What happened
On July 16, 2018, at approximately 23:00 local time, an Agusta AW139 helicopter, registration EC-KLM, was conducting scheduled night training exercises off the coast of Alboraya, Valencia. The mission, operated by Babcock Mission Critical Services, was designed to maintain the crew's qualifications for maritime survivor rescue.
While the aircraft was in a stationary hover approximately 50 feet above a practice sailboat, the rescue technician began the deployment maneuver. As the technician moved toward the exit, they fell into the sea. The fall occurred because the technician's harness was not properly connected to the hoist hook. The impact with the water caused a compression fracture of the T12 vertebra, resulting in one serious injury and requiring several days of hospitalization.
The investigation
The CIAIAC investigation focused on the actions of the crew members in the cargo cabin, specifically the hoist operator and the rescue technician. The investigation examined the adherence to standard operating procedures (SOPs) during the deployment of the rescuer.
Investigators reviewed the lighting conditions within the cargo cabin, the coordination between the crew, and the technician's use of signaling equipment. The inquiry also looked into the physiological state of the crew, noting that the technician had recently transitioned from day shifts to night shifts, which may have impacted reaction times and attention levels.
Findings
- The primary cause of the accident was the failure to connect the rescuer's hook to the hoist during the deployment process.
- The crew in the cargo cabin failed to adhere to established operator procedures, specifically regarding the verification of the lifeline connection and the positioning of the rescuer at the door.
- There was evidence of a lack of attention or relaxation of standards, likely due to the training nature of the flight.
- Inadequate lighting within the cargo cabin may have increased workload and reduced the crew's ability to perceive critical details.
- The rescue technician's use of signaling equipment was suboptimal; the helmet strobe light was not activated prior to the fall, and the technician was unable to activate the life jacket strobe due to the physical impact and the inflation of the vest.
- The technician's recent shift change from day to night operations may have contributed to decreased attention and increased reaction times.