What aircraft was involved and where did it happen?

The accident on 2022-12-05 involved a Bell 206, registration PK-CDO, operated by Carpediem Aviasi Mandiri, at Mining 01 Helipad, Tanah Merah, Papua, ID.

What was the probable cause of the accident?

The accident was caused by the lack of perimeter control and movement monitoring at the landing site, which permitted a local resident to enter the tail rotor's danger zone unnoticed.

Fatal Tail Rotor Strike During Cargo Unloading in Papua

A local resident was fatally injured after approaching the tail rotor of a Bell 206 B3 during an unscheduled cargo flight in Indonesia.

What happened

On 5 December 2022, a Bell 206 B3 helicopter, registration PK-CDO, operated by PT Carpediem Aviasi Mandiri, was conducting unscheduled cargo operations in the Papua region of Indonesia. After completing several successful landings in the Kampung Kawe area, the aircraft proceeded to a landing site at Mining 1, located on an unpaved road within a residential settlement.

During the unloading of cargo, the pilot kept the engine running while remaining inside the cockpit. The Helicopter Landing Officer (HLO) disembarked to manage the cargo. While the unloading process was underway, a loud impact was heard from the rear of the aircraft. The HLO discovered a person lying on the ground near the tail section. Simultaneously, several local residents began running away from the aircraft, leading the HLO to believe a security threat was developing. Fearing for their safety, the HLO instructed the pilot to depart immediately. During the subsequent takeoff, the pilot noted the baggage door was unsecured, but because no other systems showed abnormalities, the crew decided to return to Iwot Helipad. Upon landing and shutting down the engines, the crew discovered significant damage to the tail rotor blades. It was later confirmed that a local resident had approached the aircraft with the intent to board, inadvertently striking the rotating blades, which resulted in one fatality.

The investigation

The KNKT investigation focused on the management of ground movement and risk assessment during remote operations. Investigators examined the aircraft's maintenance records, the pilot's flight history, and the operator's safety management systems. The inquiry reviewed the company's Hazard Identification and Risk Assessment (HIRA) for operations in Papua, which had previously identified the presence of people near the aircraft as a significant hazard. The investigation also looked into the operational procedures used during cargo unloading at unpaved, non-permanent landing sites.

Findings

The primary cause of the accident was the absence of access restrictions and inadequate monitoring of the helicopter's rear area, which allowed a resident to approach the aircraft unaware of the tail rotor's rotation.
While the operator's HIRA had identified the risk of personnel injury, the necessary mitigation strategies—such as utilizing ground personnel to monitor movement—were not integrated into specific operational procedures for the pilot or HLO.
The landing site at Mining 1 lacked the infrastructure to control public access, and the HLO was unable to maintain a clear line of sight to the tail rotor while simultaneously managing cargo unloading.

Safety action

Following the accident, the aircraft operator issued safety notices to all personnel regarding the dangers of the tail rotor area and the importance of thorough pre-flight planning. The KNKT issued safety recommendations urging the operator to ensure that all identified risk mitigations from HIRA processes are formally implemented into detailed operational guidance and to conduct site-specific risk assessments for all flight routes.