Engineer killed by tail rotor.
 

https://www.cbc.ca/news/canada/briti...port-9.7214588

By the third time the aircraft's engine was started, one of the helicopter's pedals was engaged, which went undetected, and it began rotating quickly. Both ground workers tried to get out of the way, but were stuck multiple times by the tail rotor.

TSB said the pilot was not expecting the helicopter’s rapid rotation and was looking down when the rotation began. The report said the pilot’s attention was split between the maintenance operations and his cellphone, which was connected to a Bluetooth earpiece.

What a terrible, avoidable event.
Some lessons to be learned here.

Link to the full report.

https://www.tsb.gc.ca/eng/rapports-r.../a23p0040.html

Yes, I also read the report and have distributed it amongst colleagues.

We can all be Monday morning quarterbacks etc, or say "there by the grace of God go I", but some of the behaviours displayed by the pilot are so far outside of what I consider basic professional discipline and airmanship, that I cannot find any redeeming factors.:mad::mad:

I find it bizarre that a ground run, with no intent to fly falls through the regulatory cracks and apparent commonsense practices. Unfortunately, we seem to experience preventable accidents similar to this every few years.



I proposed an AS350B3 Functional Check Flight (FCF) Procedures Course for an international flight training company in 2018. I envisioned it as a 1-day add on to a refresher course with the primary goals:

• Enhances operational safety and reduces risk.
• Reduce downtime due to improper knowledge and techniques.
• Provides for standardized procedures.

Ground School Topics included:

· Regulations

· FCF (Preflight, Ground and Flight) Safe Practices

· Brief Systems Review from a Post-Maintenance Perspective (emphasis on engine, hydraulics, and electrical), VEMD Maintenance and Configuration

· MEL & RFM Section 8.3 Flight Testing Procedures

· CRM in the Maintenance Test Flight Environment

Simulator Sessions included:

· SIT (runup procedures/checks)

· 2-hour flight, MTF Procedures (emergency review, autorotation, EPC, RFM 8.3 checks, etc.)

Sadly, my proposal was not accepted. I still have most of the material that was collected for the courses’ development. It appears it is needed now more than ever.

If it made it to flight idle before it rotated, then it would have happened faster than you could react to. Plus keep in mind the right skid was off the ground and tail skid hit the ground during the sequence. My guess given their location and the task they may have been knocked down first before trying to get away. Sometimes when sheet hits the fan we dont always react as we think we would. Really feel for the AME on this one given what he went through and saw.

Agreed, when the rotors are turning, you are flying - just because you haven't lifted to the hover doesn't mean you can sit there with your head up your a*se.

In the military, we have always had a clear difference between a ground run for engine testing/leak checks etc and rotors engaged ground runs (REGR).

A REGR would be briefed and authorised like any other flight with due consideration for what might go wrong including the need to lift to the hover so the pilot was always ready.

As 212man says, the pilot's behaviour in this incident was so clearly outside the bounds of basic professional discipline and airmanship and a complete abdication of his duty of care.

Does anyone know if the relatives of the deceased and injured to legal action against the pilot?

I read somewhere today that legal action has started against the pilot, company, and 3 others. Apologies butt cannot find the link from where I am currently.
Found it..
https://lethbridgenewsnow.com/2026/0...pter-accident/

Crab Tricky to do a ground run without rotors engaged in a 350 !

I was taught from day zero that if the engine(s) are running then you should behave as if you are going flying.

I had a stand up shouting match (he started it) with an engineer who refused to strap in for a ground run. We waited until he did. it took 30 minutes would you believe?

He argued for half an hour about why he didn't need to strap in for an engaged ground run. Just why!?

I showed up once for ground runs at a maintenance co in Europe. The aircraft was barely assembled and there was a plastic box where the pilots seat should be. I demurred and asked for a seat. Half an hour later i was called back - there was a seat.

I went up, shook the seat and it came loose in my hand. I laid it on the tarmac and flew back to Uk.

I did a ground run the other day and at the end the engineer said... "did you really need your life-jacket on?"

Fair enough but i treat every start like it's the real thing - good habits may save your life one day..

As for listening to your phone or an ipod during aground run... As 212 says i try hard never to say "i would not do that", but " I would not do that"!

Very sad indeed

The TSB report shared in link from Albatross is sure worth reading to try to understand what happened. This wasn't a case of fuselage reacting to torque from the driven rotor, rather fuselage rotated right (clockwise seen from above). An extract from report:

"When the engine was started the 3rd time, the right anti-torque pedal was fully forward. Then, with the pilot’s feet either lightly resting on the bottom of the anti-torque pedals or not on them at all, once engine power was increased to flight idle a significant yaw force was exerted on the helicopter".

I am no pilot, but shouldn't the pilot have felt with his feet that the pedals were not roughly aligned with one another on the third start?

This accident occurred 6 May 2023. The report at 1.18.3 mentions a subsequently reported very similar Canadian case on 28 Sept 2025 where another Squirrel likewise had a right yaw during ground running when pilot didn't have his feet on the pedals. Fortunately no injuries in that case, just some damage to the helicopter.

It is astounding the negligence and lack of care and attention the report documents. That is an attitude that was heading towards an accident, unfortunately others paid the price.

Exactly the reason to treat it like a full flight.

completely right - that is why he was so negligent, it is absolute basic piloting.

I'm sure this will go through the civil courts (in fact probably already has) but from what I've read this pilot is fortunate that this didn't end up in a criminal court. I'd suggest that the level of negligence here is well into the culpable range.

Many years ago, we were on S&R stbi at a BoB display at Gaydon (?) Parked next to us were the Army Sioux display team. Came their start time and one was having problems. The Team Leader already had his machine fully rotors running and got out, leaving it unattended, while he went to help his team member !
I have mentioned this previously and I seem to recall that this was considered to be 'standard practice' in AAC ops. :(

Not suggesting this is a good idea, but not as big a risk on a helicopter without hydraulic pedals. Less chance of them having a mind of their own.

This was a totally avoidable accident. A ground run is just as capable of going wrong as a planned flight and should never be carried out without all the basic safety precautions as such.

In my RAF days, flying Support Helicopters there was a song:

There's a Wessex on the ground, on the ground
With its rotors going round, going round
It jumps up and down and shakes itself to bits
And gives its passenger the $hits, $hits, $hits.

Based on a true story.

That's a hard nope right there.

Saw a guy get sacked for watching a soccer game on his cellphone whilst torquing down the rotor head.

​​​​​​​There's a time and a place for the cell, and during safety critical tasks ain't it.

From the report:

"His feet rested either on the floor of the helicopter or lightly on the bottom of the anti-torque pedals."

From experience, the feeling is so unnatural and uncomfortable with the pedals out of position (near neutral) this person at the controls must have had his feet off of the pedals. One of many indications that this person’s level of neglect was enormous.

making it yet another mandatory training will not reduce ignorance.

Online Training voice: “Is it ok to take ‘trippy diet pills’ and watch tic tok videos while flying?”

YES.

OLTV: “You have not scored successfully. Try again.”

NO

OLTV: ”You have passed. Your certificate has been uploaded.”



Manager: “We have a safety program”.

I'm not sure if it was the one that rolled itself over between the hangars at Shawbury late 80s/early 90s?

Every Wessex pilot knew the risks of ground resonance in the old girl but more scary was doing full power pulls with the aircraft chained to the ground - you knew if any one of the chains let go, it was going to be brown underpants time.

Full power runs in a helicopter chained to the ground?
Not sure that's a statement about the helicopter, or the pilots...
:)

For reference purposes......

Not to excuse any behavioural issues that have already been highlighted, but a few additional things that came to mind:

(1) The B3 has a larger tail rotor than the B2 - this means even small pedal movements generate noticeably more powerful forces. Additionally, the starting position for the B3 is defined by Airbus as having the left tail rotor pedal 2cm forward; the B2 does not have this stipulation and the POH simply refers to 'neutral' (which I suspect most pilots would take to mean having the pedals level with one another). Interestingly, outwith the start list, the B3 POH also refers to the tail rotor pedal positions in varying different ways ("mid position", "re-centralize", "pedals centred") and all seem to be referring to a 'neutral' position.

(2) Pilot had limited experience on the type variant (6.5hr on AS350B3) - as the B3 is FADEC controlled, it equates to the 'throttle' (collective twist grip) effectively being a binary switch from ground idle to flight idle with a computer controlling the rate of acceleration between these two points. In contrast, the B2 has a manual 'throttle' (fuel flow lever) - although it is entirely possible to move this rapidly, it takes the conscious action of the pilot and a swift movement would feel unnatural / unusual (POH: "Gradually increase the fuel flow, maintaining a constant rate of rotor acceleration"). Although the acceleration of the B3 is not what could be considered as overly 'harsh', it could catch out a pilot who is lacking focus and / or is new to a FADEC system.

(3) The pilot had spotted an abnormal position of one of the skid gear springs on the pre-flight - the report doesn't seem to offer any additional information, but if the spring was not adequately making contact with the ground then it could reduce friction between the skids and the tarmac. Alternatively, if it was pushing the skid up at the rear, there could be a similar loss of friction. The single photo of the aircraft in the accident report doesn't offer any appreciable indication of which spring was at fault, but the circular score marks appear concentrated around the left-hand skid.

From experience, I've had the B3 rotate unintentionally during spool up from ground to flight idle due to one of the skids being on a loose rock / gravel surface - admittedly the rotation was of a limited degree but still occurred even though the pedal position was as per the POH and my feet were on the pedals.

It used to be SOP for new ac just off the production line.

Stories from a tent camp:
I was told years ago of a brass blade weight slug violently departing a Bell 47 Blade at full RPM ..outside a hangar near Toronto.
The blade weight penetrated the hangar, a couple of walls therein and came to rest in the wall of the startled maintenance dept secretary’s office mere feet from her head.
Meanwhile the newly overhauled G4-A thrashed itself to pieces out on the ramp. No one was hurt but there was considerable excitement for a while. Fortunately both pilot and engineer were strapped in and shaken but not stirred.

Another tail was of a 205 test that consisted of attaching a choker firmly secured to the ground to the cargo hook and pulling full power for some kind of check…topping perhaps.
Power was then to be reduced the ac landed, shutdown and adjustments made.
Well after 5 or 6 runups the last run is satisfactory and the pilot decides to, at full power to punch off the choker, The instantaneous rate of climb was spectacular the G forces startling.
When order was restored and the aircraft landed it was found that the airframe was severely bent. The pilot also had a sore neck because the forces had snapped his head and helmet violently forward
Don’t know if this is true but it was a good story.

The song was in SH songbook some years before that.

That's exactly what happened to a mate at Culdrose in the late 1960s. A chain let go and the Wessex ended up thrashing itself around on its side and the pilot was rendered unconscious with severe head injuries even though he was of course strapped in and wearing a helmet. He never flew again due to his injuries.

Apologies for continuing the thread drift (I am one of those who cannot understand the mentality of anyone who thinks it acceptable to take phones, videos or music into a live helicopter cockpit...); I think the SH songbook occurrence refers to the one which future Air Marshal TJ endured at Odiham. On extracting himself from the wreckage, he walked in the line office and entered a fault in the F700 along the lines of "when AFCS engaged on ground, aircraft rolls over onto its' back".

Sometimes there are legit maintenance requirements to apply collective or tail rotor pitch during a ground run. And sometimes no matter how much you prepare, sheet happens. Unfortunately, balancing an AS350 #1 TR driveshaft is not one of those times, and no matter how you look at it, there was just too much wrong up front to any make sense of this incident.

Logic and commonsense would dictate that greater care and safety rather than less should have been applied because:

1. A noted discrepancy with the skids

2. Performing a nonstandard procedure

3. Presumed lack of experience/training for procedure

4. Loose or removed covers and panels

5. Use of external electrical power

6. Use and connection of balancing equipment

7. Potential for improper, incorrect or faulty maintenance consequences

8. Personal outside the aircraft

9. No communication with personal outside the aircraft

Remember one of those trying to get one of the fuel computers to reproduce an intermittent fault. Scheduled for 2 hours, by an hour and a half I was losing the will to live, starting to need a wee and seriously considering sacking it off when it finally failed.

Got programmed for the same thing the next evening, I respectfully requested someone else might be considered for the task.