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FINAL REPORT

2008-201-4 P AVIATION ACCIDENT

Kimle 12 July 2008

Mi-34C RY-XFC

The sole objective of the technical investigation is to reveal the causes and circumstances of aviation accidents, incidents or irregularities and to initiate the necessary technical measures and make recommendations in order to prevent similar cases in the future. It is not the purpose of this activity to apportion blame or liability.

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This present investigation was carried out on the basis of

Act XCVII of 1995 on aviation,

Annex 13 to ICAO Convention on Civil Aviation, put in force in Hungary by MTCW (Ministry of Transport, Communications and Water) Decree 20/1997. (X. 21.) on the declaration of the annexes of the Convention on International Civil Aviation signed in Chicago on 7th December 1944,

Act CLXXXIV of 2005 on the technical investigation of aviation, railway and marine accidents and incidents (hereinafter referred to as Kbvt.),

MET Decree 123/2005 (XII. 29.) on the regulations of the technical investigation of aviation accidents, incidents and irregularities;

In absence of other related regulation of the Kbvt., the Transportation Safety Bureau of Hungary carried out the investigation in accordance with Act CXL of 2004 on the general rules of administrative authority procedure and service,

The Kbvt. and the MET Decree 123/2005 (XII. 29.) jointly serve the compliance with the following EU acts:

a) Council Directive 94/56/EC of 21 November 1994 establishing the fundamental principles governing the investigation of civil aviation accidents and incidents, with the exception of its Annex;

b) Directive 2003/42/EC of the European Parliament and of the Council of 13 June 2003 on occurrence reporting in civil aviation, with the exception of its Annex I and Annex II.

The competence of the Transportation Safety Bureau of Hungary is based on Government Decree 278/2006 (XII. 23.) from 1st January 2007.

Under the aforementioned regulations

The Transportation Safety Bureau of Hungary shall investigate aviation accidents and serious aviation incidents.

The Transportation Safety Bureau of Hungary may investigate aviation incidents and irregularities which - in its judgement - would have resulted in accidents in other circumstances.

The technical investigation is independent of any administrative, infringement or criminal procedures.

In addition to the aforementioned laws, the ICAO DOC 6920 Manual of Aircraft Accident Investigation is applicable.

This present Final Report shall not be binding, nor shall an appeal be lodged against it.

Persons participating in the technical investigation did not act as experts in other procedures concerning the same case and shall not do so in the future.

The IC shall safe keep the data having come to their knowledge in the course of the technical investigation. Furthermore the IC shall not be obliged to make the data – regarding which the owner of the data could have refused the disclosure of the data pursuant to the relevant act – available to other authorities.

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This present Final Report

was completed based on the Draft Report compiled by the IC and approved by the Director-General of TSB and sent to the concerned parties and organisations – defined by law - for reflections.

At the same time, the Director-General of TSB invited the concerned persons and organisations to participate in the closing discussion of the Final Report.

The closing discussion was held on 12 May 2009, in which the pilot was present.

The IC incorporated the reflections of the concerned parties on the draft into the Final Report.

Appendix 3 contains a reflection from the pilot, which was not taken into consideration by the IC while compiling the Final Report. The IC accepted the data of the power company EDASZ regarding the height of the power poles.

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DEFINITIONS

AGL (altitude) above ground level

IC Investigating Committee

ICAO International Civil Aviation Organization

Kbvt. Act CLXXXIV of 2005 on the technical investigation of aviation, railway and marine accidents and incidents

MET Ministry of Economy and Transport (Gazdasági és Közlekedési Minisztérium, GKM)

MTCW Ministry of Transport, Communications and Water (Közlekedési, Hírközlési és Vízügyi Minisztérium, KHVM)

n.a. not available

NTA AD National Transport Authority, Aviation Directorate

QFE atmospheric pressure- Q - at Field Elevation

QNH atmospheric pressure- Q - at Nautical Height

TSB Transportation Safety Bureau (of Hungary)

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BRIEF DESCRIPTION OF THE OCCURRENCE

Occurrence category accident

Aircraft

manufacturer OAO Moscowsky Vertoletny Zavod imeni Milya

type Mi-34C

registration RY-XFC

serial number 9783001501005

owner private owner

operator Kobo-Coop-96 Kft.

lessee Kobo-Coop-96 Kft.

Occurrence date and time 12 July 2008, 15:50

location Kimle

Number of injured persons

fatal none

serious 3

Aircraft damage destroyed

State of registry Romania

Registering authority CAA Romania

Authority supervising manufacturing Federal Aviation Authorities of Russia

Competent investigating organization Transportation Safety Bureau

Time zone used in the draft report LT

Reports and notifications

The occurrence was reported to the dispatcher of the TSB at 16:01 on 12 July 2008 by the dispatcher of the Győr-Sopron County Disaster Response Directorate.

The dispatcher of the TSB: - reported to TSB’s head of department on duty at 16:02 on 12 July 2008, then

- notified the duty personnel of NTA AD at 16:15 on 12 July 2008.

Investigating committee

On 12 July 2008 The Director-General of the TSB assigned the following Investigating Committee (hereinafter referred to as IC) for the investigation of the accident:

Investigator-in-Charge Sándor SIPOS department head member János ESZES investigator member István JÁDI field investigator

Due to organisational changes, the Director-General of TSB assigned the following Investigating Committee on 19 January 2009:

Investigator-in-Charge: István PAPP investigator

Member: János ESZES investigator

Overview of the investigation procedure

Once the wreckage of the helicopter had been recovered from the river, the IC conducted an on-site examination of the wreckage, simultaneously with the examination by the police and the National Disaster Response Directorate survey teams. Indications of the cockpit instruments as well as the position of switches and flight controls were recorded.

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The IC and the police interviewed the eyewitnesses, the pilot and the passengers of the helicopter. The police took custody of the wreckage which was subsequently transported to the operator’s premises for further examination.

The IC held an additional technical examination of the wreckage, with particular attention to the engine and other elements of the powertrain on 1 September 2008. The findings of the examination were documented.

A short summary of the occurrence

The helicopter was involved in leisure flight activity (aerial sightseeing) during a festivity in the village of Darnózseli. According to eyewitnesses’ accounts, the helicopter made three or four rounds before the accident flight (with alternating pilots). The helicopter took off for the last flight with one female and two male passengers on board.

Following takeoff, the helicopter flew over the castle in Novákpuszta then it continued on a westerly course over the Mosoni-Duna river. The pilot told the IC that they flew at 130 metres. The passengers could not estimate the altitude. Eyewitnesses on the ground saw the helicopter flying just above the treetops near the Novák campsite before continuig West over the river.

After 6-7 minutes of flying, the helicopter collided with a high voltage power line at the 60-river km mark of Mosoni-Duna, and tore all three cables. The rotor blades and the tail broke off. The helicopter fell into the river and sank (the water is about 5 metres deep there). The pilot and the passengers activated the cabin door emergency release mechanisms. Tthe pilot and two passengers were able to exit the cabin on their own, while one passenger needed assistance to leave the already submerged helicopter. The pilot and the passengers were taken to hospital by the arriving emergency medical team.

The wreckage was recovered two days after the accident. The IC conducted an examination of the helicopter, then on 1 September 2008 another technical examination of the helicopter took place at the operator’s premises at Bőny airfield.

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1. FACTUAL INFORMATION

1.1 History of the flight

The helicopter took off for a sightseeing flight with 3 passengers from Darnózseli, approximately at 15:44. After taking off the helicopter flew over the castle of Novákpuszta then continued West over the Mosoni-Duna.

The pilot and the eyewitnesses on the ground (on the water, to be precise) remember the flight altitude differently. The pilot told the IC he was flying at 130 metres, while all the eyewitnesses saw the helicopter flying at treetop level over the castle and later over the Novák campsite before heading West over the river. The passengers could not give an estimate of the altitude.

The accident happened at the 60th river km of the Mosoni-Duna (N 47o 49’ 39”, E 17o 22’ 58”), where the helicopter collided with a 20 kV power line, tore the cables and subsequently fell into the river. The Mosoni-Duna is slightly curved at this location, there are trees along both banks. of the river. The elevation of the terrain is 113 metres above sea level. The time of the accident was 15:50. The sky was clear and sunny.

1.2 Injuries to persons

Injuries Crew Passengers Other

Fatal – – –

Serious – 3 –

Minor 1 – –

None – – –

1.3 Damage to aircraft

The airframe suffered serious damage, its repair is not economical. The engine is basically intact and can be installed on another aircraft, after minor repairs and the necessary checks. The rotors and the main gearbox are irreparable.

1.4 Other damage

All three cables of the 20 kV power line were torn, therefore villages of Károlyháza, Kimle, Hédervár, Ásványráró, Darnózseli, Lipót, Dunaremete, and Püski were without power between 15:50 and 18:18.

1.5 Personnel information

1.5.1 The pilot

Age and gender 52-year old male

Licence data

Professional valid until 31 DEC 2008

Medical valid until 26 SEP 2008

Licence type powered aircraft A; helicopter A

Ratings helicopter trainer

Flying experience, hours/takeoffs

Total 671 hrs / 2075

In the previous 30 days 5 hrs / 38

In the previous 7 days n.a.

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In the previous 24 hours 32 mins / 4

On the given aircraft category n.a.

On the given type 38 hrs 53 mins / 131

1.6 Aircraft information

1.6.1 Certificate of airworthiness

The aircraft did not have a valid NTA AD-issued certificate of airworthiness.

The helicopter was in experimental registry therefore it did not have a certificate of airworthiness. The CAA of Romania issued a „Permit to Fly” which was valid until 11 November 2008. (See Appendix 1.) According to this permit, the aircraft:

– shall conduct only daylight VFR flights,

– shall not carry persons whose presence is not essential for the purpose of the flight.

1.6.2 General data

hours flown number of landings

Since manufacturing 321 hrs 30 mins 1225

Since last overhaul n.a. n.a.

Since last maintenance 10 hrs 24 mins 89

According to the technical documentation, the last periodic (after 100 hours) maintenance was done on 30 January 2008 by the operator at Bőny airfield. There was no problem in the operation of the aircraft between the maintenance and the accident.

1.6.3 Engine data

hours flown

Since manufacturing 319 hrs 48 mins

Since last overhaul n.a.

Since last maintenance 7 hrs 28 mins

1.6.4 Main gearbox data

Flight hours since manufacturing

321 hrs 19 mins

Date of installing on aircraft 11 June 1997

Date of last overhaul n.a.

Date of last maintenance 30 January 2008

1.6.5 Loading data

Empty mass 1028 kg

Mass of fuel 100 kg

Commercial load 320 kg

Total 1448 kg

Maximum allowed takeoff mass 1450 kg

Type/grade of fuel used: B 91/115 gasoline.

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1.7 Meteorological data

A slow cold front approached the Carpathian Basin from NW. In the Basin the weather was dry, warm, with clear skies and brisk and warm Southerly winds. At the time of the accident the wind speed was 7-8 m/s from 170-1900. The pilot told the IC he felt stronger winds at 150 metres. The wind blowing from South could have an effect on the helicopter flying West. Visibility was about 20 km. The weather was suitable for flying. (See Appendix 2.) At the location of the accident the wind crossed a treeline at a right angle and thus could have caused turbulence. However, according to the eyewitnesses, the helicopter made several flights over the river previously therefore the pilot was able to experience the wind conditions.

The helicopter was flying West (with a heading of approx. 245o) therefore the glare could have caused trouble in the pilot’s vision (the Sun was approx. 45o above the horizon).

1.8 Aids to navigation

The aircraft was equipped with navigational instruments described in the aircraft’s airworthiness certificate and they functioned normally. They had no effect on the course of events therefore their analysis was not required.

1.9 Communications

The aircraft was equipped with communications instruments described in the aircraft’s airworthiness certificate and they functioned normally. They had no effect on the course of events therefore their analysis was not required.

1.10 Aerodrome information

The aircraft took off from a temporary take-off and landing site in Darnózseli (N 470 50’ 53” E 170 25’ 16”) for which the pilot had a permit from the CAA. The site was a grassy rectangular area, with two sides free of obstacles. The elevation was 115 metres above sea level.

1.11 Flight recorders

The aircraft had a flight data recorder (type RN-4) on board but it was not operative, therefore it did not record any data.

1.12 Wreckage and impact information

The aircraft was flying at low (cca. 10-15 metres) altitude, heading 2620, near Kimle, over the Mosoni-Duna, in good weather conditions, when the accident happened.

The location is shown on the map below. The helicopter collided with a power line, and the rotor blades and the tail boom broke off. The aircraft subsequently fell into the river.

The IC believes that the aircraft was functioning normally and there was no mechanical failure that could lead to the accident. This assumption is reinforced by the fact that the rotor blades were rotating with high speed and they were thrown 250-300 metres away from the rest of the wreckage.

The maximum take-off mass of the aircraft was within the operational limits.

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The recovery of the wreckage from underwater – involving divers - was started on the day following the accident and lasted two days. The fuselage was found and recovered in two parts (the tail boom separated in the accident). The rotor blades broke in several pieces and most of the remains – being lightweight - were carried away by the current.

The police took custody of the wreckage and it was transported to the nearby Bőny airfield, the base of the maintenance organisation. The IC conducted a secondary examination of the wreckage in order to record the instrument readings and to determine the condition of the engine. The findings are below:

A) Engine bay, left-hand side:

– The accessory gearbox, the accessories (ignition magnets, fuel and oil pumps, carburetor, generator, starter air distributor, air compressor) were undamaged.

– The air intakes were intact, the exhaust pipes were also intact.

– Cylindres, cylinder heads and valve covers were intact.

– There was no visible sign of an oil leak.

– The engine anchor points were intact and free of deformation.

B) Engine bay, right-hand side:

– The oil tank contained 11 litres of liquid.

– The main reductor could be rotated by the rotor.

– The ribbed end of the tail rotor driveshaft was separated from the main gearbox.

– The tail boom was broken off the fuselage. The driveshaft was also broken, as well as the control rods for the tail rotor and all electrical wires. The tail rotor was undamaged, could be rotated and its blades controlled.

– The right-hand side of the fuselage was seriously damaged.

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The IC believes that the accessories were functioning normally at the time of the accident therefore they could not cause the accident.

C) Cabin:

– There were no marks or scratches from the power line cable on the front of the cabin.

– Reading of the artificial horizon was 80, negative.

– Speedometer reading was 95 km/h.

– Variometer reading was 16 m/s (58 km/h), descent.

– Barometric altimeter reading was 25 metres, reference altitude setting was at 748,0 Hgmm.

– Radio altimeter reading was 21 metres, dangerous altitude was set to zero.

– Clock stopped at 16:16.

– The collective control was at upper end.

– The on-board FDR was not in use.

– The engine power control was at nominal (the throttle valve was open at 800).

– The rotor brake was released (free rotation).

– The clutch was in closed (connected) position.

– The fuel level reading was at 120 litres.

– The FM radio was tuned to 129.90 MHz.

– The front doors were missing (they were dropped after the helicopter fell into the river), the left-hand side back door was in place, the right-hand side back door was broken off.

– The seat belts were installed and appropriate for use.

– The IC believes that the controls and the instruments were functioning normally at the time of the accident therefore they could not cause the accident.

D) Main rotor:

– Three blades were broken off at their base, one blade was broken cca. 1.6 metre from its base.

– The shock absorbers were undamaged.

– The control rods of the rotor head were deformed but the IC determined that the damage occurred during the recovery from underwater.

– The IC believes that the main rotor damage is a consequence of the impact and it did not cause the accident.

E) Engine (M-14 V-26):

– The spark plugs of the No. 1 ignition system were removed and checked by the IC. The gaps were normal. The plug of cylinder No. 5 was slightly corroded. There was water in cylinders No. 4, 5 and 6. The IC also found oil in cylinder No. 6.

– The IC made a borescopic check of the cylinders and found no damage on the inner surfaces.

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– The throttle valve was open at 800.

– The main shaft could be rotated with ease by a tool, without noise or obstruction.

– There was water in the main gearbox. The oil filter was clean, the magnetic plug was clean and free of metallic chips. The oil felt smooth for touch.

– The carburetor (AK-14V, serial: 11010295006) was removed and disassembled by the IC. The throttle valve, the jets, the regulator needle, and the membrane were clean and undamaged.

The IC believes that the engine was functioning normally at the time of the accident therefore it could not cause the accident.

F) Main gearbox bay:

– The main gearbox was filled with B-3V oil, up to 3/4 of the maximum level. The gears could be moved freely by hand.

– The main gearbox cover was cracked at its left side, the crack extended to bolts No. 5, 6, 7 and 8.

The IC believes that the main gearbox damage is a consequence of the impact and it did not cause the accident.

G) Conclusion:

The IC believes that the helicopter was operating normally at the time of the accident.

1.13 Medical and pathological information

The pilot of the aircraft: 52-year old man.

The blood test found no alcohol in the pilot’s system.

The pilot possessed a valid Class 2 medical certificate. According to the pilot, he wore his glasses and the spare glasses were on board.

The IC does not have information on the pilot’s psychophysical condition prior and during the flight.

The pilot did not lose his consciousness in the course of the accident. He was treated at a hospital with minor injuries and subsequently released.

Passenger 1: 30-year old man.

Neck vertebra injuries and broken ribs.

Passenger 2: 25-year old woman.

Multiple fractures to limbs.

Passenger 3: 27-year old man.

Skull fracture.

Medical forensics examination

Not applicable.

1.14 Fire

There was no fire.

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1.15 Survival aspects

There were canoe riders on the river who notified the emergency medical services and the police.

The Mosonmagyaróvár police received the notification at 15:42 and the police patrol arrived at the scene at 15:50. The police alerted the local fire brigade at 15:49, and the firemen arrived at 16:03. The police also alerted the emergency medical services at 15:54, and the ambulance car arrived at 16:04.

The chances of survival were enhanced by the following circumstantes:

– the pilot and the passengers used their seatbelts,

– the front doors were dropped by their quick release mechanism,

– the eyewitnesses and the pilot helped the passengers to escape from the submerged helicopter,

– the helicopter was a full metal construction which partially shielded the occupants from the electric shock and absorbed much of the force of the impact,

– the helicopter was flying low when the collision occurred.

Due to the fact that the accident happened in a G type airspace and the pilot did not file a flight plan in advance (which was possible based on the current regulations), the pilot could not request for search and rescue.

1.16 Tests and research

There was no need to conduct tests and research for reaching the conclusion.

1.17 Organisational and management information

The characteristics of the organizational and management environment had no effect on the course of events therefore their analysis was not required.

1.18 Additional information

According to the current regulations (Ministerial decree 14/2000 (XI.14.) KöViM modified by a decree 115/2005 (XII. 27.) GKM, and the joint decree 26/2007 (III.1.) GKM-HM-KvVM) the use of G type airspace is possible without the need of filing a flight plan, communicating on the assigned radio channels, or setting the SSR code on the aircraft’s transponder. However, by not using these measures the pilot precluded himself from receiving timely assistance in case of an accident.

The IC does not intend to publish additional information other than the factual information above.

1.19 Useful or effective investigation techniques

The investigation did not require techniques differing from the traditional approach.

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2. ANALYSIS

Accounts of eyewitnesses, the pilot, and passengers, as well as the findings of the examination of the helicopter wreckage were the basis for the analysis. The IC did not have data from devices of objective control because the flight data recorder installed on the aircraft was not operating during the flight.

The aircraft was technically airworthy before takeoff. The IC did not find any signs of technical malfunction. The flight controls were fully functional during the whole flight. The engine was operating normally, this statement is proven by the fact that the rotor blades tore off and flew to a great distance – 250…300 m - from the helicopter which is a telltale sign of a high-energy rotor. The eyewitnesses did not see or hear unusual signs or sounds prior to collision with the wires.

The readings of the cockpit instruments, the position of controls and switches, the visual and borescope check of the engine as well as the the condition of the rotor and main gearbox provide a consistent picture about the course of the events,and support the IC’s opinion that the helicopter’s systems were functioning normally and were not a contributing factor in the accident.

The pilot possessed a valid PPL (helicopter „A”) licence but he could not present a document proving his type rating for the given type of aircraft.

Flying a helicopter at low altitudes requires special training and preparation due to the danger of colliding with obstacles and the special flying technique this task demands. The pilot’s main reference is his/her own vision, and a special scanning routine is required for constant monitoring of the relief, the obstacles, and the flying birds. These objects, approaching the aircraft with a relatively high angular velocity, paired with turbulence which is common at low altitudes, make the pilot’s task difficult. The IC could not find a proof that the pilot had prepared for the low-altitude flight and that he possessed a permit for conducting such flights.

Neither did the IC find a small-scale map with the obstacles and the avoidance flight paths calculated and marked.

The helicopter carried an experimental registration mark and did not have a valid airworthiness certificate. It did have a valid permit to fly issued by the Romanian CAA. According to the permit, the operation of the aircraft was restricted to flights where the following conditions are met:

– daylight VFR flights,

– no persons can be carried during flights except persons whose presence is essential to the purpose of the flight.

Based on the analysis of weather conditions the IC believes that the pilot could experience difficulties in seeing through the windshield which was lit by the sun from a southwesterly direction.

The IC determined that the accident was most probably caused by the operating of the aircraft at a very low altitude.

The IC reconstructed the flight path relevant to the accident.

The helicopter was involved in leisure flight activity (aerial sightseeing) during a festivity in the village of Darnózseli. The sightseeing opportunity was adversised on the village’s website. The helicopter took off for the last flight with one female and two male passengers on board. The pilot possessed a permit for the takeoff from the temporary takeoff and landing site.

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Following takeoff, the helicopter flew over the castle in Novákpuszta then it continued on a westerly course over the Mosoni-Duna river towards Kimle. Eyewitnesses on the ground saw the helicopter flying just above treetops, over the river. The pilot told the IC that they flew at 130 metres.

According to the pilot’s account, he reset the barometric altimeter for the altitude of the takeoff site and flew by QFE altitude. If the IC accepts this explanation, then the helicopter must have descended about 120 metres prior to collision with the power lines. The IC, however, could not find any evidence that such an extreme descent really happened. Therefore the IC examined the possibility that the pilot reset the barometric altimeter to QNH.

At the time of the recovery of the wreckage from underwater, the reading on the barometric altimeter was 748,0 Hgmm. Assuming it as QNH altitude, in metres it means about 132 metres above mean sea level. The average elevation of the terrain is 113 metres above sea level, the height of the obstacle is about 12 metres, adding the two yields 125 metres. The accuracy of the altimeter is influenced by:

– errors stemmed from the barometric measuring method (local air pressure, air temperature, temperature gradient etc.), and

– instrument errors.

The typical indication error of the barometric altimeters on ground level is ± 15 metres.

Therefore it is possible that the pilot saw 130 metres on the altimeter while he was actually flying 7-12 metres above the ground, this is why the helicopter could collide with the power lines.

The safe altitude over a flat terrain is 150 metres (cca. 500 feet). Safe altitude is the minimal altitude by instrument which provides a safe flight without the risk of colliding with terrain or tall obstacles even in restricted visibility. The pilot shall know the safe altitude in case of flying low and in emergency descent.

The pilot told the IC that he believed the accident was caused by sudden and unexpected changes in wind speed and direction. The meteorological expert opinion states that, considering the terrain and vegetation near the accident site, over 150 metres the airflow was laminar while turbulence was possible at altitudes of 35-45 metres. The IC believes that the wind speed was much lower than the airspeed therefore it could not have significant effect on the safety of the flight.

A short summary of the specifics of conducting low altitude flights:

– Planning: Decision on the flight, preparation, selection of a map of proper scale, study the selected route, the terrain and the nearby obstacles.

– Actual flight: Resetting the altimeter. In Hungary, the barometric altimeters are reset to the sea level of the Baltic Sea. The use of the QNH method is practical because the maps indicate the elevations relatively to sea level. The radio altimeter offers the possibility of setting a dangerous altitude (the IC determined that the dangerous altitude was set below zero).

When flying at low altitude, the pilot shall visually estimate the altitude and occasionally check the radio altimeter for control. It is advisable to continuously scan the terrain for altitude estimation (150-200 m ahead) as well as for obstacles (800-1000 m ahead). The heading should be kept with the help of select reference objects and the compass readings. When making a turn, the pilot’s attention should be on the terrain, the altitude and the bank angle. Flying low over a meandering river, coupled with an improper flying technique and/or not inadequate experience can easily lead to unexpected situations.

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According to one of the passengers’ account, there was a loud bang coming from behind, then the helicopter dropped, swayed, and finally fell into the river. (It is unprecedented that a relatively new full-metal helicopter loses its tail boom during a level flight without any external cause.)

The IC believes that the helicopter was flying at low altitude and the main rotor collided with the power lines with its blades running behind the rotor mast, i.e. over the tail boom. The rotor blades broke off, and the sudden excessive dynamical load on the tail rotor caused its moment to surge, which in turn bent and eventually broke off the tail boom. The IC found no marks or scratches either on the upper part of the cabin or the cowling of the main gearbox, therefore it was the most probable conclusion that the helicopter hit the cables with the main rotor.

One of the canoe riders who assisted in pulling the passengers out of the water, told the IC that he asked the pilot whether he knew why they fell into the river. The pilot seemed to be surprised and said he did not knew. He then was told they hit a power line.

Ministerial decree 14/2000. (XI.14.) KöViM determines the rules of use of the Hungarian airspace and the country’s airports. The IC determined that the following rules were not met during the flight:

„3.4.1. With the exception of take-off and landing, aerial work, and special flights of state aircraft, VFR flights shall not be conducted

a) over densely populated areas of cities and villages as well as groups of people in the open, at altitudes less than 1000 feet (300 metres) AGL in relation to the highest object found within a circle of 600-metre-radius circle with the aircraft in its centre,

b) over terrain not listed under subparagraph a) at altitudes less than 500 feet (150 metres) AGL, with the exception of flight requiring special permission, hot air or gas balloon flights, or paraglider/hang-glider flights.”

Law XCVII of 1995 on air transport, Section III – Rules of air transport states the following:

„52.§ (2) Transport of passengers and goods by an aircraft is allowed only if the pilot possesses a written authorisation to do so from the operator or maintainer of the aircraft.” The IC has no knowledge of such a document.

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3. CONCLUSIONS

The IC determined that:

the pilot possessed a valid professional and medical licence,

the Vb could not find any documentation regarding the pilot’s type rating or permits for low altitude flights,

the aircraft was airworthy from a technical viewpoint,

the pilot’s psychophysical conditions were not a contributing factor in the accident,

all systems of the helicopter were operating normally until the impact,

according to the „Permit to Fly” document, the helicopter was not suitable to transport passengers,

the performance of ATM services was not a contributing factor in the accident,

there was no meteorological phenomenon considered dangerous to flying present in the area at the time of the accident.

3.1 Direct causes of the occurrence

The flight was conducted without adequate planning and at an unjustifiably low altitude,

The radio altimeter was not set to dangerous altitude,

The helicopter was used for flights which are not allowed in the documentation,

It is possible that the pilot was experiencing difficulties in seeing through the windshield which was lit by the sun from a southwesterly direction while he was flying West.

3.2 Indirect causes of the occurrence

The pilot did not possess all the required certificates and ratings.

The preparation for a low altitude flight was not adequate.

A small-scale map indicating the obstacles along the planned flight route is required to be on board for low altitude flights. The IC determined that there was no such map on board during the accident flight.

The radio altimeter was not set to the height of the lowest obstacle.

3.3 Risk factors which cannot be linked to the occurrence

According to the „Permit to Fly” document, the helicopter was not suitable to transport passengers.

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4. SAFETY RECOMMENDATIONS

Similar occurrences can be prevented by adhering to the existing rules and regulations, therefore the IC believes that issuing a safety recommendation is not necessary.

5. APPENDICES

1. Official correspondence from the CAA of Romania

2. Expert opinion of the meteorologist expert of TSB (in Hungarian)

3. The opinion of the pilot (in Hungarian)

Budapest, „ „ June 2009.

István PAPP IIC

János ESZES IC member

NOTE:

This present document is the translation of the Hungarian version of the Final Report.

Although efforts have been made to translate it as accurately as possible, discrepancies may occur.

In this case, the Hungarian is the authentic, official version.

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Appendix 1

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Appendix 2

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2008-201-4P

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Appendix 3