CFIT Accident Eurocopter EC 145 F-ZBPZ, Sunday 1 December 2019
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Date:Sunday 1 December 2019
Time:20:47 LT
Type:Silhouette image of generic EC45 model; specific model in this crash may look slightly different    
Eurocopter EC 145
Owner/operator:Sécurité Civile
Registration: F-ZBPZ
MSN: 9056
Fatalities:Fatalities: 3 / Occupants: 3
Other fatalities:0
Aircraft damage: Destroyed
Location:between Rove and Pennes-Mirabeau, Bouches-du-Rhône 13 -   France
Phase: En route
Departure airport:Marseille-Provence Airport (MRS/LFML)
Destination airport:Le Luc-Le Cannet Airport (LFMC)
Investigating agency: BEA-E
Confidence Rating: Accident investigation report completed and information captured
Eurocopter EC 145 (BK 117C-2) callsign Dragon 30, impacted terrain between Rove and Pennes-Mirabeau near Marseilles. The 3 occupants died.

Causes of the event:
The accident was caused by an inadvertent re-entry into a cloud layer, which combined with too high a speed and too low an altitude to detect the terrain in time to avoid it.
In addition to the speed and height of flight, a number of other deviations made the collision with the terrain unavoidable, including the setting of the radio altimeter alarm at 300 ft and the failure to apply the backup procedure for unintentional re-entry into the cloud layer.
The lack of topographical knowledge of the area overflown and incomplete navigation preparation resulted in the pilot's incorrect situational awareness. The pilot did not carry out the operational adaptation of the Marignane base.
The overload of work for the pilot in the seconds before the accident probably made him unable to monitor the radio altitude and to use the Euronav 7 navigation system.
The choice to conduct the flight under VFR is not appropriate, as the VMC conditions were not met at Marseille Provence. However, the conditions allowed for a special VFR clearance to be requested, but the pilot did not request it from ATC.

These decisions reflect an internal time pressure on the crew, probably caused by the high motivation for the upcoming rescue missions, as well as an operational culture favouring VFR flight in marginal conditions.
The Marseille Provence control displays a laissez-faire attitude with the non-compliance of the Dragon 30 with VFR flight rules.
The crew displayed a transponder code corresponding to urgent hospital transport, inducing a false perception of emergency for the controller.
The controller's encouragement to cross the runway centrelines quickly may have created a sense of urgency for the helicopter pilot, encouraging him to maintain high speed despite the deteriorating weather conditions.
The pilot's extensive aviation experience may have led to a sense of risk control on his part and generated an overconfidence in him on the part of the MOB, resulting in the observed perseverance and lack of relinquishment.
The MOB repeatedly questions the pilot's decisions but in a non-argumentative way, not allowing for any questioning of the actions. The two flight crew members' awareness of the situation was divergent.
The overload of work in the moments preceding the accident can be explained by the pilot's extensive experience in multi-pilot operations in the military.
On the documentation side, several irregularities were found in the GHSC operational documentation.
They contributed to the accident by not allowing the pilot to assess whether the conditions were suitable for visual flight. GHSC crews based their decisions regarding the flight regime on incomplete or outdated texts.
Finally, the operations manual of the Marseille Provence control agency does not sufficiently cover the special procedures and exemptions granted to civil security helicopters.

Accident investigation:
Investigating agency: BEA-E
Report number: 
Status: Investigation completed
Download report: Final report

_____________________ (photo) (photo)



Revision history:

02-Dec-2019 06:40 Iceman 29 Added
02-Dec-2019 06:43 Iceman 29 Updated [Embed code, Photo]
02-Dec-2019 06:44 Iceman 29 Updated [Date, Time, Embed code]
02-Dec-2019 06:45 Iceman 29 Updated [Operator]
02-Dec-2019 06:49 Iceman 29 Updated [Departure airport, Destination airport, Narrative]
02-Dec-2019 06:54 Iceman 29 Updated [Embed code]
02-Dec-2019 06:57 Iceman 29 Updated [Embed code, Narrative]
02-Dec-2019 07:06 Iceman 29 Updated [Narrative]
02-Dec-2019 07:11 Aerossurance Updated [Nature, Destination airport, Narrative]
02-Dec-2019 07:12 Aerossurance Updated [Source]
02-Dec-2019 11:29 Iceman 29 Updated [Location, Destination airport, Narrative]
02-Dec-2019 15:09 Iceman 29 Updated [Embed code]
02-Dec-2019 15:09 Iceman 29 Updated [Embed code]
02-Dec-2019 17:59 Iceman 29 Updated [Phase, Embed code]
03-Dec-2019 00:54 Iceman 29 Updated [Embed code]
03-Dec-2019 01:01 Iceman 29 Updated [Embed code, Narrative]
03-Dec-2019 08:23 Iceman 29 Updated [Date, Time, Source]
03-Dec-2019 19:55 Iceman 29 Updated [Registration, Cn, Operator, Source, Narrative]
03-Dec-2019 22:00 Iceman 29 Updated [Source]
04-Dec-2019 01:32 RobertMB Updated [Aircraft type, Location, Source, Narrative]
15-May-2020 11:04 harro Updated [Registration, Cn]
15-Apr-2021 18:23 harro Updated [Operator, Nature, Destination airport, Embed code, Narrative, Category, Accident report]
17-Apr-2021 14:25 Aerossurance Updated [Time, Embed code, Narrative]
01-May-2021 09:39 Aerossurance Updated [Source]
01-May-2021 09:44 Aerossurance Updated [Embed code]
14-Nov-2023 15:49 harro Updated [Other fatalities]

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