Report on the Accident to AS332 L2 Super Puma Helicopter, G-WNSB on Approach to Sumburgh Airport on 23 August 2013
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AIRCRAFT ACCIDENT REPORT 1/2016 AAir AccidentsA InvestigationIB Branch Report on the accident to AS332 L2 Super Puma helicopter, G-WNSB on approach to Sumburgh Airport on 23 August 2013 AIRCRAFT ACCIDENT REPORT 1/2016 Air Accidents Investigation Branch Report on the accident to AS332 L2 Super Puma helicopter, G-WNSB on approach to Sumburgh Airport on 23 August 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 2016 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 15 March 2016 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 February 2016 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 AS332 L2 Super Puma helicopter, registration G-WNSB, on approach to Sumburgh Airport on 23 August 2013. Yours sincerely Keith Conradi Chief Inspector of Air Accidents © Crown Copyright 2016 iii Air Accident Report: 1/2016 G-WNSB EW/C2013/08/03 Contents Introduction ...................................................................................................................... 1 Summary .......................................................................................................................... 2 1 Factual information ................................................................................................ 5 1.1 History of the flight .......................................................................................... 5 1.1.1 Background ....................................................................................... 5 1.1.2 Pre-flight planning ............................................................................. 5 1.1.3 First two sectors ................................................................................ 6 1.1.4 Accident sector ................................................................................. 7 1.2 Injuries to persons ......................................................................................... 12 1.3 Damage to aircraft ........................................................................................ 12 1.4 Other damage ............................................................................................... 13 1.5 Personnel information .................................................................................. 13 1.5.1 Commander .................................................................................... 13 1.5.2 Co-pilot ............................................................................................ 13 1.5.3 Crew background, training, experience and duty time .................... 14 1.5.3.1 Commander .................................................................. 14 1.5.3.2 Co-pilot ......................................................................... 14 1.5.4 Training and checking ..................................................................... 15 1.5.4.1 Simulator training.......................................................... 15 1.5.4.2 Sea survival training ..................................................... 16 1.5.5 Flight crew interviews ...................................................................... 16 1.5.6 Air Traffic Control personnel ........................................................... 17 1.6 Aircraft information ........................................................................................ 17 1.6.1 General ........................................................................................... 17 1.6.2 Aircraft description .......................................................................... 17 1.6.3 Integrated Flight and Display System (IFDS) .................................. 18 1.6.3.1 Smart Multifunction Display .......................................... 18 1.6.3.2 Primary Flight Display (PFD) ........................................ 19 1.6.3.3 Navigation and Mission Display (NMD) ........................ 19 1.6.3.4 Automatic Flight Control System (AFCS) ..................... 20 1.6.3.5 Electrical trim actuators ................................................ 22 1.6.4 IFDS system test ............................................................................. 23 1.6.5 Helicopter emergency equipment ................................................... 23 1.6.5.1 Crash Position Indicator (CPI) ...................................... 23 1.6.5.2 Liferafts ......................................................................... 24 1.6.5.3 Aircraft exits .................................................................. 26 1.6.5.4 Flotation equipment ...................................................... 27 © Crown Copyright 2016 v Contents Air Accident Report: 1/2016 G-WNSB EW/C2013/08/03 1.6.6 Maintenance information ................................................................. 28 1.6.6.1 Deferred defects ........................................................... 28 1.6.6.2 Maintenance history ..................................................... 28 1.6.7 AS 332 L2 IFR operating limitations ............................................... 28 1.7 Meteorological information ............................................................................ 29 1.7.1 Synoptic situation ............................................................................ 29 1.7.2 Sumburgh forecasts ........................................................................ 29 1.7.3 Aftercast .......................................................................................... 29 1.7.4 Sumburgh actual weather reports ................................................... 30 1.7.5 Automatic Terminal Information Service (ATIS) .............................. 30 1.7.6 Other airports in the region ............................................................. 31 1.7.7 Departure airport ............................................................................. 31 1.7.8 Sea surface conditions .................................................................... 31 1.8 Aids to navigation .......................................................................................... 32 1.8.1 Ground-based navigation aids ........................................................ 32 1.8.2 Helicopter navigation aids ............................................................... 32 1.9 Communications ........................................................................................... 32 1.10 Aerodrome information ................................................................................. 33 1.10.1 Sumburgh Airport ............................................................................ 33 1.10.2 Alternate airport, Scatsta ................................................................ 33 1.10.3 Other airports in the region ............................................................. 33 1.11 Flight recorders ............................................................................................. 34 1.11.1 Introduction ..................................................................................... 34 1.11.2 Additional sources of recorded information ..................................... 34 1.11.3 Approach to Alwyn North platform .................................................. 35 1.11.4 Accident sector ............................................................................... 35 1.11.5 Commander’s reference to speed and CVFDR parameter validity ... 39 1.12 Wreckage and impact information ................................................................ 40 1.12.1 General ........................................................................................... 40 1.12.2 Initial wreckage examination ........................................................... 41 1.12.3 Recovered fault code data .............................................................. 42 1.12.4 Review of helicopter performance .................................................. 42 1.13 Medical and pathological information ............................................................ 43 1.13.1 Deceased ........................................................................................ 43 1.13.2 Survivors ......................................................................................... 44 1.14 Fire ...............................................................................................................