Aircraft Accident Report AAR 1/2023 - Leonardo AW169, G-VSKP

AIRCRAFT ACCIDENT REPORT 1/2023 AAIB Air Accidents Investigation Branch Report on the accident to Leonardo AW169, G-VSKP at King Power Stadium, Leicester on 27 October 2018 Unless otherwise indicated, recommendations in this report are addressed to the appropriate regulatory authorities having responsibility for the matters with which the recommendation is concerned. It is for those authorities to decide what action is taken. In the United Kingdom the responsible authority is the Civil Aviation Authority, CAA House, 45-49 Kingsway, London WC2B 6TE. AIRCRAFT ACCIDENT REPORT 1/2023 Air Accidents Investigation Branch Report on the accident to Leonardo AW169, registration G-VSKP at King Power Stadium, Leicester on 27 October 2018 This investigation has been conducted in accordance with Annex 13 to the ICAO Convention on International Civil Aviation, EU Regulation No 996/2010 and The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2018. The sole objective of the investigation of an accident or incident under these Regulations is the prevention of future accidents and incidents. It is not the purpose of such an investigation to apportion blame or liability. Accordingly, it is inappropriate that AAIB reports should be used to assign fault or blame or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. iiPrinted in the United Kingdom for the Air Accidents Investigation Branch © Crown Copyright 2023 This report contains facts which have been determined up to the time of publication. This information is published to inform the aviation industry and the public of the general circumstances of accidents and serious incidents. Extracts may be published without specific permission providing that the source is duly acknowledged, the material is reproduced accurately and it is not used in a derogatory manner or in a misleading context. Cover picture courtesy of JML. Published: 6 September 2023. iiiAircraft Accident Report: 1/2023 G-VSKP AAIB-25398 Contents � Crown Copyright 2023 Contents Contents Introduction.......................................................................................................................1 Summary...........................................................................................................................2 1 Factual information.................................................................................................5 1.1 History of the flight...........................................................................................5 1.1.1 Background........................................................................................5 1.1.2 Previous flights on 27 October 2018..................................................5 1.1.3 Accident flight.....................................................................................7 1.2 Injuries to persons............................................................................................9 1.3 Damage to the aircraft. ....................................................................................9 1.4 Other damage................................................................................................10 1.5 Personnel information. ...................................................................................10 1.5.1 Pilot..................................................................................................10 1.5.2 Background information...................................................................10 1.5.2.1 Pilot ...............................................................................10 1.5.2.2 Front seat passenger.....................................................11 1.5.3 Training and checking.......................................................................11 1.6 Aircraft information.........................................................................................12 1.6.1 Maintenance and bearing manufacturing process review................12 1.6.2 Aircraft description...........................................................................13 1.6.3 Tail rotor duplex bearing development history.................................23 1.6.4 AW169 and AW189 tail rotor design and certification .....................25 1.6.5 Duplex bearing design and load analysis........................................27 1.6.5.1 Factors contributing to tail rotor control loads............... 27 1.6.5.2 Factors affecting the demand for tail rotor lift. ...............28 1.6.5.3 Duplex bearing specification and load spectrum development..................................................................30 1.6.5.4 Control of bearing discard life and inspection tasks...... 34 1.6.6 AW189 and AW169 flight test load surveys.....................................37 1.6.7 Tail rotor certification testing............................................................40 1.6.7.1 Tie down helicopter rig endurance test..........................40 1.6.7.2 Flight test programme...................................................42 1.6.7.3 Tail rotor actuator certification testing............................43 1.6.8 Tail rotor system failure emergency procedures..............................44 1.6.9 Helicopter performance....................................................................45 1.6.10 Bird strike protection........................................................................48 1.6.11 Fuel tanks........................................................................................49 ivAircraft Accident Report: 1/2023 G-VSKP AAIB-25398 Contents © Crown Copyright 2023 Contents 1.6.12 Cabin configuration..........................................................................49 1.6.13 Health and Usage Monitoring System (HUMS)...............................49 1.6.14 Air-Data Attitude Heading Reference System (ADAHRS) – data bus limits.................................................................................53 1.6.15 Flight Control Computer (FCC)........................................................54 1.6.16 Crew alerting system.......................................................................54 1.7 Meteorological information.............................................................................54 1.8 Aids to navigation...........................................................................................54 1.9 Communications............................................................................................54 1.10 Aerodrome information. .................................................................................55 1.10.1 Aerodrome.......................................................................................55 1.10.2 LCFC training ground.......................................................................55 1.10.3 King Power Stadium........................................................................55 1.11 Recorded information.....................................................................................55 1.11.1 Flight recorder..................................................................................56 1.11.2 Avionics............................................................................................57 1.11.3 Witness videos and imagery............................................................59 1.11.4 Personal electronic devices.............................................................60 1.11.5 Radar and air traffic control radio transmissions .............................60 1.11.6 Accident flight...................................................................................60 1.11.7 Previous flights.................................................................................66 1.11.8 HUMS..............................................................................................68 1.11.9 Comparison of recorded data with published li

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Aircraft Accident Report AAR 1/2023 - Leonardo AW169, G-VSKP

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