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Section/division Accident and Incident Investigations Division Form Number: CA 12-14a

PRELIMINARY ACCIDENT REPORT

Accident and Incident Investigations Division

Accident - Preliminary Report -

AIID Ref No: CA18/2/3/9738

Figure 1: Bell UH-H1 Helicopter type

Description: The UH-1H helicopter with registration ZS-HLP was involved in a fatal accident during fire-fighting in Vermaklikheid in the Western Cape, Republic of South Africa. The pilot who was the sole occupant on board was fatally injured and the helicopter was destroyed.

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DESCRIPTION OF ACCIDENT Reference Number : CA18/2/3/9738

Name of Owner/Operator : FFA Assets

Manufacturer : RICHARDS HEAVYLIFT HELO INC

Model : Bell UH-H1

Nationality : South African

Registration Marks : ZS-HLP

Place : Vermaaklikheid, Western Cape

Date : 23 October 2018

Time : 07:37Z

All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. Purpose of the Investigation: In terms of Regulation 12.03.1 of the Civil Aviation Regulations (CAR) 2011 this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to apportion blame or liability.

Any person who has information concerning this accident should contact the AIID on AIIDinbox@caa.co.za Investigations process:

The Accident and Incident Investigations Division (AIID) of the SACAA was informed about an Aircraft Accident, involving a Huey Helicopter UH-1H, which occurred at Vermaaklikhed, Western Cape on 23 October 2018. The occurrence was reported to the AIID Investigator on call at 0745Z on 23 October 2018. The AIID appointed an Investigator-in-charge with a second in charge. Notifications were sent to the Sate of Registry, State of Operator, State of Manufacture and Design, SACAA and NTSB, the State assigned an Accredited Representative to the Investigation. The AIID will lead the investigation and issue the Final Report. The information contained in this Preliminary Report is derived from the factual information gathered during the ongoing investigation into the Occurrence. Later Interim reports or the Final Report may contain altered information in case new evidence appears during the ongoing investigation that requires changes to the information contained in this Report. The AIID Reports are made publicly available at: http://www.caa.co.za/Pages/Accidents%20and%20Incidents/Aircraft-accident-reports.aspx

Notes: 1. Whenever the following words are mentioned in this Report with first Capital letter, they shall mean

the following:

(Accident)- this investigated accident;

(Aircraft)- the Helicopter involved in this Accident;

(Investigation)- the investigation into the circumstances of this Accident;

(Pilot) – the pilot involved in this Accident;

(Report)- this Accident Report.

2. Photos and figures used in this Report were obtained from different sources and may be adjusted from the original for the sole purpose of improving the clarity of the Report. Modifications to images used in this Report are limited to cropping, magnification, file compression, or enhancement of colour, brightness, contrast, or the addition of text boxes, arrows or lines.

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Disclaimer:

This report is produced without prejudice to the rights of the CAA, which are reserved.

Table of Contents

TABLE OF CONTENTS PAGE NO

1. Factual Information 5

1.1 History of flight 5

1.2 Injuries to personnel 6

1.3 Damage to aircraft 6

1.4 Other Damage 7

1.5 Personnel Information 7

1.6 Aircraft Information 7

1.7 Meteorological Information 8

1.8 Aids to Navigation 8

1.9 Communications. 9

1.10 Aerodrome Information 9

1.11 Flight Recorders 9

1.12 Wreckage and Impact Information 9

1.13 Media and Pathological Information 13

1.14 Fire 13

1,15 Survival Aspects 13

1.16 Tests and Research 13

1.17 Organization and Management Information 13

1.18 Additional Information 14

1.19 Useful or Effective Information 14

2 Analysis 14

3 Conclusion 14

3.1 General 14

3.2 Findings 14

3.3 Probable Cause/s 14

3.4 Contributory Factors 14

4 Safety Recommendations 14

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List of abbreviations and definitions

ABBREVIATION DEFINITION

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1. FACTUAL INFORMATION

1.1. History of Flight 1.1.1 A Huey helicopter (UH-H1) with registration ZS-HLP and a Call sign (Ch-Papa) operated by

Kishugu Aviation was engaged in a commercial fire-fighting operation in the area of Vermaaklikheid, Western Cape, when the accident occurred. Every year this fire-fighting operation takes place in the Western Cape and other affected areas around South Africa, where this type of veld fire outbreak occasionally occurs due to extreme weather temperatures or any other cause of veld fire. A dedicated team of ground fire fighters and the aircraft support deploys to assist in fire-fighting operations. The operator is based in Nelspruit, Mpumalanga province; however some of the helicopters are stationed in a few identified locations around the Western Cape Province.

1.1.2 On the day of the accident, a fixed-wing aircraft Spotter (Sp14) and a helicopter (Ch-Papa) were deployed for the fire-fighting operation in the area of Vermaaklikheid. The Spotter took off from George airport at approximately 0336Z and on arrival at the site he began with his aerial survey. The helicopter was stationed at Still Bay. The pilot completed a pre- flight inspection which was followed by a Jet A-1 fuel uplift of approximately 586 litres. The pilot took off from Still Bay, which is approximately 35km east of the Vermaaklikheid area at approximately 0415Z and headed to the firefighting operational site. Upon arrival at approximately 0440Z the helicopter landed on a dedicated landing zone around the operational area to connect the Bambi bucket. At 0450Z the helicopter took-off to commence with the firefighting operation. The operation was conducted for approximately 1 hour and 6 minutes, where after the helicopter landed at approximately 0556Z and uplifted 578 litres of Jet A1 fuel.

1.1.3 The helicopter took-off again at approximately 0650 and commenced with fire-fighting operations. During this time the helicopter was assisted by one of the residents flying a R44 helicopter, with safe operation and communication established. At approximately 0623Z, the Spotter reported that he was going to refuel at the Mossel Bay airfield. At approximately 0737Z, while airborne, the Spotter was made aware by one of the operational controllers that the helicopter ZS-HLP had crashed in the area of the operational site. At this time the R44 had also gone to refuel. During that time the R44 pilot was also informed that Ch Papa crashed at the operational site. Upon finish to refuel, the R44 pilot took off and rushed to the accident site where he found Ch Papa in flames with emergency personnel assisting.

Figure 1: Shows the helicopter as observed following the accident

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1.1.4 The eyewitness, who is also a fire fighter and was stationed near the crash site at the time, stated that at the time when the helicopter had just unloaded water over the fire line, he observed the helicopter making a 180 degrees turn towards the left , as if it was going to fetch more water. The helicopter appeared to be flying at a low level as compared to the ground level of observation; however it was flying over the ravine. He then suddenly saw the bambi bucket flying at a height above the main rotor near the tail rotor, followed by a loud bang. The helicopter began drifting towards the right. Debris were then observed separating from the helicopter. The helicopter was observed manoeuvring in the manner of an object that has lost control, with a violent shaking on the tail rotor, followed by two rolls to the right before impacting the ground. The helicopter came to a stop next to the trees and a post impact fire erupted with thick dark smoke and engulfed most of the helicopter fuselage. A couple of witnesses who were around the accident site ran towards the helicopter with the intention to assist with the rescue.

1.1.5 Emergency responders were contacted and other people who were close to the accident site

began rushing towards the crash site, where they found the pilot lying next to the burning wreckage. They pulled the pilot away from the wreckage. The emergency responders then arrived, at which time they declared the pilot fatally injured and removed him from the accident site. Later the veld fire spread towards the accident site and burned the remains of the helicopter; however part of the tail boom survived. The helicopter fire was extinguished, but later the veld fire consumed some of the wreckage at the accident site. The helicopter was destroyed by the post-impact fire and the veld fire that was in the surrounding area at the time of the accident.

1.1.6 The helicopter accident occurred during daylight visual meteorological conditions whilst in a fire-

fighting operation on a farm with GPS coordinates (S 34°19'30.88", E 0 21° 2'23.58") and a field elevation of 454ft above mean sea level.

1.2. Injuries to Persons

1.2.1 The pilot, being the sole occupant, was fatally injured during the accident sequence.

Injuries Pilot Crew Pass. Other

Fatal 1 - - -

Serious - - - -

Minor - - - -

None - - - -

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1.2 Damage to Aircraft

The helicopter was destroyed by the impact forces and a post-impact fire

Figure 2: Helicopter as it was found the next day

1.3 Other Damage 1.3.1 Limited to the vegetation in the open veld. 1.4 Personnel Information 1.4.1 The pilot joined Kishugu Aviation in 2014 as an operational pilot and he was stationed in the

area of the Western Cape. According to his colleagues, the pilot always demonstrated a high moral standard of leadership and dedication towards his duties. According to the available information, the pilot was well experienced and knowledgeable with the helicopter type’s operational limits. The pilot’s licence was revalidated on 25 May 2018 following a competency and instrument rating renewal on 17 May 2018.

Nationality South African Gender Male Age 70

Licence Number 0270015712 Licence Type Commercial pilot licence

Licence valid Yes Type Endorsed Yes

Ratings Instrument, culling, sling load, winching, instructor grade 2

Medical Expiry Date 30 November 2018

Restrictions None

Previous Accidents Corrective lenses

Flying Experience:

Total Hours 3408

Total Past 90 Days Unknown

Total on Type Past 90 Days Unknown

Total on Type Unknown

Please note the information above is as per provided by the operator based on the information contained in the available documents. The investigation team is looking for the pilots flying experience logbook which will be discussed in the final report.

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1.5 Aircraft Information

The following information was extracted from Richard’s Heavy-lift Helicopter Operator’s manual

1.5.1 The Huey UH-H1 helicopter is a Richards’s heavy-lift helicopter type, mostly used by military

and commercial operations.

Note: The certification approval and process for the type of operation will be discussed in the

final report.

Airframe:

Type Helicopter

Serial Number 68-15554

Manufacturer Richards Heavy lift Helo Inc

Date of Manufacture 1967

Total Airframe Hours (At time of Accident) 9494.8

Last MPI (Date & Hours)(Phase 1-6) 26 February 2018 9454.9

Hours since Last MPI 39.9

C of A (Expiry Date) 31 December 2018

C of R (Issue Date) (Present owner) 09 July 2012

Operating Categories 127

Engine:

Type Honeywell TS3-L-13B

Serial Number LE-15746B

Hours since New 5423.3

Hours since Overhaul 1840.8

Main Rotor:

Type Bell Helicopter 204-011-250-113

Serial Number A00000632/ A886

Hours since New 2460

Hours since Overhaul TBO not reached (Life limit of 4000hrs)

Note: Both main rotor blades serial numbers: A00000632 and A886 with 2161.0 life hours were installed on 21 June 2016 at 9195.8 airframe hours. Main rotor blades have a life limit of 4000hours.

Tail Rotor:

Type V.H.A LCC 2042200-101

Serial Number A369/ A365

Hours since New 396.6

Hours since Overhaul TBO not reached (Life limit of 2500hrs)

Note: The tail rotor blades serial numbers: A369 and A365 were installed with 0hours on 04 December 2015 at 9098.2 airframe hours during phase 5 & 6 inspection.

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1.6.2 A preliminary review of the maintenance records revealed that the helicopter scheduled

maintenance of phase 1 to 6 was conducted on the date of 26 February 2018 at 9454.9

airframe hours. The helicopter was then issued with the certificate of airworthiness, which was

to expire on 31 December 2018.

1.7 Meteorological Information

1.7.1 Meteorological information of the accident site as provided from South African Weather Service

Wind direction 350°C Wind speed 20kt Visibility CAVOK

Temperature 32 Cloud cover None Cloud base None

Dew point 04 QNH 1019hPa

1.8. Aids to Navigation

1.8.1 To be discussed in the final report.

1.9 Communications

1.9.1 The helicopter was equipped with one VHF (very high frequency) radio, as approved by the

regulator. No defects were recorded in it before the flight. According to the Spotter 14 all

operational communication was conduct through the aircrafts high frequency equipped radios.

No anomalies were experienced during operation or prior to the accident.

1.10 Aerodrome Information

1.10.1 The accident did not occur anywhere near the aerodrome. It occurred on a busy terrain with

GPS coordinates (S 34°19'30.88", E 0 21° 2'23.58") and a field elevation of 454ft above mean

sea level.

1.11 Flight Recorders

1.11.1 The helicopter was not equipped with a flight data recorder or cockpit voice recorder. Neither

was required by the relevant aviation regulations.

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1.12 Wreckage and Impact Information

1.12.1 The accident site as it was found by the investigation team following the eyewitness statement,

to reference the point of initial impact, is shown below.

The wreckage was located over a distance of approximately 150m from the ravine edge in the direction north-north westerly. Although the site was burned overnight due to the veld fire, some of the trees were bent in the direction towards where the main wreckage was found lying on its right with the fuselage burnt to ashes, facing northwest.

Figure 3: Arial view of the accident site following the accident

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Figure 4: Shows a google map view of the accident as per co-ordinated components plotting

From the initial point where the loud bang from the helicopter was heard, some of the tail rotor composite was found at the edge of the ravine.

A large piece of the main rotor composite material was found in the bush at a distance of approximately 30 metres (m) from the ravine edge towards the direction where the main wreckage was found.

At approximately 8m from the main rotor composite material, ground scar marks on the rocky surface were observed which were related to main rotor strike. This also could be associated with the large composite material of the main rotor, as found prior to the marks, which could have disintegrated due to the hard impact with the ground at high main rotor rotational energy.

Next to scar marks at approximately 12m, the left skid gear was found facing in a north-easterly direction. It had some scar marks associated with an object that was ripped from its mounting position

The left-hand side doors of the helicopter were also found around this section with signs of bending damage, as if they were pulled towards the back from their assembly position.

At this point, which was approximately 75m from the main wreckage, broken bush trees were observed along the route path of the aircraft wreckage, bending towards where the main wreckage was found. Along the path, part of the fuselage pieces was also found.

In reference to the helicopter main wreckage position, at approximately 100m near the road, a large piece of the main rotor leading edge was found hanging on the trees. Next to it was a short piece of the left-hand side step front part. The remaining large piece of the left-hand side step was found at a distance of approximately 50 m from the right-hand side of the main wreckage. The two pieces were compared for separation damage. The damage was also associated with objects cut off by a cable.

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More of the main rotor composite materials were found as we got closer to the main wreckage along the wreckage trail. The day after the accident, the wreckage was found to be mostly consumed by the veld fire by the investigating team. The following photos taken on the day of the accident were provided to the investigating team by the first people who witnessed the accident and helped to pull the pilot away from the burning wreckage. The main rotor blades with the connecting rotor head were found lying next to the main helicopter wreckage.

Figure 5: Shows the bambi bucket hanging on the main rotor blade before it was burned by veld fire.

The bambi bucket was found lying over the main rotor. Both main rotor blades composite material were disintegrated. One of the main rotors was missing a part of rotor leading edge outer piece of approximately 1.5m, which was found next to the road hanging on a tree. The damage that contributed to the separation of the main rotor piece is associated with hard contact with the ground, with main rotor high rotational energy. Further observation revealed that the same rotor blade had lost most of the composite material which was found along the wreckage trail marks. The other main rotor had bending on approximately the same point where the other piece had separated.

Figure 6: Shows the main rotor blade that has a missing piece of the outer part

The figure shows the condition of the main rotor following the accident and the condition of the main rotor after it was further destroyed by the veld fire that was ongoing in the surrounding area at the time of the accident. More evidence of the bambi bucket sling strap cover with the bucket electric wires for the release mechanism was found on the edges of the damaged piece.

More damage was observed on the tail rotor tips and the tail rotor fin. Composite materials were found around the area where the witnesses stated that they heard a loud bang when

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the helicopter was in a turn, following fire booming. The tips of both tail rotor blades were damaged in a similar manner. More composite material was found in the tail fin faring cover, which was also damaged. The tail rotor blades had damage associated with forced bending near the blade root neck.

Figure 7 Shows the damage on the tail rotor blades and the tail rotor drive shaft faring cover

The tail rotor drive shaft had broken. More evidence of the tail rotor shaft damage was observed near the engine connecting coupling which had a twisted deformation. This damage is associated with drive shaft twisting, following tail rotor impact with an object when the shaft was turning with high engine-driven power.

Figure 8: Shows the right elevator mounting position and the damaged elevator

The right-hand side elevator was damaged. Part of the outer elevator section had damage that demonstrated having been ripped from the inner part of the trailing edge through the cross section towards the outer part of the leading edge.

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Figure 9: Shows the mast assembly connecting point of the main rotor head

The mast assembly damage at the point where the main rotor head connects to the assembly has broken off and separated.

1.13 Medical and Pathological Information 1.13.1 To be discussed in the final report. 1.14 Fire 1.14.1 The post impact fire erupted and destroyed the aircraft. 1.15 Survival Aspects 1.15.1 To be discussed in the final report

1.16 Tests and Research 1.16.1 To be discussed in the final report. 1.17 Organizational and Management Information 1.17.1 The operator is one of the main operators for the Working on Fire operations. According to the

preliminary findings, the operator held a valid air service licence (ASL) issued by the Department of Transport. They also held a valid operational certificate, which was to expire on 31 December 2018. The helicopter was endorsed in their operational specification certificate under standard part 127, with the operation inclusive for the helicopter type.

1.17.2 The aircraft maintenance organisation that maintained the helicopter is operator-owned and they held a valid AMO certificate which was issued on 29 January 2018. According to the available information, the helicopter was maintained in accordance with the manufacturer’s prescribed procedure. The helicopter’s scheduled maintenance of phase 1 to 6 was conducted on 26 February 2018 at 9454.9 airframe hours. The helicopter was then issued with the certificate of airworthiness, which was to expire on 31 December 2018.

1.18 Additional Information 1.18.1 To be discussed in the executive report

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1.19 Useful or Effective Investigation Techniques 1.19.1 None 2. Findings 2.1. General

From the evidence available, the following preliminary findings were made with respect to this Accident. These shall not be read as apportioning blame or liability to any particular organisation or individual. To serve the objective of this Investigation, the following sections are included in the conclusions heading:

2.2 Findings- are statements of all significant conditions, events or circumstances in this Accident. The

findings are significant steps in this Accident sequence but they are not always causal, or indicate deficiencies.

2.2.1 The pilot was qualified and knowledgeable of the helicopter’s limitations. He held a commercial

helicopter licence with over 4000 flying hours. His licence was revalidated on 25 May 2018 following competency and instrument rating renewal on 17 May 2018. His medical certificate was valid and was to expire on 30 November 2018.

2.2.2 The pilot joined the operator in 2014 and was based in Knysna for operational requirement in the Western Cape.

2.2.3 The helicopter was issued with a certificate of registry (CoR) issued on 09 July 2012. It was

2.2.4 The helicopter was issued with a certificate of airworthiness (CoA) originally issued on 23

December 2015 with an expiry date of 31 December 2018. It was issued with no special conditions which was in contrast with the previously issued CoA.

2.2.5 The helicopter had approximately 39.9 flying hours following the major maintenance schedule

phase 1 to 6, which was conducted in accordance with the manufacturer’s prescribed procedures on 26 February 2018 at 9454.9 flying hours and will expire on 25 February 2020 or at 9604.9 flying hours.

2.2.6 The helicopter operator was issued an operating certificate (FO 12823) and was issued on 17 January 2017 and had an expiry date of 31 December 2018.

2.2.7 The helicopter was maintained by the operator-owned AMO which was issued with an approval

on 29 January 2018 and had an expiry date of 31 December 2018. 2.2.8 The maintenance records revealed that all accident-affected major parts (main rotor blades, tail

rotor blades and the mast assembly) of the helicopter were within the limits of their life span. 2.2.9 The on-site observation revealed that the tail rotor had struck the tail fin, based on the finding of

the wreckage review. 2.2.10 Also, parts of the main rotor blades composites were found near the place where the helicopter

was initially heard making a loud bang sound and along the wreckage trail.

3. Ongoing Investigation 3.1. The SACAA investigation is on-going and we will be looking into other aspects of this

occurrence, which may or may not have safety implications.