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ASN Wikibase Occurrence # 203333
Last updated: 21 May 2018
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Date:15-NOV-2017
Time:02:39 LT
Type:Silhouette image of generic S76 model; specific model in this crash may look slightly different
Sikorsky S-76C+
Owner/operator:Helijet International
Registration: C-GHHJ
C/n / msn: 760500
Fatalities:Fatalities: 0 / Occupants: 4
Other fatalities:0
Airplane damage: None
Category:Serious incident
Location:Tofino/Long Beach Airport, British Columbia -   Canada
Phase: Approach
Nature:Ambulance
Departure airport:Vancouver International Airport, BC (YVR/CYVR)
Destination airport:Tofino Airport, BC (YAZ/CYAZ)
Investigating agency: TSB Canada
Narrative:
On 15 November 2015, at 01:35 Pacific Standard Time, the Helijet International Inc. Sikorsky S-76C+ helicopter departed at night from Vancouver International Airport, Canada on a night visual flight rules medical evacuation flight to Tofino/Long Beach Airport with 2 paramedics and 2 pilots on board. While conducting a visual approach to runway 29, the crew disengaged the autopilot at an altitude of 600 feet above sea level and manoeuvred toward the planned landing area. At approximately 02:39, on short final, the helicopter's airspeed slowed, a high rate of descent developed, rotor speed began to decrease, and directional control was lost. Control was re-established over a beach, after the helicopter had descended to approximately 3 feet above ground level, and approximately 67 feet below the airfield elevation at Tofino/Long Beach Airport. The pilots then observed normal engine and drivetrain parameters and climbed to 500 feet above sea level to conduct a second approach. During this approach, additional control difficulties were encountered, but the helicopter was able to land. There were no injuries, there was no fire, and the emergency locator transmitter was not activated.

Findings as to causes and contributing factors:
1. The flight was conducted under night visual flight rules without sufficient ambient or cultural lighting to maintain adequate visual reference to the surface.
2. Required briefings were not conducted. As a result, by the final approach, neither crew member had developed a correct or complete mental model of the landing site.
3. When the pilot flying realized that the location of the landing zone was closer than expected, the large control inputs made to adjust the descent angle and speed resulted in a hazardous approach profile.
4. During the approach, both crew members were occupied with maintaining visual reference to the landing zone, and the hazardous approach profile went unrecognized.
5. While a visual approach was being conducted to a temporary night helipad at an unlit aerodrome at night, positive control of the helicopter was lost.
6. Helijet International Inc.'s standard operating procedures (SOPs) provided little guidance in a number of areas, including crew briefings, night visual flight rules requirements, and black-hole approach and landing procedures. As a result, the flight crew conducted a visual approach without the benefit of effective SOPs, which contributed to poor decision making and coordination.
7. The flat authority gradient in the cockpit was not identified and addressed by the crew, and the corresponding assumptions of crew skill and experience directly affected the quality of resource management and communication style.
8. The accepted practice of not fully briefing all approaches contributed to the ineffective crew coordination in this occurrence, reducing information exchanged between 2 senior crew members.
9. Because the processes described in Helijet International Inc.'s safety management system (SMS) were not being used effectively, the SMS did not help the company identify and mitigate the risks associated with its night medical evacuation operations.
10. At the time of the occurrence, there was a lack of resources and training dedicated to the company's SMS, limiting its effectiveness in mitigating the risks in night operations.

Sources:

http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2015/a15p0217/a15p0217.asp

Accident investigation:
cover
  
Investigating agency: TSB Canada
Status: Investigation completed
Duration: 1 month
Download report: Final report


Revision history:

Date/timeContributorUpdates
24-Dec-2017 14:13 harro Added

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