Pilot Debrief

BELL 429 near Georgetown, DE — 2016-07-11

Final reportERA16LA253
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Date
2016-07-11
Location
Georgetown, DE, USA
Airport
GED
Aircraft
BELL 429
Registration
N1SP
Category
Helicopter
Highest injury
Fatal
Fatalities
1
Phase of flight
Hover

Probable cause

The emergency response team's failure to ensure that the system operator was secured to the helicopter, which resulted in his fall during the recurrent rescue hoist training operation.

NTSB narrative

The purpose of the flight was for an emergency response team to complete recurrent rescue hoist training from the helicopter. The three-person team included a rescue specialist, a system operator, and a safety officer. Each crewmember needed to complete 3 evolutions in each position to complete the recurrent training. During an evolution, the system operator would be positioned on the helicopter's skid while the rescue specialist would be lowered from, then picked up and brought back into, the helicopter as it hovered about 100 ft above ground level. After three evolutions, the pilot would land the helicopter; the crew would rotate positions and restart the process. According to a rescue checklist, the security of each member's safety harness was checked before each takeoff. The accident flight was the seventh evolution of the day, and the first flight where the fatally-injured crewmember acted as the system operator. The safety officer and rescue specialist reported they checked and verified that the restraints were secure. The helicopter then lifted off the ground, moved to the practice area, and the system operator requested and was granted permission by the pilot to move to the helicopter skid. The system operator stepped onto the skid and fell from the helicopter. The pilot stated that throughout the accident sequence, the crew was not rushing while they completed the checklists. Examination of the system operator's equipment did not reveal any failures or malfunctions that would explain the fall. Additionally, examination of the tether to the helicopter did not reveal any abnormalities. In the absence of any equipment failure, it is likely that the system operator was not fastened to the helicopter.

Analysis

Primary failure mode
Human factors
First missed decision gate
System operator should not have moved to the skid without additional safety checks.

NTSB coding

Evidence available

  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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