What happened
On 23 April 2023, an Agusta AW119 MK-II helicopter, registration VT-RNK, operated by Kestrel Aviation, was involved in a fatal ground accident at the Kedarnath helipad. The aircraft had arrived at the site to pick up three passengers, who were officials from UCADA.
Upon landing, the pilot signaled for the passengers to wait while a ground handler offloaded essential supplies from the aircraft. While the ground staff was occupied with closing the left-hand door, the passengers approached the helicopter from the front right side. During this process, one passenger moved toward the rear of the aircraft, likely attempting to reach the left side of the helicopter. In doing so, the individual came into contact with the running tail rotor, resulting in one fatality.
The investigation
AAIB India's investigation focused on the ground handling procedures and the circumstances surrounding the embarkation process. Investigators examined the operator's Standard Operating Procedures (SOPs) and the movement of personnel at the helipad.
The inquiry established that the helicopter engines remained running during the ground operations due to operational constraints, including the high altitude of the Kedarnath helipad and the need for engine cooling. The investigation also looked into the passenger briefing process and the adequacy of ground personnel available to manage the boarding of passengers.
Findings
- The primary cause of the accident was the passenger's movement into the path of the running tail rotor.
- A critical contributing factor was the lack of a safety briefing for the passengers prior to boarding, as required by established SOPs.
- The operator lacked sufficient manpower at the helipad to ensure passengers were properly escorted by dedicated staff during embarkation.
- The passengers were escorted to the aircraft by UCADA personnel rather than the operator's designated staff.
- There is currently no single entity responsible for the overall supervision of flight operations and safety at the Kedarnath helipad.
Safety action
- It is recommended that the DGCA ensure all helicopter operators strictly adhere to safety briefing protocols, ensuring all passengers are briefed in a designated area regardless of their background.
- Operators should ensure sufficient personnel are available at helipads to safely escort passengers without being distracted by other tasks.
- The DGCA should consider authorizing a specific organization to supervise flight operations at the Kedarnath helipad to improve coordination and safety.