Snagging of Bambi Bucket(2) in vegetation, tipping forward ...1.6.4 Bambi Bucket 15 1.7...

Ministère de la Transition Écologique et Solidaire

Bureau d’Enquêtes et d’Analysespour la sécurité de l’aviation civile

INVESTIGATION REPORTAccident on 4 October 2015 at Voh (New Caledonia)to Airbus Helicopters AS350-B3registered F-OIAOoperated by Hélicocéan

Published: March 2020

F-OIAO - 4 October 20152

The BEA is the French Civil Aviation Safety Investigation Authority. Its investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liabilities.

BEA investigations are independent, separate and conducted without prejudice to any judicial or administrative action that may be taken to determine blame or liability.

SPECIAL FOREWORD TO ENGLISH EDITION

This is a courtesy translation by the BEA of the Final Report on the Safety Investigation published in May 2019. As accurate as the translation may be, the original text in French is the work of reference.

Safety investigations


Table of Contents

SAFETY INVESTIGATIONS 2

SYNOPSIS 7

ORGANISATION OF THE INVESTIGATION 9

1 - FACTUAL INFORMATION 10

1.1 History of the flight 10

1.2 Injuries to persons 11

1.3 Damage to aircraft 11

1.4 Other damage 11

1.5 Personnel information 11

1.5.1 Pilot 111.5.2 Mechanic 13

1.6 Aircraft information 13

1.6.1 Airframe 131.6.2 Engine 131.6.3 Swing slung-load system 141.6.4 Bambi Bucket 15

1.7 Meteorological information 16

1.8 Aids to navigation 16

1.9 Telecommunications and radar tracking 16

1.10 Aerodrome information 16

1.11 Recorders and computers 161.11.1 Flight recorders 161.11.2 VEMD computer 161.11.3 ECU computer 17

1.12 Wreckage and impact information 17

2.1 Examination of accident site 171.12.2 Examination of wreckage on site 191.12.3 Detailed examination of wreckage 19

1.13 Medical and pathological information 20

1.14 Fire 20

1.15 Survival aspects 20

1.16 Tests and research 20

1.16.1 Estimation of helicopter weight 201.16.2 Performance calculations 21


1.17 Organizational and management information 211.17.1 General information about Hélicocéan 211.17.2 FFH activity at Hélicocéan 221.17.3 Regulatory requirements concerning specialized activities 231.17.4 Changes in regulations concerning specialized activitiesin metropolitan France 231.17.5 FFH training at Hélicocéan 241.17.6 Working hours and flight time 25

1.18 Additional information 28

1.18.1 Witness statements 281.18.2 Differences between Bambi Bucket and FAST Bucket 35

1.19 Useful or effective investigation techniques 36

2 - ANALYSIS 40

2.1 Scenarios 40

2.2 Personal and collective pressure 42

2.3 FFH training 43

2.4 Safety management based on experience 44

3 - CONCLUSION 46

3.1 Findings 463.1.1 The accident 463.1.2 The company 463.1.3 Helicopter and Bambi Bucket 473.1.4 The pilot 473.1.5 Regulatory framework 473.2 Causes of the accident 48

4 - SAFETY RECOMMENDATIONS 49

4.1 Measures taken by the company since the accident 49

4.1.1 Safety management 494.1.2 Training 494.1.3 Working hours and time off 49

4.2 Training in specialized activities 50

4.3 Assistance to pilots for firefighting helicopter missions 51

4.4 Helicopter pilot working hours 52

APPENDICES 53


GlossaryAD Airworthiness Directive

ADS-B Automatic Dependent Surveillance – Broadcast

ATO Approved Training Organisation

AW Aerial Work

CAT Commercial Air Transport

CoA Certificate of Airworthiness

COSPAS SARSAT

Cosmicheskaya Sistyema Poiska Avariynich SudowSearch and Rescue Satellite-Aided Tracking

CRS Certificate of Release to Service

DAC-NC Direction de l’Aviation Civile de Nouvelle-Calédonie (Directorate of Civil Aviation - New Caledonia)

DGAC Direction Générale de l’Aviation Civile (French civil aviation authority)

DNC Déclaration de Niveau de Compétence (Declaration of proficiency)

EASA European Aviation Safety Agency

ECU Electronic Control Unit

EFH Equivalent Flight Hours

FFH FireFighting Helicopter

GNSS Global Navigation Satellite System

HESLO Helicopter External Sling Load Operations

MGB Main GearBox

OCC Operator Conversion Course

OM Operations Manual

RDFE Responsable Désigné de la Formation des Équipages (Designated crew training manager)

RDOA Responsable Désigné des Opérations Aériennes (Designated air operations manager)

RDOS Responsable Désigné des Operations au Sol (Designated ground operations manager)

SAMU Service d’Aide Médicale Urgente (Emergency medical services)

SANA Safety Assessment of National Aircraft


SMS Safety Management System

SPO SPecialized Operations

STC Supplemental Type Certificate

TR Type Rating

TRE Type Rating Examiner

TRI Type Rating Instructor

VEMD Vehicle and Engine Monitoring Display


Synopsis

Code No: BEA2015-0609.en

Time Around 13:15(1)

Operator HélicocéanType of flight General aviation, firefighting

Persons on board Pilot and mechanic

Consequences and damage Pilot and mechanic fatally injured, helicopter destroyed

(1)Unless otherwise stated, all times given in this report are in local time. Eleven hours should be subtracted to obtain Coordinated Universal Time (UTC).

Snagging of Bambi Bucket(2)in vegetation, causing helicopter to tip forward and then collide with

ground, during firefighting flight

(2)External water scooping and drop equipment for firefighting. The 2024S has a capacity of 910 l.

The pilot, accompanied by a mechanic, was carrying out a firefighting mission in the vicinity of Voh, using a helicopter equipped with a Bambi Bucket. Just after refuelling, the pilot carried out several manoeuvres probably associated with scooping attempts in a mangrove area. The Bambi Bucket became snagged in the vegetation; the helicopter tipped forward and collided with the vegetation and ground.

The following factors may have had an impact on the management of the safety margins and recovery capabilities in a degraded situation:

pressure due to the fire and a high workload for the pilot still in the learning phase of the firefighting helicopter (FFH) activity;

a scooping and firefighting technique still being acquired, leaving little resources available to manage unforeseeable events.

The following factors may have contributed to this situation:

insufficient FFH training and the absence of supervised flights which meant that it was not checked that the pilot had a sufficient level of command of the techniques for a real fire. This is linked in part, to the period of pressure and rapid development experienced by the company and in part, to the limited regulatory framework for issuing Declarations of proficiency (DNC) for the specialized activities in New Caledonia;

a period of intensive activity, particularly in terms of learning. This activity was linked, in particular, to the operational constraints of the company which quickly needed a designated crew training manager (RDFE) and a “Dauphin” SA365 instructor;

personal pressure felt by the pilot and her determination to succeed in this new job which probably led her to accept all the missions without having the necessary distance to express her possible worries or difficulties.


The BEA has addressed the following safety recommendations to New Caledonia regarding:

the initial theoretical training and practical training in instruction and under supervision for a specialized activity;

the working hours of helicopter pilots performing aerial work.

The BEA has addressed the following safety recommendations to the French civil aviation authority (DGAC) regarding:

the content of the DNCs for the specialized activities not covered by the European regulations;

the problem of transferring a DNC from one company to another and from one environment to another.

The BEA has addressed the following safety recommendations to the Directorate of Civil Aviation - New Caledonia (DAC–NC) regarding:

inclusion in the operators’ Specialized Activities Manual, of a systematic period of supervised flights in real conditions after obtaining a FFH DNC;

examination of aids that helicopter operators carrying out FFH missions could provide to pilots for carrying out their missions, and in particular, to guide them in their decisions.

The BEA has addressed to the DAC-NC, in consultation with the aerial work helicopter operators in New Caledonia, a safety recommendation regarding:

working hours of their crew.


ORGANISATION OF THE INVESTIGATION

Article L.1621-2 of the Code of Transport, modified by article L.1862-2 for its application in New Caledonia, specifies that all civil aviation accidents or serious incidents are the subject of a safety investigation as provided for in the applicable rules in metropolitan France under the terms of articles 11, 12 and 13 of Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation.

The BEA was notified of the accident on the day it occurred. The initial observations on the accident site were made by a BEA field investigator. A team of two BEA investigators arrived in New Caledonia nine days after the accident, accompanied by a technical advisor from Airbus Helicopters and a technical advisor from Turbomeca(3), in order to carry out detailed examinations of the site, the helicopter and the Bambi Bucket along with the first acts of the investigation.

As the Bambi Bucket is manufactured by the Canadian company, SEI Industries, the Transportation Safety Board of Canada (TSB) appointed an accredited representative in accordance with Annex 13 to the Convention on International Civil Aviation. The equipment manufacturer was contacted through the accredited representative.

(3)Turbomeca became Safran Helicopter Engines in 2016.


1 - FACTUAL INFORMATION

1.1 History of the flight

The pilot, usually based at Nouméa, was on call for a five-day period at Koné for firefighting missions in the north of the island. The company has accommodation for the crews there and a helicopter is stationed for all of the firefighting season.

During this on-call period, the pilot had fought different fires in the areas around Voh and Ouégoa on Friday 2 and Saturday 3 October.

On Sunday 4 October, around 10:45, the pilot was instructed to fight a new fire in the Voh area, around 16 km from Koné.

She took off with a company mechanic at around 10:50. On arriving at Voh, she disembarked the mechanic and flew around the fire with a civil defence officer who was already on site. At 11:08, she took off again with the mechanic to fight the fire, in radio contact with the civil defence officer. A Bell 214 B1 from another company arrived shortly after to participate in fighting the same fire and was also in contact with the the civil defence officer on the ground.

Figure 1: Location map of New Caledonia

Around 12:45, the pilot reported that she was returning to Koné to refuel. Before leaving the area, she flew a reconnaissance of the fire with the civil defence officer. At Koné, the crew took on 330 l of fuel.


Meanwhile, the Bell 214 B1 pilot had had a technical problem with his scooping system which obliged him to return to his Nandaï base at around 100 kilometres to the south-east of the fire.

At 13:03, the F-OIAO pilot sent a SMS to the Hélicocéan on-duty member of staff informing them that refuelling was finished. She also contacted the civil defence officer by radio but the quality of the signal meant that the message was inaudible. No radio contact was made subsequently.

At 13:35, the signal from a 121.5 MHz emergency locator transmitter was picked up by a passenger plane en route. At 14:40, a COSPAS SARSAT message(4) was received from the F-OIAO’s 406 MHz emergency locator transmitter. The wreckage was located at 15:45 at the edge of a branch of the mangrove, situated at less than two kilometres to the south west of the fire. The two occupants had suffered fatal injuries.

As New Caledonia does not have radar coverage and the helicopter was not equipped with flights recorders or an ADS-B system, it was not possible to accurately reconstitute its path.

1.2 Injuries to persons

Injuries

Fatal Serious Minor/None

Crew 2 - -

Passengers - - -

Others - - -

1.3 Damage to aircraft

The Helicopter was destroyed.

1.4 Other damage

Not applicable.

1.5 Personnel information

1.5.1 Pilot

Female, aged 47, holder of a helicopter commercial pilot licence since 1998 with:

Flight Instructor FI(H) rating obtained in 2006 on different types of helicopter including the AS350/EC130 in 2008, renewed on 23 September 2015;

Flight Instructor FI(H) rating obtained on 23 September 2015 on the SA365/EC155 and on AW109;

Type Rating Instructor TRI(H) obtained on 2 September 2015 on the SA365/EC155; Type Rating Examiner authorization TRE(H) obtained in 2011 on the AS350/EC130,

renewed on 4 September 2015; Type Rating Examiner authorization TRE(H) obtained on 4 September 2015 on the

SA365/EC155SP.

(4)World system of emergency locator beacons to locate people in distress (https://cospas-sarsat.cnes.fr/fr).


She also held a helicopter commercial pilot licence issued by the United States in 2012.

On 31 August 2015, she obtained a “Dauphin” SA365 TR and on 29 September she registered a flight instructor licence for multi-engine helicopters FI(H)-ME with the Civil Aviation licences office.

She had also followed a technical training course in 2014 qualifying her to carry out daily checks and ADs on the AS350-B2/-B3 and to issue CRS for these checks.

Experience

Total: 4,780 flight hours on helicopter of which 1,445 on the different versions of the “Ecureuil” AS350.

In the previous three months: 82 flight hours of which 50 on the different versions of the “Ecureuil” AS350.

In the previous seven days: flight hours of 13 h 20 min of which 12 h 20 min on the different versions of the “Ecureuil” AS350.

Between 1998 and 2014, the pilot worked as pilot and instructor for various employers in metropolitan France and the Reunion. For a few months in 2014, she was a Designated crew training manager (RDFE) at Tahiti, in Polynesia.

She then worked in Guyana between August and December 2014 where she obtained a hoisting and lifting DNC in September; she carried out this activity to little extent during this period.

In March and April 2015, she worked in metropolitan France for a company where she obtained a type rating on Agusta AW109. She then started an Operator Conversion Course (OCC) for the Mulhouse emergency medical services. She abandoned the course before obtaining the line rating and resigned explaining that she wanted to focus on other professional choices.

She joined Hélicocéan in New Caledonia at the end of May 2015. At the time of her recruitment, the pilot provided a Declaration of proficiency stipulating, in particular, experience corresponding to:

fifteen flight hours of lifting operations; four FFH flight hours for approximately 50 water drops.

It was not possible to determine the scope in which she had acquired the FFH experience claimed in this Declaration of proficiency.

Between her arrival at Hélicocéan at the end of May 2015 and the day of the accident, she logged a total of 130 flight hours, of which nearly 100 hours on the “Ecureuil” AS350 helicopter and the rest on the “Dauphin” SA365N.

Edition 1.0, amendment 5 of the Hélicocéan Operations Manual (OM), dated 15 September 2015, specified that the pilot was the company’s RDFE.

On 2 and 3 June, she obtained a FFH DNC in the company, on an AS350-B2. This DNC comprised two flights of 1 h 15 min and 1 h 05 min respectively.


On 11 August, she carried out a FFH flight of 1 h 35 min on the AS350-B3 F-OIAO and a check-out flight on 14 September of 20 minutes on a “Dauphin” SA365N equipped with a FAST Bucket(5) (number of scooping operations unknown in both cases). On 26 September, she carried out a FFH flight of 2 h on the AS350-B2 F-OIAH(6). She then participated in a firefighting on-call period from Koné on the A350-B3 F-OIAO:

2 October, flight time of 2 h 10 min and 23 scooping operations with a FAST Bucket; 3 October, flight time of 3 h 05 min and 20 scooping operations then 50 minutes and

12 scooping operations with a FAST Bucket; 4 October, flight time of 2 h 28 min before the accident with a Bambi Bucket (number

of scooping operations unknown).

Her total FFH experience at Hélicocéan, excluding the DNC and check-out flight, was thus 12 h 25 min of which 8 h 50 min in the three days prior to the accident.

1.5.2 Mechanic

Male, aged 31, aircraft mechanic at Hélicocéan, holder of an aircraft maintenance licence issued in 2005.

The company’s Specialized Activities Manual valid at the time of the accident specified that a second crew member, that is to say a technician or technical assistant trained in in-flight service may participate in FFH missions if required.

1.6 Aircraft information

1.6.1 Airframe

Manufacturer: Airbus HelicoptersType: AS350-B3Serial Number: 4308Registration: F-OIAOEntry into service: delivered new to Hélicocéan in 2007Use: approximately 2,100 flight hours and nearly 5,000 cycles

The last 100 h/12 month scheduled maintenance inspection was carried out on 26 June 2015 at 2,037 flight hours. The helicopter equipped with the emergency floatation gear was weighed at this time: the total empty weight measured was 1,378 kg. The fuel tank capacity was 540 l. The helicopter’s maximum authorized weight with an external load was 2,800 kg.

1.6.2 Engine

Manufacturer: TurbomecaType: Arriel 2B1Serial Number: 23456Entry into service: installed new on the AS350-B3 F-OIAO in 2007

The maintenance of the engine was covered by a contract with the engine manufacturer, Turbomeca with respect to its maintenance plan and embodiment of service bulletins.

(5)The FAST Bucket is both a scooping and drop system used in firefighting. Its characteristics and differences with the Bambi Bucket are described in section 1.18.2.

(6)It was not possible to determine if the DNC and the flights of 11 August and 26 September were carried out with a FAST Bucket or a Bambi Bucket.


The air intake of the engine, as for all the Hélicocéan helicopters, was equipped with a FDC/Aerofilter sand filter, installed as per a STC approved by EASA. The company explained that these optional filters were installed to conserve the engines in the New Caledonia dusty, tropical and salt-laden environment.

1.6.3 Swing slung-load system

The helicopter was equipped with a swing type slung-load system with a release hook which could carry a maximum weight of 1,400 kg.

This system was made up of:

a load indicator which allowed the pilot to estimate the quantity of water scooped up; an electric load release system activated by a pushbutton installed on the cyclic pitch

stick; a mechanical load release system activated by a handle installed under the collective

pitch control lever.

Load indicator

Figure 2: Swing slung-load system

Electric load release button

Mechanical load release

handle

Figure 3: Cyclic pitch stick/collective pitch control lever


1.6.4 Bambi Bucket

The helicopter was equipped with a 2024S type Bambi Bucket water scooping and drop system attached to the swing system. This equipment is manufactured by the Canadian company, SEI Industries.

The total measured length of this Bambi Bucket is around 4.65 m. The total weight of the system is 965 kg when the bucket is completely full of water.

The Bambi Bucket is filled by scooping. The quantity of water carried can be pre-adjusted on the ground using straps, the position of which limit the diameter of the Bambi Bucket and thus its total volume. This adjustment cannot be modified in flight.

On F-OIAO and all the helicopters of the company, the water drop was electrically controlled by a pushbutton attached by two collars to the twist grip of the collective pitch control lever(7).

Water release button

Figure 4: F-OIAO water drop control

This control releases a cable which in turn releases a fabric valve which opens under the weight of the water. After the drop, a spring returns the cable and valve to their initial position ready for a new scooping operation.

Figure 5: Bambi Bucket ready for scooping with valve retracted on left and in process of dropping water

with valve open on right

(7)The Bambi Bucket model installed and the assembly observed on F-OIAO was different to what is certified and proposed as an option by Airbus Helicopters which is the model 2732S with the water release button built into the cyclic pitch stick and not attached with collars to the collective pitch control lever.


1.7 Meteorological information

At the time of the accident, there was a south-south-east wind of between 20 kt and 25 kt with gusts of more than 30 kt in the Voh region The sky was clear to few clouds and visibility was greater than 10 km.

The weather reports for Koné airport, situated at around 16 km south-east of the accident site were:

METAR NWWD 040130Z AUTO 17016KT 140V200 9999 NCD 26/12 Q1019= METAR NWWD 040200Z AUTO 17015G26KT 130V220 9999 NCD 26/12 Q1018=

1.8 Aids to navigation

The front face of a Garmin GNS430 was found. This type of equipment does not have a non-volatile memory and does not record the position data. It was not possible to determine whether the pilot was using this equipment at the time of the accident.

1.9 Telecommunications and radar tracking

At the time of the accident, the crew were not in contact with any control unit. They were in radio contact with the civil defence officer coordinating, from the ground, the various means engaged in the firefighting. These radio exchanges were not recorded.

The persons in radio contact at the time of the accident said there had been no mayday call or emergency message from the pilot.

New Caledonia has no radar coverage. At the time of the accident, the ADS-B system was being deployed in New Caledonia. F-OIAO was not equipped with one.

1.10 Aerodrome information

The helicopter was stationed at Koné airport during the firefighting on-call period. Hélicocéan had fuel drums there to allow the crews to refuel.

1.11 Recorders and computers

1.11.1 Flight recorders

F- OIAO was not equipped with flight recorders. The regulation in force did not require this for this type of aircraft.

1.11.2 VEMD computer

The helicopter was equipped with a VEMD. This is a multifunction screen installed on the instrument panel and designed to display the flight data and certain engine parameters. The VEMD records failure messages and limit exceedances for maintenance aid purposes.

The computer was damaged. Its electronic boards were extracted and analysed at the BEA. The data corresponding to the event flight was identified and showed a flight time of 2 hours 28 minutes and 12 seconds: 17 failures and 1 exceedance were recorded.

The analysis of the data recorded by the VEMD concluded that all the failures recorded during this flight were consecutive with the impact with the ground or with obstacles.


1.11.3 ECU computer

The helicopter was equipped with an ECU which was in good condition. This is a computer which controls the fuel flow and manages the engine parameters. Failure messages are recorded for maintenance aid purposes. Major failure messages, directly linked to the fuel flow control function are sent to the VEMD by the ECU.

The analysis of the VEMD data showed that the failures originating from the ECU were recorded at the time of the impact with the ground and were the result of the accident.

1.12 Wreckage and impact information

2.1 Examination of accident site

The accident occurred in an area of mangrove, situated at less than two kilometres to the south west of the fire. The vegetation is composed of mangrove trees reaching a height of around six metres. The branches, particularly rigid, are densely intertwined. The site was at the edge of a branch of open water of a width of around 30 m. At the time of the accident, the wind direction was markedly along the branch axis.

Figure 6: Position of wreckage and fire zone

The observation of the vegetation found broken branches and scars up to around 20 m before the position of the wreckage. These scars were made by the path of the helicopter and Bambi Bucket. They give an idea as to the final part of the helicopter’s path before colliding with the ground, with a marked tailwind.


Scars left by the helicopter and Bambi Bucket’s passage

Cut made by the rotor disk

Figure 7: Position of wreckage and scars in vegetation

A large cut in the vegetation corresponding to the main rotor disk was found between these initial scars and the impact point. The profile of the cuts observed in the vegetation was consistent with a nose-down attitude of around 60 to 70° and a left bank.

Cut made by the rotor disk

Figure 8: Position of wreckage and scars in vegetation


1.12.2 Examination of wreckage on site

The helicopter wreckage had a high nose-down attitude. The emergency floatation gear was not activated. The Bambi Bucket was still attached to the hook of the slung-load system.

A broken branch of a wide section was trapped in the Bambi Bucket. It was possible to match this branch with the broken trunk of one of the mangrove trees in the area before the final position of the wreckage.

Figure 9: Branch broken by Bambi Bucket

1.12.3 Detailed examination of wreckage

The wreckage was transported to Nouméa – La Tontouta air base. The examination of the wreckage did not reveal any element likely to call into question the correct operation of the helicopter at the time of the accident. All the damage observed resulted from the accident.

The engine was in a general good internal and external condition and only had some damage resulting from the accident. Observations found that it was operating and providing power to the main and tail rotors at the time of the accident. It was not possible to quantify this level of power.

The engine air intake was equipped with a FDC/Aerofilter sand filter. There was no noticeable fouling. This type of filter is equipped with by-pass valves which open in the event of clogging: on the accident helicopter, they were in the closed position but slightly ajar, probably as a result of the helicopter’s collision with the ground.

The swing slung-load system was correctly connected to the helicopter both electrically and mechanically.

The hook mechanical opening system (handle under the collective pitch lever, see paragraph 1.6.3) correctly operated and allowed load release. The electrical opening system could not be tested due to the damage found. The release control button was in the armed position.

Parts of the Bambi Bucket had failed or were deformed. This damage was the consequence of it penetrating the vegetation with high energy. The Bambi Bucket capacity adjustment straps were adjusted to allow the maximum volume of water to be carried.

The mechanism of the water drop system and the Bambi Bucket fabric valve were found in an intermediate position. This configuration could indicate that the water drop had been activated just before impact, the drop system not having had time to automatically re-position itself. It is also possible that the fabric valve had not completely returned to its initial position after the previous water drop.


1.13 Medical and pathological information

Autopsies were carried out on the pilot and mechanic. No element which might be associated with an incapacity or disorder was found.

1.14 Fire

Not applicable.

1.15 Survival aspects

The observation of the site and the attitude of the wreckage indicate that the helicopter entered the vegetation with a high nose-down attitude. On the accident site, the vegetation is dense and the branches very rigid. The observation of the wreckage and the autopsies confirm that the accident was not survivable.

1.16 Tests and research

1.16.1 Estimation of helicopter weight

When the helicopter was last weighed, a few months previously, the total empty weight measured with the emergency flotation system was 1,378 kg.

The weight of a full Bambi Bucket is given as 965 kg by the manufacturer while the weight of the swing slung-load system is 14 kg. The weight of the crew and their personal effects can be estimated at 170 kg.

The flight time of 2 h 28 min recorded in the VEMD corresponds to the time between the take-off at 10:50 and the estimated time of the accident at around 13:18. This indicates that during the various touchdowns, at Voh for the reconnaissances of the fire zone or at Koné for refuelling, the pilot had kept the engine running.

Recorded times Estimated times Fuel ~10:45 Mission launched ~10: 50 Take-off from Koné with mechanic 430 l

11:00 Arrival at Voh and fire reconnaissance flight with civil defence officer

11:08 Departure to scooping zone with mechanic Fire fighting (number of scoops not known)

~12:45 Return to Voh and fire reconnaissance flight with civil defence officer

12:50 Departure to refuel at Koné with mechanic 13:00 Arrival at Koné and refuelling +330 l

13:03 SMS advising refuelling finished sent 13:13 Return to scooping zone with mechanic 13:18 Accident

13:35 Signal from a 121.5 MHz emergency locator transmitter received

The company specified that the average consumption of the helicopter was around 180 to

200 l/h. This is a fixed value used by the crews for the weight sheets and can vary according to the type of mission and piloting technique.

It can be estimated that the flight time between the two refuelling operations was around 2 h 10 min which corresponds to a fuel consumption of between 390 l and 435 l. The documents found indicate that on leaving Koné the morning of the accident, the fuel tank was 80% full which represents around 430 l of fuel. In any case, there was very little fuel left in the tank on returning to Koné for refuelling, although it was not possible to precisely determine this remaining fuel. The documents found indicate that the crew added 330 l of fuel at Koné.


The helicopter’s maximum authorized weight was 2,800 kg. Its weight at the time of the accident, with the Bambi Bucket full, has been estimated as:

High estimation (consumption: 180 l/h)

Low estimation (consumption: 200 l/h)

Helicopter’s empty weight 1,378 kg Swing system 14 kg Full Bambi Bucket 965 kg Crew and personal effects 170 kg Fuel at departure 335 kg (430 l) Consumption to Koné (2 h 10’) -305 kg (390 l) -339 kg (435 l)

(reduced to 335 kg at departure)

Fuel uplift +257 kg (330 l) Consumption after Koné (0 h 18’) -42 kg (54 l) -47 kg (60 l) Total: 2,773 kg 2,738 kg

1.16.2 Performance calculations

The helicopter manufacturer simulated out of ground effect performance levels in the temperature and pressure conditions of the day of the accident, without wind(8). These simulations determined that in hover flight with load and with the air intake equipped with a FDC/Aerofilter sand filter(9) such as the one installed on the helicopter in the accident:

on applying 100% engine torque, the maximum weight is 2,792 kg; the engine torque limitation occurs at 103.8%, for a maximum weight of 2,864 kg.

If the FDC/Aerofilter sand filter is contaminated and the by-pass valves open, the performance levels are degraded:

the engine torque limitation occurs from 98.3%, for a maximum weight of 2,757 kg.

These estimations and simulations, along with the observation of the wreckage, show that the helicopter with the Bambi Bucket full was very close to its maximum weight at the time of the accident and in all likelihood had the necessary power to stay in hover flight. It had a reduced power margin for carrying out manoeuvres, in particular in the strong and irregular wind conditions prevailing at the time of the accident.

Due to the direction of rotation of the helicopter blades, when the required power is close to the available power, the helicopter has a tendency to start rotating left.

1.17 Organizational and management information

1.17.1 General information about Hélicocéan

Hélicocéan is a company based at Nouméa which carries out different aerial work (AW) and commercial air transport (CAT) activities by helicopter. The CAT is a minor activity representing 15 to 17 % of the company’s activity.

(8)The helicopter manufacturer was not able to simulate the effect of the wind on performance.

(9)These estimations are derived from tests carried out by the manufacturer in 2004 on an AS350-B3.


At the time of the accident, the company’s AW activities included:

agricultural spraying; parachute drops; slung-load transportation; helihoisting; banner towing; firefighting; air surveys, photography, observations and surveillance requiring the installation of

specific devices; activities requiring general air traffic rule derogations (such as power line inspection

and pulling or aerial culling of invasive species).

The company trains its pilots for the DNCs required for its activities.

In compliance with the applicable regulatory requirements for aerial work companies in New Caledonia (10), Hélicocéan has a Specialized Activities Manual registered with its regulatory authority, the DAC-NC. At the date of the accident, the Specialized Activities Manual in force was edition 6, amendment 0, registered a few days beforehand, on 15 September 2015.

A few months before the accident and the recruitment of the pilot, the company’s previous RDFE had ceased his activity. The company was therefore confronted with the need to recruit a new pilot able to assume the role of RDFE.

The company’s fleet was composed of five “Ecureuil” AS350s (models BA, B2 and B3) and a “Dauphin” AS365N. It employed five pilots under the responsibility of a chief pilot.

At the time of the accident, the company was rapidly developing: it was on the verge of winning a big CAT contract for the SAMU which it was getting ready to perform with two EC135 twin-engine helicopters which it was in the process of purchasing.

There had been no previous accidents in the company. A few incidents had been reported to the DAC-NC. A SMS was in the process of being set up in the company in 2015.

1.17.2 FFH activity at Hélicocéan

Héliocéan had won, at the end of July 2015, a contract with the North Province for air services in the prevention, protection and fighting of bush fires and support to civil defence operations, valid for one year, and renewable twice.

A month later, the company also obtained a contract with the New Caledonian government regarding the provision for three years (2015, 2016 and 2017), of air services in the prevention, protection and fighting of bush fires using firefighting helicopters . This contract covered all of the New Caledonian territory.

The company’s implementation of the contract with the North Province included on-duty periods of five days at Koné and two travel days (back and forth) between Nouméa and Koné. During daylight hours, the expected intervention time after notification of a fire was 30 minutes.

(10)Described in section 1.17.3.


The contract specified that no person other than the pilot, mechanic and aircraft officer designated by the operations supervisor was authorized to board the helicopter during the water drop phase.

The company’s Specialized Activities Manual specified that if necessary, a technician or technical assistant trained in in-flight service could be present on board during the firefighting activities, to the exclusion of any other passenger.

1.17.3 Regulatory requirements concerning specialized activities

Fire fighting with helicopters and the associated training are defined as specialized activities by the decree of 24 July 1991 concerning conditions of use of civil aircraft in general aviation. This decree applies in New Caledonia.

It requires the operator to write a Specialized Activities Manual, its purpose being to describe the rules and procedures to be followed along with all the necessary information and instructions so that the various operation objectives are reached in satisfactory safe conditions. The Specialized Activities Manual is registered with its competent aviation authority; the latter does not approve it but can ask the operator to make modifications. The operator is obliged to carry out its operations in compliance with its registered Specialized Activities Manual.

The decree of 24 July 1991 specifies that for each specialized activity, the flight crew must have received a DNC issued by an organization designated by the operator. The Specialized Activities Manual must also provide the procedures for maintaining this level of proficiency. The organization carrying out the training in specialized activities must register a reference file with the aviation authority and comply with it. The registering of this is the equivalent of approval.

Annex 1 to the decree of 24 July 1991 gives a canvas for writing the Specialized Activities Manual. The proposed canvas for the reference file for DNC training indicates that the file must contain the minimum experience requirements along with the training and maintaining proficiency programme. This canvas gives no guide as to the volume or to the type of training required according to the type of specialized activity performed.

1.17.4 Changes in regulations concerning specialized activities in metropolitan France

Since 21 April 2017, most CAT operations are governed in metropolitan France by an European regulation: Part-SPO(11). The regulation deals with the activity carried out, irrespective of the operator who carries out this activity, whether they be a public or private entity. Certain operations of public benefit, including firefighting, are excluded from the basic European regulation No 1139/2018(12), and as a consequence from Part-SPO: for these operations, the DGAC considers that the decree of 24 July 1991 continues to apply.

The European regulation regarding aerial work operations (SPO) does not apply to New Caledonia. Since the publication of the regulation, the decree of 24 July 1991 continues to apply and its updates are the subject of implementing laws on a case-by-case basis.

(11)Regulation (EU) No 965/2012 of 5 October 2012 laying down the technical requirements and administrative procedures applicable to air operations, known as AIR-OPS, including Part-SPO which describes the operational requirements applicable to the operation of an aircraft for commercial specialized operations or (commercial or not) specialized operations with a complex motor-powered aircraft.

(12)Regulation (EU) No 2018/1139 of the European Parliament and of the Council of 4 July 2018 on common rules in the field of civil aviation and establishing a European Union Aviation Safety Agency.


The European regulation Part-SPO has a chapter on helicopter sling work (subpart HESLO). This text defines different types of sling work (HESLO 1 to HESLO 4) according to, among other things, the length of the sling. For slings of less than 20 m, without positioning, the type of work is called HESLO 1.

The text specifies:

required experience before starting training for a HESLO 1 activity; initial theoretical training; practical training divided into a training part and a supervised part.

Before starting HESLO 1 training, a minimum experience of ten flight hours is required on the type of helicopter that will be used for the operation.

A trainee pilot must perform at least five flight hours in training including at least 50 sling loading/unloading cycles.

At the end of the training, the pilot must carry out, under supervision, at least five flights in real conditions for a total minimum time of eight flight hours, including at least 80 sling loading/unloading cycles. In addition, the pilot must have a minimum experience of 300 flight hours as pilot-in-command and must be declared capable of carrying out sling work.

A check for continuing proficiency is required every two years. This includes a compulsory theoretical part and a practical part for pilots who cannot show at least 20 sling working hours in the preceding 12 months.

1.17.5 FFH training at Hélicocéan

Issue 6 of the Specialized Activities Manual, registered with the DAC-NC on 15 September 2015 was in force at the time of the accident. There were no changes with respect to training aspects from the previous issue of 11 August 2010.

Hélicocéan is referenced with the DAC-NC to train its personnel in the DNCs required for its operation, including the training for the FFH DNC(13).

The experience required by Hélicocéan to carry out the FFH activity was the following:

a total of 700 flight hours; possession of a sling work DNC; at least two flight hours in this activity (including training flights).

The training for a FFH DNC provides for a ground course of two hours. The flight part provides for three sessions each to last 30 to 60 minutes, with a minimum of 20 drops. This flight part is validated by a flight check-out of 30 minutes. The training for the FFH DNC does not stipulate any practice on a real fire. No supervised flight is provided for after obtaining the DNC.

Hélicocéan’s Specialized Activities Manual specifies in chapter 1.4.4. that the pilot’s continuing proficiency will be validated if the latter has carried out the specialized activity at least once within a 12 month period.

(13)See the appended lifting and FFH DNC programme.


1.17.6 Working hours and flight time

1.17.6.1 Regulatory aspects

Labour Code

The New Caledonia Labour Code(14), codified in 2008, applies to flight crews operating helicopters.

Book II, Title II, chapter I of the legislative part of the Labour Code fixes the legal number of working hours:

The effective legal number of working hours of employees is fixed at 39 hours per week. Section 2 specifies the maximum number of working hours. The number of hours

worked per day cannot exceed ten hours except in the case of derogations or a temporary increase in activity. In the same week, the number of working hours cannot exceed 48 hours. In the event of exceptional circumstances or in certain professions, companies may be authorized by the Executive of the territory to exceed, for a limited period, the 48 hour limit, without, however, this leading to more than 60 hours being worked per week.

Article Lp221-20 specifies that for crews in shipping and air transport companies, a congress resolution may waive the provisions of this section ([i.e. section 2]) regarding the maximum number of 48 working hours per week.

Book II, Title III, chapter I of the legislative part of the Labour Code describes the weekly rest provisions:

Weekly rest is mandatory. It will be at least 24 consecutive hours per week. As a rule this will be on Sunday.

Derogations exist in certain cases, in particular for urgent work, seasonal activities or an exceptional increase in activities. Air transport is not explicitly mentioned.

Resolution No 77 of 16 January 1990

The congress resolution referred to in article Lp221-20 is Resolution No 77 of 16 January 1990, still in force in 2015, regarding the number of working hours of professional flight crews in civil aviation.

It has one section for crews working on aeroplanes other than jet planes and a second section for crews working on jet planes. There is no specific section for crews working on helicopters, by default, the first section will be considered(15):

The average number of effective working hours corresponds to a monthly average of 85 hours spread over the year.

The number of consecutive flight hours cannot exceed eight hours over a 24 hour period for a crew member who is not relieved or seconded by another crew member.

It is specified that flight crews assigned to short or medium length routes must benefit, at their posting residence, from at least one rest period per week of no less than 36 consecutive hours.

The rest period must be at least equal to twice the number of flight hours carried out since the previous rest period (at least eight hours).

(14)https://dtenc.gouv.nc/reglementation-du-travail/code-du-travail

(15) In the absence of a specific section on helicopters, Hélicocéan takes this first section as a reference.

https://dtenc.gouv.nc/reglementation-du-travail/code-du-travailhttps://dtenc.gouv.nc/reglementation-du-travail/code-du-travailhttps://dtenc.gouv.nc/reglementation-du-travail/code-du-travailhttps://dtenc.gouv.nc/reglementation-du-travail/code-du-travail


The limitations may be waived in the case of urgent or public benefit flights. In all cases, the total number of flight hours shall comply with the following limits:

over one month, 130 h; over a period of two consecutive months: 230 h; over 3 months, 330 h; over one year, 1,050 h.

Decree of 20 December 2012

The decree of 20 December 2012(16) applicable in New Caledonia, specifies the helicopter operating conditions in the scope of CAT activities. The annex, OPS 3T, applicable in New Caledonia, does not have sub-part Q, i.e. part on number of working hours.

1.17.6.2 Application by Hélicocéan

The firefighting activity is one of the specialized activities of aerial work. The decree of 24 July 1991(17) specifies that the operators carrying out specialized activities must have a Specialized Activities Manual. This manual must have a chapter dedicated to the number of working hours, specifying the limitations fixed by the operator regarding the flight time and time off, along with the possible derogations to these various limitations.

Hélicocéan states in its Specialized Activities Manual that it complies with Resolution No 77 of 16 January 1990.

Excerpt from Hélicocéan Specialized Activities Manual

1.17.6.3 Audit of flight crew working periods and rest periods

On 12 April 2011, the DAC-NC carried out an audit concerning the working hours and time off of the Hélicocéan flight crews.

The conclusions of the audit indicate no non-conformity. It is specified that Hélicocéan complies with the provisions of resolution No 77 of 16 January 1990 quoted above and that the volume of flight hours remains well below the regulatory limitations.

With respect to the work cycles, it is specified that:

the normal work cycle for CAT is: one day off (night/day/night)/six working days maximum/one day off (night/day/night);

in AW, if the flight crew are required to exceed six consecutive working days, a rest period of three consecutive days is granted.

The audit specifies two regulatory points with respect to CAT (resolution 77):

section I art 4: the Hélicocéan flight crew must benefit, at their posting residence, from at least one rest period of 36 h per period of seven days following a rest period;

section I art 7: any derogation from the regulatory limitations must be the subject of an exceptional authorization request made to the authority.

(16)Decree regarding helicopter operating techniques by a public CAT company in New Caledonia, French Polynesia and Wallis and Futuna.

(17)Cf. section 1.17.3.


1.17.6.4 Regulations concerning emergency civil air operations by helicopter

The decree of 9 August 2007 concerning the technical inspection of emergency civil air operations by helicopter applies in metropolitan France to fire fighting or fire watches. It is not applicable in New Caledonia.

The division of the duty time is based:

1. Either on a calendar week composed of day duty periods over five days followed by a recurrent rest period.2. Or on cycles, which include a succession of day duties to the exclusion of any night service up to a limit of 12 consecutive days between two recurrent rest periods. The maximum time of each cycle is 18 weeks.3. Or on cycles, which include a succession of day duties or a succession of night services up to a limit of seven consecutive days between two recurrent rest periods. The maximum time of each cycle is 12 weeks.

The activity cycles followed by Hélicocéan for the FFH activity belong to cycle 2. The flight crews subject to this work pattern benefit from a consecutive and scheduled recurrent rest period of one day for two consecutive duty days, i.e. for 12 consecutive duty days, a scheduled recurrent rest period of six consecutive days.

Whatever the work pattern followed by the flight crews, the effective flight time cannot exceed eight hours per 24 hour period, nor 35 hours per week nor 75 hours per calendar month.

With respect to the succession of several activities, it is specified that when a flight crew member ceases performing an activity covered by the scope of application of this decree to carry out another activity, s/he first benefits from the daily rest and, if applicable, the compensatory recurrent rest period specified by this decree.

When a flight crew member who has been following another work pattern is called on to perform one of the activities covered by the scope of application of this decree, the company shall ensure, before s/he is assigned to a duty period and/or an emergency civil air operation, that s/he has previously benefited from the daily rest period and, if applicable, the recurrent rest period corresponding to their former work patten, the said rest period not being less than 11 consecutive hours.

With respect to the inspection procedures, the companies are required to present, when requested by the agents of the competent inspection body, a record of the duty schedule showing, opposite each day, the name of the flight crew member, the time at which the duty period started and ended, the daily rest periods and the recurrent rest periods.


1.18 Additional information

1.18.1 Witness statements

1.18.1.1 Visual witness

A witness was observing the manoeuvres of the FFHs at the time of the accident. He was on high ground situated a little less than four kilometres north west to the accident site, from where he had an unobstructed view.

Figure 10: position of witness with respect to accident site

He explained that he arrived around 12:30 and observed the comings and goings of the two helicopters. He then left to return at around 13:15 in the hope of seeing the helicopters again. A few minutes later he heard and then saw one of the helicopters returning to the mangrove to scoop up water in the same place as previously.

He explained that he saw the helicopter repeat the same manoeuvre several times: the aircraft descended in hover towards the water surface, stabilized there for a few moments, then climbed and made a right loop before returning to the same point to start again. This manoeuvre was repeated three to four times.

He specified that he did not know if the Bambi Bucket was full as from his position, it was only a red dot. He was not certain that water had been released.

During the last manoeuvre, he saw the helicopter climb and then in all likelihood, make a right-hand turn. It seemed to him that the helicopter descended steadily.

He did not see the collision with the ground as he had looked away at that moment.


1.18.1.2 Former employers

The pilot worked for several employers in metropolitan France from 2003 to 2007; she then worked in the overseas territories. She worked both as pilot and instructor. For her successive employers and besides the training flights, her flying missions generally concerned the transporting of passengers or occasionally, aerial work without loads.

Her former employers generally underlined that she was safety conscious and did not take unnecessary risks, acting in accordance with procedures. She was described as meticulous in preparing and performing a flight and having very good flying skills for the CAT missions which had been entrusted to her.

Before arriving in New Caledonia, she had worked for a few months in Guyana from August 2014: her employer in Guyana specified that she wanted to carry out more slung-load transportation. She had thus obtained a hoisting and lifting DNC. He specified that on acquiring this DNC, she had never performed this activity in his company. He added that there was no FFH activity in Guyana.

Prior to her posting in Guyana, the pilot had spent some time in the same company in metropolitan France. The executive vice-president of this company had participated in the pilot’s integration. He underlined that she had great flying abilities and that the renewal of her TR had posed no problem.

He had then supervised her lifting DNC training to completion but had not validated it as he considered that her level of learning did not yet meet the requirements of the activity performed by the company in metropolitan France. He knew that she was going to shortly leave for Guyana where the company’s lifting activity only consisted of the transport of fuel drums and thought that she would have no difficulty in finalizing this lifting DNC adapted to the local requirements.

Her employer in Guyana added that she found the climate difficult and was tired. She left the company in December 2014.

1.18.1.3 Nouméa licensing office

The manager of the Nouméa licensing office mentioned that she had met the pilot several times in the weeks preceding the accident and in particular:

31 August 2015: issuing of “Dauphin” SA365 TR; 2 September 2015: renewal of TRI(H)(18); 4 September 2015: renewal of TRE(H)(19); 23 September 2015: renewal of FI(H)(20); 29 September 2015: registration of FI/ME(21) file.

She mentioned that on 23 September, on completion of the FI(H) test, it was initially planned to immediately renew the rating in order to carry out the FI/ME test back-to-back. The pilot seemed tired and asked for the FI/ME test to be postponed; the test ultimately took place the next day, 24 September.

She added that the pilot accumulated tests and training in addition to her professional activity and that she said that she was tired.

(18)Type Rating Instructor – Helicopter.(19)Type Rating Examiner – Helicopter.(20)Flight Instructor – Helicopter.(21)Multi-Engine.


1.18.1.4 Hélicocéan director and quality, SMS & safety manager

The company director explained that it was difficult to recruit pilots or mechanics. A lot of the personnel did not want to stay on a long-term basis in New Caledonia and the company had to rely on pilots and mechanics who temporarily came from France, on fixed-term contracts.

In the weeks preceding the recruitment of the pilot, the company found itself urgently needing to recruit a new RDFE, the previous RDFE having left several months beforehand. The pilot had already been a RDFE when previously working in Tahiti and as a result, her profile corresponded to this need.

The company’s quality, SMS & safety manager also participated in the pilot’s recruitment process. She added that the company also imperatively needed a “Dauphin” SA365 instructor in order to be able to renew the TR of the other pilots. Her instructor experience also met this need subject to appropriate training.

The director and quality, SMS & safety manager explained that the taking into account of tiredness in the company is not formalized. They added, nevertheless, that the pilot activity is monitored during the FFH duty periods in order to plan for a replacement when a certain number of flight hours have been reached. They also specified that the pilots knew that if they felt tired, they could always say it and that they would be heard.

1.18.1.5 Pilot’s friend

A helicopter pilot and instructor for another company got on well with the pilot and met her regularly. She explained that since the pilot’s arrival in New Caledonia in May, the latter had accumulated training courses in order to obtain ratings (“Dauphin” SA365, FFH) which represented an intensive workload. She also held the position of RDFE which likewise, implied a lot of work.

On completion of the training on the “Dauphin” SA365N , a few weeks before the accident, an offer was made to the pilot of becoming the local contact in New Caledonia for the ATO who had carried out her training. The pilot viewed this prospect as a consecration.

On several occasions she had had the opportunity of talking with the pilot about her knowledge of the region and aerology: the pilot did not know New Caledonia well but she felt confident because of her previous mountain flying experience, in particular in La Reunion.

After being released to FFH operations, the pilot told her that she had some apprehension about the activity but that the positive feedback after her first mission had reassured her: she still needed some practice and would have appreciated an adaptation period flying with another pilot on her first fires.

She added that the pilot had told her that relations within the company were very good and that everyone was implicated and ready to provide help and advice if necessary.


1.18.1.6 Pilot’s FFH instructor

The instructor who had given the FFH training to the pilot works in another company. He is a regular service provider at Hélicocéan.

Before the pilot’s recruitment, he had been consulted about her CV and had endorsed it. From the outset, it was intended that the pilot would become the company’s RDFE.

On the pilot’s arrival in the company, they had carried out a check flight in a pre-mountainous zone. He had then recommended furthering her training for aerial work in a mountain environment(22). This training consisted in around six to seven flight hours. He had also proposed that initially she flew with another pilot during missions to the nickel mines. These missions did not involve slung-load transportation.

The pilot’s instructor explained that this was the first time the company had recruited a new pilot in several years.

Initially, it was not intended that the pilot would carry out a sling work activity at Hélicocéan and her sling DNC obtained at a previous employer’s was not revalidated. This former sling DNC was nevertheless considered as meeting the prerequisite in the Specialized Activities Manual in order to envisage a FFH DNC. The pilot did not have previous FFH experience.

He explained that he had performed two flight hours with her to obtain the FFH DNC. These two flight hours were carried out in the vicinity of Nouméa. The FFH DNC does not include any drop on a real fire.

The preparation for the FFH DNC starts by the presentation of the different equipment: FAST Bucket and Bambi Bucket. He explained that the partial filling of the Bambi Bucket was difficult and that refuelling was carried out so that the Bambi bucket could be completely filled, which was not the case with the FAST bucket. According to him, the pilot had been taught the technique for partially filling the Bambi bucket.

He taught the practice of very partially filling the Bambi Bucket before the first scooping operation in order to check that no technical failure will prevent the water drop.

He explained the technique that he teaches: first observe the fire zone and the surrounding obstacles. Then search for a scooping point reasonably close to the fire and at a distance from obstacles such as power lines or high ground. Once the scooping point has been identified, determine the approach path which must always be the same for the subsequent scooping operations. Descend into the wind, or possibly, with a crosswind, to scoop water. When the Bambi Bucket is full, bring the helicopter into hover and check both the load indicator and the available power by reading the VEMD. Stabilize the Bambi Bucket between 50 cm and 1 m from the surface of the water using the rear-view mirror. Then bring the helicopter into a slight nose-down attitude and start moving forward into the wind by slightly increasing the power to minimize the sink. It is possible to reduce power on reaching 30 to 40 kt and the turn must never be started before a speed of around 40 kt, as the helicopter is then accelerating and climbing.

(22)The aerial work activity in a mountainous area is not the subject of a DNC.


The presence of a headwind facilitates the start of forward flight but the pilot must be very careful not to turn too early which would result in a sudden reduction in lift(23). He explained that no wind limit is defined for carrying out FFH missions. A strong steady wind may be preferable to a moderate gusty wind. If the wind is a crosswind, the pilot must turn to face the wind. If the wind is a headwind, there is no preferential side for turning.

He added that the emergency release of the Bambi Bucket was taught. He specified, however, that a pilot will generally drop the water before releasing the Bambi Bucket.

Before flight, the weight calculations can be carried out using a dedicated software which is at the pilots’ disposal. He added that he recommended giving priority to a manual calculation, on site.

According to him, the pilot flew in a smooth and calm manner. Despite the large number of flight hours that she had logged, she was discovering an activity in which she was not an expert and performed the techniques that she had been taught in a very safety-conscious way. He had not observed any deviation in her scooping technique compared with what he had taught her.

1.18.1.7 Company’s chief pilot

The chief pilot at Hélicocéan explained that the pilot’s application met a need even if her experience, mainly in CAT, meant additional training was going to be necessary. He added that experience had shown that the transition from AW to CAT was easier than the reverse.

He explained that the pilot had quickly had a busy schedule, between the missions, training (“Dauphin” SA365 TR, FFH activity, etc.) and her position as RDFE.

The pilot’s first missions on the nickel mines were difficult for her but the feedback had been positive which had reassured her(24). These missions included landing on difficult sites.

The pilot flew for 4 h 25 min in order to familiarize herself with the New Caledonia environment. These flight hours were first carried out around Nouméa, then to Koné and finally around the island.

At the time of the accident, there was no provision for dual-pilot flights after the FFH DNC.

On Friday, 2 October, the first day of the mission at Koné and two days before the accident, the pilot had sent him a SMS in order to ask about the wind limits not to be exceeded for flying to a fire. She specified that there had been a 38 kt wind and that a 40 kt wind was forecast for the following day. He replied that [a pilot] must stay within the helicopter’s and pilot’s limits. She replied that she understood, that she would go and see and if she was unable to intervene, she would advise of this. She added that she would keep safety in mind as this is what mattered to her.

He then specified that [a pilot] must always have a way out and not to hesitate to dump the water. She then replied that yes, she had thought of this twice and had been ready to do so. He added, however, that she had never told him about her apprehension with confronting fires.

(23)This sense of safety linked to the wind, combined with the risk of turning “too early” was mentioned by all the FFH pilots met during the investigation.

(24)Another of the company’s pilots specified that during her missions at the mines, the customer reports were not good because of the slowness of her manoeuvres.


The fire the day of the accident was large with a strong wind and residential areas were threatened. He explained that according to a pilot’s character, pressure may be felt about the progression of the fire. The pilot was new to the activity: wanting to do her best, she may have exceeded her limits.

He added that during FFH missions, the weight of the helicopter decreases as the mission progresses, making the work easier. Refuelling puts the pilot back into the initial conditions which can be difficult.

1.18.1.8 Civil defence officer

A civil defence officer, based at Koné, had been coordinating the aircraft fighting various fires for several days. He had boarded F-OIAO with the pilot the two days leading up to the accident.

Two days beforehand, the helicopter had been equipped with a FAST Bucket. During the afternoon, a fire had been reported in Voh. The civil defence officer had taken the mechanic’s seat in order to survey a fire zone and give instructions to the pilot. During this flight, he realised that she probably did not have FFH experience as she did not know all of the fire vocabulary.

She told him that she wanted to have someone on board with her during the FFH missions in order to find her bearings with respect to the fire and also because she did not have a lot of experience of the region. During certain phases, she would not be able to manage the radio and pilot at the same time.

He therefore decided to stay with her and participated in two water scooping and drop operations. In his opinion, the water drops were not accurate enough and lacking in effectiveness.

The day before the accident, the helicopter was equipped with a FAST Bucket again. He took off with the pilot and mechanic to carry out the reconnaissance of a fire in Ouégoa, in the north of the island. The pilot used a map to find her way and not GNSS equipment(25): he noticed that she did not know the island well and did not head in the right direction. On arriving in the vicinity of the fire, he disembarked while the pilot accompanied by the mechanic took off again to fight the fire. They then returned to Koné where they refuelled.

The civil defence officer then took off again with the pilot but without the mechanic in order to survey various fire outbreaks in the surrounding area. Shortly after, they were informed of a new fire not far from Koné and immediately intervened. He thus participated in around a dozen scooping and drop operations with the pilot. For the last scooping operation, they decided to change strategy but flew very close to a power line. They then decided to turn back.

With respect to the pilot’s scooping technique, he explained that in the previous days she always used the same technique: she positioned the helicopter in hover and then descended in order to immerse the FAST Bucket, monitoring it with the rear mirrors. She then climbed to raise the bucket out of the water and turned to the right before accelerating in the direction of the drop zone. On Friday, 2 October, the two scooping operations had been carried out with a crosswind while on Saturday, 3 October, the 12 scooping operations had been carried out with a headwind.

(25)Satellite position-ing system associat-ing various global coverage systems including the American GPS.


He had the impression that the pilot was a calm person but that she lacked experience and needed to be reassured. She seemed worried about the strength of the wind. He explained that on the day of the accident, the conditions were very windy, with wind speeds of around 65 km/h (35 kt) with strong gusts.

He specified that in the evening she had contacted her company’s chief pilot. She had then told the civil defence officer that if the wind was more than 35/40 kt the next day, she would not take off. They did not discuss the near collision with the power line and the difficulties encountered during the day.

On Sunday, 4 October, the day of the accident, the pilot took off from Koné at around 10:50 with the mechanic. The civil defence officer was already in Voh, near the fire zone. When the helicopter arrived, he boarded it to carry out an aerial survey of the fire zone and to give firefighting instructions. He then disembarked and the pilot, accompanied by the mechanic, started firefighting operations. Initially, the water drops were lacking in effectiveness as the pilot had poor visibility due to the smoke. A new aerial survey was carried out with the civil defence officer. She then took off again with the mechanic to continue the mission. The second FFH had not yet arrived.

He did not know exactly where the pilot was scooping water but he specified that there were no more than two minutes of flight time between the point where the water was collected and the fire zone. The helicopter was this time equipped with a Bambi Bucket.

When the pilot reported that she was returning to Koné to refuel, the civil defence officer asked her to come and land at Voh first so that he could board the helicopter with her and carry out a new aerial survey of the fire. After a reconnaissance flight time of around four minutes, the pilot allowed the civil defence officer to disembark and headed to Koné with the mechanic.

Later, he heard a radio message from the pilot but this message was distorted. The pilot had directly returned to the water scooping site, without making prior radio contact and without joining the civil defence officer first. Usually, the pilots returned to the civil defence officer after an interruption in order to coordinate the rest of the mission.

1.18.1.9 Bell 214 B1 crew

The pilot of the Héli-Lift Bell 214B1 was carrying out the same firefighting mission. He was not in the vicinity of Voh at the time of the accident but located the wreckage subsequently.

The pilot explained that the two crews did not scoop water in the same place so as not to hinder each other. He had not seen the pilot’s scooping technique.

Most of the Héli-Lift pilots were not French speakers and were systematically accompanied by an interpretor who also helped them with the fire fighting. The interpretor on board the Bell 214B1 that day explained that between their arrival and the departure of F-OIAO, they carried out three or four drops together. He saw the pilot scoop water twice and had not noticed anything particular in her scooping technique.

The day of the accident, the conditions were difficult as it was very windy and the presence of power lines in the fire zone complicated operations.

The interpretor remembered having a long discussion with the pilot a few weeks before the accident: he had given her information about the specific vocabulary used by firemen fighting a fire. He thought she seemed stressed as she had never done this type of work before.


1.18.1.10 Fixed-term contract pilot

Following the accident, a pilot from metropolitan France was taken on by the company on a fixed-term contract. According to him, the F-OIAO pilot had quickly taken up the position of RDFE which represents a substantial workload in addition to flying.

He explained that in New Caledonia, a civil defence fireman generally boards the FFHs in order to survey the area. He then disembarks to coordinate the fire fighting from the ground.(26)

Unlike metropolitan France, the civil defence does not have heavy water bombers such as Canadairs. The FFHs thus constitute the sole aerial firefighting means here. The FFH missions that he had carried out in New Caledonia were thus a lot longer than in metropolitan France. To illustrate this intensive activity, he said that he had totalled 1,600 scoops in seven years of activity, of which 930 scoops had been performed for the company in New Caledonia during his two fixed-term contracts of a few months.

When he worked for the company, he exclusively used a FAST Bucket, a Bambi Bucket being available as a back-up. He added that it was easier to change from a Bambi Bucket to a FAST Bucket than the reverse as the possibility provided by the FAST Bucket to release some water before gaining height facilitated the manoeuvre. It is possible to adjust the quantity of water in the Bambi Bucket but it requires experience. This adjustment can be between 80 and 100 kg. He added that the differences between the two types of equipment were not taken into account to a great extent in the company.

1.18.2 Differences between Bambi Bucket and FAST Bucket

The Bambi Bucket and the FAST Bucket are two systems for carrying and dropping water based on a similar principle with, nevertheless, notable differences. In both cases, water is scooped in a similar way and dropped using an electrically-controlled valve system.

Figure 11: Bambi Bucket/FAST Bucket

The main difference lies in the drop valve: on a FAST Bucket, the valve is continually controlled open for as long as the electrical control is depressed. On a Bambi Bucket, it is a fabric valve which opens on hitting the pushbutton once. With a FAST Bucket, the pilot can thus release water in several goes while the opening of the Bambi Bucket valve releases all of the water in one go.

(26)The pilot explained that this was not the case in metropolitan France where a firefighting officer systematically helped the pilot during FFH missions.


This FAST Bucket characteristic allows, in particular, the quantity of water scooped to be adjusted: the Operations Manual specifies that: “The volume of water carried in the FAST Bucket can be reduced by releasing some water while pulling the bucket out of the water source. With the standard system, this can be done manually by simply pressing the release switch until the desired amount of water is left in the bucket.”

With a Bambi Bucket, the pilot can also adjust the quantity of water carried, but to a lesser extent and less easily. To do this the Operations Manual specifies that “The pilot can vary the bucket’s capacity by the speed at which it is pulled from the water. As the submerged bucket is lifted, water pressure expands the fabric bucket shell and its internal fiberglass battens flex outward, increasing the bucket’s volume.” The Operations Manual specifies that “Most pilots find it takes a dozen or so fills to get the feel of variable fill action on the Bambi bucket.”

It should be noted that after the accident, the manufacturer of the FAST Bucket ceased production. The company was taken over by the manufacturer of the Bambi Bucket and the new Bambi Bucket models are now available with a continuously controlled valve system similar to that on the former FAST Buckets. Hélicocéan now uses the Bambi Buckets equipped with this latter system.

1.19 Useful or effective investigation techniques

Analysis of pilot’s work schedule with regard to regulations concerning working hours

Reference documentsAs Resolution No 77 of 16 January 1990 only deals with the case of aeroplane pilots, the New Caledonian Labour Code is thus the only regulatory reference directly applicable to helicopter flight crews in terms of working hours(27).

The Labour Code regulates the number of working hours, without making a distinction between types of activity. Thus for pilots, it makes no distinction between working hours in flight and on the ground. Resolution No 77 only regulates the activity directly linked to the performance of flights and does not take into account the working hours not linked to the flight activity. A major difference between the two regulatory references is in the weekly rest periods (24 hours in the Labour Code compared with 36 hours in Resolution No 77).

In agreement with the DAC-NC, Hélicocéan complied with Resolution No 77, considering that it provided better protection for the pilots.

The decree of 9 August 2007 is applicable in metropolitan France for FFH operations. New Caledonia did not issue a decree to make it applicable locally(28). This decree takes into account duty cycles. As this concept was absent from the Labour Code and Resolution No 77, the investigation took this decree as a basis for analysing the pilot’s schedule.

Pilot’s scheduleThe following diagram was produced using the data transmitted by Hélicocéan. It details the pilot’s activity and days off in the company from the day of her arrival. The working hours and flight hours are indicated for each period of activity between two rest periods.

(27)Cf. section 1.17.6.1.

(28)Cf. section 1.17.6.4.


Pilot's schedule since her arrival at Hélicocéan

22/5 23/5 24/5 25/5 26/5 27/5 28/5 29/5 30/5 31/5F S S M T W T F S S

1/6 2/6 3/6 4/6 5/6 6/6 7/6 8/6 9/6 10/6 11/6 12/6 13/6 14/6 15/6 16/6 17/6 18/6 19/6 20/6 21/6 22/6 23/6 24/6 25/6 26/6 27/6 28/6 29/6 30/6 1/7M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W

26h30' (of which 6 h on call) 1h2001:20

2/7 3/7 4/7 5/7 6/7 7/7 8/7 9/7 10/7 11/7 12/7 13/7 14/7 15/7 16/7 17/7 18/7 19/7 20/7 21/7 22/7 23/7 24/7 25/7 26/7 27/7 28/7 29/7 30/7T F S S M T W T F S S M T W T F S S M T W T F S S M T W T

18h

31/7 1/8 2/8 3/8 4/8 5/8 6/8 7/8 8/8 9/8 10/8 11/8 12/8 13/8 14/8 15/8 16/8 17/8 18/8 19/8 20/8 21/8 22/8 23/8 24/8 25/8 26/8 27/8 28/8 29/8F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S

53h10'

30/8 31/8 1/9 2/9 3/9 4/9 5/9 6/9 7/9 8/9 9/9 10/9 11/9 12/9 13/9 14/9 15/9 16/9 17/9 18/9 19/9 20/9 21/9 22/9 23/9 24/9 25/9 26/9 27/9 28/9 29/9 30/9 1/10S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T

9h30 duty 07:50

02:00 4h30(02:30+02:0

2/10 3/10 4/10F S S

02:45

Keydate Colour codeDay Time off

Number of hours worked between two weekly rest FHperiods (the block of colour indicates the main FFH xx:xxactivity per day) CAT xx:xxNumber of flight hours (FH) between two AW xx:xxweekly rest periods (the colour of the number Training xx:xxindicates the activity corresponding to the FH)

RDFE workInstruction

06:05 (02:10+03:

20h40 (of which 15h25' on duty)

04:35 (20'+1h20+2h55' 02:35

37h 22h0504h

23:3015:0504h25 (03:10+01:15)

05:25

25h30'

XXh (0X+ 0Y:00)

XX

07h20 (7h+ 20')

09:2534h45'

03:40 05:35

28h30' 37h14h45 (13:05+01:40)06:05 08:40

72h (of which 70h20' on duty)

48h30'

65h10' (of which 56h10' on duty)04:00 05h (01:55+01:30+01:35)

01h40

24h45

11:20

20h30' of which 7h30' on duty20h 40' of which 5h on call18h30 of which 7h30 on duty

41h15' (of which 12h on call)

16h of which 6h on call

Figure 12: Pilot’s schedule

Description of contentThe pilot’s schedule shows the following activities:

a training period on her arrival from 26 May to 4 June including the hours corresponding to the FFH DNC of 2 and 3 June;

twenty-four days of mine aerial work, principally between June and August; two FFH duty periods of eight days in July, without flying, and of seven days in August

with a flight time of 1 h 35 min on 11 August; a second training period from 19 August to 5 September; a few training flights; four FFH duty days broken up by rest, training and commercial air transport in

September with a FFH flight of two hours on 26 September; three FFH duty days at Koné on 2, 3 and 4 October.

In terms of hours, these activities represent:

working hours of around 175 h per month including the duty hours and around 130 h without the duty hours;

a maximum number of 72 working hours between two rest periods if the duty hours are taken into account or 53 h 10 min without the duty hours;

a total flight time of 110 h 10 min of which 49 h of flight training and instruction, 7 h 20 min of CAT, 41 h 35 min of AW and 12 h 15 min of FFH work.


Duty periodsThe first FFH duty period was carried out at the beginning of July. This period represented eight consecutive days, a duty time of 72 h which included flight hours of 1 h 40 min. The second FFH duty period in August represented seven consecutive days, a duty time of 65 h 10 min which included FFH flight hours of 1 h 35 min, CAT flight hours of 1 h 55 min and AW flight hours of 1 h 30 min. The first duty period was followed by four days off and the second by three days off(29).

There is no definition in the Labour Code or in Resolution No 77 of the meaning of duty, the maximum number of consecutive days and/or the associated rest periods. In the absence of this, Hélicocéan is free to define the length of the duty periods and associated rest periods. At the time of the accident, there was no information about this in the Hélicocéan OM or Specialized Activities Manual.

As a comparison, the rest periods defined in cycle 2 (the most used in metropolitan France) of the decree of 9 August 2007 are one day off for two days of duty, i.e. three and a half days for seven days of duty or three days off for six days of duty.

During the pilot’s second FFH duty week, commercial air transport and aerial work flight hours can be seen in her schedule. This succession of various activities is not covered by the texts in force. As a comparison, the decree of 9 August 2007, applicable in metropolitan France, specifies that it is mandatory to have a rest period when passing from emergency civil air operations to another activity.

Even if no regulatory framework specifies the succession of days worked/days off for the duty periods, the pilot’s first two duty periods are consistent with practices in metropolitan France and do not show anything remarkable which could have had an impact in terms of fatigue.

Weekly hours and time off in pilot’s scheduleThe Labour Code specifies a working week limit of 48 effective hours maximum and a rest period of at least 24 consecutive hours per week. Resolution No 77 requires 36 h of consecutive rest per week.

At the end of May, beginning of June, the pilot’s schedule shows a succession of four to five days of work for one to three days off in the first weeks. The working hours are less than 39 h.

From July, the schedule shows the number of hours worked as being more than 48 h per period between two rest periods and consecutive work periods of more than six days without exceptional authorization. These exceedances concern training periods.

(29)Hélicocéan specified that during these duty periods, the pilot was based at her home ready to intervene on a fire during the day.


Training periodsThe pilot’s schedule includes 18 days of training from 19 August to 29 September. From 19 August to 5 September, there are, in particular, 16 days of training over a period of 18 calendar days. The instruction and training flights continued until 19 September, broken by rest periods, FFH duty days and CAT flights.

In both the Labour Code and Resolution No 77, there is an ambiguity as to what constitutes a week. If the administrative week from Monday to Sunday is taken, the pilot did in fact have a day’s rest per week. However, if the week is taken as seven consecutive days, the days off are insufficient and the working hours too high without a specific derogation. A total training time of 53 h 10 min can be seen in the first period of seven consecutive days and of 48 h 30 min in the last seven days.

For both these theoretical and practical training periods, the audit carried out by the DAC-NC in 2011 does not provide specific information about the work and rest period rules which would be applicable. This audit only provides specific information about the AW and CAT activities.

Moreover, Resolution No 77 only takes into account flight hours and not office hours. Thus, in the pilot’s work schedule of 53 h 10 min, only 4 h 25 min are taken into account. Resolution No 77 appears to be less restrictive than the Labour Code for this point.

No specific framework limits the training periods of a helicopter pilot in New Caledonia. The training weeks performed by the pilot comprise less days off and more weekly working hours than that defined in the Labour Code if the theoretical training hours are taken into account.

Conclusion There is nothing noteworthy in the pilot’s first two duty periods in terms of fatigue. The pilot’s schedule includes exceedances of the limits defined in the Labour Code for the training periods.

The busy schedule in terms of training and the acquisition of new skills may have generated periods with a high cognitive and emotional load which could have facilitated chronic fatigue setting in and impair learning capabilities.

The duty period in which the accident occurred was preceded by several days off. The analysis of the pilot’s schedule does not reveal an activity level which could be the direct cause of acute fatigue the day of the event.


2 - ANALYSIS

2.1 Scenarios

On 2 October, the pilot accompanied by a mechanic, started a FFH duty period of five days on the Koné base. They were provided with accommodation close to the base and had all the equipment required for routine servicing and refuelling of the helicopter on site.

This was the pilot’s fourth FFH duty period and the first based outside the Hélicocéan premises(30). During the previous duty periods, she had only carried out two firefighting flights of a total time of 3 h 35 min. According to witnesses, the pilot had some apprehension about these duty periods but felt reassured by her first two firefighting interventions.

On 2 and 3 October, the pilot had fought several fires in strong wind conditions. The wind was a cause of concern for the pilot and she had contacted the company’s chief pilot asking him to specify the limits that the wind could impose. The latter had not detected that the pilot had particular worries and told her to take into account the helicopter’s limits and

Snagging of Bambi Bucket(2) in vegetation, tipping forward ...1.6.4 Bambi Bucket 15 1.7...

Documents

Transcript of Snagging of Bambi Bucket(2) in vegetation, tipping forward ...1.6.4 Bambi Bucket 15 1.7...