On 5 September 2013, the Australian Transport Safety Bureau (ATSB) released its final investigation report into the loss of control involving Eurocopter1 AS350BA, registered VH RDU, which occurred 93 km north of Rockhampton Airport, Queensland on 8 September 2011. Subsequently, the ATSB became aware of new and significant evidence in relation to the helicopter’s hydraulic pump drive system, including the associated drive belt. Information had been provided through the ATSB’s confidential reporting scheme (REPCON) indicating the reporter’s safety concerns about the hydraulic pump drive belt. As a result, and in accordance with clause 5.13 of Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation, the ATSB reopened the investigation.
This supplementary report highlights the additional information gained as a result of reopening the investigation and confirms that the drive belt that was installed in VH-RDU at the time of the accident was authorised for use and within its service life limit. Review and analysis of the additional information determined that, while it would be beneficial to add some additional information to the final investigation report, no change was necessary to the findings in the report that was released to the public on 5 September 2013.
Revised final released 18 February 2014
On 8 September 2011, a chartered Eurocopter AS350BA registered VH-RDU, with a pilot and two passengers on board, collided with terrain on approach to a helicopter landing site (HLS). The HLS was located on a peak of Double Mountain South in the Shoalwater Bay military training area, 93 km north of Rockhampton Airport, Queensland. The pilot and front seat passenger were fatally injured and the rear seat passenger received serious injuries. The helicopter was substantially damaged and there was no fire.
What the ATSB found
The ATSB found that the pilot lost control of the helicopter at low speed or while hovering. The reason for that loss of control could not be positively established, although it is most likely to have resulted from environmental and operational factors.
The investigation was unable to determine whether authorisation of pilot tasking in this case had complied with the operator’s procedures. The assignment of the pilot to the task did not directly contribute to the accident. However, had a formalised and documented risk assessment of the task been prepared and considered as part of the authorisation process, as prescribed by the operator’s Safety Management System, it is likely there would have been a greater awareness of the suitability or otherwise of the pilot for the tasking. The physical characteristics of the HLS were not a contributing factor to the accident.
However, the HLS was found to be potentially hazardous for a pilot who was unfamiliar with its characteristics and not current with the difficulties likely to be encountered with pinnacle and confined helicopter landing sites.
This accident highlights the need for helicopter operators to be aware of the potential safety risks associated with tasking pilots, especially those with little experience on the helicopter type, into an operating environment for which their competency has not been established or regularly checked. While pinnacle and confined area operations are part of the normal competencies of a licenced helicopter pilot, they are degradable skills that should be confirmed current prior to the assignment of flights that may involve such locations.
Preliminary report release 11 July 2011
At about 1140 Eastern Standard Time on 8 September 2011, a Eurocopter AS350BA helicopter, registered VH-RDU, with a pilot and two passengers on board, collided with terrain on approach to land at a helicopter landing site that was located on a peak of Double Mountain South, Queensland.
The pilot and front seat passenger were fatally injured and the rear seat passenger received serious injuries. The helicopter was substantially damaged. There was no fire.
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The pilot was assigned to a task for which he most likely lacked experience on both the helicopter type and the nature of the flying.
|Who it affects:||Heli Charters Australia Pty Ltd|
The minimal clearance from obstructions, unfavourable surface conditions and a lack of appropriate wind indication at the helicopter landing site (HLS) increased the risk associated with operations to the HLS, particularly for a pilot unfamiliar with the site.
|Who it affects:||All helicopter landing site owners|
|Date:||08 September 2011||Investigation status:||Completed|
|Time:||1140 EST||Investigation level:||Systemic - click for an explanation of investigation levels|
|Location:||93 km north of Rockhampton|
|State:||Queensland||Occurrence type:||Loss of control|
|Release date:||18 February 2014||Occurrence category:||Accident|
|Report status:||Final||Highest injury level:||Fatal|
|Type of operation||Aerial Work|
|Damage to aircraft||Serious|