Report on the accident to Eurocopter (Deutschland)

176 Pages·2015·2.55 MB·English

AIRCRAFT ACCIDENT REPORT 3/2015
A AIB
Air Accidents Investigation Branch
Report on the accident to
Eurocopter (Deutschland) EC135 T2+, G-SPAO
Glasgow City Centre, Scotland
on 29 November 2013

AIRCRAFT ACCIDENT REPORT 3/2015
Air Accidents Investigation Branch
Report on the accident to
Eurocopter (Deutschland) EC135 T2+, G-SPAO
Glasgow City Centre, Scotland
on 29 November 2013
This investigation has been conducted in accordance with
Annex 13 to the ICAO Convention on International Civil Aviation,
EU Regulation No 996/2010 and
The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996.
The sole objective of the investigation of an accident or incident under these Regulations
is the prevention of future accidents and incidents. It is not the purpose of such
an investigation to apportion blame or liability.
Accordingly, it is inappropriate that AAIB reports should be used to assign fault or blame
or determine liability, since neither the investigation nor the reporting process has been
undertaken for that purpose.
© Crown Copyright 2015
This report contains facts which have been determined up to the time of publication. This
information is published to inform the aviation industry and the public of the general
circumstances of accidents and serious incidents.
Extracts may be published without specific permission providing that the source is duly
acknowledged, the material is reproduced accurately and it is not used in a derogatory manner
or in a misleading context.
Published 23 October 2015
Printed in the United Kingdom for the Air Accidents Investigation Branch
ii
Department for Transport
Air Accidents Investigation Branch
Farnborough House
Berkshire Copse Road
Aldershot
Hampshire GU11 2HH
October 2015
The Right Honourable Patrick McLoughlin
Secretary of State for Transport
Dear Secretary of State
I have the honour to submit the report on the circumstances of the accident to
Eurocopter (Deutschland) EC135 T2+, registration G-SPAO, in Glasgow City
Centre, Scotland on 29 November 2013.

Yours sincerely
Keith Conradi
Chief Inspector of Air Accidents
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Air Accident Report: 3/2015 G-SPAO EW/C2013/11/04
Contents
Introduction ......................................................................................................................1
Summary ..........................................................................................................................2
1 Factual Information ................................................................................................4
1.1 History of the flight ..........................................................................................4
1.1.1 Background .......................................................................................4
1.1.2 The flight ...........................................................................................4
1.2 Injuries to persons ...........................................................................................8
1.3 Damage to the helicopter ................................................................................8
1.4 Other damage .................................................................................................8
1.5 Personnel Information .....................................................................................9
1.5.1 Pilot ...................................................................................................9
1.5.2 Police Observers .............................................................................10
1.5.2.1 Front seat observer ......................................................10
1.5.2.2 Rear seat observer .......................................................10
1.6 Aircraft information ........................................................................................10
1.6.1 General ...........................................................................................10
1.6.2 Aircraft description ...........................................................................11
1.6.3 Warnings, cautions and system displays .........................................11
1.6.3.1 Warning Unit ..................................................................11
1.6.3.2 Central Panel Display System (CPDS).........................12
1.6.4 Fuel System ....................................................................................13
1.6.4.1 Tank arrangement.........................................................13
1.6.4.2 Fuel tank vent system...................................................14
1.6.5 Fuel contents system ......................................................................16
1.6.5.1 Fuel sensors .................................................................16
1.6.5.2 Fuel contents gauges ...................................................17
1.6.5.3 Manufacturer’s Information Notice ...............................18
1.6.6 Fuel consumption ............................................................................19
1.6.7 Fuel contents cautions and warnings ..............................................19
1.6.8 Main rotor head and main rotor blades ...........................................20
1.6.9 Maintenance information .................................................................21
1.6.9.1 Fuel system indications ................................................23
1.6.9.2 Maintenance procedures ..............................................23
1.6.10 Weight and balance ........................................................................24
1.6.11 Night Vision Imaging Systems (NVIS).............................................24
1.7 Meteorological information ............................................................................25
1.7.1 General ...........................................................................................25
1.7.2 Actual weather reports ....................................................................25
1.7.2.1 Glasgow Airport ............................................................25
1.7.2.2 Edinburgh Airport ..........................................................25
1.7.3 Weather minima ..............................................................................26
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1.8 Aids to navigation ..........................................................................................26
1.8.1 Pilot’s equipment .............................................................................26
1.8.2 Police Observers’ equipment ..........................................................26
1.9 Communications ...........................................................................................27
1.10 Heliport information .......................................................................................27
1.11 Flight recorders .............................................................................................28
1.11.1 Radar ..............................................................................................28
1.11.2 CCTV ..............................................................................................29
1.11.3 ATC radio transmissions .................................................................29
1.11.4 Avionics ...........................................................................................29
1.11.4.1 Central Panel Display System ......................................29
1.11.4.2 Flight Control Display Module.......................................31
1.11.4.3 Warning Unit (WU) .......................................................32
1.11.4.4 Full Authority Digital Engine Control units ....................34
1.11.5 Role equipment ...............................................................................34
1.11.6 Fuel consumption ............................................................................35
1.11.7 Time line ..........................................................................................36
1.11.8 Flight recorders in aircraft ...............................................................37
1.11.8.1 Current requirements....................................................37
1.11.8.2 Previous AAIB investigations involving police aircraft ..40
1.11.8.3 Previous AAIB Safety Recommendations ....................40
1.11.8.4 Flight recorder technology ............................................43
1.11.8.5 ICAO Standards and Recommended Practices ...........43
1.11.8.5 EASA regulations..........................................................44
1.12 Wreckage and impact information ................................................................45
1.12.1 The accident site .............................................................................45
1.12.2 The helicopter .................................................................................45
1.12.3 The fuselage and landing gear .......................................................46
1.12.4 Fuel system examination ................................................................47
1.12.4.1 Fuel tank contents sensors...........................................47
1.12.4.2 Other fuel system components .....................................48
1.12.5 Engines and transmission ...............................................................48
1.12.6 Fuel metering units .........................................................................49
1.12.7 Main rotor head and main rotor blade examination ........................49
1.12.8 Flying controls .................................................................................51
1.12.9 Hydraulic pumps and reservoirs .....................................................51
1.12.10 Cabin heating and ventilation ..........................................................51
1.13 Medical and pathological information ............................................................52
1.14 Fire ................................................................................................................52
1.15 Crashworthiness ...........................................................................................52
1.15.1 EC135 crashworthiness ..................................................................52
1.16 Tests and research ........................................................................................53
1.16.1 Fuel .................................................................................................53
1.16.2 EC135 T2+, G-NWEM ....................................................................53
1.16.3 EC135 fuel system simulation and testing ......................................54
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1.16.4 Engine rundown simulation .............................................................57
1.16.5 Main transmission gear box oil pressure decay ..............................57
1.16.6 Helicopter pitch attitude modelling ..................................................57
1.16.7 Warning unit testing ........................................................................58
1.16.8 Flight and static trials ......................................................................58
1.16.8.1 Flight trials ....................................................................58
1.16.8.2 Static trials ....................................................................60
1.16.9 Manufacturer’s flight trials ...............................................................60
1.17 Organisational and management information ...............................................61
1.17.1 General ...........................................................................................61
1.17.2 Procedures ......................................................................................62
1.17.2.1 Police air operations .....................................................62
1.17.2.2 Police Observers ..........................................................62
1.17.2.3 Radio Altimeters ...........................................................63
1.17.2.4 Fuel policy ....................................................................64
1.17.2.5 Emergency landing and ditching ..................................65
1.17.2.6 Manufacturer’s flight reference cards ...........................65
1.17.3 Pilot training ....................................................................................66
1.17.3.1 Introduction ...................................................................66
1.17.3.2 Autorotation ..................................................................67
1.17.3.3 Fuel system ..................................................................68
1.18 Additional information ...................................................................................69
1.18.1 Police helicopter tasking .................................................................69
1.18.2 Previous events ..............................................................................70
1.18.2.1 Autorotations ................................................................70
1.18.2.2 Fuel pump switching errors ..........................................70
2 Analysis ................................................................................................................71
2.1 Operations ....................................................................................................71
2.1.1 The flight .........................................................................................71
2.1.2 Fuel system management ...............................................................76
2.1.3 Fuel policy .......................................................................................78
2.1.4 Training ...........................................................................................79
2.1.5 Double engine flameout ..................................................................79
2.1.5.1 Safety action .................................................................80
2.1.6 Autorotation .....................................................................................81
2.1.7 NVGs ..............................................................................................82
2.2 Engineering ...................................................................................................82
2.2.1 Introduction .....................................................................................82
2.2.2 Main and tail rotor system ...............................................................83
2.2.3 Engines ...........................................................................................83
2.2.4 Fuel Transfer System ......................................................................84
2.2.5 G-NWEM incident and subsequent tests ........................................84
2.2.6 Fuel contents indications ................................................................85
2.2.6.1 Erroneous indications ...................................................86
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2.2.7 Fuel pump switch positions .............................................................86
2.2.7.1 Prime pump switches ...................................................86
2.2.7.2 Fuel transfer pump switches.........................................87
2.2.8 Fuel consumption ............................................................................87
2.2.9 EC135 crashworthiness ..................................................................87
2.3 Flight recorders .............................................................................................88
2.4 Safety actions ...............................................................................................91
3 Conclusion ............................................................................................................94
(a) Findings ........................................................................................................94
(b) Causal Factors ..............................................................................................95
(c) Contributory factors .......................................................................................96
4 Safety Recommendations ...................................................................................97
4.1 Safety Recommendations .............................................................................97
4.2 Summary of safety actions ............................................................................99
Appendices
Appendix A: Extracts from the manufacturer’s flight reference cards
Appendix B: Airbus Helicopters Information Notice 2693-I-28, dated 5 March 2014
Appendix C: Eurocopter Information Notice 2535-I-28, dated 21 January 2013
Appendix D: Eurocopter Alert Service Bulletin EC135-28A-018
Appendix E: Eurocopter Alert Service Bulletin EC135-28A-019
Appendix F: Fuel Policy - extracts from the Police Air Operations Manual (PAOM),
Part 1 and the operator’s PAOM, Part 2 and Operations Manuals
Appendix G: Emergency landing and ditching - extracts from operator’s Operations
Manual
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