doi fy 05 aviation mishaps - u.s. department of the … delta junction, ak july 6, 2005 delta...
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5 Aircraft Accidents5 Aircraft Accidents
9 Incidents with Potential9 Incidents
with Potential
DOI FY 05 Aviation MishapsDOI FY 05 Aviation Mishaps
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NTSB 831.13 Flow and dissemination of accident or incident information.
(b) … Parties to the investigation may relay to their respective organizations information necessary for purposes of prevention or remedial action.
… However, no (release of) information… without prior consultation and approval of the NTSB.
This is PRELIMINARY information, and is provided for accident prevention purposes only
This is PRELIMINARY information, and is provided for accident prevention purposes only
Ground RulesGround RulesDOI FY 05 Aviation MishapsDOI FY 05 Aviation Mishaps
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Talkeetna, AKApril 15, 2005
Talkeetna, AKApril 15, 2005
DeHavilland DHC-2Beaver
(wheel/ski)MissionPassenger and cargo transport
DamageSubstantial
Injuries2 minor
ProcurementARA
NTSB IDANC05LA058
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IssuesUnnecessary
risk taking
High risk pilot
Maintenance inspection
Pre-mission briefing
Wreckage preservation
Talkeetna, AKApril 15, 2005
Talkeetna, AKApril 15, 2005
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DeHavilland DHC-2Beaver
(wheel/ski)MissionPassenger and cargo transport
DamageSubstantial
Injuries2 minor
ProcurementARA
NTSB IDANC05LA058
Talkeetna, AKApril 15, 2005
Talkeetna, AKApril 15, 2005
After landing on the Ruth Glacier, Denali National Park, the pilot taxied outside of the normal maneuver area to drop cargo in a convenient location.
While taxiing, the aircraft approached and attempted to clear a crevasse.
However, the aircraft sustained substantial damage while attempting to jump the crevasse.
Two NPS passengers received minor injuries.
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Ruth Glacier landing area
Normal landing area
Normal landing area
Normal parking
area
Normal parking
area
Normal takeoff
area
Normal takeoff
area
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Ruth Glacier landing area
Approximate touchdown areaApproximate
touchdown area
“We’ve got a big hole in
front of us”
“We’ve got a big hole in
front of us”
Intended drop off
point
Intended drop off
point
Tail started to
slide downhill
Tail started to
slide downhill
and ground pathand ground path
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Intended drop off
point
Intended drop off
point
Tail started to
slide downhill
Tail started to
slide downhill
Two large campsite
holes(5’x5’x5’)
Two large campsite
holes(5’x5’x5’)
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Crevasse
Direction of travel
Approximately 50 feet
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Crevasse
Nearly invisible due to the slope
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Damage to wing, gear, and frame
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Injury to rear seat passenger due to lack of shoulder harness and FAA authorized modification to the
front seat.
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NTSB Probable CauseTalkeetna, AK, April 15, 2005NTSB Probable Cause
Talkeetna, AK, April 15, 2005
Probable CauseThe NationalTransportation Safety
the probable cause ofBoard determined that
this accident was …
“The pilot's selection of unsuitable terrain for taxi after landing, which resulted in the collapse of the main landing gear and structural damage to the right wing and forward fuselage. A factor associated with the accident was the rough and uneven terrain.”
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Issues
NBC AMD ObservationsTalkeetna, AK, April 15, 2005NBC AMD ObservationsTalkeetna, AK, April 15, 2005
- Conduct a more thorough background check to identify high-risk pilots
- Conduct a more thorough maintenance check to identify issues such as seats, that although technically legal, are unnecessarily dangerous
Corrective Actions/Options
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Issues
NBC AMD ObservationsTalkeetna, AK, April 15, 2005NBC AMD ObservationsTalkeetna, AK, April 15, 2005
- Improve wreckage preservation after an aircraft accident / incident
- Conduct a more thorough pre-mission briefing to improve communications and reduced risk
Corrective Actions/Options
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Delta Junction, AKJuly 6, 2005
Delta Junction, AKJuly 6, 2005
Cessna A185F(wheel)
MissionCargo transport
DamageSubstantial
InjuriesN/A
ProcurementFleet
NTSB IDANC05TA106
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Delta Junction, AKJuly 6, 2005
Delta Junction, AKJuly 6, 2005
IssuesUnnecessary
risk taking
Go in light before you go in heavy
Pre-use inspection of landing areas
Medium risk syndrome
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Delta Junction, AKJuly 6, 2005
Delta Junction, AKJuly 6, 2005
Cessna A185F(wheel)
MissionCargo transport
DamageSubstantial
InjuriesN/A
ProcurementFleet
NTSB IDANC05TA106
While ferrying a 55 gallon drum of jet fuel into an unprepared landing strip the aircraft’s tail wheel struck the ground approximately 53 feet short of the landing area.
The aircraft became airborne for approximately 75 feet before the main gear touched down on the landing strip. Shortly thereafter the propeller impacted the runway.
The pilot was not injured, but the aircraft received substantial damage.
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Last Chance Strip
N64 ° 23’ 49”W144° 16’ 48”
2,300’ MSL
32/14 1000’ x 16’
Gravel
Primarily a one-way strip due to 2-3 ° upslope (140 °)
The narrow valley makes going around,
especially at high gross weight,
impossible
Airstrip is not maintained
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Final approach at approximately 100’ AGL
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Initial tail wheel impact approximately 53’ prior to the cleared area
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Rut where right main gear touched down with rain shower in background
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Area where right main gear went into brush
Area of propeller strikes
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Right main gear track
Brush impacted by right horizontal
stabilizer
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Horizontal Stabilizer (inverted)
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Scratch marks on the underside of right-hand horizontal stabilizer
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Wrinkling under a fairing at the inboard end of the right-hand horizontal stabilizer
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Inboard view of the crack rack to the inboard right-hand rib of the horizontal stabilizer
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Fuselage damage caused by left horizontal stabilizer and hidden under a fairing
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Interior view of damage to aft tailboom bulkhead
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NTSB Probable CauseDelta Junction AK, July 6, 2005
NTSB Probable CauseDelta Junction AK, July 6, 2005
Probable CauseThe NationalTransportation Safety
the probable cause of“The pilot misjudged distance /Board determined that
this accident was …altitude during the landing touchdown and subsequent undershoot, and his failure tomaintain directional control ofthe airplane during the landingroll, which resulted in an on-ground encounter with highvegetation.”
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Discussion
NBC AMD ObservationsDelta Junction, AK, July 6, 2005
NBC AMD ObservationsDelta Junction, AK, July 6, 2005
Corrective Actions/Options - Pre-season inspection of
high-risk landing areas --Thorough, documented inspection using a checklist, with results available for pilot briefingsConducted by an aviation specialist
Discrepancies repaired or marked depending on risk assessment
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Discussion
NBC AMD ObservationsDelta Junction, AK, July 6, 2005
NBC AMD ObservationsDelta Junction, AK, July 6, 2005
- Pilots should routinely make a practice approach and landing at low gross weights before taking loads into unfamiliar remote or unprepared landing areas
- Landings at locations where it is impossible to conduct a safe –go-around should not be considered routine
Corrective Actions/Options
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Hughes 500D
MissionCadastral Survey
DamageSubstantial
InjuriesN/A
ProcurementExclusive Use
NTSB IDANC05TA111
Delta Junction, AKJuly 28, 2005
Delta Junction, AKJuly 28, 2005
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Delta Junction, AKJuly 28, 2005
Delta Junction, AKJuly 28, 2005
IssuesUnnecessary
risk taking
Land as soon as possible after suspected damage
Safety training for ground personnel
Remote fuel site monitoring and maintenance
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Hughes 500D
MissionCadastral Survey
DamageSubstantial
InjuriesN/A
ProcurementExclusive Use
NTSB IDANC05TA111
During a cadastral survey, the pilot of the aircraft struck the top of a Black Spruce tree while attempting an approach into a confined area to pick up two passengers.
All five of the main rotor blades received damage.
Delta Junction, AKJuly 28, 2005
Delta Junction, AKJuly 28, 2005
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Landing Direction
15°-20° Upslope
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Impact tree
Landing Direction
45’
35’ 60’
Approximate position of survey crew
NOTE: MD-500 main rotor diameter is 26’4”
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Tree Marks
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NTSB Probable CauseDelta Junction AK, July 28, 2005
NTSB Probable CauseDelta Junction AK, July 28, 2005
Probable CauseThe NationalTransportation Safety
the probable cause of“The pilot's failure to maintain clearance from trees during the approach to landing, which resulted in the main rotor blades striking a tree. A factor associated with the accident was the tree.”
Board determined that
this accident was …
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Discussion
NBC AMD ObservationsDelta Junction, AK July 28, 2005
NBC AMD ObservationsDelta Junction, AK July 28, 2005
- Good Communication Procedures
- Installed Experimental Remote Camera for real time weather
- Excellent Base Operations support
TheRIGHT STUFF
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Discussion
NBC AMD ObservationsDelta Junction, AK July 28, 2005
NBC AMD ObservationsDelta Junction, AK July 28, 2005
- Do not allow operations to continue after a blade strike is known or suspected to have occurred
- Train new crews in LZ clearing and safety procedures
- Remote fuel sites should be monitored and maintained properly
Corrective Actions/Options
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Piper PA-18
MissionLaw Enforcement
DamageSubstantial
InjuriesN/A
ProcurementFleet
NTSB IDANC05TA126
Coldfoot, AKAugust 20, 2005
Coldfoot, AKAugust 20, 2005
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Coldfoot, AKAugust 20, 2005
Coldfoot, AKAugust 20, 2005
IssuesMore complete
aerial recon of remote landing sites
Develop a back-up plan prior to landing
Plan the flight, fly the plan (avoid last second changes)
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Piper PA-18
MissionLaw Enforcement
DamageSubstantial
InjuriesN/A
ProcurementFleet
NTSB IDANC05TA126
Coldfoot, AKAugust 20, 2005
Coldfoot, AKAugust 20, 2005
After landing to a remote “bush” airstrip the pilot attempted to taxi to the side to clear the strip.
During the taxi the left main landing gear hit a rut and the aircraft tipped forward on to its nose.
The pilot was not injured, but the aircraft received substantial damage to the firewall and forward fuselage.
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Engine deflected to the right and damage to propeller blades
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Damage to firewall
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NTSB Probable CauseColdfoot AK, August 20, 2005
NTSB Probable CauseColdfoot AK, August 20, 2005
Probable CauseThe NationalTransportation Safety
the probable cause of“The pilot's selection of Board determined that
this accident was …unsuitable terrain for landing,which resulted in the airplanenosing down during the landingroll. A factor associated withthe accident was the roughand uneven terrain.”
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Discussion
NBC AMD ObservationsColdfoot, AK July 20, 2005
NBC AMD ObservationsColdfoot, AK July 20, 2005
Corrective Actions/Options
- Conduct your aerial recons as though your life depends on it
- Have a primary plan… and a back-up plan (a way out)
- Avoid spontaneously changing your plan
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Elko, NVAugust 23, 2005Elko, NV
August 23, 2005
PZL M-18TTurbine
DromaderMissionFire Suppression
DamageSubstantial
InjuriesMinor
ProcurementCall When Needed
NTSB IDLAX05TA277
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Elko, NVAugust 23, 2005Elko, NV
August 23, 2005
IssuesUnnecessary risk
taking
Be alert to changing weather conditions -especially heavy winds
Don’t hesitate to turn down a mission when appropriate
Communications
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Elko, NVAugust 23, 2005Elko, NV
August 23, 2005
PZL M-18TTurbine
DromaderMissionFire Suppression
DamageSubstantial
InjuriesMinor
ProcurementCall When Needed
NTSB IDLAX05TA277
After performing a retardant drop under downhill and downwind conditions the aircraft was unable to establish an adequate rate-of-climb to prevent ground impact.
The pilot elected to make an emergency off-airport landing under control rather than attempt to fly out.
The pilot received minor injuries.
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Point of initial impact
Heading 054°
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Issues
NBC AMD ObservationsElko, NV, August 23, 2005
NBC AMD ObservationsElko, NV, August 23, 2005
TheRIGHT STUFF
- Mishap reporting and response coordination was excellent
Proper notification to AM and Bureau National Office
Medical evacuation of pilot
Wreckage preservation
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Issues
AM ObservationsElko, NV, August 23, 2005
AM ObservationsElko, NV, August 23, 2005
Corrective Actions/Options
- Weather recognitionBe alert to changing weather conditions -especially heavy winds
- Keep lines of communication open
- I am not going back out there because…”
- Doing “dry runs” is an acceptable practice
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Discussion
DOI FY 05 Aviation MishapsDOI FY 05 Aviation Mishaps
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DOI FY 05 Aviation MishapsDOI FY 05 Aviation Mishaps
2 Aircraft Accidents2 Aircraft Accidents
3 Incidents with Potential3 Incidents
with Potential
and the year is still young !!!and the year is still young !!!Ideas for Managing Risk
Avoid taking unnecessary risksAvoid taking unnecessary risksMedium risk syndromeMedium risk syndromeProject Aviation PlansProject Aviation PlansPre-mission briefingsPre-mission briefings
Mitigate known risksMitigate known risks
Turn-down protocolTurn-down protocolHave an escape planHave an escape plan
Pre-use inspectionsPre-use inspections
Document remaining hazardsDocument remaining hazards
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DOI FY 05 Aviation MishapsDOI FY 05 Aviation Mishaps
2 Aircraft Accidents2 Aircraft Accidents
3 Incidents with Potential3 Incidents
with Potential
and the year is still young !!!and the year is still young !!!
Lessons learned (again)
Don’t fly in a damaged aircraftDon’t fly in a damaged aircraft
Timely mishap reporting and SAFECOMsTimely mishap reporting and SAFECOMs
Crew Resource Management(speak up, and shut up, when appropriate)
Crew Resource Management(speak up, and shut up, when appropriate)
Use checklistsUse checklists
Aviation Life Support Equipment(take care of it and it will take care of you)
Aviation Life Support Equipment(take care of it and it will take care of you)