Loss of control involving Eurocopter MBB-BK 117 B-2, VH-VSA, 28 km south-south-east of Port Pirie Aerodrome, South Australia, on 15 February 2013

AO-2013-030

Summary

What happened

On 15 February 2013, the crew of a Eurocopter Helicopter MBB‑BK117 B-2 (BK117), registered VH-VSA, were conducting a trauma recovery flight from Port Pirie to Adelaide Hospital, South Australia. After reaching the cruise altitude of 5,000 ft above mean sea level, the crew observed fluctuations of the hydraulic system pressure gauges. Shortly after, the helicopter sustained an uncommanded and violent nose-up pitch and rolled left before descending. The pilot regained control at about 800 ft above ground level. Control checks by the pilot confirmed normal control had resumed and the pilot flew the helicopter back to Port Pirie Aerodrome. No injuries were reported by the occupants and the helicopter sustained minor damage.

What the ATSB found

The ATSB did not find any mechanical or system faults that could account for the hydraulic system pressure fluctuations. The ATSB found that the helicopter was being operated at a weight, density altitude and airspeed, and in meteorological conditions that were conducive to the onset of retreating blade stall. The uncommanded and violent nose-up pitch and left roll were consistent with the onset of that condition. The pilot’s instinctive action of pushing the cyclic control forward delayed recovery from the stall.

What's been done as a result

The operator issued an urgent Immediate Safety Notification advising all company BK117 pilots of the conditions conducive to retreating blade stall and the correct actions to recover from that condition.

Safety message

This incident highlights the importance of pilot awareness of the factors conducive to retreating blade stall, including high all-up weight, high density altitude, high airspeed, manoeuvres that increase flight loads and flight in turbulence. Similarly, the importance of initially reducing collective pitch to optimise recovery is emphasised as incorrect recovery actions can result in loss of control of the helicopter.

Occurrence summary

Investigation number AO-2013-030
Occurrence date 15/02/2013
Location 28 km SSE of Port Pirie Aerodrome
State South Australia
Report release date 15/07/2014
Report status Final
Investigation level Defined
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Eurocopter
Model BK117
Registration VH-VSA
Serial number 7186
Sector Helicopter
Operation type Medical Transport
Departure point Port Pirie, SA
Destination Adelaide Hospital, SA
Damage Minor