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Analysis

Summary

When the pilot began the right banked turn, he exposed the helicopter to firstly, a left crosswind, then a quartering tail wind. Flying at low airspeeds and operating out of ground effect, the helicopter was satisfying several of the operational conditions necessary to experience an uncommanded right yaw or LTE as outlined in Bell OSN 206-83-10.

The pilot indicated no awareness of operational conditions necessary to experience LTE, or knowledge of recovery techniques to counteract the onset of LTE. The failure of the helicopter to recover from the LTE condition following the pilot's reported corrective actions, was probably a result of his lateness to recognise the onset of LTE in sufficient time to permit recovery.


Organisational Factors

CASA's audit of August 2000 found that the checking of line pilots by the Chief Pilot was irregular and ineffective. Pilot flight checks were conducted in areas unreflective of actual operating conditions. In addition, those flight checks were of insufficient duration to appropriately assess the pilot's skills. Safety awareness training of personnel was considered inadequate. The operator had not established a sufficient maintenance control program. This resulted in the operation of company helicopters with overdue maintenance requirements. The lack of a formal pilot induction program, adequate checking of line pilots for currency, adequate documentation of line pilot training, a company Flight Safety Program, and a formal system of maintenance control all contributed to a less than adequate safety culture within the company.


CASA surveillance

The March 1999 fatal accident may have justified an increase in surveillance as per CASA guidelines. CASA management however, did not revise surveillance of the operator following recommendations from area managers and Flying Operations Inspectors. As a result, the safety oversight of the operator by CASA may have been less than recommended in CASA guidelines. Following this latest occurrence, CASA subsequently increased its level of surveillance of the operator.


CASA surveillance documentation

Examination of the CASA aircraft file for this helicopter and other aircraft files, has identified a trend of non-compliance by operators to resolve discrepancies noted on the ASR ASSP 604 form. Non-acquittal of ASRs could also display a trend of non-compliance to airworthiness issues.

 
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