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ASN Wikibase Occurrence # 19941
Last updated: 15 February 2020
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Date:18-SEP-2004
Time:22:54
Type:Silhouette image of generic S76 model; specific model in this crash may look slightly different
Sikorsky S-76C
Owner/operator:Norrlandsflyg
Registration: SE-JUJ
C/n / msn: 760424
Fatalities:Fatalities: 0 / Occupants: 5
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Location:E of Skräckskär -   Sweden
Phase: Approach
Nature:Ambulance
Departure airport:Gotland
Destination airport:Häradsskär
Narrative:
The SAR helicopter with a crew of five on board took off from Gotland to pick up a person with an acute heart condition on Häradsskär and fly him to Linköping University Hospital (a HEMS mission). The weather was judged to be good and the sortie viewed by the crew as a routine mission, however a message that the patient's condition had worsened may have resulted in extra pressure during flight planning. The flight took place under VFR in darkness with the commander as pilot flying (PF).

During the approach to the island the pilots located the house where the patient was staying through the light from the windows. Apart from this the only external reference point in the area was the light from the lighthouse only. The commander decided, after passing the island, to make a right turn and then approach it from the north and into the wind.

As the helicopter approached the final the commander stated that he intended to make a relatively steep approach. He felt that the initial glide towards the island was without problems even though he lacked visual contact with the ground and the strong light from the lighthouse at times masked the weaker light from the house windows. Shortly after the pilot had made visual contact in his spotlights with some skerries in the direction of flight, the co-pilot reported that the helicopter had sunk below 100 ft in altitude.

A few seconds later the winch operator saw in the light from the spotlights that the helicopter was rapidly approaching the water level and that the waves "were going in the wrong direction". He shouted. "We're moving backwards!" which the commander interpreted as "Watch out!" u2013 the Swedish words "Vi backar" and "Akta!" sounding very similar. Before the commander could react, the helicopter struck the water.

The helicopter’s emergency floats were armed but not actuated. All the crew members except the nurse had received theoretical and practical training in emergency evacuation of a helicopter under water, (HUET), including the use of emergency breathing equipment (HEED).

The helicopter rapidly filled with water and all on board except the commander evacuated it. Trapped in the cabin, the commander managed only after several unsuccessful attempts to free himself and leave the helicopter before it sank. He has said that he would probably not have managed this without the HEED emergency breathing system (EBS), which he emptied completely. All were later rescued by the military rescue helicopter stationed at Berga.

The investigation revealed that the pilots underestimated the difficulty of landing under circumstances then prevailing, and that the procedures and the technical equipment available for them to be able to perform a safe landing were not employed. In addition, departures were made from the operational procedures in force which, moreover, are judged to have been inadequate regarding HEMS flight. The accident was caused because of a lack of adequate routines and procedures for the activity in question, and existing procedures were not followed completely.

Cause: The accident was caused by the absence of sufficient routines and procedures for the particular operation, and the fact that existing routines were not fully followed.

Sources:

http://www.havkom.se/assets/reports/rl2006_16e.pdf (Report RL 2006:16e)


Revision history:

Date/timeContributorUpdates
25-May-2008 02:19 harro Added
12-Jun-2010 12:55 TB Updated [Operator, Location, Damage, Narrative]
18-Apr-2016 08:54 Aerossurance Updated [Source, Narrative]
13-Jul-2016 08:44 Aerossurance Updated [Narrative]
13-Jul-2016 08:49 Aerossurance Updated [Source]

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