Start-up procedure oversight on S-92A helicopter

No fatalities • Broome, Western Australia

A lack of specific call-out procedures and pilot unfamiliarity with certain start-up requirements led to an incident involving the collective lever on an S-92A.

What happened

During a morning shift, the flight crew experienced significant time pressure due to an unexpected increase in workload, which reduced the time available for flight planning. This pressure was noted by the crew prior to the flight. During the start-up sequence of the S-92A, the collective was not lowered at the required time.

The investigation

The investigation focused on the crew's workload and the specific operational requirements of the aircraft. It was noted that the Pilot Monitoring (PM) was performing their first flight in this specific role on the S-92A. This particular aircraft model required the collective to be lowered during start-up, a task the PM had not previously performed in this role. Furthermore, the operator's fleet did not include other helicopters that required this specific start-up action.

While the operator's standard operating procedures mandated that the collective be lowered, the investigation found that there was no requirement for a verbal call-out to verify the position of the lever. The investigation also examined the division of labour, noting that while the crew had discussed responsibilities, the operator's documentation lacked a specific division of tasks between the Pilot Flying (PF) and the PM during start-up.

Findings

  • The flight crew faced increasing time pressure due to an unexpected workload.
  • The PM's unfamiliarity with the S-92A start-up procedure, specifically regarding the lowering of the collective, contributed to the error.
  • The absence of a mandatory call-out in the operator's procedures meant there was no secondary check to verify the collective position.
  • The operator's documentation did not explicitly define the division of tasks between the PF and PM during the start-up phase.

Probable cause

The incident was driven by time pressure on the crew and the PM's lack of experience with the S-92A's unique start-up requirements, compounded by a lack of mandatory verbal verification procedures.

Frequently asked questions

What happened in the 2016-11-10 Sikorsky Aircraft S-92A accident near Broome, Western Australia?

A lack of specific call-out procedures and pilot unfamiliarity with certain start-up requirements led to an incident involving the collective lever on an S-92A.

Were there any fatalities in the 2016-11-10 Sikorsky Aircraft S-92A accident?

No fatalities were recorded in this accident.

What aircraft was involved and where did it happen?

The accident on 2016-11-10 involved a Sikorsky Aircraft S-92A, registration VH-ZUQ, at Broome, Western Australia.

What was the probable cause of the accident?

The incident was driven by time pressure on the crew and the PM's lack of experience with the S-92A's unique start-up requirements, compounded by a lack of mandatory verbal verification procedures.

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