ASN Wikibase Occurrence # 188020
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| Date: | Tuesday 4 August 2015 |
| Time: | 19:00 UTC |
| Type: |  Robinson R44 Raven II |
| Owner/operator: | Synergy Aviation |
| Registration: | C-FNHD |
| MSN: | 11704 |
| Year of manufacture: | 2007 |
| Fatalities: | Fatalities: 0 / Occupants: 2 |
| Aircraft damage: | Minor |
| Location: | 31.4 nm WNW of Edson, AB (CYET) -
 Canada
|
| Phase: | Manoeuvring (airshow, firefighting, ag.ops.) |
| Nature: | Survey |
| Departure airport: | Edson Airport, AB (YET/CYET) |
| Edson Airport, AB (YET/CYET) | |
| Confidence Rating: |  Information verified through data from accident investigation authorities |
While conducting pipeline surveillance operations and maneuvering at approximately 250 feet AGL, the crew noticed that there was no data being recorded from the Gas Leak Detection (GLD) unit.
The pilot then confirmed visually that the 12kg GLD unit was no longer attached to the aircraft cargo hook. The crew determined, using the recorded data, where the GLD unit most likely had been released. The aircraft was landed in a clear area nearby and inspected for damage. None was found.
After contacting company operations, a plan was made to recover the GLD unit. The GLD unit was found with only minor cosmetic damage to the frame. The crew reinstalled the unit on the cargo hook and disabled the electrical cargo release system, leaving the manual release system intact. The aircraft then returned to CYET.
Subsequent inspection by company maintenance found no faults with the electrical or manual cargo release system. The electrical release system on the aircraft incorporates an optional release switch on the left seat base which the pilot and the technician were not aware of. The company has deactivated these optional switches for all operations without dual controls installed.
According to an IOGP report:
"WHAT WENT WRONG:
1. Contractor's safety management system's risk assessment process did not include threat of inadvertently activating the hook release.
2. Contractor's Safety Management System internal audit process did not identify incomplete risk assessment.
3. Owner of helicopter did not direct configuration of cargo hook as industry standard by installing secondary electrical release. Owner did not communicate presence of secondary release to operator.
4. Contractor's procedure of accepting an aircraft is not risk based and does not include Flight Operations department.
5. GLD equipment set up did not consider optimal layout inside helicopter cockpit.
6. There is no policy requiring risk assessment to evaluate temporary versus permanent equipment installation.
CORRECTIVE ACTIONS AND RECOMMENDATIONS:
1. Company with aviation operations should develop an aviation risk register.
2. Aviation contractor risk assessment must include activities performed for the company.
3. Helicopter external load equipment and activities should be considered safety critical.
4. Company's aviation contractor's internal audit system should ensure that a comprehensive risk management process is in place.
CAUSAL FACTORS:
PROCESS (CONDITIONS): Organizational: Inadequate work standards/procedures
PROCESS (CONDITIONS): Organizational: Inadequate hazard identification or risk assessment
PROCESS (CONDITIONS): Organizational: Inadequate communication"
Sources:
CADORS Number: 2015C3060
http://www.iogp.org/pubs/2015sh.pdf
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 10-Jun-2016 18:19 | Aerossurance | Added |
| 10-Jun-2016 18:24 | Aerossurance | Updated [Departure airport, Destination airport, Narrative] |
| 10-Jun-2016 18:25 | Aerossurance | Updated [Date] |
| 04-Mar-2024 17:14 | ASN | Updated [Departure airport, Destination airport] |
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