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ASN Wikibase Occurrence # 162556
Last updated: 15 June 2019
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Date:29-NOV-2013
Time:22:22 UTC
Type:Silhouette image of generic EC35 model; specific model in this crash may look slightly different
Eurocopter EC 135T2+
Owner/operator:Bond Air Services opf. Police Scotland
Registration: G-SPAO
C/n / msn: 0546
Fatalities:Fatalities: 3 / Occupants: 3
Other fatalities:7
Aircraft damage: Written off (damaged beyond repair)
Location:Clutha Vaults Bar, Glasgow -   United Kingdom
Phase: En route
Nature:Survey
Departure airport:Glasgow City Heliport (EGEG)
Destination airport:Glasgow City Heliport (EGEG)
Narrative:
The helicopter departed Glasgow City Heliport (GCH) at 2044 hrs on 29 November 2013, in support of Police Scotland operations. On board were the pilot and two Police Observers. After their initial task, south of Glasgow City Centre, they completed four more tasks; one in Dalkeith, Midlothian, and three others to the east of Glasgow, before routing back towards the heliport. When the helicopter was about 2.7 nm from GCH, the right engine flamed out. Shortly afterwards, the left engine also flamed out. An autorotation, flare recovery and landing were not achieved and the helicopter descended at a high rate onto the roof of the Clutha Vaults Bar, which collapsed. The three occupants in the helicopter and seven people in the bar were fatally injured. Eleven others in the bar were seriously injured.

Fuel in the helicopterís main fuel tank is pumped by two transfer pumps into a supply tank, which is divided into two cells. Each cell of the supply tank feeds its respective engine. During subsequent examination of the helicopter, 76 kg of fuel was recovered from the main fuel tank. However, the supply tank was found to have been empty at the time of impact. It was deduced from wreckage examination and testing that both fuel transfer pumps in the main tank had been selected off for a sustained period before the accident, leaving the fuel in the main tank, unusable. The low fuel 1 and low fuel 2 warning captions, and their associated audio attention-getters, had been triggered and acknowledged, after which, the flight had continued beyond the 10-minute period specified in the Pilotís Checklist Emergency and Malfunction Procedures.

The helicopter was not required to have, and was not fitted with, flight recorders. However, data and recordings were recovered from non-volatile memory (NVM) in systems on board the helicopter, and radar, radio, police equipment and CCTV recordings were also examined.

During the investigation, the EC135ís fuel sensing, gauging and indication system, and the Caution Advisory Display and Warning Unit were thoroughly examined. This included tests resulting from an incident involving another EC135 T2+.

Despite extensive analysis of the limited evidence available, it was not possible to determine why both fuel transfer pumps in the main tank remained off during the latter part of the flight, why the helicopter did not land within the time specified following activation of the low fuel warnings and why a MAYDAY call was not received from the pilot. Also, it was not possible to establish why a more successful autorotation and landing was not achieved, albeit in particularly demanding circumstances.

The investigation identified the following causal factors:
1. 73 kg of usable fuel in the main tank became unusable as a result of the fuel transfer pumps being switched off for unknown reasons.
2. It was calculated that the helicopter did not land within the 10-minute period specified in the Pilotís Checklist Emergency and Malfunction Procedures, following continuous activation of the low fuel warnings, for unknown reasons.
3. Both engines flamed out sequentially while the helicopter was airborne, as a result of fuel starvation, due to depletion of the supply tank contents.
4. A successful autorotation and landing was not achieved, for unknown reasons.


The investigation identified the following contributory factors:
1. Incorrect management of the fuel system allows useable fuel to remain in the main tank while the contents in the supply tank become depleted.
2. The RADALT and steerable landing light were unpowered after the second engine flamed out, leading to a loss of height information and reduced visual cues.
3. Both engines flamed out when the helicopter was flying over a built-up area.

Seven Safety Recommendations have been made.

Sources:

http://abcnews.go.com/International/t/story/helicopter-crashes-roof-glasgow-pub-21053638?ref=https%3A%2F%2Fwww.google.com%2F
http://www.mirror.co.uk/news/uk-news/glasgow-police-helicopter-crash-live-2866925
http://www.dailyrecord.co.uk/news/scottish-news/breaking-news-police-helicopter-crashes-2866927
https://www.pprune.org/rotorheads/528850-police-helicopter-crashes-onto-glasgow-pub.html
http://www.copfs.gov.uk/media-site/latest-news-from-copfs/579-clutha-helicopter-crash-investigation-process-explained
http://www.heraldscotland.com/news/transport/clutha-draft-report-distributed-to-legal-teams-as-investigation-nears-end.124917319
https://www.scotsman.com/news/transport/clutha-helicopter-crash-answers-within-days-1-3922159
http://aerossurance.com/helicopters/clutha-police-heli-accident/

https://www.eveningtimes.co.uk/news/16892422.pilot-who-handed-over-helicopter-on-day-of-clutha-crash-represented-at-hearing/

AAIB ________________________________

http://www.caa.co.uk/applicationmodules/ginfo/ginfo_photo.aspx?regmark=G-SPAO&imgname=G-SPAO001&imgtype=jpg
http://www.caa.co.uk/application.aspx?catid=60&pagetype=65&appid=1&mode=detailģmark=spa&dataindex=2
https://www.gov.uk/aaib-reports/s9-2013-eurocopter-ec135-t2-g-spao-29-november-2013
https://www.gov.uk/aaib-reports/s2-2014-eurocopter-ec135-t2-g-spao-29-november-2013
http://www.aaib.gov.uk/cms_resources.cfm?file=/G-SPAO%20Press%20Release%20v2.pdf
https://www.gov.uk/aaib-reports/aircraft-accident-report-aar-3-2015-g-spao-29-november-2013

Safety recommendations:

Safety recommendation 2015-030 issued 19 October 2015 by AAIB to EASA
Safety recommendation 2015-031 issued 19 October 2015 by AAIB to CAA
Safety recommendation 2015-032 issued 19 October 2015 by AAIB to CAA
Safety recommendation 2015-033 issued 19 October 2015 by AAIB to CAA
Safety recommendation 2015-034 issued 19 October 2015 by AAIB to CAA
Safety recommendation 2015-035 issued 19 October 2015 by AAIB to EASA
Safety recommendation 2015-036 issued 19 October 2015 by AAIB to EASA


Revision history:

Date/timeContributorUpdates
30-Nov-2013 02:15 Geno Added
30-Nov-2013 03:01 angels one five Updated [Registration, Operator, Location]
30-Nov-2013 03:42 JINX Updated [Aircraft type, Cn, Operator, Location, Source, Damage]
30-Nov-2013 10:30 Captainpicasso Updated [Other fatalities, Source, Narrative]
30-Nov-2013 15:23 gerard57 Updated [Total fatalities, Narrative]
30-Nov-2013 16:01 gerard57 Updated [Total fatalities, Other fatalities]
30-Nov-2013 16:12 Anon. Updated [Total fatalities, Other fatalities, Source]
30-Nov-2013 18:48 Captainpicasso Updated [Narrative]
01-Dec-2013 15:45 Anon. Updated [Operator]
02-Dec-2013 02:40 JINX Updated [Other fatalities]
02-Dec-2013 07:23 Anon. Updated [Other fatalities]
11-Dec-2013 15:53 harro Updated [Time, Phase, Nature, Departure airport, Destination airport, Source]
12-Dec-2013 18:40 gerard57 Updated [Other fatalities, Source, Narrative]
04-Sep-2014 16:31 TB Updated [Aircraft type, Operator, Location, Source, Narrative]
09-Sep-2014 09:40 Aerossurance Updated [Location, Source, Narrative]
09-Sep-2014 09:41 Aerossurance Updated [Source]
28-Nov-2014 11:24 Aerossurance Updated [Source, Narrative]
06-May-2015 11:22 Aerossurance Updated [Source]
21-May-2015 02:45 Dr. John Smith Updated [Location, Embed code, Narrative]
21-May-2015 02:46 Dr. John Smith Updated [Narrative]
21-May-2015 02:47 Dr. John Smith Updated [Departure airport, Destination airport]
20-Oct-2015 19:07 Aerossurance Updated [Location, Narrative]
20-Oct-2015 19:12 Aerossurance Updated [Aircraft type, Narrative]
20-Oct-2015 20:35 Aerossurance Updated [Source, Narrative]
23-Oct-2015 09:24 Aerossurance Updated [Source, Narrative]
22-Nov-2015 23:03 Aerossurance Updated [Source]
20-Sep-2018 19:09 Iceman 29 Updated [Source, Embed code]

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