ASN Wikibase Occurrence # 59678
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| Date: | Saturday 25 April 2009 |
| Time: | 19:35 |
| Type: |  Eurocopter EC 145 |
| Owner/operator: | Sécurité Civile |
| Registration: | F-ZBPR |
| MSN: | 9034 |
| Year of manufacture: | 2003 |
| Fatalities: | Fatalities: 4 / Occupants: 4 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | SW of Bastia, Haute-Corse 2B -
 France
|
| Phase: | En route |
| Nature: | Ambulance |
| Departure airport: | Ponte-Leccia |
| Bastia | |
| Investigating agency: | BEAD |
| Confidence Rating: |  Accident investigation report completed and information captured |
The helicopter (callsign "Dragon 2B") transported a pregnant woman to hospital in Bastia, Corsica. She gave birth in flight. Shortly afterwards the helicopter crashed in a mountainous region. The new-born baby, the mother, the doctor, the pilot and an engineer were killed.
Causes of the event
Environmental Context :
- On April 25, 2009, the Lancone Pass is affected by rare meteorological phenomena;
- the aircraft was flying close to the terrain at the time of the go-around.
Technical assessments confirm the information provided by the UMS/SSQAR and rule out any technical cause.
The causes of the occurrence are related to the human factor.
3.2.1. Causes leading to the entry into the layer.
The pilot was probably misrepresenting the weather situation.
The lack of standards regarding the use of the Lancone Pass as a "bad weather route" may have encouraged the pilot to continue his flight in deteriorating weather conditions.
By crossing the ridgeline perpendicularly and at a very low height, the pilot did not maintain a permanent clearance.
The pilot probably experienced a perseveration phenomenon.
3.2.2. Causes of the collision with the ground without loss of control of the aircraft.
The go-around procedure was initiated when the lateral and vertical margins were minimal and the initial parameters were not stabilized.
The transition to IFR was known but probably not prepared.
The stacking of tasks could have caused saturation that could have led to an attention-capture phenomenon.
The pilot was probably making a mental misrepresentation of his trajectory. In particular, he was not aware of accelerating in the face of the terrain.
Accident investigation:
 |
|
Sources:
http://www.tv5monde.com/TV5Site/info/article-Corse_cinq_morts_dont_un_nouveau_ne_et_sa_mere_dans_un_crash_d_helicoptere.htm?idrub=1&xml=newsmlmmd.c2021cef7fecfd6c735e740eee9927ad.fd1.xml
http://www.eurocopter.com/site/docs_wsw/RUB_963/Potential.pdf
https://www.defense.gouv.fr/english/content/download/523468/8774002/S-2009-005-A_.pdf
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 26-Apr-2009 10:53 | Lercherlschas | Added |
| 26-Apr-2009 10:54 | harro | Updated |
| 27-Apr-2009 03:34 | RobertMB | Updated |
| 07-Jul-2009 11:00 | rotorspot | Updated |
| 11-Aug-2010 10:41 | TB | Updated [Aircraft type, Operator, Other fatalities, Location, Source] |
| 01-Nov-2012 11:30 | TB | Updated [Aircraft type, Source] |
| 23-Nov-2012 09:57 | TB | Updated [Aircraft type] |
| 27-Jul-2020 14:34 | KagurazakaHanayo | Updated [Total fatalities, Total occupants, Source, Narrative] |
| 27-Jul-2020 14:37 | harro | Updated [Narrative, Accident report, ] |
| 24-Oct-2020 12:21 | Aerossurance | Updated [Aircraft type, Accident report] |
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