Report on the Air Accident Near Turøy 29 April 2016 with Airbus
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Issued July 2018 REPORT SL 2018/04 REPORT ON THE AIR ACCIDENT NEAR TURØY, ØYGARDEN MUNICIPALITY, HORDALAND COUNTY, NORWAY 29 APRIL 2016 WITH AIRBUS HELICOPTERS EC 225 LP, LN-OJF, OPERATED BY CHC HELIKOPTER SERVICE AS The Accident Investigation Board has compiled this report for the sole purpose of improving flight safety. The object of any investigation is to identify faults or discrepancies which may endanger flight safety, whether or not these are causal factors in the accident, and to make safety recommendations. It is not the Board's task to apportion blame or liability. Use of this report for any other purpose than for flight safety shall be avoided. Accident Investigation Board Norway • P.O. Box 213, N-2001 Lillestrøm, Norway • Phone: + 47 63 89 63 00 • Fax: + 47 63 89 63 01 www.aibn.no • [email protected] Photos: AIBN and Trond Isaksen/OSL Accident Investigation Board Norway Page 2 INDEX NOTIFICATION ................................................................................................................................. 3 SUMMARY ......................................................................................................................................... 4 1. FACTUAL INFORMATION .............................................................................................. 6 1.1 History of the flight .............................................................................................................. 6 1.2 Injuries to persons ................................................................................................................ 9 1.3 Damage to aircraft ................................................................................................................ 9 1.4 Other damage ....................................................................................................................... 9 1.5 Personnel information .......................................................................................................... 9 1.6 Aircraft information ........................................................................................................... 10 1.7 Meteorological information ............................................................................................... 33 1.8 Aids to navigation .............................................................................................................. 34 1.9 Communications ................................................................................................................ 35 1.10 Aerodrome information ..................................................................................................... 36 1.11 Flight recorders .................................................................................................................. 36 1.12 The accident site and wreckage information ..................................................................... 43 1.13 Medical and pathological information ............................................................................... 52 1.14 Fire ..................................................................................................................................... 52 1.15 Survival aspects ................................................................................................................. 53 1.16 Tests and research .............................................................................................................. 53 1.17 Organisational and management information .................................................................... 86 1.18 Additional information ..................................................................................................... 101 1.19 Useful or effective investigation techniques .................................................................... 118 2. ANALYSIS ...................................................................................................................... 120 2.1 Introduction ...................................................................................................................... 120 2.2 The accident sequence ..................................................................................................... 121 2.3 Failure mode investigation ............................................................................................... 123 2.4 The fatigue cracks in the second stage planet gear .......................................................... 124 2.5 No warnings of the impending failure ............................................................................. 126 2.6 Possible initiation and contributing factors ...................................................................... 128 2.7 Maintenance history ......................................................................................................... 134 2.8 The G-REDL accident – comparison and follow-up ....................................................... 137 2.9 Certification review ......................................................................................................... 142 2.10 Current design criteria for large rotorcraft ....................................................................... 144 2.11 Continued airworthiness .................................................................................................. 147 2.12 Means of monitoring and further research ....................................................................... 150 2.13 Accident data availability ................................................................................................ 151 2.14 Safety actions following the LN-OJF accident ................................................................ 153 3. CONCLUSIONS .............................................................................................................. 157 3.1 Main conclusion ............................................................................................................... 157 3.2 Findings ............................................................................................................................ 157 4. SAFETY RECOMMENDATIONS ................................................................................. 165 REFERENCES................................................................................................................................. 169 APPENDICES ................................................................................................................................. 171 Accident Investigation Board Norway Page 3 AIR ACCIDENT REPORT Type of aircraft: Airbus Helicopters EC 225 LP Super Puma Nationality and registration: Norwegian, LN-OJF Owner: Parilease, Paris, France Operator: CHC Helikopter Service AS, Norway Crew: 2, both fatally injured Passengers: 11, all fatally injured Accident site: Storeskitholmen near Turøy, Øygarden municipality, Hordaland county, Norway (60° 27.137 N 004° 55.835 E) Accident time: Friday 29 April 2016 at 1155 hours All times given in this report are local time (UTC + 2), if not otherwise stated. NOTIFICATION The Accident Investigation Board Norway (AIBN) was notified by the Joint Rescue Coordination Centre for Southern Norway at 1200 hours. The first message received was that a helicopter had lost its main rotor near Turøy, and fire and smoke on the ground were observed. Preparations to dispatch a team was initiated immediately. The first team of investigators from the AIBN was at the scene at 1850 hours. In accordance with International Civil Aviation Organisation (ICAO) Annex 13, the Bureau d’Enquêtes et d’Analyses pour la Sécurité de l'Aviation Civile (BEA) in France was notified as the State of design and the State of manufacture. The BEA appointed an Accredited Representative to lead a team of investigators from the BEA and advisors from Airbus Helicopters (the designer and manufacturer) and Safran Helicopter Engines1. In accordance with Regulation (EU) No 996/2010, the European Aviation Safety Agency (EASA), the Regulator responsible for the certification and continued airworthiness of the helicopter, was notified of the accident and participated as advisor to the AIBN. The Norwegian Civil Aviation Authority (CAA-N), the operator CHC Helikopter Service AS and the Norwegian Defence Laboratories (NDL) at Kjeller were also advisors and part of the team. The Air Accidents Investigation Branch in the UK (AAIB) together with the metallurgical laboratory at QinetiQ, Farnborough in UK had relevant experience from the investigation of the helicopter accident off the coast of Scotland in 2009 with an Airbus Helicopters AS 332 L2, G- REDL. For that reason they were asked to assist during the investigation. The AAIB appointed an Accredited Representative and advisors from QinetiQ as part of the team. Later, the Bundesstelle für Flugunfalluntersuchung (BFU) in Germany was notified as the State of manufacture of an essential component. 1 Formerly Turbomeca Accident Investigation Board Norway Page 4 SUMMARY The accident with LN-OJF On 29 April 2016 the main rotor suddenly detached from an Airbus Helicopters EC 225 LP Super Puma, operated by CHC Helikopter Service AS. The helicopter transported oil workers for Statoil ASA and was en route from the Gullfaks B platform in the North Sea to Bergen Airport Flesland. The helicopter had just descended from 3,000 ft and had been established in cruise at 140 kt at 2,000 ft for about one minute. The flight was normal and the crew received no warnings before the main rotor