Accident to the Airbus EC135 registered F-HJAF on 08/12/2020 at Bonvillard
Collision avec la végétation au retour d'un vol d'instruction à l'hélitreuillage de nuit
On 8 December 2020, the flight schedule for the EC135 registered F-HJAF, operated by SAF HELICOPTERS involved six training flights: two morning flights, two afternoon flights and two night flights. This training was carried out in the scope of a specific approval for commercial air transport hoist operations (SPA.HHO).
At the end of the afternoon, the two crews held a briefing before the two night flights. The review of the weather forecast had revealed that there would be a disturbance bringing snow in the evening. Given the arrival of this disturbance, the very short exercise programme (three hoist operations) and the proximity of the exercise site (situated at 3.2 NM south-east of the aerodrome at an altitude of 1,820 m), all the persons concerned took the decision to carry out the two flights one after the other and to switch crews with the rotor turning at the end of the first night flight.
For these two night flights, the crew on board was made up of an instructor pilot, a pilot in instruction, an instructor hoist operator, a hoist operator in training and two rescuers who were taking part in the hoist operations.
After the first night flight, the first crew (pilot in instruction and hoist operator in training) was replaced by the second pair. The instructor pilot, the instructor hoist operator and the two rescuers remained on board during this switch over.
The second pilot in instruction took off at 17:00 from Albertville aerodrome bound for the exercise site. Having arrived at the area, the pilot carried out the same exercises as during the
previous flight.
Upon completion of the exercises, the pilot flew out of the hover and gained speed on a heading roughly oriented north-west and then initiated a left turn while remaining in level flight. The helicopter headed towards the mountainside, collided with the vegetation, and then with
the ground.
The BEA has issued two safety recommendations to SAF HELICOPTERES.
The BEA issues 2 safety recommendations:
- Recommendations FRAN-2022-017 and FRAN-2022-018 / Safety management for new operations
When the civil aviation authorities grant an approval for an activity, this means that, through the setting up of tailored procedures, the operator was able to demonstrate both its ability to meet the regulatory requirements (traceability, tracking, airworthiness, crew competencies, etc.), and that the procedures put in place ensure a sufficient level of safety for its operations.
However, the investigation showed that SAF HELICOPTERES had not clearly defined the operational objectives underlying its wish to obtain the specific approval for the use of hoists in commercial air transport (SPA.HHO), in particular the SPA.HHO “night” approval. The lack of precision concerning the operational context envisaged after obtaining the SPA.HHO approval raises the question as to the basis on which SAF HELICOPTERES:
- carried out the safety impact assessment for the SPA.HHO approval;
- defined the associated training and determined that the pilots in training had enough experience - in particular night flight experience - for them to follow this training.
As an example, SAF HELICOPTERES specified to the BEA during the investigation that the operational objective was to be able to finish mountain rescue operations started at the end of the day, after nightfall. There were no plans to initiate helicopter hoist operations at night. This operations restriction, which SAF HELICOPTERES indicated it wanted to impose on itself, was not clearly mentioned in the company's Operations Manual (OM). While the first flight carried out on the day of the accident at nightfall could fall into this operational framework, the second flight carried out when the night was fully established, with no moon, introduced additional difficulties which went beyond the operational framework mentioned by the instructor and by SAF HELICOPTERES.
The risk map drawn up by SAF HELICOPTERES seems to show that the safety impact assessment:
- Was not taken as an opportunity to explore the risk factors specific to both night and mountain operations.
- Focused nearly exclusively on the hoist operation phase which characterises SPA.HHO operations, without explicitly addressing the arrival at and departure phases from the mission site, which involves forward flight close to the terrain.
- Did not include a section specific to training flights undertaken as part of this
SPA.HHO approval.
The risk analysis was not extended beyond the map. The expected scope of the barriers listed in this map was not specified either.
When the helicopter collided with the terrain, the hoist exercise had ended, and the pilot in training was expected to head back to the aerodrome. From this point of view, it could be considered that the accident does not correspond to a risk specific to the SPA.HHO approval. Nevertheless, the accident brought to light two risk factors specifically related to the context of the SPA.HHO training programme:
- Flight in direct proximity with the terrain, in a mountainous area and at night, in natural light conditions in which it was not possible to distinguish close obstacles, constituting an environment for which the experience of the pilot in training was probably overestimated.
- A flight which combined pilot training and hoist operator training, i.e. a context likely to increase the number of unforeseen events, the points requiring attention and the needs for coordination between the cockpit and the rear section of the helicopter.
These specific risk factors had not been anticipated by SAF HELICOPTERES in the safety impact assessment carried out to obtain the SPA.HHO approval.
In particular, the brightness of the night (light night or dark night) was not a decisional and limiting criterion for night flight in a mountainous region in immediate proximity with the terrain.
Consequently, the BEA recommends that:
- SAF HELICOPTERES define the operational context and limits of the day and night mountain rescue flights (including or not helicopter hoist operations) in order to carry out the safety impact assessment for these operations and to determine the associated training and experience criteria. [Recommendation FRAN-2022-017].
- SAF HELICOPTERES ensure that the operational context and limits of all its flights are defined in order to carry out an appropriate risk analysis. [Recommendation FRAN-2022-018]..
The recommendations are being processed
The status of the recommendations is available at SRIS2: click here
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Note: in accordance with the provisions of Article 17.3 of Regulation No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation, a safety recommendation in no case creates a presumption of fault or liability in an accident, serious incident or incident. The recipients of safety recommendations report to the issuing authority in charge of safety investigations, on the measures taken or being studied for their implementation, as provided for in Article 18 of the aforementioned regulation.