In-flight oxygen valve failure causes helicopter fire during medical evacuation

Casualties unknown • Cabra (Córdoba), ES

A medical evacuation helicopter was destroyed by a fire caused by an oxygen cylinder valve failure during engine start-up in Cabra, Spain.

What happened

On August 10, 2024, at approximately 20:15 UTC, a LEONARDO A109S helicopter, registration EC-NRI, operating as a HEMS (Helicopter Emergency Medical Service) flight, was involved in an accident at a sports field in Cabra, Córdoba. The aircraft, operated by AVINCIS, had landed to collect a patient suffering from a myocardial infarction.

After the patient was loaded and the stretcher secured, the pilot began the engine start sequence. During this time, a medical professional attempted to administer oxygen to the patient. Upon opening the valve of an oxygen cylinder, a sound similar to a deflagration occurred, immediately triggering a fire in the left side of the cabin.

The crew and medical personnel attempted an emergency evacuation. The HEMS crew member attempted to release the stretcher from its mountings despite the flames, eventually managing to free the patient's torso, though the patient's legs remained momentarily trapped. The patient, the crew member, and a medical professional all sustained severe injuries (burns). The pilot and the doctor were uninjured. The aircraft was destroyed by the fire, and the incident caused damage to the artificial turf of the sports field.

The investigation

Investigators utilized crew testimony and surveillance footage from the sports complex to pinpoint the fire's origin. The fire started inside the cabin, specifically in the area between the left front seatback and the front of the stretcher, where the oxygen therapy system was located.

The medical equipment used was an Aerolite HEMS kit, which utilized a 5-liter Takeo B5 oxygen cylinder manufactured by Air Liquide Medical Systems (ALMS). The investigation focused on the remains of the oxygen cylinders, which were sent to a laboratory in France for examination.

Findings

Laboratory analysis of the cylinder remains concluded that the fire originated within the valve of the Takeo B5 cylinder, specifically at the distribution valve, before spreading to the pressure regulator and the 4-bar pressure outlet.

Investigators determined that the most probable ignition mechanism was heating caused by oxygen flow friction, although the possibility of ignition via particle impact has not been ruled out. While the origin and ignition mechanism were identified, the total destruction of the aircraft prevented investigators from determining what caused the high oxygen flow rate that led to the event.

Probable cause

The fire was caused by a failure within the distribution valve of an oxygen cylinder, likely ignited by heat generated from oxygen flow friction or a particle impact.

Frequently asked questions

What happened in the 2024-08-10 LEONARDO A109 accident near Cabra (Córdoba), ES?

A medical evacuation helicopter was destroyed by a fire caused by an oxygen cylinder valve failure during engine start-up in Cabra, Spain.

What aircraft was involved and where did it happen?

The accident on 2024-08-10 involved a LEONARDO A109, registration EC-NRI, at Cabra (Córdoba), ES.

What was the probable cause of the accident?

The fire was caused by a failure within the distribution valve of an oxygen cylinder, likely ignited by heat generated from oxygen flow friction or a particle impact.

Investigation report by the Spanish Civil Aviation Accident and Incident Investigation Commission (CIAIAC). Original record: https://www.transportes.gob.es/recursos_mfom/comodin/recursos/a-024-2024_dp_nm.pdf. This page is a structured re-presentation; facts and quotes are in the Comision de Investigacion de Accidentes e Incidentes de Aviacion Civil (CIAIAC), Spain - Ministerio de Transportes y Movilidad Sostenible.

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