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ASN Wikibase Occurrence # 213130
Last updated: 16 September 2021
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Date:10-JUL-2018
Time:16:45 LT
Type:Silhouette image of generic GAZL model; specific model in this crash may look slightly different
Aérospatiale SA 342M Gazelle
Owner/operator:ALAT (French Army Light Aviation)
Registration: F-MGNI/3866
MSN: 3866
Fatalities:Fatalities: 1 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:15 km E of Port Bouet -   Cote d'Ivoire
Phase: Manoeuvring (airshow, firefighting, ag.ops.)
Nature:Military
Departure airport:Camp de Port-Bouët, Abidjan
Destination airport:Camp de Port-Bouët, Abidjan
Investigating agency: BEA-É
Narrative:
A French Gazelle helicopter crew made up of a pilot and a pilot in command carried out a mission to raise awareness of the procedures for guiding a helicopter in fire support for the Armed Forces of Côte d'Ivoire (FACI). At the end of the mission, the crew performed, at the request of the French officer supervising the Ivorian trainees, a demonstration of a manoeuvre representative of a cannon firing pass.
At the end of the dive phase, the pilot stabilized the altitude and then made a sharp right turn in a slight climb. During the turn, the aircraft pitched nose-down with a steep bank. The aircraft struck a pole and a power line before crashing a few metres further on.
The pilot died; the pilot in command was seriously injured. The aircraft was substantially damaged.

Causes of the event
Organisational and human factors are at the root of the event.
The accident, which is the combination of multiple factors, resulted from :
- the execution of an unplanned, uncontrolled maneuver, performed beyond the aircraft's capabilities and outside the regulatory framework;
- the search for sensations, the desire to demonstrate one's know-how and assert one's belonging to the group, and the need for a demonstration of strength;
- the feeling of routine associated with a mission considered to be unmotivating, encouraging the search for a rewarding maneuver;
- the culture of certain Gazelle squadrons that maintain obsolete know-how;
- the short notice between the designation and the departure of the crew on secondment, preventing the pilot in command from measuring the technical capabilities of the pilot;
- the contagion to the crew of a certain euphoria of the ground personnel leading to an underestimation of the risks;
- the presence of an audience with whom the crew wanted to enhance their social image;
- the demographic composition of the group participating in the mission on the ground and in the air;
- fatigue leading to inappropriate decision making;
- the combination of the lack of aeronautical experience of the Gazelle helicopter detachment commander and a particular hierarchical gradient;
- the absence of initial CRM training for the officer in charge of the training session, particularly in the area of deviation management (error, violation);
- the physical and symbolic distance between the DETALAT command and the crews of the Gazelle helicopter detachment;
- the absence of mandatory monitoring of the Gazelle crews' skills in implementing evasions;
- the misinterpretation of certain messages regarding acceptable safety practices;
- the alteration of the safety culture within certain ALAT units that led to a progressive normalization of the deviations.

Sources:

http://www.aviafora.com/forums/forum/helicopter-fora/gazelles/343-shrieking-gazelles?p=9530#post9530
https://fighterjetsworld.com/2018/07/10/french-soldier-killed-another-wounded-in-a-military-helicopter-crash/
http://aerossurance.com/helicopters/culture-cfit-alat-gazelle
https://www.defense.gouv.fr/english/portail-defense/ministry/organisation/organisation-du-ministere-des-armees/organismes-dependant-du-ministre/les-bead/bea-e/2018/rapports-2018/t-2018-09-a

Accident investigation:
cover
  
Investigating agency: BEA-É
Status: Investigation completed
Duration: 1 year and 5 months
Download report: Final report

Media:


Revision history:

Date/timeContributorUpdates
11-Jul-2018 05:54 gerard57 Added
11-Jul-2018 07:49 rotorspot Updated [Aircraft type, Total fatalities, Source]
11-Jul-2018 10:09 gerard57 Updated [Narrative]
11-Jul-2018 11:38 TB Updated [Aircraft type, Operator, Source]
11-Jul-2018 15:04 HeliNews Updated [Source, Narrative]
11-Jul-2018 16:25 HeliNews Updated [Operator, Location, Narrative]
11-Jul-2018 19:49 Aerossurance Updated [Time, Location, Narrative]
11-Jul-2018 19:51 Aerossurance Updated [Operator, Narrative]
29-Dec-2019 18:06 harro Updated [Time, Registration, Cn, Phase, Departure airport, Destination airport, Source, Narrative, Accident report, ]
29-Dec-2019 18:35 harro Updated [Location, Narrative, Accident report, ]
29-Dec-2019 18:36 harro Updated [Departure airport, Destination airport, Accident report, ]
19-May-2020 07:35 Aerossurance Updated [Source, Embed code]

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