What happened
On March 6, 2003, at 16:50 local time, an Aerospatiale SA-365-C2 helicopter, operating as an air ambulance for the 112 SOS-Galicia emergency service, departed from Santiago de Compostela to provide medical assistance to a patient suffering from a heart attack. The flight lasted approximately nine minutes.
The destination was a flat area in the municipality of Oroso, characterized by trees roughly five meters high and nearby electrical power lines. During the landing maneuver, the pilot attempted to hover at an altitude of less than one meter to bring the medical team as close to the patient as possible. During this low-altitude approach, the main rotor blades contacted vegetation on the left side of the aircraft's forward path, resulting in abrasions to the blades. The aircraft landed safely, and all 4 occupants—the pilot, a trainee pilot, a doctor, and a nurse—remained uninjured.
The investigation
The investigation focused on the operational decision-making during the landing and the crew's role in obstacle monitoring. The landing site was near the minimum dimensions required by the operator's HEMS manual, which specifies a clearance area of two rotor diameters.
The investigation examined the crew composition, noting that while the pilot in command was fully qualified, the second pilot was a trainee without a type rating for the SA-3ively-365-C2. Additionally, although the medical staff was on board, they were not acting as HEMS crew members for this specific flight and therefore had no assigned duties regarding flight support or obstacle monitoring.
Findings
- The primary cause of the incident was the pilot's failure to maintain adequate separation from obstacles during the landing maneuver.
- The pilot's decision to approach the patient closely may have been driven by an excess of confidence or a desire to minimize the medical team's walking distance, potentially leading to an underestimation of the risks.
- The pilot's position in the right-hand seat made it difficult to perceive obstacles on the left side of the aircraft once they had been passed.
- The lack of active monitoring by the trainee pilot and the medical staff, who were not performing designated HEMS crew duties, contributed to the lack of situational awareness regarding the nearby trees.