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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters



Safeguard Magazine

Incident investigation—Beyond safe limits

Summary

A helicopter on a commercial heli-skiing flight with six passengers crashed near a mountain summit, resulting in the death of one passenger and serious injuries to three others. Issues with the aircraft’s loading contributed to loss of control.

CONTEXT

  • • 
    The helicopter was among several operating in the area of the Mt Aspiring National Park taking skiers to the top of ski runs.
  • • 
    The weather was fine and clear with light winds.
  • • 
    The aircraft was on its fourth heli-ski run of the morning.

DETAIL

  • • 
    Near to landing on a ridgeline at 2300m the helicopter descended below the intended angle of approach.
  • • 
    The pilot abandoned the approach and turned the machine away from the ridgeline.
  • • 
    The helicopter sank at a faster rate than expected and struck the snow-covered slope heavily. It rolled 300m down the mountain.
  • • 
    The cabin broke apart and five occupants were flung out, one of whom was trapped under the machine and died.
  • • 
    The other two occupants remained strapped to their seats inside what was left of the cabin.

BACKGROUND

  • • 
    The weight of the helicopter exceeded the maximum permissible by about 30kg.
  • • 
    The aircraft’s centre of gravity was about 3cm ahead of the forward limit.
  • • 
    The machine was hovering at or close to its operating limits for the height above sea level.
  • • 
    The aircraft was controllable and its engine was delivering full power.
  • • 
    The pilot was trained and experienced in mountain flying and heli-skiing operations.

LESSONS

  • • 
    The operator’s standard operating procedures did not require its pilots to routinely calculate the performance capability of their helicopter for each flight.
  • • 
    Use of standardised passenger weights rather than actual weights risked operating helicopters close to the limits of their performance.
  • • 
    There is a culture among some New Zealand helicopter pilots of operating their machines beyond the manufacturer’s stated limits.
  • • 
    This culture may have become normalised.
  • • 
    Mountain flying places extra demands on aircraft and pilots, and operators’ safety management systems need to reflect this.
  • • 
    Operators should keep comprehensive and formal records of pilot training to assist performance monitoring and professional development.
  • • 
    This is particularly important as safety managers and training managers move through the industry.
  • • 
    Operators should ensure all passengers and crew fasten seatbelts and adjust them tightly across the hips.
  • • 
    Injuries may have been reduced if all passengers had worn their seat belts tightly fastened.

Note: this incident saw the operator charged and convicted under the HSW Act 2015, the first time the Civil Aviation Authority has prosecuted under health and safety law.

Thomson Reuters

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