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ASN Wikibase Occurrence # 71765
Last updated: 22 November 2017
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Date:21-JAN-2010
Time:20:16 LT
Type:Silhouette image of generic A139 model; specific model in this crash may look slightly different
AgustaWestland AW139
Owner/operator:INAER opf Salvamento Marítimo (SASEMAR)
Registration: EC-KYR
C/n / msn: 31228
Fatalities:Fatalities: 3 / Occupants: 4
Other fatalities:0
Airplane damage: Written off (damaged beyond repair)
Category:Accident
Location:Mediterranean Sea, 4.5 nm S Almería -   Spain
Phase: En route
Nature:Training
Departure airport:Almería (LEAM)
Destination airport:Almería (LEAM)
Investigating agency: CIAIAC
Narrative:
Impacted the sea (CFIT) during the return from a night SAR winch training flight. Visual allusion lead to a misconception on aircraft altitude. Only the winch operator survived.

The following factors contributed to the accident:

1. Possible crew fatigue resulting from:
• The demands of the SAR operation.
• The excessive workload placed on the captain by assuming his own tasks and responsibilities and many of the copilot’s.
• The excessive cognitive effort made by the copilot due to a lack of SAR experience and to the effort required to understand and communicate in a foreign language.

2. Inadequate crew training in SAR operations and CRM techniques that:
• Hampered the captain’s handling of the unresolved conflict between giving the copilot more autonomy while fully confiding in his flying skills.
• Prevented the copilot from being sufficiently assertive to communicate his difficulty in staying abreast of the flight due to the captain’s unreported actions and his desire to complete the flight successfully with a captain who was very much his senior.
• Impeded the captain and copilot from identifying and managing their fatigue.
• Impeded the crew’s handling of the transition between a highly demanding activity (SAR exercises) and a routine activity (return flight).
• Resulted in the crew’s constant exposure and habituation to the LANDING GEAR and ONE FIFTY FEET audio warnings, which made these warnings ineffective in preventing the impact.

3. The definition and inappropriate use of SAR checklists not adapted to the helicopter model and to SAR operations, and which included disengaging the Flight Director.

4. The lack of regulations specific to SAR operations in Spain and the low requirements placed on the operator by the provider of the SAR service.

This report contains 17 safety recommendations for State Aviation Safety Agency (AESA), as one of the bodies designated by Spain as its civil aviation authority, for the Spanish Maritime Safety Agency (SASEMAR), the responsible of the SAR service, for INAER HELICÓPTEROS OFF-SHORE, as the SAR operator, and for the European Aviation Safety Agency (EASA), as the certifying authority for the emergency locator transmitter.

Sources:

http://www.elmundo.es/elmundo/2010/01/21/andalucia/1264109728.html
http://www.elpais.com/articulo/espana/superviviente/helicoptero/accidentado/Almeria/recupera/recuerda/nada/elpepuesp/20100122elpepunac_11/Tes
http://www.stuff.co.nz/world/3259311/NZ-pilots-body-found-after-helicopter-crash
http://www.pprune.org/rotorheads/402948-sar-heli-down-almeria.html http://www.fomento.es/nr/rdonlyres/70dd0c48-1459-407a-9d9f-99d00819505a/97971/2010_002_a_interim_statement.pdf
http://www.fomento.gob.es/NR/rdonlyres/C6E653F5-E80D-42A8-9562-B8EB29B71E0F/113643/2010_002_A_ENG.pdf


Revision history:

Date/timeContributorUpdates
22-Jan-2010 00:31 gferran Added
22-Jan-2010 06:59 RobertMB Updated [Time, Aircraft type, Cn, Operator, Location, Phase, Source, Narrative]
22-Jan-2010 07:00 RobertMB Updated [Aircraft type, Source]
22-Jan-2010 07:27 RobertMB Updated [Aircraft type, Registration, Cn, Operator, Location, Phase, Nature, Source, Narrative]
24-Jan-2010 15:35 RobertMB Updated [Source, Narrative]
25-Jan-2010 12:13 83.52.82.35 Updated [Total occupants, Source]
27-Jan-2010 03:00 FLYINGBROTHER1 Updated [Other fatalities, Damage]
13-Jul-2010 00:13 TB Updated [Aircraft type, Location]
04-Aug-2010 03:51 78.6.124.186 Updated [Source]
24-May-2011 02:14 114.160.230.57 Updated [Source, Narrative]
19-Dec-2012 04:50 TB Updated [Source, Narrative]
19-Dec-2012 04:54 TB Updated [Location, Departure airport, Destination airport, Narrative]
03-May-2016 10:26 Aerossurance Updated [Time, Operator, Location, Phase, Destination airport, Source, Narrative]
03-May-2016 10:26 Aerossurance Updated [Source]
30-Apr-2017 07:38 Aerossurance Updated [Operator]

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