What happened
On 16 November 2020, an Airbus Helicopters MBB BK117 D-2/H145, registration EC-MJK, was performing a Helicopter Emergency Medical Service (HEMS) mission near Piera, Barcelona. The aircraft had departed from Sabadell to provide urgent medical assistance to a resident.
Upon arrival, the pilot selected a landing site in a confined area close to the patient's home. The site was characterized by several obstacles, including power lines, telephone lines, vehicles, and rubbish containers. During the landing maneuver, the pilot attempted to settle the aircraft on a terrain slope that exceeded the manufacturer's established limits. As the pilot lowered the collective to settle the aircraft, the fuselage lifted and the rotor disc lowered, causing one of the main rotor blades to strike the aircraft's upper cable cutter. The impact caused significant damage to the cable cutter, a main rotor blade, the front copilot window, and one of the skid struts. All four occupants—the pilot, a HEMS technical crew member, and two medical personnel—were unharmed.
The investigation
The CIAIAC investigation examined the flight data recorder, cockpit voice recordings, and video footage of the impact. The investigation analyzed the pilot's approach, the suitability of the chosen landing site, and the crew's performance.
Investigators determined that while the pilot performed an adequate high-altitude reconnaissance, the low-altitude reconnaissance was incomplete. The investigation also reviewed the pilot's training, noting that recurrent training for slope landings was conducted exclusively via flight simulators. Furthermore, the investigation looked into the crew's coordination, noting that the technical crew member was managing communications with the emergency center, which was outside his primary responsibilities.
Findings
- The chosen landing site was a confined area with a slope exceeding the limits established by the manufacturer.
- The dimensions of the landing area were smaller than the minimum requirements established by the operator.
- The pilot ignored multiple audible "MAST MOMENT" warnings during the landing sequence.
- The pilot attempted to settle the aircraft on a slope that was too steep, leading to the rotor blade strike.
- The crew'1s focus was heavily divided by the need to monitor numerous ground obstacles, including cables and bins, which contributed to a loss of situational awareness regarding the terrain slope.
- The pilot prioritized proximity to the patient over the safety of the landing site, ruling out a safer, nearby football field to avoid delaying medical treatment.