Norway AW101 accident report cites human, organizational factors

The Norwegian Accident Investigation Board (Statens havarikommisjon for Forsvaret – SHF) has highlighted the role of human and organizational factors in an incident in November 2017, when a AW101-612 rescue helicopter rolled over during start-up.

A Leonardo AW101 search-and-rescue helicopter owned by the Royal Norwegian Air Force rests on its side after a failed ground run on Sola Airport near Stavanger, Norway, Nov. 25, 2017.
A Leonardo AW101 search-and-rescue helicopter owned by the Royal Norwegian Air Force rests on its side after a failed ground run on Sola Airport near Stavanger, Norway, Nov. 25, 2017. Carina Johansen/AP Images Photo
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The incident occurred on Nov. 24, 2017. It involved the first Leonardo AW101 Norway had received, part of 16 helicopters intended to replace the Westland WS-61 Sea Kings in service with the Royal Norwegian Air Force (RNoAF).

The aircraft was being operated by the operational test and evaluation (OT&E) AW101 unit. Two pilots were seated in the helicopter when it rolled onto its right side outside a hangar at Sola air base, the SHF stated. While no one was injured in the incident, the platform suffered comprehensive damage.

According to the SHF, the incident occurred during a ground run of the helicopter’s engines following a compressor wash. The investigation showed that the collective was in a higher position than usual when the rotor was accelerated. This meant that “the rotor blades were at an angle of attack capable of producing a significant amount of lift,” the SHF stated. “Because the rotor was accelerated using two engines rather than one, it achieved full rotational speed. The combined forces from the main rotor and the tail rotor were sufficient to make the helicopter roll over.”

The report said that over time, ambitious timelines for the acquisition of the new rescue helicopters, combined with delays in the helicopters’ development, “created a situation of persistent time pressure for all parties involved.” This time pressure, as well as the ongoing development of the platform, the training aids and documentation, “caused challenges in regards to the training that pilots and other personnel from OT&E AW101 received from the provider.”

When combined with the fact that a number of the pilots lacked the experience and continuity that the training program was based on, this led to known and unknown shortcomings in the pilots’ skills and competencies after completing training, the report stated. “The constant demand for progress negatively affected quality assurance in various parts of the organization, and contributed to elevated and unidentified operational risk,” it added.

The report stated that no unknown or sudden technical malfunction contributed to the incident. It said that “a number of human and organizational factors contributed to the incident developing without anyone identifying or correcting the deviations,” such as shortcomings in the crew’s system knowledge and experience with the AW101-612, insufficient risk awareness, shortcomings in the training received, deviations from the checklist, and imprecise checklist wording.

The Leonardo AW101 was handed over to the Royal Norwegian Air Force just a week before the incident, and was still a month away from its official delivery ceremony. Leonardo Photo
The Leonardo AW101 was handed over to the Royal Norwegian Air Force just a week before the incident, and was still a month away from its official delivery ceremony. Leonardo Photo

After the incident, the RNoAF cancelled operations with the AW101 in Norway until further notice, and began an additional training program for OT&E AW101 personnel, the report said. Changes were made to the unit’s organization, including the addition of two new crews. Planned, complementary training was given by the helicopter provider, while the RNoAF “took measures to clarify and strengthen the role of the Air Force part of the project organization in shielding, supporting and supervising the activity of OT&E AW101.”

Additionally, the country’s Inspectorate of Air Operations gave increased priority to the AW101 by increasing staffing in the helicopter department and performing inspections of OT&E AW101.

The accident investigation board compiled a list of safety issues related to the incident and to the broader organization associated with the acquisition and operations of the AW101. It also made recommendations that could help improve safety in the armed forces, several of which have been addressed through the measures already taken.

There is still reason to consider additional measures for some recommendations, including — but not limited to — quality assurance of the technical documentation of the helicopter and the role of the defense sector in the project board, the report said.

Leonardo has yet to respond to a request from Vertical for comment.

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5 thoughts on “Norway AW101 accident report cites human, organizational factors

  1. Post accident, it seems these people are on the right track. Lack of “crew’s system knowledge, deviations from checklists, imprecise checklists” lead me to believe they had little chance of a successful transition on the pre-accident timeline. Notwithstanding a less than perfect checklist, who puts a finger on the start button without verifying collective, cyclic and pedal position? Apparently, that one failure caused this and the things they are correcting probably needing doing anyway. I’ll bet everyone involved with this unfortunate episode would have said…”yes, safety is job #1″. It plainly and simply wasn’t.

  2. Stable Door is NOW bolted ! !
    Basic skills – If for any reason the Collective is up, Maybe elastomerics ( I don’t know this type) then as soon as the Rotors are rotating ( Even slowly) the Collective can be pushed down, there were after all two pilots onboard.

  3. Interesting detail you can see on the first picture in the background and which seems not to be mentioned in the report: watch the windsock in the background, it seems to had significant wind and it seems that it came about 60 to 80 degrees from the left, certainly hence the non head wind direcion of the ship during start up contributed also to the flip over.

  4. We tend to forget the basics. A proper pre start check ensures all controls neural.
    Again, few helicopters are designed to have a static collective in little up position, which should be bought back to down after rotor starts.
    A complete casual attitude shown by both pilots while handling helicopters.
    All pilots of every unit must be briefed regarding this avoidable incident.

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