalmag.com/news/pas...-photo-flight/
In my opinion this first half of this ‘Disclosure’ is the authors own dramatic build up to the accident and the remainder, gleamed and further dramatised by the author from true facts found by official accident investigation teams........
Video cams are good stuff. My previous post number 113 in this thread has proved to be valid. The FAA are very foolish if they don't either ban doors open flights for people who are tourists and require factory seatbelts to be worn at all times in helicopters. I mean really, would a pilot ever not wear their seatbelt? Why should a passenger be allowed to wear anything other than a factory or STC'ed seatbelt? No tethers except for trained professionals. Trained means trained by the company doing the flight and the training has to be specified in the general ops manual or in a LOA for the operator. Same for doors opened. There is no argument that I can imagine that ameliorates this stuff. This is not a situation that can be nit- picked. They need a large hammer on these operations. Don't get me started on flying passengers you know or suspect are somehow intoxicated. My wife was a CFII and she once refused to fly with a law enforcement officer who had a concealed weapon. He offered the info and understood completely that her request was valid. Left his Glock in his car. Many thought she was being unreasonable but it is pilot discression. Same with alcohol for the safety of the pilot as well as the passenger. Shoot, they really shouldn't serve alcohol on commercial flights. I know I'm tired of obnoxious drunks on airplanes.
By the way waivers are not worth the paper they are written on and you can't waive your legal rights when negligence is in the air.
By the way waivers are not worth the paper they are written on and you can't waive your legal rights when negligence is in the air.
When it comes to an intoxicated passenger it is not up to the pilots discretion since 14 CFR § 91.17 clearly states: Except in an emergency, no pilot of a civil aircraft may allow a person who appears to be intoxicated or who demonstrates by manner or physical indications that the individual is under the influence of drugs (except a medical patient under proper care) to be carried in that aircraft.
This pilot knowingly loaded an intoxicated passenger and had him sit in the front seat!
This pilot knowingly loaded an intoxicated passenger and had him sit in the front seat!
I doubt the pilot will admit to knowing when under oath. I think it would be impossible to prove the pilot knew the passenger was over the limit for driving if they said "I had no way of knowing without a breath test meter if the person was intoxicated". How many people are drunk from the airport bar when they get onboard? Are the pilots remiss for not checking each one as they board? Are they held responsible when the guy causes the aircraft to be diverted for bad behaviour. I know what the regs say but has anyone ever been violated for that? Imagine the corporate pilots who would be between a rock and a hard place if they really had to check their VIPs. Uber better look out with their taxicab helicopter ops. The rules are fine but there are many that are difficult to enforce.
That's going to be up to the judges but they have audio/video proof of the conversations where the person in the front seat admits to having had a few drinks and that he's feeling a bit tipsy. The pilot even acknowledges it with a joke in response. https://dms.ntsb.gov/pubdms/search/d...786&mkey=96850
And I am sure it happens all the time in the corporate flying world but as long as no one gets hurt it's like it never happened. It's cases like this where we'll see what the courts decide on since the breaking of the rule could've caused this kind of outcome. It may or may not be used against the pilot/operator.
And I am sure it happens all the time in the corporate flying world but as long as no one gets hurt it's like it never happened. It's cases like this where we'll see what the courts decide on since the breaking of the rule could've caused this kind of outcome. It may or may not be used against the pilot/operator.
Last edited by verticalspin; 29th Sep 2019 at 03:05. Reason: wording
Got to agree with verticalspin here. It's not about knowing when someone is over the limit for driving. The wording says, "...appears to be intoxicated." So what's "intoxicated" mean? Overly-boisterous, disruptive behavior? The passenger freely admitting that he had a number of drinks ("liquid courage") prior to the flight?
If the FAA wanted to, they could be violating pilots all the time for allowing people who "appear to be intoxicated" onboard their aircraft. Last job I had, my boss was "under the influence" more often than not. Let's be honest, in the corporate world, if pilots stopped allowing drunk people on their aircraft, there would be very little flying done. That's an exaggeration, of course, but anyone who's ever flown corporate (or charters!) knows what I'm talking about. As long as nothing happens and nobody dies...
Ah, but there's the rub. In this case people did die. And maybe it was caused by the (admittedly) drunk guy who's seat belt or harness tether or whatever got tangled under the throttle and pulled it back when he sat up. Maybe the NTSB will trace the chain of events of the accident back, and focus on allowing the "drunk" guy and decide to go after the pilot and/or the operator this time.
Would you?
If the FAA wanted to, they could be violating pilots all the time for allowing people who "appear to be intoxicated" onboard their aircraft. Last job I had, my boss was "under the influence" more often than not. Let's be honest, in the corporate world, if pilots stopped allowing drunk people on their aircraft, there would be very little flying done. That's an exaggeration, of course, but anyone who's ever flown corporate (or charters!) knows what I'm talking about. As long as nothing happens and nobody dies...
Ah, but there's the rub. In this case people did die. And maybe it was caused by the (admittedly) drunk guy who's seat belt or harness tether or whatever got tangled under the throttle and pulled it back when he sat up. Maybe the NTSB will trace the chain of events of the accident back, and focus on allowing the "drunk" guy and decide to go after the pilot and/or the operator this time.
Would you?
The problem is, the guy got through the safety check, didn't throw up or fall down. What one person sees as slightly drunk another may see as not drunk at all. What does "twisted" mean anyway? Not found in Part 1 of 14 CFR. Of course I am obfuscating here but that is what lawyers do when the law is unenforceable. Legal ramifications at a trial after an accident aside, it is always at the pilots discretion for letting a passenger onboard. After all, the ship can't fly without a pilot. It is the word " obviously" that leaves the door opened to these kinds of things. A cop can't make up their own sobriety test, can't have everyone doing something differently. Pilot judgement is kind of like that. How long would the pilot last if they said two out of four people ticketed for the birthday flight, including the birthday boy can't fly because there is alcohol in his cologne and I think he might be drunk. I'm only making the excuses that a totally distraught and embarassed pilot might make to save a career.
It should make a difference whether the pax with admitted liquid courage is sitting in 23C, or in the co-pilot seat.
In our business for example we wouldn’t put an 8-yr old in the co-pilot seat. We would only allow a child on the rear bench, based on an explicit ‘contract’ with an adult or older child to supervise the younger child.
In our business for example we wouldn’t put an 8-yr old in the co-pilot seat. We would only allow a child on the rear bench, based on an explicit ‘contract’ with an adult or older child to supervise the younger child.
Last edited by Hot and Hi; 29th Sep 2019 at 18:43.
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NTSB Accident Report, subject to further review, issued at today's public meeting:
https://t.co/vcKazFTG6Y
NATIONAL TRANSPORTATION SAFETY BOARD Public Meeting of December 10, 2019 (Information subject to editing)
Aircraft Accident Report: Inadvertent Activation of the Fuel Shutoff Lever and Subsequent Ditching Liberty Helicopters Inc., Operating a FlyNYON Doors-Off Flight Airbus Helicopters AS350 B2, N350LH New York, New York March 11, 2018 NTSB/AAR-19/04
This is a synopsis from the NTSB’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations. NTSB staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing to reflect changes adopted during the Board meeting.
Executive Summary
On March 11, 2018, about 1908 eastern daylight time, an Airbus Helicopters AS350 B2, N350LH, lost engine power during cruise flight, and the pilot performed an autorotative descent and ditching on the East River in New York, New York. The pilot sustained minor injuries, the five passengers drowned, and the helicopter was substantially damaged. The FlyNYON-branded flight was operated by Liberty Helicopters Inc. (Liberty), per a contractual agreement with NYONair; both companies considered the flight to be an aerial photography flight operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual flight rules (VFR) weather conditions prevailed, and no flight plan was filed for the intended 30-minute local flight, which departed from Helo Kearny Heliport, Kearny, New Jersey, about 1850.
Liberty operated the accident flight as a FlyNYON-branded, doors-off helicopter flight that allowed the five passengers (one in the front seat, four in the rear seats) to take photographs of various landmarks while extending their legs outside the helicopter during portions of the flight. For the accident flight (and other FlyNYON flights that Liberty operated), Liberty configured its Airbus AS350 B2 helicopter with the two right and the front left doors removed and the left sliding door locked open. Before departure, each passenger was fitted with a NYONair-provided harness/tether system that NYONair developed with the intent to prevent passengers from falling out of the helicopter. The harness/tether system used on the accident flight consisted of a full-body, workplace fall-protection harness that was secured (with a locking carabiner) to a tether, the other end of which was secured (with another locking carabiner) to an anchor point in the cabin. Each passenger also wore the helicopter’s installed, Federal Aviation Administration (FAA)-approved restraints. The pilot (who was seated in the front right seat) wore only an installed, FAA-approved restraint.
After the flight departed, it traveled past various scenic landmarks. Consistent with the standard operating procedures (SOPs) used for FlyNYON flights, the passengers were allowed (when instructed by the pilot) to position themselves to extend their legs outside the helicopter. The two passengers who had been seated in the rear inboard seats removed their installed, FAAapproved restraints and sat on the cabin floor, wearing their harness/tether systems. The passengers seated in the outboard seats were allowed to rotate outboard in their seats. To enable such freedom of movement, the SOPs allowed the passengers to wear their installed, FAA-approved restraint with the lap belt adjusted loosely and the shoulder harness routed under the arm.
A review of radar data and onboard video showed that, when the flight was proceeding northwest over Manhattan toward Central Park at an altitude of 1,900 ft mean sea level, the front passenger, who was facing outboard in his seat with his legs outside the helicopter, leaned back several times to take photographs using a smartphone. The onboard video showed that, each time he leaned back, the tail of the tether attached to the back of his harness hung down loosely near the helicopter’s floor-mounted controls. At one point, when he pulled himself up to adjust his seating position, his tether tail remained taut but appeared to pop upward. Two seconds later, the helicopter’s engine sounds decreased, and the helicopter began to descend.
As the pilot performed the emergency procedures to perform an autorotation and address the apparent loss of engine power, he noticed that the fuel shutoff lever (FSOL) was in the shutoff position and that it had been inadvertently moved to that position by the tail of the front passenger’s tether, which had become caught on it.
Although the pilot pushed the FSOL down to restore fuel flow to the engine and attempted to relight the engine, the helicopter was too low to allow engine power to be restored in time to prevent the emergency landing. The pilot pulled the activation handle to deploy the helicopter’s emergency flotation system, and he ditched the helicopter on the East River. However, the helicopter’s floats did not fully inflate, and the helicopter rolled right in the water and became fully inverted and submerged about 11 seconds after it touched down.
The pilot was able to release his installed, FAA-approved restraint after he was under water and successfully egress from the helicopter; however, none of the passengers were able to egress, and they all drowned.
The NTSB identified the following safety issues as a result of this accident investigation:
• Effect of the harness/tether system on the ability of each passenger to rapidly egress from the capsizing helicopter. The investigation found that minimally trained passengers would have great difficulty extricating themselves from the harness/tether system, each of which was equipped with locking carabiners and an ineffective cutting tool, during an emergency requiring a rapid egress.
• Emergency flotation system design, maintenance, and certification issues. The manufacturer of the helicopter’s emergency flotation system did not provide information to help operators recognize the presence of unacceptably high pull forces when activating the system; the high pull forces on the accident helicopter’s activation system (which resulted from an installation anomaly) contributed to the pilot’s mistaken belief that he had taken the necessary action to fully inflate the floats. The FAA’s certification review of the emergency flotation system design installed on the accident helicopter did not identify the manufacturer’s omission of an activation handle pull-force limitation.
• Ineffective safety management at both Liberty and NYONair. Liberty’s managers repeatedly lacked involvement in key decisions related to Libertyoperated FlyNYON flights and allowed NYONair to influence core aspects of the operational control of those flights. Ineffective safety management at both companies allowed foreseeable safety risks to remain unmitigated; these included the potential for passenger interference with the helicopter’s floor-mounted controls, partial inflation of the emergency float system, and difficulties passengers would have with the locking carabiners and cutting tools as a means to rapidly release from the harness/tether system.
• Liberty and NYONair’s exploitation of the aerial work/aerial photography exception at 14 CFR 119.1(e) to operate FlyNYON flights under Part 91 with limited FAA oversight. Federal regulations do not define the terms “aerial work” and “aerial photography” to include only business-like, work-related aerial operations. Both Liberty and NYONair demonstrated deliberate efforts to operate the FlyNYON revenue passenger-carrying flights under Part 91 as aerial photography flights and to avoid any indication that the flights may be commercial air tours, which would be subject to additional FAA requirements and oversight that did not apply to aerial photography flights.
• Lack of policy and guidance for FAA inspectors to perform a comprehensive inspection of Part 91 operations conducted under any of the 14 CFR 119.1(e) exceptions. During the investigation, the FAA determined that the accident flight was a nonstop commercial air tour operated under Part 91 per the 14 CFR 119.1(e)(2) exception. Although an air tour operated under Part 91 is subject to FAA requirements and oversight that exceed what applies to aerial photography flights, the FAA lacks policy and guidance for FAA inspectors to support a comprehensive inspection of Part 91 operations conducted under any of the exceptions in 14 CFR 119.1(e) to ensure that operators are appropriately managing any associated risks.
• Lack of FSOL protection from inadvertent activation. The certification basis for the accident helicopter’s FSOL did not require protection from inadvertent activation due to external influences, such as interference from a passenger. However, a design modification that includes protection from external influences could enhance safety.
• Need for guidance and procedures for operators to assess and address passenger intoxication. Although the passenger in the front seat on the accident flight was intoxicated, it was not possible to determine whether alcohol played a role in his inadvertent activation of the FSOL. Despite the existence of an FAA regulation prohibiting the carriage of any passenger who appears to be intoxicated or impaired, neither Liberty nor NYONair had any documented policy or guidance materials, including training, for their employees to identify impaired passengers or for denying boarding of such individuals. While FAA guidance does exist on identifying intoxicated or impaired passengers, operators that conduct revenue passenger-carrying flights under Part 91 or 135 in small aircraft could benefit from guidance specific to their operations, particularly if they have passengers seated in close proximity to the aircraft controls.
• Inadequacy of the review and approval process for supplemental passenger restraint systems (SPRSs) that the FAA implemented after the accident. The FAA’s SPRS approval process that it implemented after the accident appears to focus primarily on the SPRS release mechanism without consideration of the expected operational environment or whether the use of an SPRS is warranted. The NTSB is concerned that, without an assessment of the specific need for and use of an SPRS, the addition of an SPRS may unnecessarily complicate the emergency egress of passengers. Further, without a comprehensive hazard analysis for the use of an SPRS in the operational environment (including aircraft-specific installations), factors that could impede passenger egress, such as the potential for entanglement with headset cords, other equipment, or the SPRS itself; or adversely affect flight safety, such as the potential for the SPRS to interfere with an equipment or controls in a specific aircraft, may be present but go unidentified.
Findings
1. None of the following were factors in this accident: (1) the pilot’s qualifications, which were in accordance with federal regulations and company requirements; (2) pilot fatigue or medical conditions; and (3) the airworthiness of the helicopter.
2. The tail of the front passenger’s tether caught on the fuel shutoff lever (FSOL) during the flight, which resulted in the inadvertent activation of the FSOL, interruption of fuel flow to the engine, and loss of engine power.
3. The pilot autorotated the helicopter successfully and pulled the emergency flotation system activation handle to deploy the floats at an appropriate time; however, the floats inflated partially and asymmetrically.
4. Liberty Helicopters Inc.’s and NYONair’s decision to use locking carabiners and ineffective cutting tools as the primary means for passengers to rapidly release from the harness/tether system was inappropriate and unsafe.
5. The helicopter’s landing was survivable; however, the NYONair-provided harness/tether system contributed to the passenger fatalities because it did not allow the passengers to quickly escape from the helicopter.
6. The Federal Aviation Administration’s (FAA) approval process for supplemental passenger restraint systems (SPRS) that was implemented after the accident is inadequate because it does not provide guidance to inspectors to evaluate any aircraft-specific installations or the potential for entanglement that passengers may encounter during emergency egress.
7. Although the crossover hose in the accident helicopter’s emergency flotation system design did not perform its intended function to alleviate asymmetric inflation of the floats during a single-reservoir discharge event, buoyancy stability testing showed that even symmetric distribution of the gas from only one reservoir would not enable the helicopter to remain upright in water.
8. In the absence of information from Dart specifying pull-force limitations for the emergency flotation system’s activation handle, Liberty and other operators lack a means to inspect for and correct high pull forces that may result from an installation anomaly or other issues.
9. Although the accident pilot was aware that each gas reservoir may not discharge simultaneously, the high forces required to pull the activation handle, along with the aural and visual cues following a single-reservoir discharge, led the pilot to mistakenly believe that he had successfully pulled the handle fully aft to fully inflate the floats.
10. The Federal Aviation Administration’s certification review of the emergency flotation system design installed on the accident helicopter did not identify Dart’s omission of an activation handle pull-force limitation; thus, the FAA’s reviews of other approved emergency flotation system designs may not have identified similar omissions.
11. Improved guidance for aircraft certification offices for assessing design features, usability, and inspection methods that ensure successful deployment of an emergency flotation system could help ensure that these important aspects are considered during the certification review process for such systems.
12. Through their repeated lack of involvement in key decisions related to Liberty Helicopters-operated FlyNYON flights, Liberty’s managers allowed NYONair personnel, particularly NYONair’s chief executive officer, to influence core aspects of the operational control of those flights.
13. Ineffective safety management at both Liberty Helicopters Inc. and NYONair resulted in a lack of prioritization and mitigation of foreseeable risks.
14. Liberty Helicopters and NYONair exploited the exception at Title 14 Code of Federal Regulations 119.1(e)(4)(iii) allowing aerial photography flights to be operated under Part 91, thereby avoiding the additional Federal Aviation Administration requirements and oversight that apply to commercial air tours conducted under either Part 135 or Part 91 with an air tour letter of authorization.
15. Without regulatory language that defines the terms “aerial work” and “aerial photography” to include only business-like, work-related aerial operations, operators may attempt to take advantage of the exception at Title 14 Code of Federal Regulations 119.1(e)(4)(iii) to carry revenue passengers for personal, entertainment, or leisure purposes without the additional Federal Aviation Administration requirements and oversight that apply to other commercial, revenue passenger-carrying operations.
16. The Federal Aviation Administration principal operations inspector assigned to oversee Liberty Helicopters Inc. did not conduct additional surveillance of Liberty’s operations after being made aware of its FlyNYON flights and failed to ensure that Liberty was appropriately managing the risks associated with the significant change in operations.
17. Because the Federal Aviation Administration (FAA) continues to allow passenger revenue operations to be conducted under Title 14 Code of Federal Regulations Part 91—some of which, like the FlyNYON flight operations, transport thousands of passengers annually— the FAA must provide inspectors with sufficient guidance to pursue more comprehensive oversight with regard to potential hazards they observe and to ensure that operators sufficiently mitigate risks.
18. Although the certification basis for the accident helicopter’s fuel shutoff lever did not require protection from inadvertent activation due to external influences, a design modification that includes such protection could enhance safety more effectively than continued reliance on operational measures.
19. The risk of the NYONair-provided harness/tether system tether tail becoming entangled with the floor-mounted fuel shutoff lever existed independently from passenger intoxication and most likely depended primarily on the passenger’s positioning in the cabin.
20. When passengers are seated in close proximity to an aircraft’s controls, it is critical that they not be impaired to reduce the likelihood of interference with the pilot’s ability to safely fly the aircraft.
Probable Cause
The NTSB determines the probable cause of this accident was Liberty Helicopters’ use of a NYONair-provided passenger harness/tether system, which caught on and activated the floormounted engine fuel shutoff lever and resulted in the in-flight loss of engine power and the subsequent ditching. Contributing to this accident were (1) Liberty’s and NYONair’s deficient safety management, which did not adequately mitigate foreseeable risks associated with the harness/tether system interfering with the floor-mounted controls and hindering passenger egress; (2) Liberty allowing NYONair to influence the operational control of Liberty’s FlyNYON flights; and (3) the Federal Aviation Administration’s inadequate oversight of Title 14 Code of Federal Regulations Part 91 revenue passenger-carrying operations. Contributing to the severity of the accident were (1) the rapid capsizing of the helicopter due to partial inflation of the emergency flotation system and (2) Liberty and NYONair’s use of the harness/tether system that hindered passenger egress.
Recommendations
To the Federal Aviation Administration
1. Modify the supplemental passenger restraint system (SPRS) approval process to (1) require letter of authorization (LOA) applicants to specify a need for and the intended use of an SPRS for each aircraft; (2) require the Federal Aviation Administration to evaluate and review, for each specified aircraft, the need for the SPRS on that aircraft for all intended uses; all SPRS design, manufacture, installation, and operational considerations, including, at a minimum, the potential for passengers to become entangled during emergency egress; the adequacy of passenger emergency egress briefings; and the potential for the SPRS to interfere with aircraft controls; and (3) ensure that each LOA lists the specific aircraft on which the holder is authorized to use an SPRS.
2. Until you implement the supplemental passenger restraint system (SPRS) approval process as recommended in Safety Recommendation [1], prohibit the use of SPRS for passenger-carrying doors-off operations.
3. Review the activation system designs of Federal Aviation Administration-approved rotorcraft emergency flotation systems for deficiencies that may preclude their proper deployment, such as a lack of a means to identify high pull forces on manual activation handles or inadequate guidance on the intended use of the activation system, and require corrective actions based on the review findings.
4. Revise Miscellaneous Guidance 10 in Advisory Circular (AC) 27 and AC 29 to include design objectives for emergency flotation systems that consider human factors design objectives, such as activation handle pull-force characteristics; provisions for clear, unambiguous, and positive feedback to pilots to indicate that the float system was successfully deployed; and inspections to ensure that an installation of a manual activation system does not preclude a pilot’s ability to deploy the floats, as designed, after it has been fielded.
5. Require all commercial air tour operators, regardless of their operating rule, to implement a safety management system.
6. Revise Title 14 Code of Federal Regulations 1.1, “General Definitions,” to include definitions for the terms “aerial work” and “aerial photography” that specify only business-like, work-related aerial operations, as originally intended.
7. Revise Order 8900.1, Flight Standards Information Management System, to include guidance for inspectors who oversee Title 14 Code of Federal Regulations (CFR) Part 91 operations conducted under any of the 14 CFR 119.1(e) exceptions to identify potential hazards and ensure that operators are appropriately managing the associated risks.
8. Develop and implement national standards within 14 Code of Federal Regulations (CFR) Part 135, or equivalent regulations, for all air tour operations with powered airplanes and rotorcraft to bring them under one set of standards with operations specifications, and eliminate the exception currently contained in 14 CFR 135.1.
9. After the actions requested in Safety Recommendation [11] are completed, require owners and operators of existing AS350-series helicopters to incorporate the changes.
10. Develop guidance on how to identify intoxicated or impaired passengers and distribute it to operators who carry passengers for hire under Title 14 Code of Federal Regulations Part 91 and Part 135.
To Airbus: 11. Modify the floor-mounted fuel shutoff lever in AS350-series helicopters to protect it from inadvertent activation due to external influences.
To the European Union Aviation Safety Agency:
12. After the actions requested in Safety Recommendation [11] are completed, require owners and operators of existing AS350-series helicopters to incorporate the changes.
Aircraft Accident Report: Inadvertent Activation of the Fuel Shutoff Lever and Subsequent Ditching Liberty Helicopters Inc., Operating a FlyNYON Doors-Off Flight Airbus Helicopters AS350 B2, N350LH New York, New York March 11, 2018 NTSB/AAR-19/04
This is a synopsis from the NTSB’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations. NTSB staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing to reflect changes adopted during the Board meeting.
Executive Summary
On March 11, 2018, about 1908 eastern daylight time, an Airbus Helicopters AS350 B2, N350LH, lost engine power during cruise flight, and the pilot performed an autorotative descent and ditching on the East River in New York, New York. The pilot sustained minor injuries, the five passengers drowned, and the helicopter was substantially damaged. The FlyNYON-branded flight was operated by Liberty Helicopters Inc. (Liberty), per a contractual agreement with NYONair; both companies considered the flight to be an aerial photography flight operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual flight rules (VFR) weather conditions prevailed, and no flight plan was filed for the intended 30-minute local flight, which departed from Helo Kearny Heliport, Kearny, New Jersey, about 1850.
Liberty operated the accident flight as a FlyNYON-branded, doors-off helicopter flight that allowed the five passengers (one in the front seat, four in the rear seats) to take photographs of various landmarks while extending their legs outside the helicopter during portions of the flight. For the accident flight (and other FlyNYON flights that Liberty operated), Liberty configured its Airbus AS350 B2 helicopter with the two right and the front left doors removed and the left sliding door locked open. Before departure, each passenger was fitted with a NYONair-provided harness/tether system that NYONair developed with the intent to prevent passengers from falling out of the helicopter. The harness/tether system used on the accident flight consisted of a full-body, workplace fall-protection harness that was secured (with a locking carabiner) to a tether, the other end of which was secured (with another locking carabiner) to an anchor point in the cabin. Each passenger also wore the helicopter’s installed, Federal Aviation Administration (FAA)-approved restraints. The pilot (who was seated in the front right seat) wore only an installed, FAA-approved restraint.
After the flight departed, it traveled past various scenic landmarks. Consistent with the standard operating procedures (SOPs) used for FlyNYON flights, the passengers were allowed (when instructed by the pilot) to position themselves to extend their legs outside the helicopter. The two passengers who had been seated in the rear inboard seats removed their installed, FAAapproved restraints and sat on the cabin floor, wearing their harness/tether systems. The passengers seated in the outboard seats were allowed to rotate outboard in their seats. To enable such freedom of movement, the SOPs allowed the passengers to wear their installed, FAA-approved restraint with the lap belt adjusted loosely and the shoulder harness routed under the arm.
A review of radar data and onboard video showed that, when the flight was proceeding northwest over Manhattan toward Central Park at an altitude of 1,900 ft mean sea level, the front passenger, who was facing outboard in his seat with his legs outside the helicopter, leaned back several times to take photographs using a smartphone. The onboard video showed that, each time he leaned back, the tail of the tether attached to the back of his harness hung down loosely near the helicopter’s floor-mounted controls. At one point, when he pulled himself up to adjust his seating position, his tether tail remained taut but appeared to pop upward. Two seconds later, the helicopter’s engine sounds decreased, and the helicopter began to descend.
As the pilot performed the emergency procedures to perform an autorotation and address the apparent loss of engine power, he noticed that the fuel shutoff lever (FSOL) was in the shutoff position and that it had been inadvertently moved to that position by the tail of the front passenger’s tether, which had become caught on it.
Although the pilot pushed the FSOL down to restore fuel flow to the engine and attempted to relight the engine, the helicopter was too low to allow engine power to be restored in time to prevent the emergency landing. The pilot pulled the activation handle to deploy the helicopter’s emergency flotation system, and he ditched the helicopter on the East River. However, the helicopter’s floats did not fully inflate, and the helicopter rolled right in the water and became fully inverted and submerged about 11 seconds after it touched down.
The pilot was able to release his installed, FAA-approved restraint after he was under water and successfully egress from the helicopter; however, none of the passengers were able to egress, and they all drowned.
The NTSB identified the following safety issues as a result of this accident investigation:
• Effect of the harness/tether system on the ability of each passenger to rapidly egress from the capsizing helicopter. The investigation found that minimally trained passengers would have great difficulty extricating themselves from the harness/tether system, each of which was equipped with locking carabiners and an ineffective cutting tool, during an emergency requiring a rapid egress.
• Emergency flotation system design, maintenance, and certification issues. The manufacturer of the helicopter’s emergency flotation system did not provide information to help operators recognize the presence of unacceptably high pull forces when activating the system; the high pull forces on the accident helicopter’s activation system (which resulted from an installation anomaly) contributed to the pilot’s mistaken belief that he had taken the necessary action to fully inflate the floats. The FAA’s certification review of the emergency flotation system design installed on the accident helicopter did not identify the manufacturer’s omission of an activation handle pull-force limitation.
• Ineffective safety management at both Liberty and NYONair. Liberty’s managers repeatedly lacked involvement in key decisions related to Libertyoperated FlyNYON flights and allowed NYONair to influence core aspects of the operational control of those flights. Ineffective safety management at both companies allowed foreseeable safety risks to remain unmitigated; these included the potential for passenger interference with the helicopter’s floor-mounted controls, partial inflation of the emergency float system, and difficulties passengers would have with the locking carabiners and cutting tools as a means to rapidly release from the harness/tether system.
• Liberty and NYONair’s exploitation of the aerial work/aerial photography exception at 14 CFR 119.1(e) to operate FlyNYON flights under Part 91 with limited FAA oversight. Federal regulations do not define the terms “aerial work” and “aerial photography” to include only business-like, work-related aerial operations. Both Liberty and NYONair demonstrated deliberate efforts to operate the FlyNYON revenue passenger-carrying flights under Part 91 as aerial photography flights and to avoid any indication that the flights may be commercial air tours, which would be subject to additional FAA requirements and oversight that did not apply to aerial photography flights.
• Lack of policy and guidance for FAA inspectors to perform a comprehensive inspection of Part 91 operations conducted under any of the 14 CFR 119.1(e) exceptions. During the investigation, the FAA determined that the accident flight was a nonstop commercial air tour operated under Part 91 per the 14 CFR 119.1(e)(2) exception. Although an air tour operated under Part 91 is subject to FAA requirements and oversight that exceed what applies to aerial photography flights, the FAA lacks policy and guidance for FAA inspectors to support a comprehensive inspection of Part 91 operations conducted under any of the exceptions in 14 CFR 119.1(e) to ensure that operators are appropriately managing any associated risks.
• Lack of FSOL protection from inadvertent activation. The certification basis for the accident helicopter’s FSOL did not require protection from inadvertent activation due to external influences, such as interference from a passenger. However, a design modification that includes protection from external influences could enhance safety.
• Need for guidance and procedures for operators to assess and address passenger intoxication. Although the passenger in the front seat on the accident flight was intoxicated, it was not possible to determine whether alcohol played a role in his inadvertent activation of the FSOL. Despite the existence of an FAA regulation prohibiting the carriage of any passenger who appears to be intoxicated or impaired, neither Liberty nor NYONair had any documented policy or guidance materials, including training, for their employees to identify impaired passengers or for denying boarding of such individuals. While FAA guidance does exist on identifying intoxicated or impaired passengers, operators that conduct revenue passenger-carrying flights under Part 91 or 135 in small aircraft could benefit from guidance specific to their operations, particularly if they have passengers seated in close proximity to the aircraft controls.
• Inadequacy of the review and approval process for supplemental passenger restraint systems (SPRSs) that the FAA implemented after the accident. The FAA’s SPRS approval process that it implemented after the accident appears to focus primarily on the SPRS release mechanism without consideration of the expected operational environment or whether the use of an SPRS is warranted. The NTSB is concerned that, without an assessment of the specific need for and use of an SPRS, the addition of an SPRS may unnecessarily complicate the emergency egress of passengers. Further, without a comprehensive hazard analysis for the use of an SPRS in the operational environment (including aircraft-specific installations), factors that could impede passenger egress, such as the potential for entanglement with headset cords, other equipment, or the SPRS itself; or adversely affect flight safety, such as the potential for the SPRS to interfere with an equipment or controls in a specific aircraft, may be present but go unidentified.
Findings
1. None of the following were factors in this accident: (1) the pilot’s qualifications, which were in accordance with federal regulations and company requirements; (2) pilot fatigue or medical conditions; and (3) the airworthiness of the helicopter.
2. The tail of the front passenger’s tether caught on the fuel shutoff lever (FSOL) during the flight, which resulted in the inadvertent activation of the FSOL, interruption of fuel flow to the engine, and loss of engine power.
3. The pilot autorotated the helicopter successfully and pulled the emergency flotation system activation handle to deploy the floats at an appropriate time; however, the floats inflated partially and asymmetrically.
4. Liberty Helicopters Inc.’s and NYONair’s decision to use locking carabiners and ineffective cutting tools as the primary means for passengers to rapidly release from the harness/tether system was inappropriate and unsafe.
5. The helicopter’s landing was survivable; however, the NYONair-provided harness/tether system contributed to the passenger fatalities because it did not allow the passengers to quickly escape from the helicopter.
6. The Federal Aviation Administration’s (FAA) approval process for supplemental passenger restraint systems (SPRS) that was implemented after the accident is inadequate because it does not provide guidance to inspectors to evaluate any aircraft-specific installations or the potential for entanglement that passengers may encounter during emergency egress.
7. Although the crossover hose in the accident helicopter’s emergency flotation system design did not perform its intended function to alleviate asymmetric inflation of the floats during a single-reservoir discharge event, buoyancy stability testing showed that even symmetric distribution of the gas from only one reservoir would not enable the helicopter to remain upright in water.
8. In the absence of information from Dart specifying pull-force limitations for the emergency flotation system’s activation handle, Liberty and other operators lack a means to inspect for and correct high pull forces that may result from an installation anomaly or other issues.
9. Although the accident pilot was aware that each gas reservoir may not discharge simultaneously, the high forces required to pull the activation handle, along with the aural and visual cues following a single-reservoir discharge, led the pilot to mistakenly believe that he had successfully pulled the handle fully aft to fully inflate the floats.
10. The Federal Aviation Administration’s certification review of the emergency flotation system design installed on the accident helicopter did not identify Dart’s omission of an activation handle pull-force limitation; thus, the FAA’s reviews of other approved emergency flotation system designs may not have identified similar omissions.
11. Improved guidance for aircraft certification offices for assessing design features, usability, and inspection methods that ensure successful deployment of an emergency flotation system could help ensure that these important aspects are considered during the certification review process for such systems.
12. Through their repeated lack of involvement in key decisions related to Liberty Helicopters-operated FlyNYON flights, Liberty’s managers allowed NYONair personnel, particularly NYONair’s chief executive officer, to influence core aspects of the operational control of those flights.
13. Ineffective safety management at both Liberty Helicopters Inc. and NYONair resulted in a lack of prioritization and mitigation of foreseeable risks.
14. Liberty Helicopters and NYONair exploited the exception at Title 14 Code of Federal Regulations 119.1(e)(4)(iii) allowing aerial photography flights to be operated under Part 91, thereby avoiding the additional Federal Aviation Administration requirements and oversight that apply to commercial air tours conducted under either Part 135 or Part 91 with an air tour letter of authorization.
15. Without regulatory language that defines the terms “aerial work” and “aerial photography” to include only business-like, work-related aerial operations, operators may attempt to take advantage of the exception at Title 14 Code of Federal Regulations 119.1(e)(4)(iii) to carry revenue passengers for personal, entertainment, or leisure purposes without the additional Federal Aviation Administration requirements and oversight that apply to other commercial, revenue passenger-carrying operations.
16. The Federal Aviation Administration principal operations inspector assigned to oversee Liberty Helicopters Inc. did not conduct additional surveillance of Liberty’s operations after being made aware of its FlyNYON flights and failed to ensure that Liberty was appropriately managing the risks associated with the significant change in operations.
17. Because the Federal Aviation Administration (FAA) continues to allow passenger revenue operations to be conducted under Title 14 Code of Federal Regulations Part 91—some of which, like the FlyNYON flight operations, transport thousands of passengers annually— the FAA must provide inspectors with sufficient guidance to pursue more comprehensive oversight with regard to potential hazards they observe and to ensure that operators sufficiently mitigate risks.
18. Although the certification basis for the accident helicopter’s fuel shutoff lever did not require protection from inadvertent activation due to external influences, a design modification that includes such protection could enhance safety more effectively than continued reliance on operational measures.
19. The risk of the NYONair-provided harness/tether system tether tail becoming entangled with the floor-mounted fuel shutoff lever existed independently from passenger intoxication and most likely depended primarily on the passenger’s positioning in the cabin.
20. When passengers are seated in close proximity to an aircraft’s controls, it is critical that they not be impaired to reduce the likelihood of interference with the pilot’s ability to safely fly the aircraft.
Probable Cause
The NTSB determines the probable cause of this accident was Liberty Helicopters’ use of a NYONair-provided passenger harness/tether system, which caught on and activated the floormounted engine fuel shutoff lever and resulted in the in-flight loss of engine power and the subsequent ditching. Contributing to this accident were (1) Liberty’s and NYONair’s deficient safety management, which did not adequately mitigate foreseeable risks associated with the harness/tether system interfering with the floor-mounted controls and hindering passenger egress; (2) Liberty allowing NYONair to influence the operational control of Liberty’s FlyNYON flights; and (3) the Federal Aviation Administration’s inadequate oversight of Title 14 Code of Federal Regulations Part 91 revenue passenger-carrying operations. Contributing to the severity of the accident were (1) the rapid capsizing of the helicopter due to partial inflation of the emergency flotation system and (2) Liberty and NYONair’s use of the harness/tether system that hindered passenger egress.
Recommendations
To the Federal Aviation Administration
1. Modify the supplemental passenger restraint system (SPRS) approval process to (1) require letter of authorization (LOA) applicants to specify a need for and the intended use of an SPRS for each aircraft; (2) require the Federal Aviation Administration to evaluate and review, for each specified aircraft, the need for the SPRS on that aircraft for all intended uses; all SPRS design, manufacture, installation, and operational considerations, including, at a minimum, the potential for passengers to become entangled during emergency egress; the adequacy of passenger emergency egress briefings; and the potential for the SPRS to interfere with aircraft controls; and (3) ensure that each LOA lists the specific aircraft on which the holder is authorized to use an SPRS.
2. Until you implement the supplemental passenger restraint system (SPRS) approval process as recommended in Safety Recommendation [1], prohibit the use of SPRS for passenger-carrying doors-off operations.
3. Review the activation system designs of Federal Aviation Administration-approved rotorcraft emergency flotation systems for deficiencies that may preclude their proper deployment, such as a lack of a means to identify high pull forces on manual activation handles or inadequate guidance on the intended use of the activation system, and require corrective actions based on the review findings.
4. Revise Miscellaneous Guidance 10 in Advisory Circular (AC) 27 and AC 29 to include design objectives for emergency flotation systems that consider human factors design objectives, such as activation handle pull-force characteristics; provisions for clear, unambiguous, and positive feedback to pilots to indicate that the float system was successfully deployed; and inspections to ensure that an installation of a manual activation system does not preclude a pilot’s ability to deploy the floats, as designed, after it has been fielded.
5. Require all commercial air tour operators, regardless of their operating rule, to implement a safety management system.
6. Revise Title 14 Code of Federal Regulations 1.1, “General Definitions,” to include definitions for the terms “aerial work” and “aerial photography” that specify only business-like, work-related aerial operations, as originally intended.
7. Revise Order 8900.1, Flight Standards Information Management System, to include guidance for inspectors who oversee Title 14 Code of Federal Regulations (CFR) Part 91 operations conducted under any of the 14 CFR 119.1(e) exceptions to identify potential hazards and ensure that operators are appropriately managing the associated risks.
8. Develop and implement national standards within 14 Code of Federal Regulations (CFR) Part 135, or equivalent regulations, for all air tour operations with powered airplanes and rotorcraft to bring them under one set of standards with operations specifications, and eliminate the exception currently contained in 14 CFR 135.1.
9. After the actions requested in Safety Recommendation [11] are completed, require owners and operators of existing AS350-series helicopters to incorporate the changes.
10. Develop guidance on how to identify intoxicated or impaired passengers and distribute it to operators who carry passengers for hire under Title 14 Code of Federal Regulations Part 91 and Part 135.
To Airbus: 11. Modify the floor-mounted fuel shutoff lever in AS350-series helicopters to protect it from inadvertent activation due to external influences.
To the European Union Aviation Safety Agency:
12. After the actions requested in Safety Recommendation [11] are completed, require owners and operators of existing AS350-series helicopters to incorporate the changes.
One rarley sees a causal factor that is involved in two very distinct events that led to multiple fatalities. The tether shut off the fuel and was probably the only reason nobody who had one on was able to escape. On top of that the Dart kit pull limitation comes out of the blue to further set them up. The tether issue of not being able to release might have ended up with folks thinking that the hook knife would have been fine if the ship had floated upright and people had a few minutes to unhook or cut the tethers. That would have been a mistake for obvious reasons. The whole thing of non-professionals using tethers and loose objects like phones creeps me out. With opened doors, a shoe, hat, phone or some other piece of jetsom brought onboard with a passenger is inviting disaster.
Last edited by roscoe1; 10th Dec 2019 at 21:29.
I am in DC next week meeting with various agencies as part of the HAI Rotorcraft Safety Working Group. We had actually identified some of these issues and already have language drafted to start the process of rule changing. If anyone has ideas, (without going overboard), feel free to express them here and I will take them to the table.
Couldn't this whole thing have been prevented if Airbus had just used a toggle switch on the dash controlling an electrically-operated FSOV, like every Bell 206 has had since the beginning of time? Does any other Airbus product still use a manually-operated FSOV?
Or...for commercial ops can't we just prohibit (possibly inebriated) non-aviator passengers from sitting in a seat in which they can reach a critical control?
Or...for commercial ops can't we just prohibit (possibly inebriated) non-aviator passengers from sitting in a seat in which they can reach a critical control?