Tue, Mar 22, 2005
Canada's TSB has
released its final report on the Eurocopter AS 350 B2 helicopter
accident of January 21, 2003 in Mekatina, Ontario.
The helicopter, after experiencing a hydraulic system failure,
departed controlled flight and crashed while manoeuvring for
landing at a logging site in Mekatina. Before the incident, the
pilot and three passengers on board the helicopter were conducting
a moose survey approximately 45 nautical miles northeast of Sault
Ste. Marie, Ontario. The pilot and three passengers, all employees
of the Ministry of Natural Resources of Ontario, were killed.
The TSB found that it is likely that the hydraulic pump belt
failed in flight, causing the hydraulic failure. Examination of the
failed belt and other similar unbroken belts from other helicopters
revealed extensive cracking in the same location. Without proper
control of the helicopter, the forces encountered by the pilot
during the turn at low altitude may have been too extreme to
overcome.
As safety deficiencies
were uncovered by the TSB during its investigation, these were
immediately made known to industry and regulators so they could be
addressed as quickly as possible.
In response to the TSB findings in this investigation, many
safety actions were taken by Transport Canada and by the Direction
Generale de l'Aviation Civile:
- In early to mid-2003, Transport Canada issued two Airworthiness
Directives to advise all AS 350 helicopter operators to complete a
pre-flight check prior to every flight to ensure the proper
functioning of the hydraulic pressure and helicopter controls. It
was also specified that, in case of hydraulic failure, the aircraft
is to be landed as soon as possible.
- On October 22, 2003 the TSB issued to Transport Canada an
Aviation Safety Advisory to address the extensive cracking
deficiency on the hydraulic pump drive belt. Although the belt
manufacturer had produced a modification that incorporates a Poly-V
design drive belt, numerous operators still continued to operate
the helicopter with the belt used in this accident. On April 22,
2004 Transport Canada issued an Airworthiness Directive mandating
the replacement, by September 30, 2004, of the old belt.
After extreme cold weather testing at Inuvik, Northwest
Territories, the Direction Generale de l'Aviation Civile:
- made changes to the Rotorcraft Flight Manual concerning its
emergency procedures, the hydraulic system description and training
procedures;
- made the required modifications to the hydraulic bypass system
to reduce residual pressure to an acceptable level; and
- issued in April 2004 an Airworthiness Directive to require
hydraulic fluid to be replaced when exposed to temperatures below
-15C.
No recommendations have been issued by the TSB because the
industry and regulators have acted swiftly to address safety
deficiencies when identified during the course of the
investigation. This is considered a success, as the TSB's goal is
to advance transportation safety and to ensure that similar
accidents do not recur.
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