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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.
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.
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.