Contributor - Safety

David Jack Kenny

<h2>Preliminary Reports</h2>
<h3>Offshore Learjet Crash Claims Three</h3>
Gates Learjet 36A, May 10, 2023, San Clemente Island, California
A Learjet operated by a U.S. Navy contractor crashed into the Pacific while attempting an emergency approach to the auxiliary landing field on San Clemente Island, killing all three on board. The 1976-model jet had departed from Point Mugu Naval Air Station as the lead in a formation of two Learjets using call signs FENIX01 and FENIX02 to join Navy training exercises in Warning Area 291 (W291).
Shortly after entering W291 at 15,000 feet, the crew of FENIX02 saw the lead airplane’s flaps partially deploy and advised the lead, which acknowledged their transmission. After retracting the flaps, the lead aircraft’s crew reported “an odor in the cabin” and FENIX02’s crew saw “white or gray colored ‘smoke or gas’” coming from the aft left side of the cabin and an “unidentified fluid” trailing the airplane.&nbsp;
FENIX01 was no longer maintaining heading or altitude when FENIX02’s crew saw flames around its aft equipment door, advised the lead airplane that it was on fire, and recommended declaring an emergency. After FENIX01 did so, FENIX02 assumed the lead position to guide them to the airfield. The last radio and visual contact between them occurred as they descended through 9,000 feet.
Recorded ADS-B track data showed that FENIX01 made two left and then two right turns during its descent, crossing over the island before flying eastward just offshore. The last position fix was about one-half mile southwest of the island at an altitude of 1,338 feet. The heavily fragmented wreckage was subsequently found about four nm northeast of that fix, about one mile offshore in 300 feet of water. Portions of the wreckage showed evidence of a pre-crash fire.
<h3>Both Pilots Injured on Positioning Flight</h3>
Cessna 208B, May 12, 2023, Kajjansi Airfield, Uganda
The captain was seriously injured and the first officer sustained superficial injuries when the Caravan overturned during a runway excursion at Kajjansi Airfield. The crew had returned to Kajjansi after an uneventful revenue flight and was en route to Mweya-Kasese to board passengers for a scheduled flight to Entebbe International Airport, but returned to Kajjansi after reporting unspecified “difficulties” with the aircraft. As of this writing, details of the landing and departure from the runway have not yet been reported, but press accounts indicate that the engine and left wing separated from the airframe after it overturned.
<h3>Hog Hunter Survives Fall from Helicopter</h3>
Airbus Helicopters EC130T2, May 6, 2023, Carta Valley, Texas
A rear-seat passenger suffered serious injuries but survived after falling out of the helicopter at an altitude of about 50 feet. He was one of a four-man team hunting feral hogs on the Rancho Bellas Rocas, a large private holding about 35 miles northeast of Del Rio on the U.S.-Mexico border. The pilot and the gunner in the left rear seat were independent contractors; the owner of both the ranch and the helicopter was in the front passenger seat. The gunner in the right rear seat was a friend of the owner’s son. Both marksmen were armed with 12-gauge shotguns. The cabin doors were locked open, and the preflight safety briefing included operation of the passenger restraints, emergency exit procedures, and main rotor blade safety while shooting.
About one hour after departing from a private airfield on the ranch property, the pilot determined that they needed to return to refuel. The helicopter was moving slowly forward when the other gunner saw the passenger in the right rear seat turn 90 degrees to face out of the cabin, step onto the pedestal mounted on the right skid, then take another step forward and fall, still holding the shotgun. He notified the pilot, who landed immediately.
They found the fallen passenger unconscious but still breathing, loaded him into the cabin, and closed the doors. While refuelling, the pilot contacted emergency services by mobile phone. Advised of an “extremely lengthy” wait, the pilot flew the passenger directly to the Val Verde Medical Center in Del Rio, where they were met by a medical team. Within 20 minutes, a civilian EMS helicopter transported him to Brooke Army Medical Center in Fort Sam Houston.
The helicopter was equipped with four-point restraints, but the injured passenger had used only the lap belt, which was found unbuckled. The other occupants described his behavior during the flight as “quiet,” adding that he did not seem impaired or fatigued.&nbsp;
The Texas Parks and Wildlife Department classifies feral hogs as an exotic invasive species and advises that “Aerial gunning is a highly effective means of quickly reducing wild pig populations in areas with large expanses of sparse canopy and high densities of wild pigs.”
<h2>Final Reports</h2>
<h3>Multiple Errors Contributed to Runway Excursion</h3>
Gulfstream GIV, Aug. 21, 2021, Fort Lauderdale, Florida
The pilots’ inadequate preflight inspection of the nose gear led them to miss the ground crew’s reinstallation of a malfunctioning “pip pin” connecting the upper scissor link to the steering collar. The pin backed out during the takeoff roll; the pilot aborted the takeoff, but the nose gear sheared off and the jet hit a concrete slab mount for approach lighting equipment, damaging the fuselage and right wing. There were no injuries to any of the 14 people on board.
The pilot-in-command, a 20,000-hour ATP, said the taxi and takeoff roll seemed normal until the airplane reached 100 to 110 knots, at which a “terrible shimmy” began that got “worse and worse.” He immediately aborted the takeoff using brakes and thrust reversers and the airplane initially slowed, only to veer off the right side of the runway. The pip pin was subsequently found on the runway some 2,215 feet short of the main wreckage; the remainder of the nose gear assembly was some 900 feet further down.
The pin, which is routinely removed to increase maneuverability during towing, is equipped with spring-loaded locking balls to prevent it from backing out. A plunger button in the end of the pin, also spring-loaded, retracts the locking balls while the pin is removed or installed, and a secondary safety pin (secured to the nose gear assembly by a lanyard) is inserted through the end of the pip pin as a further safeguard. The linemen who had towed the Gulf- 
stream removed the pin without difficulty, but afterwards the plunger stuck and the balls would not extend. The G-IV handling handbook calls for replacing any pin in this condition, but after unsuccessfully trying to free the plunger, the line crew reinserted the pin and reported the anomaly to the ramp supervisor.
The supervisor recalled telling “the first crew member” who arrived, “Per tow team, check your nose pin.” However, this person was an observer pilot not type-rated in the airplane and did not recall hearing that warning.&nbsp;
The SIC conducted the preflight and observed that the pip pin was in and “flush;” he did not recall seeing the safety pin. He also acknowledged that he had received his SIC type rating via a logbook endorsement from a type-rated captain without benefit of formal ground school or a practical test, and was “limited in what I know with the aircraft.” The pin performed normally in post--accident testing.
<h2>Unexplained Bearing Seizure Caused Driveshaft Failure</h2>
Bell 505, July 15, 2022, Cairns Airport, Queensland, Australia
An overheated hanger bearing seized during a sightseeing flight, causing the tail rotor drive shaft to separate, but the reason for the seizure could not be determined. The pilot and two passengers had been airborne for about 30 minutes when the pilot briefly heard a loud “grinding noise…like metal on metal” while flying in the vicinity of Double Island.&nbsp; The noise recurred about a minute later, and the pilot decided to return to Cairns Airport, making a shallow descent to limit engine power.&nbsp;
At an altitude of about 10 feet he increased power slightly to transition to a hover. “A couple of big bangs” came from aft of the cabin and the helicopter yawed 45 degrees right. He pulled the throttle to idle, the yaw stopped, and the helicopter’s forward motion into a 10-12-knot headwind straightened it back into its direction of travel. The pilot made a successful run-on landing in the grass short of the helipad, the engine shut down normally, and the pilot and passengers disembarked uninjured.
Subsequent inspection found that the forward hanger bearing had seized. The outer race was intact but the inner race had disintegrated, with only five of the bearing’s balls still present. The tail rotor driveshaft, which also drove the oil cooler fan, was separated at that point.&nbsp;
The aft hanger bearing was found undamaged and properly lubricated. Both bearings had been lubricated 246 hours earlier during the helicopter’s most recent 300-hour inspection, and had been inspected two days before the accident after another pilot reported a strange noise that seemed to be coming from the engine bay. No sign of excessive temperature, heat damage, or unusual noise was found.
A recording of the initial noise was played for the accident pilot, who did not think it sounded like the same grinding “metal-on-metal” sound that preceded the driveshaft failure. Bell Textron advised ATSB investigators that they were not aware of any prior failures of the fan shaft bearings in Bell 505 helicopters or in the model 206, which has a drivetrain of a similar design. The failed bearing and fan shaft assembly were sent to Bell for further examination, but results had not been received by the time the ATSB issued its final report.

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