What happened
On 12 August 2022, an AW109SP helicopter, registration G-TAAS, was performing a commercial air transport mission to transfer medical personnel and a patient between hospitals. The flight departed Bristol earlier than scheduled because the medical team was ready ahead of time. During the flight, a passenger used a messaging application to notify the company's 'airdesk' of the departure. However, this message was not received until after the aircraft had already landed in Cardiff.
Because the airdesk was unaware the aircraft was en route, the Cardiff hospital was not notified to prepare the landing site. The helicopter arrived at the elevated helipad nine minutes ahead of its original estimated time. As the pilot transitioned into a hover over the pad, it became apparent that the required firefighting personnel were absent and the pad lights were extinguished. Despite these missing safety indicators, the pilot decided to proceed with the landing, judging that completing the touchdown from a stable hover was safer than performing a go-around.
The investigation
The investigation examined the communication protocols between the flight crew, the airdesk, and the hospital. It established that the use of a messaging app for departure notifications was unreliable for real-time flight following. Furthermore, the investigation looked into the site-specific procedures for the Cardiff hospital helipad and the operator's instructions for landing at elevated sites.
It was found that while the operator's general instructions required pilots to ensure a site was manned or lit, the specific procedures provided by both the hospital and the operator did not sufficiently emphasise how a pilot should visually confirm the site was prepared. Additionally, the investigation noted a lack of a formal mechanism for hospitals to disseminate specific landing procedures to all potential external operators.
Findings
- The primary cause of the lack of site preparation was the use of an unreliable communication method and the delayed receipt of the departure notification.
- The pilot did not verify the readiness of the helipad during the approach phase.
- The absence of firefighting personnel and the lack of traffic and pedestrian management at the site created a safety risk.
- Site-specific documentation failed to clearly instruct pilots on the specific cues needed to confirm the helipad was prepared.
Safety action
- The operator has reviewed its surveys for all elevated landing sites and intends to reissue them with more specific guidance for each location, following consultation with relevant hospitals.