Aviation Accident Summaries

Aviation Accident Summary GAA15CA258

Draper, UT, USA

Aircraft #1

N253HP

AIRBUS AS350

Analysis

The pilot reported that he and a tactical flight officer were conducting a high altitude rescue mission in "remote and nearly vertical" terrain with a public use helicopter, by doing a one-skid recovery. The purpose of this mission was to recover a fallen hiker.  A member of the three person ground recovery team had secured himself to a rescue rope that was anchored to the steep terrain above the plane-of-rotation of the main rotor system blades. Once the helicopter's right skid landed on a rock outcrop, the ground recovery team approached the helicopter to begin the loading process. During the approach to the helicopter, the rescue rope came in contact with a main rotor blade.   The pilot reported that the helicopter then, "rotated abruptly to the left and began to shake violently." The helicopter impacted terrain, the pilot regained control, and he then made an emergency landing at a lower altitude. He reported that upon applying power to land, the helicopter "began to shake violently again until touching down and reducing collective pitch." A postflight inspection revealed substantial damage to the main rotor system, the tail boom, and the empennage.   The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.

Factual Information

The pilot reported that he and a tactical flight officer were conducting a high altitude rescue mission in "remote and nearly vertical" terrain with a public use helicopter, by doing a one-skid recovery. The purpose of this mission was to recover a fallen hiker. A member of the three person ground recovery team had secured himself to a rescue rope that was anchored to the steep terrain above the plane-of-rotation of the main rotor system blades. Once the helicopter's right skid landed on a rock outcrop, the ground recovery team approached the helicopter to begin the loading process. During the approach to the helicopter, the rescue rope came in contact with a main rotor blade. The pilot reported that the helicopter then, "rotated abruptly to the left and began to shake violently." The helicopter impacted terrain, the pilot regained control, and he then made an emergency landing at a lower altitude. He reported that upon applying power to land, the helicopter "began to shake violently again until touching down and reducing collective pitch." A postflight inspection revealed substantial damage to the main rotor system, the tail boom, and the empennage. The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The United States Department of the Interior, National Park Service (for the National Search and Rescue Academy) has published a manual, Helicopter Rescue Techniques (2013). This manual describes the various rescue techniques that can be employed with helicopters. This manual states in part; Helicopters provide an outstanding rescue tool, but they have specific operating limitations. Recognize that the consequences of a poorly managed helicopter rescue can be swift and fatal. Rescuers need to understand these limits and have the professional discipline not to exceed them during an emergency. As accident investigators repeatedly conclude, "self-imposed psychological pressure" causes us to make poor decisions when adrenaline clouds our judgment. Poor decision-making is preventable yet, tragically, it is a factor in the vast majority of helicopter rescue accidents. The option of delaying the mission in favor of safer operating conditions is repeatedly overlooked and requires considerable discipline on the part of a rescue team. Remarkably, accidents with the same root cause occur over and over. As rescuers, we must learn from these mistakes and break this dangerous pattern of repetition. The Mountain Rescue Association (MRA) has published a manual, Helicopters in Search and Rescue Intermediate Level (2008). This manual provides intermediate level knowledge with utilizing helicopters for search and rescue operations. This manual states in part; In certain situation, pilots and rescuers may choose to perform a hovering or one-skid recovery of a rescue victim. The factors to be taken into account in selecting a site for a hovering recovery are generally the same as those for selecting a helispot. In these conditions, a smaller ground area, rougher terrain and steeper slope are permissible. On the other hand, it is extremely important that there be plenty of room for both the main rotor and the tail rotor boom, since the pilot may have to turn the helicopter in the event changes in wind direction. An experienced hand signaler, one that the pilot knows is competent, should be at the site and all ground personnel should be within the pilot's view, if at all possible. In the case of one-skid recoveries on rock outcrops, this may be impractical. The MRA has also published another manual, Situational Awareness in Mountain Rescue (2008). This manual describes the three stages of Situational Awareness during mountain rescue operations. This manual states in part; "Situational Awareness" is "the degree of accuracy by which one's perception of his/her current environment mirrors reality." Situational Awareness can also be looked at as a constantly evolving picture of the state of the environment. It is the perception and comprehension of the relevant elements in an incident within a volume of time and space. In this regard, Situational Awareness is not an event, but rather a process that only ends when the search and rescue incident is concluded. Situational Awareness requires the human operator to quickly detect, integrate and interpret data gathered from the environment. In the case of search and rescue operations, the "human detector" can be anything from the incident commander to a "field grunt." That is the beauty (and challenge) of Situational Awareness – it requires and demands awareness by all users. Stage I – Perception of Relevant Information The first stage of Situational Awareness – perception – is arguably the most important stage. After all, without perception of information, one cannot really comprehend, interpret and draw conclusions. Many accidents in search and rescue operations result from a series of different things happening. There are often a number of contributing factors that, if occurring individually, might not have resulted in an accident. Break any rescue accident down, and you will often find that there were a number of elements that came together to make that accident possible. In this important perception stage of Situational Awareness, rescuers need to be very attentive – not only to the occurrence of situations that are beyond their expectations, but to the frequency and number of those situations. This perception stage requires that you OBSERVE! In order to be an effective observer, one must remain attentive. This can be one of the greatest challenges to a search and rescue professional, as periods of inactivity and boredom can hamper one's ability to be an effective observer. Stage II – Comprehension and Interpretation of the Relevant Information The second stage of Situational Awareness is the stage wherein one attempts to comprehend and interpret the data collected in the first stage. While the collection of data and the perception of the relevant information are important, the comprehension and interpretation of that data cannot be overlooked. The key to this stage of Situational Awareness is that it requires one to have and utilize key training and experience. Stage III – Projection into the Future The third stage of Situational Awareness – projection into the future – is the stage where one puts it all together. Once the clues are interpreted, the next step is to project how that information will affect the future of the operation.

Probable Cause and Findings

The ground recovery team member's failure to secure a rescue rope during the helicopter loading process in steep terrain, resulting in the rope fouling the helicopter's main rotor system.

 

Source: NTSB Aviation Accident Database

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