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What happened

At about 1207 on 21 March 2013, a Robinson Helicopter Company R44 helicopter (R44), registered VH-HWQ, landed at a grassed area adjacent to a function centre at Bulli Tops, New South Wales. Shortly after landing, the helicopter was observed to simultaneously lift off, yaw right through 180° and drift towards nearby trees. The helicopter struck branches of the trees before descending, impacting the ground nose low and rolling onto its right side. A short time after coming to rest a fire started and engulfed the helicopter. The pilot and three passengers were fatally injured.

What the ATSB found

The circumstances of this accident were consistent with the helicopter lifting off following a deliberate or inadvertent collective input. The helicopter’s main rotor blades subsequently contacted nearby trees resulting in a loss of control and impact with the ground. The impact sequence resulted in a substantial fuel leak that was followed by an intense fire. This accident was similar to two other relatively recent fatal accidents in Australia involving R44s fitted with all-aluminium fuel tanks in which there was a fatal post-impact fire (PIF) following an otherwise survivable impact. Statistical analysis of helicopter accidents that occurred in Australia and the United States (US) between 1993 and 2013 identified a significantly higher proportion of PIF involving R44s than for other similar helicopter types. That analysis also identified that, despite the introduction of requirements for newly certificated helicopters to have an improved crash-resistant fuel system (CRFS) some 20 years previously, several helicopter types were still being manufactured without a CRFS and that many of the existing civil helicopter fleet were similarly not fitted with a CRFS.

What's been done as a result

Following this accident the Civil Aviation Safety Authority (CASA) took action to increase compliance with the helicopter manufacturer’s Service Bulletin 78B (SB-78B), requiring the fitment of bladder-type fuel tanks and other fuel system improvements. While recognising the action taken by CASA, due to concern that a significant number of Australian owners and operators had at that stage not taken steps to comply with the service bulletin, and were very unlikely to be able to do so by the required date of 30 April 2013, the ATSB released safety recommendation AO-2013-055-SR-001 to CASA that further action be taken. In response CASA released airworthiness directive AD/R44/23 requiring all owners of R44 helicopters in Australia to comply with SB-78B by the required date. Several other national airworthiness authorities (the South African Civil Aviation Authority, the Civil Aviation Authority of New Zealand and the European Aviation Safety Agency) subsequently mandated compliance with SB-78B. At the time of publishing this report the State of Design and Manufacture of the R44 helicopter had not mandated compliance with SB-78B.

The ATSB has issued a safety recommendation to the US Federal Aviation Administration (FAA) that they take action to ensure all R44 operators and owners comply with the manufacturer's Service Bulletin SB-78B and fit bladder-type tanks to improve resistance to post-impact fuel leaks. In addition, the ATSB also recommend that the FAA and European Aviation Safety Agency take action to increase the number of existing and newly-manufactured helicopters that are fitted with a crash-resistant fuel system.

Safety message

This accident highlights the catastrophic consequences of fuel-fed post-impact fire and that the most effective defence is to prevent the fire from occurring at impact by containing the fuel on board, preventing ignition, or both. In that context, the ATSB strongly encourages the fitment of a crash-resistant fuel system where possible.

 

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Preliminary report released 30 April 2013 

What happened

At about 1207 local time on 21 March 2013, a Robinson Helicopter Company R44 helicopter (R44), registered VH-HWQ, was manoeuvring at a grassed area at Bulli Tops, New South Wales. Shortly after landing, the helicopter lifted off and turned to the right. The main rotor struck branches of a nearby tree, and the helicopter descended and then rolled over onto its right side. A fire started on the grass under the rotor mast and the cabin. The pilot and the three passengers were fatally injured.

What the ATSB found

The circumstances of this accident are consistent with two recent R44 accidents in Australia involving low-energy impacts that resulted in the all-aluminium fuel tanks being breached and a fuel-fed fire. R44 accidents result in a significantly higher proportion of post-impact fires than for other similar helicopter types. The accident helicopter was equipped with an all-aluminium tank.

On 20 December 2010 the Robinson Helicopter Company issued Service Bulletin SB-78 providing for the replacement of all-aluminium tanks in R44 helicopters with bladder-type tanks that substantially reduce the likelihood of post-crash fires. On 28 September 2012 the Robinson Helicopter Company revised and reissued the service bulletin as SB-78B. This revision brought forward the compliance date for the service bulletin to 30 April 2013. The ATSB has assessed that about 100 Australian R44 helicopters will not have met the service bulletin by the due date.

What's been done as a result

In response to this accident, the Civil Aviation Safety Authority (CASA) has confirmed its understanding that the great majority of Australian R44 helicopter owners are legally required to comply with Service Bulletin SB-78B. CASA has also undertaken to contact owners who may not be required to comply and then consider further action depending on the response to that contact.

The ATSB remains concerned at the significant risk that many R44 helicopters will not comply with the service bulletin and has recommended that CASA take further action to ensure compliance.

Safety message

The fitment of bladder-type fuel tanks to R44 helicopters is a very important safety enhancement that could save lives and is very strongly encouraged. In addition, regulators and investigation agencies in other countries should take note of this report and consider what steps they can take to increase compliance with the manufacturer’s safety bulletin.

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Source:  ATSB

 
 

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Safety issues

AO-2013-055-SI-01 - AO-2013-055-SI-02 - AO-2013-055-SI-03 - AO-2013-055-SI-04 -  

Fitment of rubber, bladder-type fuel tanks to R44 helicopters

Accidents involving Robinson R44 helicopters without bladder-type tanks fitted result in a significantly higher proportion of post-impact fires than for other similar helicopter types. In addition, the existing Australian regulatory arrangements were not sufficient to ensure all R44 operators and owners complied with the manufacturer's Service Bulletin SB-78B and fitted these tanks to improve resistance to post-impact fuel leaks.

Safety issue details
Issue number:AO-2013-055-SI-01
Who it affects:All owners and operators of R44 helicopters
Status:Adequately addressed


 

Fitment of bladder-type fuel tanks to R44 helicopters (US)

Accidents involving Robinson R44 helicopters without bladder-type tanks fitted result in a significantly higher proportion of post-impact fires than for other similar helicopter types. In addition, the existing United States regulatory arrangements are not sufficient to ensure all R44 operators and owners comply with the manufacturer's Service Bulletin SB-78B and fit these tanks to improve resistance to post-impact fuel leaks.

Safety issue details
Issue number:AO-2013-055-SI-02
Who it affects:All owners and operators of R44 helicopters
Status:Safety action pending


 

Helicopters not manufactured with a crash-resistant fuel system

Although certification requirements for helicopters to include a crash-resistant fuel system (CRFS) were introduced in 1994, several helicopter types certified before these requirements became applicable are still being manufactured without a CRFS.

Safety issue details
Issue number:AO-2013-055-SI-03
Who it affects:All owners and operators of helicopters not fitted with crash-resistant fuel systems
Status:Safety action pending


 

Existing helicopters not fitted with a crash-resistant fuel system

Many of the existing civil helicopter fleet are not fitted with a crash-resistant fuel system, or do not have an equivalent level of safety associated with post-impact fire prevention.

Safety issue details
Issue number: AO-2013-055-SI-04
Who it affects:All owners and operators of aircraft not fitted with crash-resistant fuel systems
Status:Safety action pending

 
General details
Date: 21 March 2013 Investigation status: Completed 
Time: 1207 ESuT Investigation type: Occurrence Investigation 
Location   (show map):Bulli Tops, near Wollongong Occurrence type:Loss of control 
State: New South Wales Occurrence class: Operational 
Release date: 04 June 2015 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: Robinson Helicopter Co 
Aircraft model: R44 
Aircraft registration: VH-HWQ 
Serial number: 1445 
Type of operation: Private 
Sector: Helicopter 
Damage to aircraft: Destroyed 
Departure point:Bankstown, NSW
Destination:Panorama House, NSW
 
 
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Last update 18 July 2016