ASN Wikibase Occurrence # 230516
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Date: | Monday 23 October 2017 |
Time: | |
Type: | Sikorsky S-76B |
Owner/operator: | HeliService International |
Registration: | D-HHNH |
MSN: | 760395 |
Year of manufacture: | 1992 |
Fatalities: | Fatalities: 0 / Occupants: 4 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | near waypoint JUIST -
Germany
|
Phase: | En route |
Nature: | Passenger - Non-Scheduled/charter/Air Taxi |
Departure airport: | DOLWIN ALPHA |
Destination airport: | Emden |
Investigating agency: | BFU |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:During a commercial passenger transport flight from the offshore converter station DOLWIN ALPHA to the commercial airfield Emden, the helicopter almost came hit the sea. The helicopter descended to in approx. 20 ft GND and later landed safely in Emden.
The serious incident, the unintentional approaching of the water surfaces was due to inadequate airmanship with loss of situational awareness on the part of the crew.
Immediate causes:
- The helicopter flew in rain clouds
- The lower cloud limit in precipitation was lower than expected by the helicopter crew, observed at the Emden airfield and predicted by the German Weather Service.
- The descent was not finished at 500 ft GND and an alternative flight execution was not considered.
- At very low altitudes, both pilots looked out from the cockpit and neglected instrument monitoring.
- The confidence of the less experienced co-pilot in the actions and decisions of the much more experienced responsible pilot prevented his intervention.
- The procedures of the company operating the helicopter with regard to the distribution of tasks and mutual monitoring, as well as the requirements of the flight operations manual regarding the minimum flight altitude, were not observed by the crew.
Contributing causes:
- The reason for the switch-off/decoupling of the flight director was not detected by the crew
- The helicopter had to be steered by hand and the flight altitude as well as the flight speed can be controlled manually
- The crew didn't want to fly a manually controlled instrument approach to Emden.
- The helicopter in question was excluded from the company's internal flight data monitoring, which had previously been carried out voluntarily.
Systemic causes:
- In the North Sea area, visual flight conditions are often only marginal Instrument flight in uncontrolled airspace G was not possible in Germany
admissible
- The German EEZ lies below several flight information areas with different specifications and procedures, both for visual and instrument flight.
- In contrast to the adjacent FIRs, the flight information area Bremen/Langen did not have any special helicopter procedures prescribed by air law.
- Aircraft movements below approx. 1 000 ft AMSL in the area of FIR Bremen/Langen over the North Sea are generally not recorded by air traffic control radar.
- The climb through and sinking through of cloud layers and the short flight in clouds was also usual in the FIR Bremen/Langen with Offshore flights
- By the end of 2018, a flight monitoring system/flight data monitoring of all offshore flights was not required by aviation law.
Accident investigation:
|
| |
Investigating agency: | BFU |
Report number: | |
Status: | Investigation completed |
Duration: | 2 years |
Download report: | Final report |
|
Sources:
BFU
Revision history:
Date/time | Contributor | Updates |
10-Nov-2019 20:10 |
harro |
Added |
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