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ASN Wikibase Occurrence # 59678
Last updated: 10 September 2021
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Date:25-APR-2009
Time:19:35 CET
Type:Silhouette image of generic BK17 model; specific model in this crash may look slightly different
Eurocopter EC 145 (BK 117C-2)
Owner/operator:SÚcuritÚ Civile
Registration: F-ZBPR
MSN: 9034
Fatalities:Fatalities: 4 / Occupants: 4
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:SW of Bastia, Corsica -   France
Phase: En route
Nature:Ambulance
Departure airport:Ponte-Leccia
Destination airport:Bastia
Investigating agency: BEAD
Narrative:
The helicopter (callsign "Dragon 2B") transported a pregnant woman to hospital in Bastia, Corsica. She gave birth in flight. Shortly afterwards the helicopter crashed in a mountainous region. The new-born baby, the mother, the doctor, the pilot and an engineer were killed.

Causes of the event
Environmental Context :
- On April 25, 2009, the Lancone Pass is affected by rare meteorological phenomena;
- the aircraft was flying close to the terrain at the time of the go-around.
Technical assessments confirm the information provided by the UMS/SSQAR and rule out any technical cause.
The causes of the occurrence are related to the human factor.
3.2.1. Causes leading to the entry into the layer.
The pilot was probably misrepresenting the weather situation.
The lack of standards regarding the use of the Lancone Pass as a "bad weather route" may have encouraged the pilot to continue his flight in deteriorating weather conditions.
By crossing the ridgeline perpendicularly and at a very low height, the pilot did not maintain a permanent clearance.
The pilot probably experienced a perseveration phenomenon.
3.2.2. Causes of the collision with the ground without loss of control of the aircraft.
The go-around procedure was initiated when the lateral and vertical margins were minimal and the initial parameters were not stabilized.
The transition to IFR was known but probably not prepared.
The stacking of tasks could have caused saturation that could have led to an attention-capture phenomenon.
The pilot was probably making a mental misrepresentation of his trajectory. In particular, he was not aware of accelerating in the face of the terrain.

Sources:

http://www.tv5monde.com/TV5Site/info/article-Corse_cinq_morts_dont_un_nouveau_ne_et_sa_mere_dans_un_crash_d_helicoptere.htm?idrub=1&xml=newsmlmmd.c2021cef7fecfd6c735e740eee9927ad.fd1.xml
http://www.eurocopter.com/site/docs_wsw/RUB_963/Potential.pdf
https://www.defense.gouv.fr/english/content/download/523468/8774002/S-2009-005-A_.pdf

Accident investigation:
cover
  
Investigating agency: BEAD
Status: Investigation completed
Duration:
Download report: Final report


Revision history:

Date/timeContributorUpdates
26-Apr-2009 10:53 Lercherlschas Added
26-Apr-2009 10:54 harro Updated
27-Apr-2009 03:34 RobertMB Updated
07-Jul-2009 11:00 rotorspot Updated
11-Aug-2010 10:41 TB Updated [Aircraft type, Operator, Other fatalities, Location, Source]
01-Nov-2012 11:30 TB Updated [Aircraft type, Source]
23-Nov-2012 09:57 TB Updated [Aircraft type]
27-Jul-2020 14:34 KagurazakaHanayo Updated [Total fatalities, Total occupants, Source, Narrative]
27-Jul-2020 14:37 harro Updated [Narrative, Accident report, ]
24-Oct-2020 12:21 Aerossurance Updated [Aircraft type, Accident report]

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