Aircraft Accident Report AAR 3/2015 - G-SPAO, 29 November 2013
Eurocopter (Deutschland) EC135 T2+ (G-SPAO), crashed in Glasgow City Centre, Scotland, on 29 November 2013.
Introduction:
The Air Accidents Investigation Branch (AAIB) was notified at 2259 hrs on 29 November 2013 that a helicopter had crashed through the roof of The Clutha Vaults Bar, in the centre of the city of Glasgow. A team of AAIB Inspectors and support staff arrived in Glasgow at 0915 hrs the following morning to commence an investigation.
In accordance with established international arrangements, the Bundesstelle für Flugunfalluntersuchung (BFU) of Germany, representing the State of Design and Manufacture of the helicopter, the Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA) of France, representing the State of Design and Manufacture of the engines, and the National Transportation Safety Board (NTSB) of the USA, representing the State of Design and Manufacture of the Full-Authority-Digital-Engine-Controls (FADECs) on the engines, appointed Accredited Representatives to participate in the investigation. They were supported by advisors from the helicopter manufacturer, the BEA and the engine manufacturer. The European Aviation Safety Agency (EASA), the UK Civil Aviation Authority (CAA) and the helicopter operator also assisted the AAIB.
The investigation was conducted under the provisions of Regulation EU 996/2010 and the UK Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996.
Summary:
The helicopter departed Glasgow City Heliport (GCH) at 2044 hrs on 29 November 2013, in support of Police Scotland operations. On board were the pilot and two Police Observers. After their initial task, south of Glasgow City Centre, they completed four more tasks; one in Dalkeith, Midlothian, and three others to the east of Glasgow, before routing back towards the heliport. When the helicopter was about 2.7 nm from GCH, the right engine flamed out. Shortly afterwards, the left engine also flamed out. An autorotation, flare recovery and landing were not achieved and the helicopter descended at a high rate onto the roof of the Clutha Vaults Bar, which collapsed. The three occupants in the helicopter and seven people in the bar were fatally injured. Eleven others in the bar were seriously injured.
Fuel in the helicopter’s main fuel tank is pumped by two transfer pumps into a supply tank, which is divided into two cells. Each cell of the supply tank feeds its respective engine. During subsequent examination of the helicopter, 76 kg of fuel was recovered from the main fuel tank. However, the supply tank was found to have been empty at the time of impact. It was deduced from wreckage examination and testing that both fuel transfer pumps in the main tank had been selected off for a sustained period before the accident, leaving the fuel in the main tank, unusable. The low fuel 1 and low fuel 2 warning captions, and their associated audio attention-getters, had been triggered and acknowledged, after which, the flight had continued beyond the 10-minute period specified in the Pilot’s Checklist Emergency and Malfunction Procedures.
The helicopter was not required to have, and was not fitted with, flight recorders. However, data and recordings were recovered from non-volatile memory (NVM) in systems on board the helicopter, and radar, radio, police equipment and CCTV recordings were also examined.
During the investigation, the EC135’s fuel sensing, gauging and indication system, and the Caution Advisory Display and Warning Unit were thoroughly examined. This included tests resulting from an incident involving another EC135 T2+.
Despite extensive analysis of the limited evidence available, it was not possible to determine why both fuel transfer pumps in the main tank remained off during the latter part of the flight, why the helicopter did not land within the time specified following activation of the low fuel warnings and why a MAYDAY call was not received from the pilot. Also, it was not possible to establish why a more successful autorotation and landing was not achieved, albeit in particularly demanding circumstances.
The investigation identified the following causal factors:
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73 kg of usable fuel in the main tank became unusable as a result of the fuel transfer pumps being switched off for unknown reasons.
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It was calculated that the helicopter did not land within the 10-minute period specified in the Pilot’s Checklist Emergency and Malfunction Procedures, following continuous activation of the low fuel warnings, for unknown reasons.
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Both engines flamed out sequentially while the helicopter was airborne, as a result of fuel starvation, due to depletion of the supply tank contents.
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A successful autorotation and landing was not achieved, for unknown reasons.
The investigation identified the following contributory factors:
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Incorrect management of the fuel system allows useable fuel to remain in the main tank while the contents in the supply tank become depleted.
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The RADALT and steerable landing light were unpowered after the second engine flamed out, leading to a loss of height information and reduced visual cues.
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Both engines flamed out when the helicopter was flying over a built-up area.
Seven Safety Recommendations have been made.
Correction:
Some were issued concerning this report in March 2016. The report below is the updated version and contains the corrections.
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