[Peetwo]

Chalk and cheese: HLS propwash safety mitigation in the real World?? 

Remember this?

AD-2022-001: Safety risks from rotor wash at hospital helicopter landing sites - Final report 



On Wednesday Dr (Lies, damn lies and statistics) Godlike, this week's attributable to DTS, issued this presser in relation to the release of AD-2022-001 data and analysis final report... :

ATSB issues safety advisory after series of rotor wash injuries at hospital helicopter landing sites



The Australian Transport Safety Bureau has issued a safety advisory after a number of occurrences in which pedestrians were injured by rotor wash around hospital helicopter landing sites.

The notice advises medical transport operators and hospital helicopter landing site operators to engage with one another and ensure local procedures are sufficient to mitigate the risk of rotor wash associated with larger helicopters, such as the Leonardo Helicopters (AgustaWestland) AW139.

It stems from an ATSB Aviation Data and Analysis Report analysis of a series of incidents over the last five years, which considered the common factors, existing regulatory guidelines, and ways to mitigate the effects of rotor wash.

“Of the 18 helicopter rotor wash incidents reported to the ATSB in the last five years, nine occurred at hospital landing sites,” ATSB Director Transport Safety Dr Stuart Godley said.

“Six of those nine occurrences resulted in injuries to pedestrians who were within approximately 30 m of the landing site, and flight crew were not aware of the presence of pedestrians in all cases.

“In fact, in most instances, flight crew were not aware any incident had occurred at the time.”

Significantly, there were no reported occurrences of rotor wash related injuries at hospital HLS prior to the notable increase in the utilisation of AW139 for medical transport operations from 2017.

If the recommended rotor wash exclusion area for the AW139 had been applied at each HLS, it would have reduced the risk of the pedestrians being injured.

The ATSB’s report notes a range of key factors contribute to the effects of rotor wash, including the weight and size of the helicopter, the main rotor size, disc loading, prevailing winds, and flightpath.

“The flightpath is the only element that can be managed by the pilot in accordance with the operator’s procedures,” Dr Godley said.

“But as these occurrences demonstrate, pilots may be unaware of the presence of pedestrians in the vicinity, and therefore be unable to adjust their flightpath accordingly.

“As such, hospital landing site owners and helicopter owners should ensure pedestrians are not affected by rotor wash, by implementing appropriate risk controls for their landing sites, in addition to the helicopter operating procedures.”

Risk controls may include physical barriers, warning devices such as sirens, lights, high visibility warning signs, painted lines on nearby public thoroughfare to alert pedestrians to the rotor wash danger area, an inspection schedule for the landing site facility and surrounding area, and establishing a closed-loop reporting system.

Read the Safety Advisory Notice: Safety at hospital helicopter landing sites

Read the Aviation Data and Analysis Report: Downwash incidents at helicopter landing sites

Publication Date
27/09/2023

Here is the safety advisory notice:



From pg 7 of the report:

Australia

The Civil Aviation Safety Authority (CASA) does not regulate the design or operation of HLSs if
they are not an integral element of an aerodrome certified under Part 139 of the Civil Aviation
Safety Regulations (CASR) 1998. As hospital HLSs are not located at Part 139 certified
aerodromes, CASA does not regulate their design or operation...

Still not sure why Popinjay's head crew feel the need to big note themselves in bogus media disengaged press releases?? However, all in all not a bad effort from the research boffins at Popinjay HQ...  

As a passing strange coincidence, I noted the following Aerossurance post on LinkedIn:

Aerossurance
27,092 followers
1w • Edited •

https://lnkd.in/deBjpdus #helicopter #heliport #airambulance #hems #downwash #flightsafety #aviationsafety

This was the Foreword:

Foreword

This guidebook is the result of a collaborative effort coordinated by the French Aviation Safety Network (RSAF). The RSAF is a national, multidisciplinary group of experts, including industry members, helicopter operators, and experts from DGAC – the French National Aviation Authority – and The French-Speaking Airports (UAF&FA). The guidebook targets primarily heliport and airport operators. However, it was written with all stakeholders and practitioners in mind, including non-aviation organizations operating heliports (e.g., local governments, hospitals, etc.), and each of them should find useful information that they can use to address safety issues in their field of operations as well as to learn about others’ concerns. It provides a state of the art on the helicopter downwash related hazards, as well as best practices on their mitigation in the field.

The document was developed based on a review of the literature available as of November 2022. Resources include documents from the aviation industry (manufacturers and operators) and institutions (e.g., ONERA, FAA, DSAC), as well as lessons learned from past accidents and incidents with safety reports and analyses from BEA, ECCAIRS, operators, and OEMs. It is important to remember that this guidebook is not an advisory circular or a guidance material for certification purpose, nor an alternative mean of compliance (AltMOC). It does not supersede the position of the Authority in charge of issuing required approvals, regarding operations or training.

DGAC DSAC Safety Guidebook

The link to the English version of the document is provided here:
Modèle de rapport DGAC/DSAC (ecologie.gouv.fr)

(Plus Aerosurrance included this media video link: https://abc7.com/rancho-cucamonga-childr.../11812717/ )

How come there was no collaboration with Australian authorities, including CASA and the ATSB, or reference to the recently released AD-2022-01 and the associated SAN? Surely the ATSB report has been filed with ICAO and the associated occurrences are subsequently listed in the ECCAIRS database??

Also of passing strange coincidence, yesterday the AAIB reported on social media the release of a final report into a fatal accident at a hospital HLS:

AAIB
@aaibgovuk

The AAIB has published a report into a fatal accident involving a Sikorsky S-92A (G-MCGY) that occurred at Derriford Hospital, Plymouth, Devon on 4 March 2022.

Read the report here https://gov.uk/government/news/aaib-form...march-2022
#AviationSafety #HelicopterSafety

From the report:
 

AAIB Formal Report: Sikorsky S-92A (G-MCGY), Fatal accident, 4 March 2022

Several members of the public were subjected to high levels of downwash from the approach and landing of a search and rescue helicopter. One person suffered fatal injuries and another was seriously injured.

From: Air Accidents Investigation Branch
Published 2 November 2023



Summary
The helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The helicopter flew to Derriford Hospital, Plymouth, which has a Helicopter Landing Site (HLS) located in a secured area within one of its public car parks. During the approach and landing, several members of the public in the car park were subjected to high levels of downwash from the landing helicopter. One person suffered fatal injuries and another was seriously injured.

Investigation findings
The investigation identified two causal factors for this accident:

The persons that suffered fatal and serious injuries were blown over by high levels of downwash from a landing helicopter when in publicly accessible locations near the Helicopter Landing Site
Whilst helicopters were landing or taking off, uninvolved persons were not prevented from being present in the area around Derriford Hospital’s Helicopter Landing Site that was subject to high levels of downwash.
The following contributory factors were also identified:

1. The HLS at Derriford Hospital was designed and built to comply with the guidance available at that time, but that guidance did not adequately address the issue of helicopter downwash.

The hazard of helicopter downwash in the car parks adjacent to the HLS was not identified, and the risk of possible injury to uninvolved persons was not properly assessed.

A number of helicopter downwash complaints and incidents at Derriford Hospital were recorded and investigated. Action was taken in each case to address the causes identified, but the investigations did not identify the need to manage the downwash hazard in Car Park B, so the actions taken were not effective in preventing future occurrences.

Prior to this accident, nobody at Derriford Hospital that the AAIB spoke to was aware of the existence of Civil Aviation Publication (CAP) 1264, which includes additional guidance on downwash and was published after the HLS at Derriford Hospital was constructed. The document was not retrospectively applicable to existing HLS.

The operator of G-MCGY was not fully aware of the Derriford Hospital HLS Response Team staff’s roles, responsibilities, and standard operating procedures.

The commander of G-MCGY believed that the car park surrounding the Derriford Hospital HLS would be secured by the hospital’s HLS Response Team staff, but the co‑pilot believed these staff were only responsible for securing the HLS.

The Derriford Hospital staff responsible for the management of the HLS only considered the risk of downwash causing harm to members of the public within the boundary of the HLS and all the mitigations focused on limiting access to this space

The Derriford Hospital staff responsible for the management of the HLS had insufficient knowledge about helicopter operations to safely manage the downwash risk around the site.

The HLS safety management processes at Derriford Hospital did not result in effective interventions to address the downwash hazard to people immediately outside the HLS.

HLS safety management processes at Derriford Hospital did not identify that the mitigations for the downwash hazard were not working well enough to provide adequate control of the risk from downwash.

Communication between helicopter operators and Derriford Hospital was ineffective in ensuring that all the risks at the Derriford Hospital HLS were identified and appropriately managed.

Safety at hospital HLS throughout the UK requires effective information sharing and collaboration between HLS Site Keepers and helicopter operators but, at the time of the accident, there was no convenient mechanism for information sharing between them.

Safety action and recommendations
Following this accident, safety action was taken by the helicopter operator, Derriford Hospital and NHS England Estates to control and mitigate the risk. Additional action by Derriford Hospital and NHS England Estates to improve safety is either planned or in progress.

Helicopters used for Search and Rescue and Helicopter Emergency Medical Services (HEMS) perform a vital role in the UK and, although the operators of these are regulated by the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are not. It is essential that the risks associated with helicopter operations into areas accessible by members of the public are fully understood by the Hospital Landing Site Keepers and that effective communication between all the stakeholders involved is established and maintained. Therefore, nine Safety Recommendations have been made to address these issues.

Chief Inspector’s statement

Crispin Orr, Chief Inspector of Air Accidents said:

“This was an unusual and distressing accident in which an aircraft undertaking a mission to save life, sadly also resulted in the death of an uninvolved person and serious injury to another, who were blown over by high levels of downwash from a landing helicopter.

“Our in-depth investigation revealed systemic safety issues around the design and operation of hospital helicopter landing sites which need to be addressed at a national level.  Helicopters used for search, rescue and emergency medical services play a vital role, but it is essential that the risks associated with helicopter downwash are understood and well-managed.

“The investigation has raised awareness of this issue and been a catalyst for important safety action, which has been taken to mitigate the immediate risk.  In addition, nine recommendations have been made in this report to help improve coordination between the aviation and NHS stakeholders, to ensure the protection of uninvolved persons from helicopter operations at hospital helicopter landing sites across the UK.”

Read the report

Read that whole report and weep...   Without fear nor favour IE independently written and formatted under the direction and in total compliance with ICAO Annex 13 - 

Plus there is even a reference to a ATSB October 2021 Occurrence Brief: https://www.atsb.gov.au/publications/occ...b-2021-028

1.18.3.1 Australian Transportation Safety Board (ATSB) Investigation

In January 2022, the ATSB published an Aviation Occurrence Brief following
an accident where a pedestrian was seriously injured after being blown over
by a helicopter as it approached a hospital HLS. The pedestrian was reported
to have been walking about 50 m from the HLS, which was on an elevated
platform approximately 8 m above the road. The helicopter was an Augusta
Westland AW139, which has a maximum takeoff mass of 6,800 kg and a main
rotor diameter of approximately 14 m.

The ATSB said that they had received five reports involving ‘rotor wash’
(downwash) events at hospital HLSs since 2016, and three of them had
occurred at the same hospital. Before re-commencing operations at the HLS,
the operator and hospital took the following actions:

● They reduced the maximum number of helicopters allowed
on the HLS from two to one.
● They implemented pedestrian marshalling procedures for all
helicopter movements, so that operations only occur when no
pedestrians are within 30 m of the HLS.

The hospital engaged a consultant to review the design of the HLS, and the
ATSB publicised the following safety message in their report:

‘Helicopters produce significant main rotor downwash, especially
during hover taxi, take-off and while approaching to land. It is
important that the risk of downwash related injuries, either by direct
exposure or by being struck by loose items, be assessed prior to
using a helicopter landing site (HLS).

As pilots have limited ability to reduce rotor downwash during these
phases of flight, securing loose items in the vicinity of the HLS and
keeping people a safe distance away are the most effective ways
of preventing injury.’

Hmm...strange that, even though all three reports were apparently being worked on and composed on or around the same time, there appears to be no reference to the AD-2022-001 report or indeed the SAN (and visa versa)?? 

MTF...P2