Aviation safety investigations & reports

Collision with terrain involving a Bell 206L-1, VH-NBR, at Banks Peak, Moa Island, Queensland, on 22 April 2020

Investigation number:
AO-2020-023
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final report

Download final report
[Download  PDF: 462KB]
 

What happened

On 22 April 2020, a Bell 206L1-C30P helicopter, registered VH-NBR, was being operated by Nautilus Aviation on a passenger charter flight from Kubin Airport, Queensland, to Banks Peak, on Moa Island. On board were the pilot and two passengers.

While manoeuvring at the helicopter landing site (HLS), the helicopter’s tail rotor contacted trees. The helicopter then rotated rapidly to the right, collided with terrain, and was destroyed. The passengers were seriously injured, and the pilot sustained a minor injury.

What the ATSB found

The ATSB found that the design and maintenance schedule of the HLS made it susceptible to overgrowth. Vegetation had overgrown the site, obscuring the edges and surface of the helipad. The helipad was elevated above the ground, which made positioning of the helicopter on the helipad vital for the safe conduct of a landing.

It was also found that the pilot’s use of a flight helmet very likely reduced the severity of the pilot’s injuries.  

What has been done as a result

The operator amended its helicopter landing site template to include a grading system for site assessment by the chief pilot/deputy chief pilot prior to tasking pilots. It also developed a risk assessment template for landing at non-surveyed sites. In addition, the operator sent an alert to all the operator’s pilots to reinforce the go-around procedure as stated in its operations manual, and this procedure was performed on all remote area check flights. All cross-hired aircraft were migrated to the operator’s flight following system, which allowed the ability to track these aircraft in real time while on task.  

The Department of Home Affairs, as owner of the HLS, conducted a formal risk assessment of Banks Peak and other higher-risk HLSs throughout the Torres Strait. It also ceased flying operations to landing sites deemed to have unacceptable risks until sufficient control measures had been implemented. In addition, it is developing a detailed HLS brief for aircraft operators and is considering the most appropriate mechanisms for systematic engagement with other users of the sites. 

Safety message

The design and ongoing maintenance of helicopter landing sites and helipads in a tropical environment is an important function. The frequency of the maintenance schedule must be sufficient to account for the rapid plant growth to enable safe use of the site.

Helicopter landing site owners are encouraged to add touchdown/positioning markings to their facilities. Pilots can choose natural features in lieu of human-made markers where markers are absent. Additionally, if a landing cannot be conducted as planned, pilots should reject the landing and re-evaluate their options from a safe position.

The wearing of helmets is an important safety consideration when performing utility aerial work. The survivability in the event of an accident is greatly increased, as highlighted by this accident.

Download final report
[Download  PDF: 462KB]
 
 
 

The investigation

General details
Date: 22 April 2020   Investigation status: Completed  
Time: 0813 AEST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Banks Peak, Moa Island   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Collision with terrain  
Release date: 21 January 2021   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer Bell Helicopter Co  
Aircraft model 206L-1  
Aircraft registration VH-NBR  
Serial number 45232  
Operator Nautilus Aviation  
Type of operation Charter  
Sector Helicopter  
Damage to aircraft Substantial  
Destination Banks Peak, Moa Island, Queensland  
Last update 28 January 2021