AAIU report into crash of EI-SBM

The Air Accident Investigation Unit (AAIU) of the Department of Transport has published it's report into the crash of Agusta A109E registered EI-SBM at Dunshaughlin Co. Meath on March 20 2008. On the date of the crash, the pilot of the helicopter and sole occupant was en route from Celtic Heliport in Knocksedan Co. Dublin to Weston Aerodrome Co. Kildare. En route he advised Dublin ATC that he was approaching Dunshaughlin. Shortly afterwards he again called ATC advising that he had a problem, immediately reported that he would have to make an emergency landing and called 'Mayday'. The helicopter landed in boggy ground and rolled onto it's left side. Due to the complete inaccessibility of the crash site the Dublin based Irish coastguard helicopter was used to airlift the pilot to Our Lady of Lourdes Hospital in Drogheda, Co. Louth. The pilot suffered severe back injuries in the crash.
As part of the investigation the pilot was interviewed twice by the AAIU team. In his interviews the pilot recalled that he was flying on autopilot at an altitude of 800ft and at a speed of 120 kts. Winds were gusting from the SW at 30-35 kts with 6-8 km visibility. Approaching Dunshaughlin he heard a loud bang from the rear of the helicopter at which point the nose pitched up and yawed violently to the right. He immediately disengaged the auto pilot (AP) and applied full left pedal to counteract the yaw but this had no effect. The pilot believed that he had lost tail rotor control so he lowered the collective to see if it would counteract the yaw, an action which would also drop the airspeed. As the helicopter drifted towards Dunshaughlin the pilot applied power in an attempt to get the craft clear of the built up area. Once clear he entered into an autorotation, shut down both engines and lowered the undercarriage. He recalled that the helicopter was spinning at such a rate that the centrifugal force pushed him back into his seat as he attempted to reach the undercarriage lever. As the radio altimeter reached 50ft the pilot attempted to flare the craft. The next thing he remembers is lying on the ground 3 to 4m from the helicopter, looking at it lying on its side, unaware of the circumstances of the impact or how he got out. 
The initial AAIU investigation at the crash site found some cleaning cloth material entangled on the long tail rotor drive shaft between the first and second bearing.  It also found that the drive shaft was completely severed forward of the second bearing, thus cutting off drive to the tail rotor gearbox. In researching the maintenance history of EI-SBM the investigation team found that the helicopter which was normally kept at Weston Aerodrome was ferried to Celtic Helicopters at Knocksedan Heliport on February 4 2008 for it's annual 300 hr maintenance check. This check was completed on March 5 2008, on which date two post maintenance test flights were performed prior to it's ferry back to Weston where normal operations commenced the next day. Over the next twelve days, a total of sixty flights were made, all which were flown by the pilot. During this time the helicopter was hangared at Weston where there is no maintenance facility available to the operator. On March 20 the pilot flew to Knocksedan to have new engine fire bottles fitted as these had not been available when the earlier check was carried out, loan bottles having been fitted. A tail rotor crack inspection was also carried out in compliance with an Airworthiness Directive.
The Agusta flight manual requires that the tail drive shaft bearings be inspected each day under the heading of 'First Flight of the Day'. This requires opening of the fairing that covers the tail long drive shaft. The pilot confirmed to the investigation team that he had carried out his check on March 18 and March 19 but did not find any cloth material.
In examing the failed drive shaft the investigating team concluded that the shaft had failed as a result of metal fatigue arising from the eccentric loading caused by the cleaning cloth which had become entangled in the drive shaft. Although several possibilities are mooted, the team were unable to determine when and by whom the cleaning cloth was left in the area of the drive shaft. 
In relation to the experience of the pilot when the sudden failure occurred the AAIU noted that the pilot had completed his type training two years before a simulator was available in Europe. This meant that his training for certain types of emergencies could only be carried out on a real helicopter thus restricting the type of emergencies which could be practiced.


This final report carries two safety recommendations :
The European Aviation Safety Agency should strongly encourage all helicopter pilots to undergo simulator training, where available on their Initial Type Rating course and thereafter, to undertake emergency training when training for it's revalidation. 
That the Irish Aviation Authority issue a Notice to maintenance organisations in relation to the control of tools and materials used during maintenance in accordance with the requirements of JAR 145.