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ASN Wikibase Occurrence # 165996
Last updated: 26 October 2019
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Date:05-MAY-2014
Time:09:11 LT
Type:Silhouette image of generic BK17 model; specific model in this crash may look slightly different
Kawasaki BK 117B-2
Owner/operator:Garden City Helicopters
Registration: ZK-HJC
C/n / msn: 1061
Fatalities:Fatalities: 0 / Occupants: 5
Other fatalities:0
Aircraft damage: Minor
Location:near Springston, Canterbury -   New Zealand
Phase: Landing
Nature:Ambulance
Departure airport:Ashburton Hospital
Destination airport:Christchurch Hospital (NZJC)
Investigating agency: TAIC New Zealand
Narrative:
On 5 May 2014 the pilot of a BK117 helicopter with four other people on board experienced a double engine power loss during a hospital patient transfer flight between Ashburton and Christchurch. The pilot made an emergency landing without power onto farmland near Springston, with no injuries sustained by the occupants and minor damage to the helicopter.

It was later determined that the double engine power loss had been caused by lack of fuel flow to the engines, despite there being a large quantity of fuel in the main fuel tanks. The cause of the lack of fuel flow to the engines was the pilot's incorrect management and configuration of the aircraft's fuel supply system, which prevented the fuel in the main tanks getting to the engines.

The pilot's lack of recent experience on the BK117 was a contributory factor in this event, including the absence of any recent training or competency assessment on the aircraft type. The pilot did not refer to a checklist when carrying out the normal pre-flight, before-start and after-start procedures. Had he referred to a checklist he would have likely corrected the error in the fuel system configuration before flight. The company that operated the helicopter did not have any procedures in place to address the lack of recent experience, such as additional training, supervision or a policy on the use of written checklists in such a situation.

A contributing factor to the power loss was the pilot's inability to detect the caution lights that would have alerted him to the incorrectly configured fuel system, due to the cockpit lighting dimmer switch being left on in daylight. A modification of the helicopter to enable the use of night vision equipment was found to have adversely affected the readability of the caution lights during daylight, when the cockpit lighting dimmer was on. A design feature of the BK117 fuel system meant that both engines lost power within seconds of each other.

The Commission made the following findings:
- both engines lost power due to fuel starvation, because the pilot did not switch on the fuel transfer pumps after starting the engines
- the pilot should not have operated the flight because he had not been assessed for his type-specific knowledge or checked for competency on the BK117 in the previous five years, and he lacked recent experience on the aircraft type
- the operator's system for maintaining oversight of its pilots' proficiency and currency was not robust enough to ensure that this pilot was proficient and sufficiently current to fly the BK117
- a cockpit lighting modification to the helicopter had adversely affected the readability of the caution lights during daylight, when the dimmer switch was on. Brightly illuminated caution lights should have alerted the pilot to the incorrectly configured fuel system and the low fuel levels in the supply tanks, and could have prevented the incident
- the helicopter was not designed to generate an aural warning of a critically low fuel level in the supply tanks. An aural warning, as fitted to later designs, would have alerted the pilot to the potential loss of engine power, and could have prevented the incident
- the operator did not require pilots to refer to written checklists if they lacked recent experience on an aircraft type. The pilot did not refer to a written checklist; had he done so he would have been prompted to: switch the fuel transfer pumps on, which would have prevented the fuel starvation; and turn the dimmer switch off, which should have ensured the caution lights were visible to the pilot.

Sources:

http://www.stuff.co.nz/national/10010262/Rescue-chopper-emergency-landing
https://www.verticalmag.com/news/pilots-lack-of-recent-experience-cited-in-2014-double-engine-power-loss/
http://aerossurance.com/helicopters/dim-negative-transfer-flameout/
https://taic.org.nz/inquiries

Safety recommendations:

Safety recommendation 006/16 issued 25 February 2016 by TAIC to CAA NZ
Safety recommendation 007/16 issued 25 February 2016 by TAIC to Garden City Helicopters
Safety recommendation 008/16 issued 25 February 2016 by TAIC to CAA NZ

Accident investigation:
cover
  
Investigating agency: TAIC New Zealand
Status: Investigation completed
Duration:
Download report: Final report


Revision history:

Date/timeContributorUpdates
05-May-2014 04:12 Geno Added
05-May-2014 08:25 harro Updated [Aircraft type]
05-May-2014 10:18 TB Updated [Time, Aircraft type, Location, Narrative]
18-Apr-2016 16:37 Aerossurance Updated [Time, Source, Narrative]
23-Apr-2016 10:38 Aerossurance Updated [Source]
12-Oct-2016 19:06 TB Updated [Location, Source]

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