Aviation safety investigations & reports

Collision with water, Robinson Helicopter Company R44 Raven 1, VH-MEB, Pier 35, Melbourne, Vic., 29 December 2007

Investigation number:
AO-2007-069
Status: Completed
Investigation completed

Summary

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Following completion of a scenic charter flight, at about 1905 Eastern Daylight-saving Time on 29 December 2007, a Robinson Helicopter Company R44 Raven 1, registered VH-MEB, departed the Pier 35 private helipad, located adjacent to the Yarra River, Melbourne, Vic. on a private flight to return to the operator's base, with two pilots on board. Witnesses located at a nearby marina, reported that shortly after the helicopter's takeoff in a north-north-westerly direction, it banked left and turned to the south-west, passing a marina while at a height of about 30 to 35 ft above mean sea level (AMSL). Witnesses reported that during the accident flight takeoff, the helicopter passed to the west of a channel marker in the river adjacent to the pad. During the departure from the pad on previous flights the helicopter had passed to the east of the channel marker.

The helicopter's forward airspeed decreased and it 'rocked or wobbled in the air' then pitched nose up, rolled to the left, descended and impacted the water. The handling pilot exited the helicopter via the right side, where he was seated, and was recovered by the crew of a nearby boat. The other pilot, who was the chief pilot of the operator, did not exit the helicopter and was fatally injured.

The investigation found that the helicopter did not gain altitude, departed controlled flight, descended and struck the water. During this event, the main rotor revolutions per minute (RPM) were at a lower than normal value to sustain controlled flight. The investigation could not identify any problems with the helicopter, its systems or engine, which would have led to the low main rotor RPM as witnessed. The investigation determined that environmental factors in combination with pilot handling technique probably resulted in the low main rotor RPM event.

Following the accident, the helipad operator ceased all helicopter operations at Pier 35 and any on-going use of that pad by any person.

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Preliminary

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Preliminary report released 14 March 2008

At about 1905 Eastern Daylight-saving Time, on 29 December 2007, a Robinson Helicopter Company R44 Raven 1 (R44), registered VH-MEB was being operated under the charter category with two pilots on board. Following a passenger scenic flight, the helicopter departed Pier 35 helipad, located adjacent to the Yarra River, Melbourne, Vic. to return to the operator's base. Witnesses nearby reported that shortly following the takeoff, in a north-north-west direction, the helicopter banked left and turned to the south-west, passing a marina at a height of about 30-35 ft AMSL. Witnesses reported that the helicopter's forward airspeed decreased and that it 'rocked or wobbled in the air' then pitched nose up, rolled to the left, descended and impacted the water.

The handling pilot was able to exit the helicopter via the right side and was recovered by the crew of a boat. The other pilot did not exit the helicopter and was fatally injured. The body of the pilot was subsequently recovered from the wreckage by Victorian Police Search and Rescue Squad divers.

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Inquest

VH-MEB response to the Coroner

The ATSB notes that the Victorian Coroner, Mr J Olle, having conducted an investigation into a 2007 fatal Robinson R44 helicopter accident at Pier 35, Melbourne Victoria, has recently released a finding into the death without holding an inquest. The ATSB made submissions to assist the coronial investigation. The Coroner’s findings largely adopt the findings made by the ATSB in its report published on 8 May 2009. 

Circumstances of the accident

Following completion of a scenic charter flight, the helicopter departed the Pier 35 private helipad that was located adjacent to the Yarra River in Melbourne, Victoria, with two pilots on board.

The helicopter's forward airspeed decreased and it 'rocked or wobbled in the air' then pitched nose up, rolled to the left, descended and impacted the water. One pilot was fatally injured

ATSB findings

The investigation found that the helicopter did not gain altitude, departed controlled flight, descended and struck the water. During this event, the main rotor revolutions per minute (RPM) were at a lower than normal value to sustain controlled flight. The investigation could not identify any problems with the helicopter, its systems or engine, which would have led to the low main rotor RPM. The investigation determined that environmental factors in combination with pilot handling technique probably resulted in the low main rotor RPM event.

Towering take-off

One of the matters for consideration was whether a ‘towering takeoff’ could be safely used over buildings surrounding the helipad, rather than going over the water. The ATSB noted that there were risks involved in conducting such a take-off, but that it was an option to clear the objects to the south of the helipad and avoid the potentially higher risks of a take-off with a tailwind over the water.

The Coroner accepted that a towering take-off was possible but noted it should only be used in circumstances where pertinent information on the use  of the Pier 35 helipad were known to the pilot (see the Coroner’s recommendation below).

ATSB safety issue and the Coroner’s recommendation

The ATSB identified a safety issue that ‘there was not readily available information for pilots planning to use the helipad on the pad’s unique characteristics, including constraints on operations and, in particular, the fact that the windsock may provide erroneous wind indications in some weather conditions.’ It was considered likely that the then position of the windsock resulted in erroneous indications of the wind direction on the day of the accident.

Pier 35 is under management of a new operator who has relocated the windsock. This operator has also published a policy on the use of the helipad that is available at http://melbourneheli.com/landing_policy.html.

As a result the inquest, the Coroner issued the following recommendation to the new operator:

1.      Place signage at Pier 35 helipad in relation to its unique characteristics. For example the sign could warn that wind from the south-south-west may be deflected over the Pier 35 boat storage shed. This signage may assist in heightening awareness as to the possibility of turbulence or eddies existing on the opposite of the boat shed so that pilots can complete a risk analysis and adopt procedures to assist the performance of the helicopter in those conditions.

Other matters in the Coroner’s findings

The ATSB focussed on factors that contributed to the development of the accident or that increased safety risk. The Coronial investigation looked at these factors but also noted that the new operator of the helipad had made changes to improve safety at the Pier 35 helipad. Readers should refer to the Coroner’s findings to ensure they are understood in their own context.

ATSB investigations and coronial investigations

Coronial investigations are separate to ATSB investigations. In this matter the respective authorities are in accord as to the factors that contributed to the development of the accident.

The ATSB's report can be downloaded by clicking on the link: ATSB Report.

The Coroner's report can be obtained from the Coroner's Court of Victoria. Contact details are available at: http://www.coronerscourt.vic.gov.au/home/. Queries regarding the Coroner's findings should be directed to the Coroner's Court of Victoria.

 

General details
Date: 29 December 2007   Investigation status: Completed  
Time: 1905 ESuT   Investigation phase:  
Location   (show map): near Westgate Bridge (VFR)   Investigation type: Occurrence Investigation  
State: Victoria   Occurrence type: Collision with terrain  
Release date: 08 May 2009   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Robinson Helicopter Co  
Aircraft model R44  
Aircraft registration VH-MEB  
Serial number 1674  
Type of operation Charter  
Sector Helicopter  
Damage to aircraft Destroyed  
Departure point Pier 35 Melbourne, Vic.  
Departure time 1905  
Destination Carribean Gardens  
 
Injuries
  Crew Passenger Ground Total
Fatal: 1 0 0 1
Minor: 1 0 0 1
Total: 2 0 0 2
Last update 14 November 2018