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Imagery Description |
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Event Description |
On December 7, 2011, a Eurocopter AS350-B2 helicopter, operating as a “Twilight Tour” sightseeing trip, unexpectedly made several changes in direction and altitude before crashing into mountainous terrain. Four passengers and the pilot were killed. The wreckage showed that a flight control input rod was not connected between one of the three hydraulic servos and the main rotor. |
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Self-Locking Nuts |
The investigation found, first of all, that the company’s maintenance personnel were reusing nuts that did not meet the criteria specified by Eurocopter and FAA guidance. This negated the safety benefits of one of the two required locking devices. |
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Fatigue |
Both the mechanic and the quality control inspector, who inspected the maintenance work completed by the shift right before the accident, were likely fatigued during the December 6 shift due to an insufficient adjustment period to working an earlier shift than normal. |
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Work Cards |
The maintenance documentation did not clearly delineate specific inspection and completion steps, which can allow these tasks to be more vulnerable to error through human factors. |