Hard-landing pilot should not have flown
New Zealand’s Transport Accident Investigation Commission has issued a report into the hard landing of a BK117 helicopter air ambulance in 2014, saying that the pilot ‘should not have operated the flight’.
New Zealand’s Transport Accident Investigation Commission (TAIC) has issued a report into the hard landing of a BK117 in 2014, saying that the pilot ‘should not have operated the flight’. The Westpac Rescue Helicopter was operated by Garden City Helicopters Limited on behalf of Canterbury West Coast Air Rescue Trust.
On 5 May 2014, the service’s BK117 B-2, tail number ZK-HJC, suffered power loss to both engines as it flew near Springston, Canterbury. There were a total of four people onboard, including a patient who was being transferred from Ashburton to Christchurch. A design feature of the BK117 fuel system meant that both engines lost power within seconds of each other. Both engines lost power due to fuel starvation, because the pilot did not switch on the fuel transfer pumps after starting the engines, says TAIC. The pilot made an emergency landing without power – the occupants were uninjured but the helicopter suffered minor damage.
The report states: “It was later determined that the double engine power loss had been caused by lack of fuel flow to the engines, despite there being a large quantity of fuel in the main fuel tanks. The cause of the lack of fuel flow to the engines was the pilot's incorrect management and configuration of the aircraft's fuel supply system, which prevented the fuel in the main tanks getting to the engines.” According to TAIC, the operator’s system for maintaining oversight of its pilots' proficiency and currency was not robust enough to ensure that this pilot was proficient and sufficiently current to fly the BK117.
TAIC notes that the pilot lacked recent experience on the BK117, and there had not received recent training or competency assessment on the aircraft type, saying that this was a contributory factor in the event. The operating company did not have any procedures in place to address the lack of recent experience, says TAIC, such as additional training, supervision or a policy on the use of written checklists in such a situation.
A further contributing factor to the power loss was the pilot's inability to detect caution lights, due to the cockpit lighting dimmer switch being left on in daylight, says TAIC: “Brightly illuminated caution lights should have alerted the pilot to the incorrectly configured fuel system and the low fuel levels in the supply tanks, and could have prevented the incident.” The report notes that the helicopter had been modified to enable the use of night vision equipment. TAIC further comments that an audio warning of a critically low fuel level in the supply tanks would have alerted the pilot to the potential loss of engine power and could have prevented the accident, but the helicopter lacked this warning, although it was fitted to later designs.
The pilot did not refer to a checklist when carrying out the normal pre-flight, before-start and after-start procedures, TAIC says, adding: “Had he done so he would have been prompted to: switch the fuel transfer pumps on, which would have prevented the fuel starvation; and turn the dimmer switch off, which should have ensured the caution lights were visible to the pilot.”
In Febraury 2016, TAIC made a number of recommendations to prevent future accidents.
The Commission called on the Director of Civil Aviation to review all modifications to the cockpit lighting on BK117 helicopters for night vision use, to ensure they do not unduly increase the risk of a similar incident occurring. If they do introduce an unacceptable level of risk, changes to the installation, such as a low-fuel-level aural warning or brighter LED (light-emitting diode) caution lights, should be required, said TAIC. Furthermore, the Director of Civil Aviation was urged to require that all safety management systems of air operators ensure appropriate training and supervision is given to pilots who lack recent experience on an aircraft type.
TAIC also called on the CEO of Garden City Helicopters Limited to amend company policies, procedures and practices relating to the management of pilot competency. These amendments, said TAIC, should include annual recurrent training and regular proficiency checks for all pilots on all aircraft types flown. For pilots who lack recent experience on an aircraft type, the amendments should introduce increased supervision, additional training, and the use of written checklists.
In conclusion, the reports declares that pilots who fly multiple aircraft types concurrently must remain vigilant to inadvertently transferring habits and procedures from one type to another, and that operators who require their pilots to fly different aircraft types must have robust policies and procedures that ensure the pilots are appropriately experienced, trained and current on each aircraft type.