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The Norwegian Accident Investigation Board (Statens havarikommisjon for Forsvaret – SHF) has highlighted the role of human and organizational factors in an incident in November 2017, when a AW101-612 rescue helicopter rolled over during start-up.
The incident occurred on Nov. 24, 2017. It involved the first Leonardo AW101 Norway had received, part of 16 helicopters intended to replace the Westland WS-61 Sea Kings in service with the Royal Norwegian Air Force (RNoAF).
The aircraft was being operated by the operational test and evaluation (OT&E) AW101 unit. Two pilots were seated in the helicopter when it rolled onto its right side outside a hangar at Sola air base, the SHF stated. While no one was injured in the incident, the platform suffered comprehensive damage.
According to the SHF, the incident occurred during a ground run of the helicopter’s engines following a compressor wash. The investigation showed that the collective was in a higher position than usual when the rotor was accelerated. This meant that “the rotor blades were at an angle of attack capable of producing a significant amount of lift,” the SHF stated. “Because the rotor was accelerated using two engines rather than one, it achieved full rotational speed. The combined forces from the main rotor and the tail rotor were sufficient to make the helicopter roll over.”
The report said that over time, ambitious timelines for the acquisition of the new rescue helicopters, combined with delays in the helicopters’ development, “created a situation of persistent time pressure for all parties involved.” This time pressure, as well as the ongoing development of the platform, the training aids and documentation, “caused challenges in regards to the training that pilots and other personnel from OT&E AW101 received from the provider.”
When combined with the fact that a number of the pilots lacked the experience and continuity that the training program was based on, this led to known and unknown shortcomings in the pilots’ skills and competencies after completing training, the report stated. “The constant demand for progress negatively affected quality assurance in various parts of the organization, and contributed to elevated and unidentified operational risk,” it added.