ASN Wikibase Occurrence # 221
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| Date: | Thursday 10 August 1995 |
| Time: | 14:25 |
| Type: |  Bell 206B-3 JetRanger III |
| Owner/operator: | Jayrow Helicopters Pty Ltd |
| Registration: | VH-FHX |
| MSN: | 2822 |
| Year of manufacture: | 1979 |
| Fatalities: | Fatalities: 1 / Occupants: 5 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Ayers Rock Aerodrome, NT -
 Australia
|
| Phase: | Standing |
| Nature: | Passenger |
| Departure airport: | Ayres Rock, NT (AYQ/YAYE) |
| Ayres Rock, NT (AYQ/YAYE) | |
| Investigating agency: | BASI |
| Confidence Rating: |  Accident investigation report completed and information captured |
On 10 August 1995, at the completion of a tourist flight the passengers were directed from the aircraft and the next load of passengers, who had been correctly briefed on approaching the helicopter while the engine was still operating, were accompanied by an attendant to the front of the helicopter.
The pilot locked the controls and debarked to assist the attendant. One passenger failed to follow the instructions and passed to the rear of the aircraft, receiving fatal injuries when struck by the tail rotor.
The matter went to court as part of claim for manslaughter (the death of the unfortunate passenger) by criminal negligence. The course of events, as presented to the court, were as follows:
"On 10 August 1995, Jayrow Helicopters Pty Ltd were operating a helicopter, registration VH-FHX, at Connellan Airport, Yulara. The helicopter was being used for scenic flights over Ayers Rock and the Olgas. Jayrow had office facilities within the general aviation area of the terminal where intending passengers assembled before boarding a mini-bus that took them to the helicopter.
At about 14:15 hours the helicopter returned from its fourth trip of the day. To ensure maximum use of the helicopter and a quick turn around of passengers, the helicopter's engine was not stopped during the dis-embarkation of returning passengers and the embarkation of intending passengers.
Jayrow's procedure was for the pilot to throttle the engine back to "ground idle", lock the controls, disable the hydraulic system and then for him to get out of the helicopter to help with the passengers. This left the helicopter's main and tail rotors still spinning whilst passengers were being moved about. This is accepted industry practice provided the passengers are kept under close and constant supervision. The passenger loading doors in use were on the far side of the helicopter in relation to where the mini-bus was parked.
The intending passengers were a group of four elderly female tourists including Madge Leitch. They were brought to the landing area in a mini-bus driven by Ms Kim Shepherdson, manageress of the Company at Yulara. Whilst travelling in the mini-bus, passengers were given a briefing by her which covered the way the intercom headsets worked, how to put their seat belts on and general safety precautions. These safety precautions should have included a warning about the danger of the spinning rotors but it seems it was not given or was mis-understood on this occasion. The passengers could not recall having been so warned when they were asked after the accident.
The helicopter landed at about the same time as the bus drew up with its passengers. The pilot followed company procedure and got out of the helicopter to help with the passengers. The manageress left her intending passengers by the mini-bus and went to the helicopter to help with those passengers leaving. She directed these out-going passengers towards the mini-bus and signalled with her hands for the intending passengers to walk over to the helicopter. She then turned her back to them and went to stand on the far side of the helicopter to talk to the pilot. Neither the pilot nor the manageress could see the intending passengers as they walked from the mini-bus.
One of the passengers, Madge Leitch, left the intending passenger group at some point along this walk between the mini-bus and the helicopter. The other three ladies did not notice her leave the group. Neither the pilot nor the manageress noticed her leave the group. She made her way to the rear of the helicopter apparently with the intention of being first to reach the loading doors. She ducked under the tail boom just forward of the vertical fin and was struck on the side of the head by the tail rotor. She suffered catastrophic head injuries and died instantly.
The pilot did not realise there was a problem until he felt an unusual vibration pass through the fuselage of the helicopter on which he was leaning. At the same time as he heard a rapid "rat a tat" noise. The manageress saw out of the corner of her eye something splatter at the rear of the helicopter and on looking directly saw one of the intending passengers lying on the ground.
The briefing given by the manageress to the passengers whilst still on the mini-bus seems to have been totally inadequate. This is not to say that they were not briefed but it does suggest that whatever briefing they were given did not achieve its primary purpose. It should be remembered that all the intending passengers had never flown in a helicopter before and perhaps had never even been close to one before. They would have been somewhat excited and anxious and perhaps not ready to listen to any briefing that might delay their fun.
Passengers are not normally left alone to find their way to a helicopter which has its rotors spinning. Those passengers leaving are physically guided to a safe area and those boarding are again physically shepherded from their waiting area to the helicopter. This allows the ground marshal to control where and when passengers move and leaves the passengers in no doubt as to where they are supposed to be. Industry best practice is for the ground marshal to place himself between the danger area and the passenger.
The manageress's training was somewhat sketchy. Although she received training in Cairns regarding escape under water, the only other training she recalled being shown in general passenger comfort type training. She said she had on-going training in Cairns with other pilots but again this seems more to do with operating the helicopter than loading and unloading passengers safely. There was no record of any training apart from the underwater escape training in Cairns.
There was no documentation within the Company Operations Manual that gave specific guidance to either the pilot or crew as to what the Company expected of them in regards to passenger control whilst loading or unloading although some general guidance was given in those sections entitled "Passenger and Crew Briefing" (Ch 310) and "Safety Briefing" (Ch 423.13).
There was a passenger information card inside the helicopter detailing the do's and don'ts for passengers, similar to that found in commercial aircraft. This card made mention of not going near the rear of the helicopter and had a diagram of a helicopter and the surrounding areas. The areas were marked in red and green - red for no-go areas and green for safe areas. This card was not available to passengers before they boarded and indeed the diagram was of a different type of helicopter.
The tail rotor of the helicopter was virtually invisible whilst it was spinning. To someone who was not aware it was there it would have been invisible. Madge Leitch was not known to have had any previous experience with helicopters and would have been unaware of the tail rotor and the danger it presented. The vertical fin positioned across the disc of the spinning rotor may have confused her into thinking the helicopter was similar to a fixed wing aircraft and that it was safe to move in the area.
She also wore prescription bi-focal sun glasses which may have contributed to her not seeing the tail rotor and the warning sign on the tail boom. The position of the sun, being virtually overhead and in front of her, may also have contributed to this as the glare would have been directed over the top of her glasses"
Jayrow Helicopters lost their appeal against the lawsuit taken out against them, and were fined AUS $30,000 plus all legal costs
Accident investigation:
 |
|
Sources:
1. http://www.atsb.gov.au/publications/investigation_reports/1995/aair/aair199502549.aspx
2. http://www.supremecourt.nt.gov.au/archive/doc/sentencing_remarks/0/98/0/NS000100.htm
3. http://www.atsb.gov.au/media/24875/ASOR199502549.pdf
History of this aircraft
Other occurrences involving this aircraft
| 14 June 1988 | VH-FHX | 0 | 200km E of Newman, WA | |
sub |
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 21-Jan-2008 10:00 | ASN archive | Added |
| 27-Apr-2014 01:20 | Dr. John Smith | Updated [Time, Cn, Operator, Total fatalities, Total occupants, Other fatalities, Location, Phase, Nature, Departure airport, Destination airport, Source, Damage, Narrative] |
| 07-Jun-2022 12:24 | Ron Averes | Updated [Location] |
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