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  • AVIATION SAFETY INVESTIGATION REPORT

    200302820

    Robinson Helicopter Company

    Model R22 Mariner

    Bents Basin State Recreation Area, NSW

    20 June 2003

    _________________________________________________________________________ Released under the provisions of Section 19CU of Part 2A of the Air Navigation Act 1920.

  • Published by: Australian Transport Safety Bureau

    Postal address: PO Box 967, Civic Square ACT 2608

    Office location: 15 Mort Street, Canberra City, Australian Capital Territory

    Telephone: 1800 621 372; from overseas + 61 2 6274 6590

    Accident and serious incident notification: 1800 011 034 (24 hours)

    Facsimile: 02 6274 6474; from overseas + 61 2 6274 6474

    E-mail: atsbinfo@atsb.gov.au

    Internet: www.atsb.gov.au

    Commonwealth of Australia 2005.

    This work is copyright. In the interests of enhancing the value of the information contained in this

    publication you may copy, download, display, print, reproduce and distribute this material in unaltered form

    (retaining this notice). However, copyright in the material obtained from non-Commonwealth agencies,

    private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want

    to use their material you will need to contact them directly.

    Subject to the provisions of the Copyright Act 1968, you must not make any other use of the material in this

    publication unless you have the permission of the Australian Transport Safety Bureau.

    Please direct requests for further information or authorisation to:

    Commonwealth Copyright Administration

    Copyright Law Branch

    Attorney-Generals Department

    Robert Garran Offices

    National Circuit

    BARTON ACT 2600

    www.ag.gov.au/cca

  • i

    CONTENTS

    CONTENTS .................................................................................................................................. i

    INTRODUCTION .......................................................................................................................iii

    EXECUTIVE SUMMARY........................................................................................................... v

    1 FACTUAL INFORMATION........................................................................................ 1

    1.1 History of the flight ........................................................................................... 1

    1.2 Injuries to persons.............................................................................................. 2

    1.3 Damage to the helicopter ................................................................................... 2

    1.4 Other damage .................................................................................................... 2

    1.5 Personnel information........................................................................................ 3

    1.6 Helicopter information....................................................................................... 3

    1.7 Meteorological information.............................................................................. 16

    1.8 Aids to navigation............................................................................................ 16

    1.9 Communications.............................................................................................. 17

    1.10 Aerodrome information.................................................................................... 17

    1.11 Flight recorders................................................................................................ 17

    1.12 Wreckage information ..................................................................................... 17

    1.13 Medical information ........................................................................................ 19

    1.14 Fire.................................................................................................................. 19

    1.15 Survival aspects ............................................................................................... 19

    1.16 Tests and research............................................................................................ 19

    1.17 Organisational information .............................................................................. 19

    1.18 Additional information..................................................................................... 19

    2 ANALYSIS ................................................................................................................ 23

    2.1 Introduction ..................................................................................................... 23

    2.2 Main rotor blade service information ............................................................... 23

    2.3 Flight crew and weather................................................................................... 23

    2.4 Regulatory action............................................................................................. 23

    3 CONCLUSIONS......................................................................................................... 25

    3.1 Findings........................................................................................................... 25

    3.2 Significant factors............................................................................................ 26

    4 SAFETY ACTION ..................................................................................................... 27

    4.1 Safety action taken by the ATSB ..................................................................... 27

    4.2 Safety action taken by the Australian Civil Aviation Safety Authority ............. 30

    4.3 Safety action taken by the US Federal Aviation Administration ....................... 31

    4.4 Safety action taken by European Aviation Safety Agency ................................ 32

    4.5 Safety action taken by the Robinson Helicopter Company ............................... 32

    Appendix A Technical Analysis Report35

  • ii

  • iii

    INTRODUCTION

    The Australian Transport Safety Bureau (ATSB) is an operationally independent multi-

    modal Bureau within the Commonwealth Department of Transport and Regional

    Services. ATSB investigations are independent of regulatory, operator or other external

    bodies.

    In terms of aviation, the ATSB is responsible for investigating accidents, serious

    incidents, incidents and safety deficiencies involving civil aircraft operations in Australia,

    as well as participating in overseas investigations of accidents and serious incidents

    involving Australian registered aircraft. The ATSB also conducts investigations and

    studies of the aviation system to identify underlying factors and trends that have the

    potential to adversely affect safety. A primary concern is the safety of commercial air

    transport, with particular regard to fare-paying passenger operations.

    At the time of the accident the ATSB was conducting aviation investigations in

    accordance with the provisions of the Air Navigation Act 1920, Part 2A. Section 19CA of

    the Act states that the object of an investigation is to determine the circumstances

    surrounding any accident, serious incident, incident or safety deficiency to prevent the

    occurrence of other similar events. The results of these determinations form the basis for

    safety recommendations and advisory notices, statistical analyses, research, safety studies

    and ultimately accident prevention programs. As with equivalent overseas organisations,

    the ATSB has no power to implement its recommendations.

    It is not the object of an investigation to determine blame or liability. However, it should

    be recognised that an investigation report must include factual material of sufficient

    weight to support the analysis and conclusions reached. That material will at times

    contain information reflecting on the performance of individuals and organisations, and

    how their actions may have contributed to the outcomes of the matter under investigation.

    At all times the ATSB endeavours to balance the use of material that could imply adverse

    comment, with the need to properly explain what happened, and why, in a fair and

    unbiased manner.

    The 24-hour clock is used in this report to describe the NSW local time of day, Eastern

    Standard Time (EST), as particular events occurred. Eastern Standard Time was

    Coordinated Universal Time (UTC) + 10 hours.

  • iv

  • v

    EXECUTIVE SUMMARY

    On 20 June 2003 at approximately 0840, a Robinson Helicopter Company Model R22

    helicopter, registered VH-OHA (OHA), was being used to conduct flying training in the

    Bankstown training area with an experienced flight instructor and student pilot. The

    helicopter was observed and heard flying in a normal manner. Witnesses reported

    subsequently hearing a number of loud bangs and one witness observed what appeared to

    be a main rotor blade separating from the helicopter. The helicopter descended to the

    ground in an inverted attitude and both occupants were fatally injured.

    Examination of the accident site and helicopter wreckage confirmed that one main rotor

    blade had failed in-flight. Examination of the helicopter and its systems did not reveal

    any other abnormality that would have contributed to the los

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