Report on air accident in the Skoddevarre mountains, Alta municipality, Troms og Finnmark county, Norway on 31 August 2019 with Airbus Helicopters AS350 B3, LN-OFU, operated by Helitrans AS

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, cannot be described as a high-energy accident. The passengers could probably have survived had an intense fire not broken out immediately. The helicopter was almost new but had not been fitted with a crash resistant fuel system. Under EU legislation, helicopters whose type certificates were issued before 1994 are not required to have crash resistant fuel system. In the USA, all new helicopters delivered after May 2020 should be equipped with crash resistant fuel system.

The Norwegian Safety Investigation Authority recommends that EASA requires that all helicopters, new and used, delivered or imported to Europe be equipped with crash resistant fuel systems in accordance with CS 27.952 or CS 29.952, regardless of their type certification date.

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, cannot be described as a high-energy accident. The passengers could probably have survived had an intense fire not broken out immediately. The helicopter was almost new but had not been fitted with a crash resistant fuel system. Passengers are exposed to unnecessarily great risk during transport by helicopters without crash resistant fuel system.

The Norwegian Safety Investigation Authority recommends EASA to not permit commercial passenger flights with helicopters not equipped with crash resistant fuel systems in accordance with CS 27.952 or CS 29.952, regardless of their type certification date.

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, cannot be described as a high-energy accident. The passengers could probably have survived had an intense fire not broken out immediately. The pilot did not wear a helmet during the flight. In general, in addition to saving the pilot’s life, use of a helmet can enable the pilot to assist passengers in the event of an accident.

The Norwegian Safety Investigation Authority recommends that the Civil Aviation Authority Norway, when approving procedures (SOP) for commercial air transport operations, ensures that the helicopter operator’s risk assessment involves aspects related to the use of helmets for pilots.

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, probably occurred after the helicopter encountered servo transparency while in descent and in a slight right-hand turn. The helicopter was heavily loaded, and its speed was increasing. The accident involving LN-OXC at Dalamot on 4 July 2011 occurred under similar circumstances. The helicopter is not equipped with technical aids that gives advance warning, or prevent reaching, of the maximum load on the main rotor, and thereby servo transparency. The NSIA is aware that Airbus Helicopters initiated a prefeasibility study in 2018 and that solutions and roadmap were presented to EASA in September 2021. So far, no solution has been implemented.

The Norwegian Safety Investigation Authority recommends that EASA requires the type certificate holder Airbus Helicopters to establish a technical solution preventing or giving advance warning of servo transparency, for helicopters that are sensitive to this phenomenon.

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, probably occurred after the helicopter encountered servo transparency while in descent and in a slight right-hand turn, at a low altitude above terrain and while its speed was increasing. Simulator training for the AS 350 should take place in an approved full flight simulator, or similar simulators that can recreate servo transparency. This is to ensure that pilots can recognise when the helicopter is about to enter a servo transparency condition, and practise manoeuvres to bring the helicopter out of such a situation.

The Norwegian Safety Investigation Authority recommends that EASA review instruction and continuous training on the AS 350. This is to ensure that the training includes attention training that enables early recognition and recovery from a servo transparency situation based on the UPRT principles.

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, probably occurred after the helicopter encountered servo transparency while in descent and in a slight right-hand turn, at a low altitude above terrain and while its speed was increasing. Simulator training for the AS 350 should take place in an approved full flight simulator, or similar simulators that can recreate servo transparency. This is to ensure that pilots can recognise when the helicopter is about to enter a servo transparency condition, and practise manoeuvres to bring the helicopter out of such a situation.

The Norwegian Safety Investigation Authority recommends that Civil Aviation Authority Norway review instruction and continuous training on the AS 350. This is to ensure that the training includes attention training that enables early recognition and recovery from a servo transparency situation based on the UPRT principles.

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, probably occurred after the helicopter encountered servo transparency while in descent and in a slight right-hand turn, at a low altitude above terrain and while its speed was increasing. The helicopter fuel tank was filled to 90% of full capacity. Helitrans AS had a standard procedure in which the minimum altitude could be understood to mean the normal flight altitude. It defined maximum nose angles, but contained no information or warnings in the SOP relating to mass or speed limitations for sightseeing flights.

The Norwegian Safety Investigation Authority recommends that Helitrans AS revise its standard procedure for sightseeing flights in general, and for AS 350 flights in particular, to better reflect the challenges related to flight altitude, mass and speed.

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, probably occurred after the helicopter encountered servo transparency while in descent and in a slight right-hand turn, at a low altitude above terrain and while its speed was increasing. The helicopter fuel tank was filled to 90% of full capacity. Helitrans AS had a standard procedure in which the minimum altitude could be understood to mean the normal flight altitude. It defined maximum nose angles but contained no information or warnings in the SOP relating to mass or speed limitations for sightseeing flights.

The Norwegian Safety Investigation Authority recommends that Civil Aviation Authority Norway, through its leadership of various safety forums for inland helicopters, raise awareness of the challenges related to flight altitude, mass and speed in general, and to the AS 350 helicopter type in particular.

The air accident on 31 August 2019 in Alta involving an Airbus Helicopters AS 350 B3, LN-OFU, occurred on a sightseeing flight with passengers. Sightseeing flights are regarded by the inland helicopter sector as the simplest form of operations and are therefore used as a means for inexperienced pilots to gain experience. The sector appears to have underestimated that inexperienced pilots can be more easily influenced and feel greater strain when carrying passengers than experienced pilots. The operator proficiency check appears to be a formality that does not include practical flying with passengers on board in the presence of an experienced pilot. Consequences in the event of an accident also appear to have been overlooked.

The Norwegian Safety Investigation Authority recommends that the Civil Aviation Authority Norway develop and publish a standard for commercial air transport operations with single engine helicopters. This should pay special attention to sightseeing flights. The standard should include guidance to develop the underlying risk assessment and a description of the operation for SOPs with accompanying requirements for qualification and training program. The standard should be developed in collaboration with the two forums for inland helicopter operations and be promoted to the operators through these.

A vicious fire broke out when an Airbus Helicopters AS 350 B3, LN-OFU, crashed in Alta on 31 August 2019. The helicopter was equipped with a lightweight flight recorder of the type Appareo Vision 1000, which stored several technical parameters in addition to audio and video records. The memory unit did not resist the fire and it was impossible to retrieve any data. The new requirements concerning lightweight flight recorders (Commission Implementing Regulation (EU) 2019/1387 SPO.IDE.H.146) do not entail audio and video recordings to be made and stored. Furthermore, it is only a requirement that sufficient information is stored to determine the flight path and speed. Especially in helicopter accidents, such a data basis is not sufficient.

The Norwegian Safety Investigation Authority recommends that EASA revise Regulation (EU) 965/2012 for lightweight flight recorders, by including requirements for further registration of data, as well as for audio and video recordings to be made and stored.

A vicious fire broke out when an Airbus Helicopters AS 350 B3, LN-OFU, crashed in Alta on 31 August 2019. The helicopter was equipped with a lightweight flight recorder of the type Appareo Vision 1000, which stored several technical parameters in addition to audio and video records. The memory unit did not resist the fire and it was impossible to retrieve any data. The new requirements concerning lightweight flight recorders (Commission Implementing Regulation (EU) 2019/1387 SPO.IDE.H.146) (EU 965/2012) do not entail all types of light aircraft used for commercial operations, for example the Robinson R44. It does not ensure the regulations’ intention to provide safety investigation authorities with sufficient information to understand accidents.

The Norwegian Safety Investigation Authority recommends that EASA revise Regulation (EU) 965/2012 for lightweight flight recorders, by extending the scope to all types of light helicopters used for commercial air transport of persons.

A vicious fire broke out when an Airbus Helicopters AS 350 B3, LN-OFU, crashed in Alta on 31 August 2019. The helicopter was equipped with a lightweight flight recorder of the type Appareo Vision 1000, which stored several technical parameters in addition to audio and video records. The memory unit did not resist the fire and it was impossible to retrieve any data. The new requirements concerning lightweight flight recorders (Commission Implementing Regulation (EU) 2019/1387 SPO.IDE.H.146) (EU 965/2012) do not entail aircraft with airworthiness certificate issued before 5 September 2022. It does not ensure the regulations’ intention to provide safety investigation authorities with sufficient information to understand accidents.

The Norwegian Safety Investigation Authority recommends that EASA revise Regulation (EU) 965/2012 for lightweight flight recorders, by extending the scope to all helicopters used for commercial air transport of persons, regardless of their certificate of airworthiness date.