Safety & Training
Reviewing the FlyNYON preliminary report
By Fred Jones
Findings from the NTSB FlyNYON preliminary accident report
By Fred Jones
The preliminary report NTSB on the March 2018 FlyNYON accident is a fascinating and terrifying examination of the circumstances that may have contributed to five fatalities. It focuses on what potentially happened onboard the AS350B2 as it crashed into New York’s East River.
The opening words emphasis it is not final, but the report can be used by operators to examine if their current procedures might expose them to risks. The preliminary report seems to suggest:
1. Shortly after the pilot realized that an engine failure had occurred, he noticed that a tether used to secure the front seat passenger was underneath the emergency fuel shutoff lever – and the lever was in the “off” position;
2. By the time the pilot moved the lever back to the “on” position, he was unable to successfully complete the re-start sequence, before completing the autorotation to the surface of the water;
3. The five passengers on board the aircraft were provided with airframe manufacturer-installed restraints, as well as full-body harnesses. The harness system was not installed by the helicopter manufacturer and comprised of off-the-shelf components consisting of a nylon fall-protection harness that was attached at the occupants’ back by a locking carabiner to a lanyard. The lanyard was secured by another locking carabiner to a hard point on the helicopter;
4. The accident flight was being conducted “doors off” and there was a practice of taking “foot selfie” photos against the NYC backdrop; and
5. Shortly after the floats were inflated, and the aircraft autorotated to the surface of the water, it listed steeply to one side (owing to incomplete inflation on one side) and rolled inverted.
Often in our industry we second-guess the actions of flight crew members. Instead, I would argue that we should focus on how we can prevent any potential preconditions for an accident from occurring in our operations. Without suggesting for a moment that any of the events de-scribed below, were relevant to the New York City accident, there are some questions we should be asking ourselves, including:
1. What safeguards are in place to ensure that all passengers (but particularly sightseeing passengers) are not intoxicated by drugs or alcohol when they board a helicopter? Is this part of your company policy, which is made clear to both employees and passengers?
2. Are harness and attachment systems approved; and can they be quickly removed by passengers under emergency circumstances?
3. Are there any potential that items from inside or outside the aircraft (including headsets, cameras or shoes) could be removed by the slipstream – and contact the tail rotor or cause harm to persons on the ground?
4. How do multiple risks and safeguards combine to create risks of their own. For example, the requirement to use special restraints for passengers and equipment while operating doors-off, but at the same time ensure that they have access to floatation devices, and protection from cold water. How can passengers communicate with the pilot without access to a headset and microphone? How can the pilot control uncertain activity in the back of the aircraft?
5. Considered together, how does the experience and training of the passengers/crew members combine with the specialized nature of the operation to contribute to the risk level for the operation as a whole? For example, how does a doors-off operation using an Aerial Ignition Device or Drip Torch compare to a doors-off sightseeing flight with in-experienced passengers, from a risk perspective?
6. To what extend have operations been subjected to a Risk Assessment to ensure that all risks have been assessed and adequately mitigated?
HAC will examine closely the final NTSB report to see what lessons can be learned from the NYC accident, in a Canadian context. Tragically, sometimes the lessons learned from serious accidents can provide the rest of the industry with valuable information that will guide the positive evolution of the Canadian industry. This particular accident seems ripe to help inform the entire commercial helicopter community on how we can go about improving our safety experience in Canada. Doors-off flight is a reality in helicopter operations. The OEMs contemplate that it can occur. Should our industry practices prescribe when, and under what circumstances, it can occur?
Fred Jones is CEO of the Helicopter Association of Canada.