WEEK 25
H2F brings you the ‘helicopter mayday of the week’ with a short accident report summary. I tell you what happened. You think more about why it happened. We all learn from it. Because that’s what accident reporting is for.
TITLE
Passenger fatally struck by tail rotor during rotors running boarding.
WHAT?
An AW119 was conducting a non-scheduled flight for civil aviation authority officials. After landing with the engine and rotors running, the pilot instructed the waiting passengers to remain clear while essential stores were unloaded. As the ground handler moved to close the left-hand cabin door after unloading, one of the passengers unexpectedly walked around the rear of the helicopter and was struck by the rotating tail rotor sustaining sustained fatal injuries.
WHERE?
Kedarnath helipad, Uttarakhand, India.
WHEN?
23 April 2023. The Indian AAIB issued its final report on 28 October 2023.
HOW?
Following an uneventful landing, the pilot signalled the three waiting aviation authority officials to remain clear while onboard stores were unloaded from the helicopter. The sole ground handler disembarked, unloading the stores from the left side, then returned to prepare the helicopter for passenger boarding. While the ground handler was occupied closing the left-hand door and the pilot was completing cockpit checks, one passenger unexpectedly left the designated boarding route, passing behind the helicopter in an attempt to reach the opposite side, and entered the tail rotor hazard area. Despite shouted warnings from accompanying officials, rotor noise prevented the passenger from hearing them. The pilot became aware only after hearing the impact and immediately shut the helicopter down.
CONDITIONS?
The investigation found that weather was not a factor. Kedarnath is a high-altitude (11,000 ft) uncontrolled helipad with no ATC or meteorological service, where traffic is managed by common radio frequency under a joint operating procedure. Because of the high traffic density, engine cooling requirements, high elevation, and potential engine restart difficulties, passenger boarding and disembarkation are routinely conducted with rotors running.
The operator’s SOP required passengers to receive a formal safety briefing, be escorted at all times by operator personnel, approach only after positive clearance from the pilot, and never proceed behind the helicopter. However, only one ground handler was available, who was simultaneously responsible for unloading stores and escorting passengers.
OUTCOME?
The passenger died at the scene after being struck by the rotating tail rotor. The helicopter sustained only a small dent to one tail rotor blade, and there was no other aircraft damage.
WHY?
The investigation identified several immediate and latent contributing factors:
- The passenger did not receive the mandatory pre-flight safety briefing. Operational staff omitted the briefing because the flight was running late and assumed aviation authority officials were already familiar with helicopter safety procedures, despite the deceased being a first-time helicopter passenger.
- Passenger escort procedures were not followed. The operator’s sole ground handler was occupied unloading stores and closing the cabin door, leaving no dedicated escort to supervise passengers during boarding.
- Organisational responsibilities at the heliport were unclear. Although the aviation authority owned the helipad, responsibility for operational safety was distributed among multiple operators.There was no single organisation or individual responsible for overall supervision, coordination and safety oversight, contributing to inconsistent application of procedures and recurring safety issues.
- No evidence was found of pilot error, aircraft malfunction or adverse weather. Instead, the investigation highlighted deficiencies in procedural compliance, passenger management and system-level oversight.
- These findings led to recommendations for mandatory passenger briefings, increased ground staffing, clearer supervisory responsibilities and licensing of the helipad.
REFERENCE?
Aircraft Accident Investigation Bureau. (2023). Final investigation report on accident involving M/s Kestrel Aviation’s Agusta AW119 MK-II helicopter VT-RNK at Kedarnath Helipad on 23 April 2023. Ministry of Civil Aviation, Government of India.
Note:
Accident reports selected from the following open source databases: US NTSB; UK AAIB; Flight Safety Foundation’s Aviation Safety Network; Australia’s ATSB. Ireland’s AAIU; Taiwan’s TTSB; France’s BEA; Spain’s CIAIAC. Germany’s BFU.
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