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Las Palmas), on 30 March 2004 Technical Report A-016/2004 TECHNICAL REPORT A-016/2004 Accident of aircraft Eurocopter SA-365-N1, registration EC-GJE, in San Bartolomé de Tirajana (Las Palmas), on 30 March 2004 Technical report A-016/2004 Accident of aircraft Eurocopter SA-365-N1, registration EC-GJE, in San Bartolomé de Tirajana (Las Palmas) on 30 March 2004 SECRETARÍA GENERAL DE TRANSPORTES MINISTERIO DE FOMENTO COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Edita: Centro de Publicaciones Secretaría General Técnica Ministerio de Fomento © NIPO: 161-03-011-0 Depósito legal: M. 23.129-2003 Imprime: Centro de Publicaciones Diseño cubierta: Carmen G. Ayala COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Tel.: +34 91 597 89 60 E-mail: [email protected] C/ Fruela, 6 Fax: +34 91 463 55 35 http://www.mfom.es/ciaiac 28011 Madrid (España) Foreword This report 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 and its causes and consequences. In accordance with the provisions of Law 21/2003 and Annex 13 to the Con- vention on International Civil Aviation, the investigation has exclusively a technical nature, without having been targeted at the declaration or assign- ment of blame or liability. The investigation has been carried out without having necessarily used legal evidence procedures and with no other basic aim than preventing future accidents. Consequently, any use of this report for purposes other than that of preven- ting future accidents may lead to erroneous conclusions or interpretations. This report has originally been issued in Spanish language. This English trans- lation is provided for information purposes only. Technical report A-016/2004 Table of contents Abbreviations ................................................................................................................................ vii 1. Factual information ............................................................................................................... 1 1.1. History of the flight ........................................................................................................ 1 1.2. Injuries to persons .......................................................................................................... 7 1.3. Damage to aircraft ......................................................................................................... 7 1.4. Other damage ................................................................................................................7 1.5. Personnel information .................................................................................................... 7 1.5.1. Pilot in command .............................................................................................. 7 1.5.2. Medical personnel ............................................................................................. 8 1.6. Aircraft information ........................................................................................................9 1.6.1. Airframe ............................................................................................................ 9 1.6.2. Airworthiness certificate .................................................................................... 9 1.6.3. Airframe maintenance record ............................................................................ 9 1.6.4. Aircraft flight manual ........................................................................................ 10 1.7. Meteorological information ............................................................................................ 10 1.8. Aids to navigation ..........................................................................................................11 1.9. Communications ............................................................................................................ 11 1.10. Aerodrome information .................................................................................................. 11 1.11. Flight recorders .............................................................................................................. 11 1.12. Wreckage and impact information ................................................................................. 12 1.13. Medical and pathological information ............................................................................ 12 1.14. Fire ................................................................................................................................. 13 1.15. Survival aspects .............................................................................................................. 13 1.16. Tests and research .........................................................................................................13 1.16.1. Analysis of the engine sound .......................................................................... 13 1.16.2. Analysis of the manoeuvrability of the helicopter after the impact with the wires ............................................................................................................... 13 1.16.3. Statement of witnesses ................................................................................... 14 1.16.4. Geometry of the impact against the wires ...................................................... 14 1.17. Organizational and management information ................................................................ 18 1.17.1. Organization of the operator .......................................................................... 18 1.17.2. Organization of the emergency coordination services of the Canary Islands ... 20 1.18. Additional information ................................................................................................... 21 1.18.1. Wire strike avoidance systems ......................................................................... 21 1.18.2. Provisions of JAR-OPS 3 regarding HEMS operations ...................................... 22 1.18.3. Requirements of the DGAC regarding HEMS operations ................................ 23 1.18.4. Regulations regarding activity and rest periods ............................................... 23 1.19. Useful or effective investigation techniques ................................................................... 23 2. Analysis .................................................................................................................................. 25 2.1. General .......................................................................................................................... 25 2.2. Emergency services coordination .................................................................................... 25 2.3. Preflight planning ........................................................................................................... 26 v Technical report A-016/2004 2.4. Selection of the landing area ......................................................................................... 26 2.5. Activities of the pilot on the ground .............................................................................. 27 2.6. Takeoff manoeuvre ........................................................................................................ 28 2.7. Visibility of the power line ............................................................................................. 29 2.8. Manoeuvring after the blade impact .............................................................................. 29 2.9. Structural behaviour of the aircraft ................................................................................ 31 2.10. Possible causes of the memory lapse ............................................................................. 32 2.10.1. Medical factors ................................................................................................ 32 2.10.2. Fatigue factors ................................................................................................ 32 2.11. Discussion of possible accident prevention measures ..................................................... 33 2.11.1. General ........................................................................................................... 33 2.11.2. Prevention of impact against wires ................................................................. 33 2.11.3. Measures after an impact with wires .............................................................. 35 3. Conclusions ............................................................................................................................ 37 3.1. Findings .......................................................................................................................... 37 3.2. Causes ........................................................................................................................... 37 4. Safety recommendations ...................................................................................................... 39 Appendices .................................................................................................................................... 41 Appendix A. Photographs ........................................................................................................ 43 Appendix B. Time table of the activity of helicopters in the area of the bus accident ............ 47 vi Technical report A-016/2004
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