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Main Rotor Blade, Bim Warning Trouble Shooting» CIAIACCIAIAC COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Report A-037/2006 Accident involving a SIKORSKY S-61N helicopter, registration EC-FJJ, on 8 July 2006, in Roque Bermejo (Tenerife – Canary Islands – Spain) Report A-037/2006 Accident involving a SIKORSKY S-61N, registration EC-FJJ, on 8 July 2006, in Roque Bermejo (Tenerife – Canary Islands – Spain) SECRETARÍA DE ESTADO DE TRANSPORTES COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Edita: Centro de Publicaciones Secretaría General Técnica Ministerio de Fomento © NIPO: 161-11-071-3 Depósito legal: M. 23.129-2003 Diseño y maquetación: Phoenix comunicación gráfica, S. L. COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Tel.: +34 91 597 89 63 E-mail: [email protected] C/ Fruela, 6 Fax: +34 91 463 55 35 http://www.ciaiac.es 28011 Madrid (España) Foreword This Bulletin is a technical document that reflects the point of view of the Civil Aviation Accident and Incident Investigation Commission (CIAIAC) regarding the circumstances of the accident object of the investigation, and its probable causes and consequences. In accordance with the provisions in Article 5.4.1 of Annex 13 of the International Civil Aviation Convention; and with articles 5.5 of Regulation (UE) n° 996/2010, of the European Parliament and the Council, of 20 October 2010; Article 15 of Law 21/2003 on Air Safety and articles 1, 4 and 21.2 of Regulation 389/1998, this investigation is exclusively of a technical nature, and its objective is the prevention of future civil aviation accidents and incidents by issuing, if necessary, safety recommendations to prevent from their reoccurrence. The investigation is not pointed to establish blame or liability whatsoever, and it’s not prejudging the possible decision taken by the judicial authorities. Therefore, and according to above norms and regulations, the investigation was carried out using procedures not necessarily subject to the guarantees and rights usually used for the evidences in a judicial process. Consequently, any use of this Bulletin for purposes other than that of preventing future accidents may lead to erroneous conclusions or interpretations. This Bulletin was originally issued in Spanish. This English translation is provided for information purposes only. Report A-037/2006 Table of contents Abbreviations ................................................................................................................................ viii Synopsis ......................................................................................................................................... xi 1. Factual information ............................................................................................................... 1 1.1. History of the flight ........................................................................................................ 1 1.2. Injuries to persons .......................................................................................................... 2 1.3. Damage to aircraft .........................................................................................................2 1.4. Other damage ................................................................................................................ 2 1.5. Personnel information .................................................................................................... 2 1.5.1. Pilot in command .............................................................................................. 2 1.5.2. F/O .................................................................................................................... 3 1.5.3. Aircraft Maintenance Technician (TMA as per Spanish abbreviations - Mechanic). 3 1.6. Aircraft information ........................................................................................................ 4 1.6.1. Airframe ............................................................................................................ 4 1.6.2. Airworthiness certificate.................................................................................... 5 1.6.3. Maintenance record .......................................................................................... 5 1.6.4. Engines ............................................................................................................. 7 1.6.5. Main rotor blades ............................................................................................. 8 1.6.6. Main rotor characteristics .................................................................................. 8 1.7. Meteorological information ............................................................................................ 9 1.7.1. Information provided to the crew ..................................................................... 9 1.7.2. Prevailing conditions .......................................................................................... 9 1.8. Aids to navigation .......................................................................................................... 10 1.9. Communications ............................................................................................................ 10 1.9.1. Communications with the La Palma Airport Control Tower .............................. 10 1.9.2. Communications with the Canaries Area Control Center ................................. 11 1.9.3. Communications with Tenerife North Airport Approach Control ...................... 11 1.10. Aerodrome information .................................................................................................. 11 1.11. Flight recorders .............................................................................................................. 11 1.11.1. Cockpit Voice Recorder (CVR) ......................................................................... 11 1.12. Wreckage and impact information ................................................................................. 14 1.12.1. Helicopter debris found and recovered ........................................................... 14 1.12.2. Impact of the helicopter with the water ......................................................... 18 1.13. Medical and pathological information ............................................................................ 18 1.13.1. Pilot in Command ........................................................................................... 18 1.13.2. Passengers ....................................................................................................... 18 1.14. Fire ................................................................................................................................. 18 1.15. Survival aspects .............................................................................................................. 19 1.15.1. Search and rescue ........................................................................................... 19 1.15.2. Survival aspects............................................................................................... 22 1.16. Tests and research ......................................................................................................... 22 1.16.1. Inspection of aircraft wreckage ....................................................................... 22 1.16.2. Study of the fracture area in the main rotor “black” blade ........................... 23 1.16.3. Detachment of the “black” blade from the main rotor head ......................... 29 v Report A-037/2006 1.16.4. Radar trace..................................................................................................... 29 1.17. Organizational and management information ................................................................ 30 1.17.1. The aircraft operator ....................................................................................... 30 1.17.2. Operational organization................................................................................. 31 1.17.3. The Maintenance organization ........................................................................ 41 1.17.4. The operating bases ........................................................................................ 46 1.18. Additional information ................................................................................................... 47 1.18.1. History of the “black” blade and VBIM/CBIM warnings .................................. 47 1.18.2. BIM warnings caused by cracks in blades. Manufacturer’s records ................. 51 1.18.3. Helicopter Flight Manual ................................................................................. 51 1.18.4. Helicopter Maintenance Manual ..................................................................... 53 1.18.5. Handling of malfunctions by operator ............................................................ 56 1.18.6. Airworthiness considerations........................................................................... 58 1.18.7. Eyewitness statements..................................................................................... 60 1.19. Useful or effective investigation techniques ................................................................... 61 2. Analysis .................................................................................................................................. 63 2.1. Events of the flight ........................................................................................................63
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