FLIGHT SAFETY F O U N D AT I O N

HELICOPTER SAFETY
Vol. 31 No. 6 For Everyone Concerned With the Safety of Flight November–December 2005

Inconsistent Placement of External-cargo Release

Switches Can Hinder Emergency Landings
In its final report on the fatal accident of a Bell 204B during a fire fighting flight, the
Transportation Safety Board of Canada said that the absence of a standard location for the
external-cargo release switch ‘increases the risk of pilot confusion during an emergency.’

FSF Editorial Staff

The pilot of a Bell 204B fire fighting helicopter The helicopter struck the ground in a wooded area
was unable to complete an emergency landing in near a small clearing next to a fire road about 0.25
part because he could not release a long line that nautical mile (0.46 kilometer) southeast of the
had become entangled in trees, the Transportation staging site on a heading “approximately 160 degrees
Safety Board of Canada (TSB) said in its final report greater than the departure heading,” the report said.
on the fatal accident.1 A post-impact fire destroyed the helicopter cabin.
The braided-fabric long line was found wrapped
The report said that the Aug. 17, 2003, accident at around a tree and extended “in a direct line to the
Bonaparte Lake, British Columbia, was caused by helicopter”; the top 15 feet (five meters) of the long
an engine failure resulting from an imbalance of the line was burned away, the report said. The water
engine compressor rotor assembly. The TSB did not bucket, which had separated from the long line, was
determine the cause of the imbalance. After the engine found in another tree.
failure, a “combination of altitude, terrain features
and the trailing long line negatively affected the Four days before the accident, after completing his
pilot’s ability to complete a successful emergency landing in daily flights, the accident pilot had flown the helicopter to
autorotation,” the report said. Kamloops, British Columbia, where company maintenance
personnel replaced the helicopter’s engine and transmission.
The helicopter was destroyed in the accident and the subsequent At the time, the airframe had accumulated 11,539 flight hours,
fire, and the pilot — the only person in the helicopter — was and the engine and the transmission were due for overhauls.
killed.
Maintenance personnel installed a Honeywell (Lycoming) T53-
The accident occurred during the first flight of the day, soon after 11B engine assembly, which had a total time of 7,398 flight
the pilot conducted a departure to the east from a staging site at hours since new and zero hours since overhaul, the report said.
about 1105 local time; an empty water bucket was at the end of the Maintenance personnel also installed a new Bell Helicopter
100-foot (31-meter) long line. Soon after takeoff, the helicopter Textron transmission assembly (part no. 204-040-009-087),
emitted a “high-pitched, oscillating sound,” the report said. which had a total time of 6,808 flight hours since new and 397
flight hours since overhaul.
“The flight path and behavior of the helicopter were normal as it
went out of view over some trees. Immediately thereafter, there The new engine and transmission were tested, adjustments were
was the pronounced sound of main-rotor-blade slap, followed made and, on Aug. 15, a test flight was conducted. Data obtained
by the sounds of impact with the trees.” during the test flight and entered in maintenance records showed
 that the engine was operating at an N1 speed2 that was 2.3 overspeed limit, and it appears to produce all desirable effects
percent below the allowable limit of 93.3 percent and that the — that is, more power while apparently remaining within the
exhaust gas temperature (EGT), which had an allowable limit allowable engine torque and EGT parameters. Without the
of 590 degrees Celsius (C; 1,094 degrees Fahrenheit [F]), was confirmation of an N1 topping check after an adjustment, it is
below the limit at 530 degrees C (986 degrees F). not known whether the N1 speed is within specifications.”

The data were recorded in the journey log as a method of On Aug. 16, the helicopter was returned to the staging site and
estimating engine power output and tracking engine performance. was flown for 8.8 flight hours. During that time, the pilot made
The N1 check (N1 topping check) was required to “confirm that several reports indicating that operations were normal; this
the engine achieves the rated performance without exceeding its indicated that the N1 adjustment apparently was beneficial.
engine data plate placard limit,” the report said.
“However, if the N1 was above specification, excessive T5
The pilot signed the journey log — a requirement in approving [turbine inlet] temperatures could result in a degradation of
the helicopter for further flight. the hot section components,” the report said.

Contrary to instructions in the Honeywell (Lycoming) engine At the end of the workday on Aug. 16, the helicopter was
maintenance manual, an engine-vibration check — a method returned to Kamloops, where it was refueled with 563 liters
of checking alignment of the engine and transmission and of (149 U.S. gallons) of Jet A fuel. (The helicopter’s maximum
detecting engine damage — was not conducted before the fuel capacity was 915 liters [242 U.S. gallons]).
helicopter was returned to service on Aug. 15 in fire fighting
operations at Bonaparte Lake.
Pilot Was Hired as Temporary Worker
“After about 20 minutes of working, the pilot relayed a
The accident pilot held an airline transport pilot certificate, with
message to the maintenance crew in Kamloops, requesting
a helicopter rating. He had about 7,500 flight hours, including
that the engine-vibration test equipment be kept,” the report
200 flight hours in Bell 204 helicopters in the 90 days before
said. “Another 30 minutes later, the pilot reported to the
the accident, and had completed a proficiency check in the Bell
British Columbia Forest Service office that the helicopter was
204 in June 2003. He had flown the accident helicopter during
unserviceable, and he returned to Kamloops.”
the last two weeks of June and again beginning Aug. 13.
The pilot said that a cowling was “buzzing” and that the
He was hired by Gemini Helicopters for a temporary assignment
engine was not producing enough power to lift the load;
to provide relief for the pilot who usually flew the helicopter.
as a result, main-rotor revolutions per minute (rpm) was
The report provided no other information about the pilot.
“drooping.” (Drooping is a reduction of the main-rotor rpm
and mechanically linked power turbine [N2] because the engine
The helicopter had been flown for nearly 11 flight hours after
is unable to sustain the existing load, the report said.)
installation of the transmission and engine.
An engine-vibration check then was conducted; it showed that
Regulations did not require the helicopter to be equipped
the engine was operating within specifications.
with a flight data recorder or a cockpit voice recorder, and the
helicopter had neither.
“The failure to perform a vibration check at initial installation,
therefore, had no bearing on the subject failure, since a vibration
check was conducted with no problems being indicated Density Altitude Estimated at 5,900 Feet
approximately 50 flying minutes after engine installation,”
the report said. At the time of the accident, a British Columbia Forest Service
weather observation at an area 14 nautical miles (26 kilometers)
After the vibration check, maintenance personnel increased southwest of the accident site included a temperature of 20
the N1 takeoff-trim setting in an attempt to correct the power degrees C (68 degrees F), with variable winds up to eight knots.
problem and the drooping problem; no records were provided The temperature at the staging site, located at 4,500 feet, was
for the N1 topping check. estimated at about 19 degrees C (66 degrees F). The report said
that the pressure altitude was about 4,620 feet and the density
“It is known that the N1 speed was established to be 97.6 percent altitude was about 5,900 feet.
at the overhaul facility, and this was the placard setting at which
the engine produced its full-rated horsepower under international Neither weight nor center of gravity was considered a factor in
standard atmosphere conditions at sea level,” the report said. “By the accident. The helicopter’s weight at the time of the accident
providing a physical restriction to fuel flow, the takeoff trim setting was estimated at 3,548 kilograms (7,822 pounds). The gross
is the N1 overspeed-protection device. It is possible to operate takeoff weight for external-load operations was 4.309 kilograms
the engine at higher N1 speeds, approaching the compressor (9,500 pounds).

2 FLIGHT SAFETY FOUNDATION • HELICOPTER SAFETY • NOVEMBER–DECEMBER 2005

 ‘Vertical Reference Kit’ by the little finger of the pilot’s right hand, was used to release
the external-cargo hook,” the report said. “This helicopter was
Had Been Installed configured differently. Although the pilot knew that the external-
cargo-hook-release switch position had been changed, and he
The accident helicopter was equipped with a “vertical reference
had used this system for two weeks in June and again for two
kit” to allow single-pilot operation from the left seat for long
days in August prior to the accident, it was not what he was
line operations. The vertical reference kit included a third foot
accustomed to.
pedal for release of the external-cargo hook, located on the
helicopter’s belly, to which the long line was attached. Within
“Studies in human behavior suggest that, among other variables,
the long line were two electrical wires that supplied the power
relative and finite amounts of practice influence which automatic
required to operate either the remote hook, located at the end
behavior occurs in an emergency situation; the more practiced
of the long line, or the bucket water-release mechanism; in
behavior will be the default behavior.”
the accident helicopter, the electrical wires were connected
to the bucket water-release mechanism. This disarmed the
The studies found that a new behavior (such as activating a
remote hook, which was not required for the operation or for
release switch with the thumb instead of with the little finger)
emergency purposes.
would not become automatic until the pilot had practiced with
the new switch configuration “for 30 days, or 85 hours, or
A standard electrical extension cord was attached to the long
1,000 repetitions or more,” the report said. “With less practice,
line. The extension cord was intended to supply electrical power
it would be difficult for the pilot to automatically and correctly
from a control box between the pilot seats to a foam-injection
select the appropriate switch to jettison the external load from
pump in the water bucket.
the helicopter.”
However, the report said, “The bucket was not equipped with
In most emergencies, the long line is released from the
such a pump, and, therefore, this cord was not serving any
external-cargo hook. Sometimes, however, the release cannot
purpose.”
be accomplished because of complicating factors, such as
insufficient time, low altitude, terrain, type of emergency and
After the accident, an examination of the external-load system
pilot familiarity with the release system. Examination of the
found that the water bucket had separated from the remote
wreckage showed that the long line had not been released and
hook. The remote hook apparently was not damaged, and tests
that it had become entangled in a tree during the attempted
found that the remote hook could be operated both manually
emergency landing. Investigators did not determine whether
and electrically. On the bucket assembly, the control head and
the pilot had attempted to release the long line or whether the
its attached shackle also appeared undamaged.
quick-release system was serviceable.
Canadian Aviation Regulations Part 527.865 and Part 529.865
“It was learned that the pilot’s normal practice was to operate
require a primary quick-release system for the external-cargo
the helicopter with the external-cargo-hook switch in the
hook, but the regulations do not specify which of five switches
armed position; however, damage prevented investigators from
typically found on the cyclic control grip of many helicopters
determining the position of this switch,” the report said.
should be configured as the quick-release switch.

“There is no common design among manufacturers and No Explanation for

operators to configure the function of these switches to suit
their types of external-load operations,” the report said.
Imbalance in Rotor Assembly

The operator of the accident helicopter — in response to another Examination of the engine revealed that the engine had failed
pilot’s preference — had reconfigured three switches on the grip because of an imbalance of the compressor rotor assembly,
so that the middle switch (activated by the thumb) controlled which led to contact between the rotor assembly and stator
the external-cargo release switch. Two other switches (the top assemblies; this contact caused the destruction of the rotor
switch, which also was activated by the thumb, and the bottom assembly. The report said that the investigation reached no
switch, which was activated by the little finger) controlled the conclusion about the cause of the rotor assembly imbalance.
bucket-water release mechanism.
The report said that the investigation’s findings as to risk
included the following:
‘Not What He Was Accustomed To’
• “Some procedures used in the engine overhaul process
“Most of the pilot’s experience consisted of long line operations, were not in accordance with the manufacturer’s overhaul
and records of the pilot’s flight time indicate that at least 2,700 manual; failure to comply with the manufacturer’s
[flight] hours of his most recent experience involved the use of instructions could compromise the integrity of the
cyclic grip configurations in which the bottom switch, operated assembly and result in failure; [and,]

FLIGHT SAFETY FOUNDATION • HELICOPTER SAFETY • NOVEMBER–DECEMBER 2005 3

 • “Field adjustments to the engine fuel control takeoff to remove one foot from a primary flight control during an
trim without the confirmation of an N1 topping check emergency, the report said in its findings as to risk.
for accuracy introduces a risk of frequent or continuous
operations at gas-generator speeds and internal After the accident, the operator standardized the location
temperatures beyond established limits.” of the switches on the cyclic grips in its helicopters (except
in its Robinson R44s, which are “incompatible for such a
The position of the wreckage indicated that the pilot probably modification,” the report said).
detected a problem and was attempting to return the helicopter
to the staging site when the accident occurred, the report In addition, the operator installed emergency release switches
said. on the collective in its Eurocopter AS 350s and “is searching
for supplemental type certificates applicable to the rest of its
“It is highly likely that the pilot had yet to change his automatic fleet,” the report said. “The rationale is that the emergency
behavior and activate the external-cargo release switch in the release systems (isolated pull handles or foot pedals) in the
‘new’ location in an emergency,” the report said. “Therefore, it other aircraft also require the use of either hands or feet to
is probable that the pilot’s action during the emergency did not operate; therefore, requiring the pilot to let go of a flight control
activate the external-cargo-hook release mechanism and, rather, to release an external load via the manual release. With the
that the trailing long line snagged a tree while the helicopter manual release on the collective, activation is possible without
was still airborne. This factor was an additional complication requiring pilots to remove their hands or feet from primary
to the survivability aspects of this accident.” flight controls.”♦

In its findings as to risk, the report said that the “inconsistent

Notes
placement” of the external-cargo release switch “increases the
risk of pilot confusion during an emergency when trying to 1. Transportation Safety Board of Canada. Aviation Investigation Report
activate the external-cargo-hook release mechanism, possibly A03P0247, Loss of Engine Power — Collision With Terrain, Gemini
complicating an emergency landing.” Helicopters Inc., Bell 204B (Helicopter) C-GEAP, Bonaparte Lake,
British Columbia, 17 August 2003.
The foot-pedal release in the accident helicopter was an approved
backup quick-release system; nevertheless, the effectiveness 2. The report defined N1 as gas-producer rotational speed, which is
of a foot-pedal release is limited because it requires a pilot indicated as a percentage of designed rotational speed.

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