AIR ACCIDENT INVESTIGATION CENTRAL DIRECTORATE CIVIL AVIATION AUTHORITY REPUBLIC OF SUDAN

FINAL HELICOPTER ACCIEENT REPORT Regarding the Helicopter Puma D-HAXM

LOCATION

DAYA N 13 07 53 E 24 16 52 DARFUR PROVINCE 25/01/06 10:30 UTC

DATE TIME

SYNOPSIS The helicopter Puma, D-HAXM operating with UNMIS was designated to evacuate a number of personnel of an NGO working in Darfur Province from a place called Daya on 25/01/06. After being loaded with thirteen passengers in addition to the three crew members, the helicopter started hovering and forward movement. On moving forward and being covered with dust a woofing sound was heard and the captain lowered the collective pitch in order to gain speed the helicopter started sinking and the right undercarriage struck a heap of stones and sheared off. The captain tried to put the helicopter on the ground by further lowering the collective pitch and the helicopter touch down and rested on its on its right side. The flight engineer cut off fuel from engines and immediately opened the main door and started evacuation of the passengers. During evacuation fire was being noticed started at the rear part of the helicopter and within minutes the whole helicopter was damaged by fire. Only twelve passengers and three crew members evacuated the helicopter. An Investigation Board was formed by the DGCA comprises; Engineer/ Abdelsamie Adam Ali Investigator-in-Charge Engineer/ Kamal omer Member of Board Flight safety officer from UNMIS joined the Board representing UNMIS Mr. Matt Drummond Mr. Emil Petrunov joined the Investigation Board as UN Accredited Representative. Notification was send to German CAA as country of Operator and to France BEA as country of manufacturer and to ICAO.

Factual Information Helicopter Puma SA330j, D-HAXM Two, Turmo 4 C Public Transport 1978 HELOG Lufttransport KG UNMIS ( as per release of Foreign Aircraft to operate in Sudan Certificate issued on 24/12/05 No. CAA-7-OPS 32) 25/01/06 10:30 UTC

Type and Registration of aircraft Number and Type of engines Category Year of manufacture Owner Operator

Date and time Location

Daya, Darfur Province N 13 07 53 E 24 16 52

Type of flight Persons on board Injuries Nature of damage Commanders license Commander flying experience First officer flying experience Information source

Passengers 3 Crew , 13 Passenger 1 crew minor, 1 Passenger fatal Helicopter damaged by fire ATPL 8050 hr. age 55 2500 hr. age 37 Phone call from Alfasher ATC and UNMIS Safety Officer.

1.1 History of Flight

The helicopter D-HAXM, serial number 1496 was designated to evacuate Non Government Organization (NGOs) staff from Daya to El Fasher. Evacuation order was planned at 08:30 local time on 25/01/06 and been activated at 11:45 same day to airlift 36 national NGO staff in addition to 2 international NGO staff. The Puma helicopter departed El Fasher to Daya ( N130753 E241652) and arrived at 13:10 local time. During approach the crew conducted an airborne visual reconnaissance of the site and landed the helicopter from the north direction. The flight of helicopter D-HAXM to Daya was uneventful. The helicopter landed facing south and the wind direction at that time SSE. The landing area dimensions about 60*40 meters. A school yard with two ground floor buildings located at about 50 meters from the centre of the landing area heading 80 to 120 degrees. The height of buildings about 5 meters. A clinic building of same height located 120 degrees from the centre of the landing site at approximately 180 meters ahead. Engines were kept running during boarding of passengers. Twelve passengers were allowed to board the helicopter, then another passenger was allowed to board as there was one seat available and the flight engineer accepted to take him. Temperature at that time was estimated to be above thirties by an eyewitness who was conducting the evacuation while the helicopter captain estimated the temperature about twenty four degrees. Daya elevation about 5200 feet. During hovering of the helicopter, a cloud of dust observed covering all the area around the helicopter and it could not be seen but its position was being estimated by its rotor blades and engines sound. The helicopter got off the ground about 2-3 meters as stated by the captain and gain about thirty knots forward speed. The eyewitness said he heard a whoosh noise during hovering which might be due to high pitch of blades and this was confirmed by the action of the captain on lowering the collective pitch when the helicopter was moving forward in Southerly direction at a lower altitude which assessed by the eyewitness as an up-normal. The helicopter managed to clear a school building in its pass which in the opinion of the eyewitness it was struggling to gain altitude. The altitude reached by the helicopter was not more than 20 feet. The up-normal noise continued during its forward movement. During turning to the right to face the wind the crew heard a woofing sound and the helicopter started going down and a hard tough shock was felt by the occupants and the helicopter collided with the ground lying on its right side. The flight engineer shut off the fuel cocks cutting off the fuel from engines and immediately opened the left passenger door and started evacuation of the passengers. The co-pilot escaped unassisted from the left

cabin door and assisted the captain, who was occupying the right seat, to get out from the cabin. The captain jumped on the rotating nose wheel and injured his right knee and by help of the co-pilot moved away from the helicopter. During evacuation fire was seen starting at the rear part of the fuselage. In five minutes time fire covered the whole helicopter. After boarding the passengers were not briefed on how to fasten or release the seat belts and how to act during emergency. Most of the passengers suffered to release their seat belts after impact of the helicopter with the ground. On counting the passengers one of them was found missing and was discovered being burnt, the victim was a girl. 1,2 Injuries to persons Injuries Fatal Serious Minor/none Crew None None 1 Passengers 1 None None Others None None None

1.3 Damage to Helicopter 13.1 The Helicopter wreckage The helicopter cockpit, passengers cabin and part of the tail boom were destroyed by the post impact fire. Two of the main rotor were destroyed by impact with the ground, but not damaged by the fire. One of the main blades in backward position was destroyed by fire, while only small part of another blade about 0.8 m long remained attached to the main rotor hub. There was no visible mechanical damage pre-accident. The left engine intake was clean without visible damage with compressor rotating freely. Right engine could not be accessed. The tail rotor drive shaft was destroyed by fire. The tail and intermediate gearbox transmit rotation freely. 1.4 Other damage A hut ( house) damaged in the village 1.5 Personnel Information 1.5.1 Pilot in Command Age : 55 years Nationality : French License number : 2009/84 Ratings : various types of helicopter, AL2 SE3130-318, SA330, ALIII 3160,Daulphin EC135, 120, SA365CN, Bell 47, 206, Agusta A109C, A100K2, A109E Total flying hours : 8050 hrs. Total on Type : 3700 hrs. Total on command : 5500 hrs. Total last e months : 80 hrs Total last 28 days : 16 hrs.

Total last 7 days : 5 hrs. Medical check class one valid 1.5.2 First officer ( Co-pilot) Age : 37 years Nationality : French License number : CPL 4407.00 Ratings : BO 206, S313/316/319, HU 30/50, SA330 Total flying Hours : 1650 hrs. Total on type : 90 hrs. Total on command Under supervision : 70 hrs. Total last 3 months : 40 hrs. Total last 28 days : 30 hrs. Total last 7 days : 10 hrs. Medical check class one valid Flight Engineer Age : 51 years Nationality : French License number : 008 Ratings : SA330J/BA, Super Puma, Gazelle Total flying hours : 2500 hrs. Total last 3 months : 80 hrs. Total last 28 days : 11 hrs. Total last 7 days : 11 hrs. Aircraft Information The Helicopter The helicopter Puma SA330J registration D-HAXM, serial No. 1496 was certified under the granted AOC No. D-BY235 by the Federal Republic of Germany for passengers. Mail and Medical Services and was limited to VFR flights only. The helicopter had a valid third party insurance valid up to 31/05/06. The helicopter had a valid Certificate of Airworthiness no 10043 issued by Federal Republic of Germany on 14/06/05. The helicopter empty weight 4370 Kg excluding the equipment of weight 128 Kg. The helicopter MTOW is 7400Kg at standard temperature and pressure. The helicopter was powered by two Turbomeca engines. The last maintenance check was 25 hrs. inspection carried out on 21/01/06 at 3850 flying hrs. and 9333 landings. The helicopter total flying hrs excluding the accident flying time was 3850 hrs. and 9333 landings.

1.5.3

1.6 1.6.1

1.6.2

Helicopter Engines

The helicopter was powered by two turboshaft engines of the family Turmo IV C manufactured by Turbomeca carrying serial numbers 546 and 1586. Engine No. 546 Manufacture date : 24/11/71 Flying hrs excluding the accident flight Total since new : 3914 hrs Total since overhaul : 592 hrs. Total hrs. on D-HAXM : 45 hrs. The free turbine of the engine was repaired without interruption of life on 27/06/95. On 29/11/99 it went through overhaul and on 4/7/01 the free turbine disc was repaired. The fuel control unit was repaired on 4/5/04. Engine serial No. 546 was removed from helicopter D-HAXU and fitted into helicopter D-HAXM on 05/12/05 with flying hours since overhaul of 888 hrs. Last maintenance check carried out was 25 hrs inspection on 21/01/06. Total flying hours on D-HAXM is 44:39 hrs. 1.6.1.2 Engine No. 1586 Type of engine : Turmo IV C Date of manufacture : 13 June 1978 Total flying hours excluding The accident flight since new : 4470:50 hrs. Total lying hrs. excluding the Accident flight since overhaul : 2089:33 hrs. Engine serial number 1586 was removed from D-HAXU and installed on DHAXM on 16/12/05. Total flying hours on D-HAXM 39:21 hrs. and last inspection was 25 hrs, inspection carried out on 21/01/06. 1,7 Meteorological Information Daya elevation is about 5200 feet asl. Temperature at Alfasher area at time of take off from the airport was thirty three degrees and in reference to elevation of Daya the helicopter crew estimated the temperature to be about 24 degrees while as estimated by the eyewitness to be above thirties. Wind direction was SSE with variable speed and was estimated by the first officer as of five knots speed. The helicopter landed in a SE direction . The temperature was estimated by an eyewitness to be above thirty degrees centigrade.

1.8 1.9

Aids to Navigation None at Daya Communication The helicopter was equipped with a VHF but no communication facility at Daya area

1.10

Aerodrome Information The accident site was at a remote area where there was no Aerodrome or heliport.

1.11

Flight Recorders The helicopter was equipped with one Fairchild voice recorder which was recovered from the wreckage on 26/01/06 after the arrival of the investigation board to Elfasher and was found in an acceptable condition with its connection terminals damaged by fire. Due to internal formalities within the CAA the Investigation Board could not get approval for read-out of the CVR. The CVR is kept under custody by the AAICD.

1.12

Wreckage and impact Information The helicopter cockpit, passengers cabin and part of the tail boom were destroyed by post impact fire. Two of the main rotor blades ( in forward position) are destroyed by the impact with the ground, but not damaged by fire. One of the main rotor blades in backward position is destroyed by fire, while small part of the fourth blade about 0.8 m long remained attached to the main rotor hub. The main rotor hub has no visible damage. All pins locking the attachment of the blades to the hub were on place without visible apparent damage. The case of the main gearbox was destroyed by fire and the gears were visible without damage. The air intake of the left engine is clean and the compressor rotates in both directions. The right engine intake was not accessible due to rubble remaining by post impact fire. The lever of the fuel control unit of left engine is at limit marked F. The right engine fuel control unit was not accessible due to fire wall separating the engines, but it appear that the lever is at the same position. Tail rotor drive shaft was destroyed . The intermediate gear box transmitted rotation freely in both directions. The tail rotor gear box had no damage and rotates freely. The tail rotor hub undamaged with blades attached to the hub and all wire locks are intact. The tail rotor blades were not damaged by impact. Parts of the main rotor blades honeycomb and skin were scattered on an area of about 20 meters diameters from the wreckage.

1.13 Medical and Pathological Information No medical check was carried out but only the captain was taken to the hospital for treating his injured knee. 1.14 Fire During evacuation fire was seen starting at the rear part of the helicopter and within five minutes the whole helicopter was engulfed with fire. There was no fire fighting equipment or fire fighting troops at Daya area. 1.15 Survival Aspect All on board of the helicopter could survive this accident if they were being briefed on how to fasten and release the seat belts. Most of the occupants had no idea about fastening and releasing the seat belts as they stated and this was due to the fact that boarding of passengers was carried out while engines were running and crew was under stress. 1.16 Test and Research None 1.17 Organization and Management Information The owner of the helicopter D-HAXM is HELOG Lufttransport KG . The company has a valid Air Operator Certificate issued by the German Federal Republic to conduct Commercial Air Transport in accordance with JAR OPS 3 and corresponding German rules and regulation subject to the operation specifications. HELOG operates at Sudan under UNMIS. The accident flight was being supervised by one of the UNMIS staff (Mr. Lavery) who instructed the crew to keep engines running and started boarding. He first boarded twelve passengers and then he added another passenger after consulting the flight engineer and not the captain. The circumstances of the circumstances of the accident did not show a significant deficiency in the operator safety systems. 1.18 Additional Information None 1.19 Useful or effective Investigation Techniques None.

2. ANALYSIS 2.1 General The flight of the helicopter Puma, serial number 1496, registration D-HAXM, Call sign UNO533, from El Fasher to Daya was uneventful and the helicopter landed at destination safely. The landing area was about 60*40 meters with some buildings in the path of take off. Daya area is surrounded by high ground and security at that time was considered to be unstable due to that the NGO staff had to be uplifted to El Fasher by at least two shifts. Daya elevation is about 5200 feet. Temperature at Alfasher area on 25/01/06 at time of take off from the airport was thirty three degrees and in reference to elevation of Daya the helicopter crew estimated the temperature to be about 24 degrees while as estimated by the eyewitness to be above thirties. 2.1.1 Take Off Area A school yard with two ground floor buildings located at about 50 meters from the centre of the take off area heading 80 to 120 degrees on take off path. The height of buildings about 5 meters. A clinic building of same height located 120 degrees from the centre of the flight path at approximately 180 meters ahead. There was a tree at a distance 6-8 meters on the left and back of the helicopter wreckage. Two of the branches 2-3 centimeters thick which face the apparent path of flight had fresh cut traces. The height of the tree about 4.5 meters. Parts of the main rotor blades honeycomb and skin were scattered on an area of about 20 meters diameters from the wreckage. Take off weight Referring to attachment A which was submitted by Helog company to the Investigation Board estimated the take off weight as follows :4370 Kg 128 Kg 270 Kg 780 Kg 1240 Kg -----------Total weight 6788 Kg The company estimated the weight of an adult passenger as 60 Kg, while the standard estimation by CAA Sudan Regulation ANR Part 8 Vol. 2 stated that male passenger weight 96 Kg and female passenger weight 74 Kg. Thus when taking the average weight for adult passenger as 85 Kg due to the fact that Helicopter empty weight Equipment and seats 3 crew members 13 passengers Fuel

total number of passengers was known but not their cauterization male or female, total weight of passengers was found to be 1105 Kg and therefore the take off weight for the accident flight was 7113 Kg. The crew estimated the out side temperature at Daya to be 25 degrees Celsius and density altitude to be 7250 feet even though the take off weight was more by 325 Kg. Density altitude calculation The Puma Flight manual was last amended 1998. The density altitude was calculated as per graphs on section 4 page 2 and 3 at 25 degrees Celsius. From the pressure altitude versus density altitude at 25 degrees density altitude found to be 7500 feet and at 33 degrees found to be 8375 feet. The accident sequence From the power plant limitation section 1.4 (04-85 Flight Manual, P 1) engines maximum power is obtained when both engines are at stop, at 99.8% gas generator r.p.m. If the pilot increases pitch still further, rotor speed will drop. According to the Flight Engineer statement during hovering engines speed was 99% and the pilot moved the helicopter backwards 3 to 4 meters trying to gain more distance for take off as he was aware of the school and clinic buildings in front of him and in the same time the co-pilot signalized to cars to clear the take off path. The Flight Engineer informed the captain about engines r.p.m but the captain did not take any action but moving the cyclic stick sideways. At that moment the whole helicopter was covered by thick dust. Due to the fact that boarding of passengers conducted while rotors being kept running and being done within ten minutes after landing and immediately take off was commenced the crew did not actually calculated their take off weight or brief the passengers on how to fasten or release their seat belts as stated by one of the passengers. During hovering the helicopter get off the ground about 3 to 4 meters as stated by the captain and on moving the helicopter forward gained 30 knots and then he moved the collective pitch a little pit down. The helicopter managed to clear the school buildings with difficulty while a whoosh whoosh sound was being heard from the helicopter, which indicates low rotor r.p.m and high pitch angle of blades. On turning right the helicopter went down and the right undercarriage struck a heap of stones and rolled on its right side and fire was seen initiated at the back of the passengers cabin. During investigation some branches of a tree were found having recent cuts and parts of the main rotor honeycomb were found scattered around. The height of the tree about 4.5 meters and it was just about 6-8 meters behind the helicopter wreckage and was within the flight path. The cloud of dust which covered the surrounding about the helicopter made visual reference to the horizon and vicinity difficult and disoriented the crew. As mentioned on the Flight Manual to take off from a clear heliport and to clear a 35 feet obstacle the take off clear distance should be not less than 300

meters while the available distance at the accident location area was not more than 60 meters. Looking into Flight Manual Charts regarding Pressure/Density altitude versus out side temperature for calculating the take off maximum weight ( attachment B) and the temperature/altitude graph submitted by Helog company to the Investigation Board (attachment A) and graph page 5 of Flight Manual ( section 1.3/ 04-85) it appears that loading was not properly estimated. From the above mentioned graphs ( attachment C ) in such case and at temperature of 25 degrees as estimated by the crew the maximum take off weight should not exceed 5625 KG. In addition to the wrong estimation of take off weight the crew did not study their flight path and the required distance for take off as it appears that the helicopter cleared the school and clinic buildings with difficulty and with critical height and on turning into wind the helicopter lost height due to impact of rotor blades with the branch of a tree on the left side of the flight path. The height of the cut branches about 5 meters and this indicates that that the helicopter started losing height on turning right into wind. After impact of rotor blades with the tree the helicopter went down and the right undercarriage impacted a heap of stones and was sheared off causing the helicopter to roll on its right side and crash.

3 3.1 3.1.1 3.1.2 3.1.3

CONCLUSION

Findings The crew was properly licensed The helicopter had a valid Airworthiness Certificate The helicopter had a valid certificate of Release to operate on Sudan issued by CAA (Operation and Flight Safety Directorate) Sudan. 3.1.4 UNMIS is the operator as stated by the above mentioned certificate (3.1.3) 3.1.5 The evacuation of the NGO personnel from Daya was conducted under the supervision of UNMIS representative who instructed the helicopter crew to keep engines running. 3.1.6 Boarding of passengers conducted while rotors running 3.1.7 The take off clear distance was below the helicopter requirement. 3.1.8 The helicopter during hovering was engulfed in thick cloud of dust. 3.1.9 The helicopter engines power during hovering did not exceed 99%. 3.1.10 A lady called Haga burnt to death inside the helicopter. She was one of GOAL staff.

3.2 3.2.1 3.2.2

Cause of the accident

Un proper planning of the flight from Daya and the imposed threat on the crew and the cloud of dust engulfed the helicopter disoriented the Captain in command and lead to crash. The procedure followed to evacuate and boarding of passengers with running rotors that imposed feeling of unsecured location considered to be a contributory factor to this accident.

44-1

SAFETY RECOMMENDATIONS
The Pilot-in-Command in accordance to the Air Law and Regulation is responsible for the operation of the aircraft and he/she should adhere to this. Boarding of passengers while engines are running is prohibited and should be discontinued by all operators. CAA (Operation Directorate) should not consider UNMIS as an operator when releasing aircraft leased by them to operate in Sudan. Aircraft shall operate under their Organization AOC and operation procedure.

4-2 4-3

A.A.Ali Investigator-in-Charge