What happened
On the night of November 24, 2002, a Bell 412 helicopter departed from Berlin Tempelhof on an emergency medical mission to Pritzwalk-Sommersberg. The crew, consisting of a pilot, copilot, emergency physician, and paramedic, intended to transport a critically ill patient to Potsdam. The flight was conducted under Visual Flight Rules (VFR).
As the helicopter approached the landing site, the pilot requested that an awaiting emergency vehicle activate its blue lights to illuminate the landing area. The pilot began a maneuver to fly around the airfield to establish a landing course. During this process, the aircraft was traveling at approximately 110 knots at an altitude of about 350 feet above the ground. Realizing that the high forward speed made an immediate landing impossible, the pilot attempted a right-hand turn to reduce speed.
During the turn, the helicopter entered a bank of fog that had not been previously detected. The pilot attempted to recover from the turn and increase power to arrest a descent, but at 22:16, the aircraft struck the ground at high speed and overturned. The impact caused the aircraft to catch fire and burn completely. The copilot sustained a fatal head injury, while the pilot and the two medical crew members were three persons seriously injured but managed to escape the wreckage.
The investigation
The BFU investigation examined the aircraft's maintenance records, which showed no technical defects or structural failures prior to the accident. The investigation also reviewed meteorological data, confirming that while the weather at the start of the flight was acceptable, localized fog and low visibility were present at the destination. The investigators also analyzed the company's operational manuals and the crew's performance of coordination and communication tasks during the approach.
Findings
- The landing approach was not stabilized, as the crew failed to use available technical equipment and navigation aids effectively to maintain a controlled descent.
- The crew decided to continue the approach despite visibility falling below the required minimums and a lack of sufficient visual references on the poorly illuminated landing site.
- The company's flight operations manual lacked adequate procedures for night VFR operations and did not provide specific guidance for landing on poorly lit surfaces.
- There was a failure in Crew Resource Management (CRM), as the crew did not effectively implement coordination procedures or utilize all available cockpit resources to analyze the deteriorating situation.
- The pilot's decision to attempt a high-speed maneuvering turn to reduce speed was unsuitable for maintaining a safe margin of safety during the approach.