Severe damage inflicted by an embarrassing ground accident on a brand new search and rescue helicopter in Norway has been pinned on organisational and human failures within the country's air force, partly driven by programme delays.
Norwegian military investigators, in their final report on the 24 November 2017 incident, determined that although the roll-over of the Leonardo Helicopters AW101 – which had been delivered one week earlier – was caused by pilot error, severe systemic failings also contributed to the accident.
These included inadequate training, poor project oversight and pressure to recover from a six-month delivery delay, which "contributed to elevated and unidentified operational risk".
Two crew were aboard the AW101 at Sola air base to perform a ground run following an engine compressor wash. However, the collective was in "a higher position than usual" for the procedure, with the rotor blades "at an angle of attack capable of producing a significant amount of lift".
In addition, two engines rather than one were used to accelerate the rotor, causing it to "achieve full rotational speed", says the report.
The pilots attempted to arrest the AW101's roll by cutting the engines and moving the cyclic lever, but they could not prevent it tipping onto its right-hand side.
The main rotor then struck the ground and "large and small pieces of the blades were torn loose", the report says.
But it notes that "ambitious timelines" for the acquisition of the new search and rescue helicopters, coupled with the delivery delay, had "created persistent time pressures for all parties involved".
In turn, this resulted in Royal Norwegian Air Force pilots from its operational test and evaluation (OT&E) unit receiving insufficient training from Leonardo Helicopters on the new type.
The instruction they received was "characterised by ongoing, delayed development of the helicopter, aids and documentation", the report says, which "contributed to uncertainty and lack of coping" by OT&E personnel.
"Combined with the fact that several of the pilots did not have the experience and continuity that the training programme was based on, this led to known and unknown shortcomings in the pilots’ skills and competencies after completing training," it says.
"The constant demand for progress negatively affected quality assurance in various parts of the organisation, and contributed to elevated and unidentified operational risk."
The human and organisational factors that contributed to the accident had developed "without anyone identifying or correcting the deviations", it says, due to an overall failing of project oversight.
"Among these were shortcomings in the crew’s system knowledge and experience with the AW101, insufficient risk awareness, deviations from the checklist, shortcomings in the training received, and imprecise checklist wording.
"This meant that the pilots chose to omit some points in the checklist. If all points in the checklist had been followed, the roll-over would not have happened."
Neither pilot was injured in the incident; the helicopter was subsequently returned to Leonardo Helicopters' Yeovil, UK factory for repair.
Flight Fleets Analyzer reveals that Norway has so far received four of an eventual 16 AW101s.
In the wake of the incident, the air force changed its training programme for the type, and received additional support from the manufacturer.