CAP1144ADELTreport (Cor)

Safety and Airspace Regulation Group
ADELT review report

CAP 1144
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Safety and Airspace Regulation Group
CAP 1144
ADELT review report
www.caa.co.uk
January 2014
CAP 1144 Contents
Contents
1 Executive summary 7
2 Acknowledgements 9
3 Introduction 10
4 Definitions and acronyms 17
5 Evaluation of failures to deploy 20

5.1 Introduction 20
5.2 Design issues 21
5.2.1 Equipment location 21
5.2.2 ADELT location 22
5.2.3 Sensor location 22
5.2.4 Electrical power location 23
5.2.5 Human factors 24
5.2.6 Sensor selection 24
5.2.7 Vibration 25
5.2.8 Water ingress 26
5.2.9 Wiring Issues 26
5.3 Installation issues 28
5.4 Manufacturing 28
5.5 Wear 28
5.6 Unknown 29
6 Evaluation of inadvertent deployments 30

6.1 Introduction 30
6.2.1 Design induced human factors errors 33
6.2.2 Robustness Faults 34
6.2.3 Vibration, distortion, liners & seals 34
6.2.4 Location & water ingress 34
January 2014 Page 4

CAP 1144 Contents
6.3 Human factors 35

6.5 Maintenance issues 36
6.6 Unknown 37
7 Evaluation of performance issues 38

7.1 Introduction 38
7.2.1 Robustness 39
7.2.2 Design induced human factors 40
7.3 Maintenance issues 40
7.3.1 Antenna issues 40
7.3.2 Errors/omissions 41
7.3.3 Excessive loads 41
7.4 Manufacturing issues 42
7.5 Unknown 42
8 Evaluation of other events 43

8.1 Introduction 43
8.2.1 Robustness 44
8.2.2 Spurious warnings 44
8.3 External events 45
8.3.1 In-flight damage 45
8.3.2 PLB Transmissions 46
8.3.3 Aircraft events 46
8.5 Unknown 46
9 Tail boom separation issues 47
10 Rotorcraft inversion considerations 50
11 Recommendations 52
12 References 54
January 2014 Page 5

CAP 1144 Contents
Appendix A List of MORs 57
Appendix B Accident investigation reports 95

B1 – Extracts From the G-ATSC Investigation 95
B2 – Extracts From the G-BBHN Investigation 96
B3 – Extracts From the G-BIJF Investigation 98
B4 – Extracts From the G-ASWI Investigation 99
B5 – Extracts From the G-BARJ Investigation 102
B6 – Extracts From the G-ASNL Investigation 103
B7 – Extracts From the G-BEON Investigation 105
B8 – Extracts From the G-BDIL Investigation 106
B9 – Extracts From the OY-HMC Investigation 108
B10 – Extracts From the G-BISO Investigation 109
B11 – Extracts From the G-AZOM Investigation 111
B12 – Extracts From the G-BJJR Investigation 112
B13 – Extracts From the G-BKFN Investigation 113
B14 – Extracts From the G-BWFC Investigation 114
B15 – Extracts From the G-BEID Investigation 116
B16 – Extracts From the G-BDII Investigation 119
B17 – Extracts From the G-BDES Investigation 120
B18 – Extracts From the G-BGKJ Investigation 123
B19 – Extracts From the G-BEWL Investigation 125
B20 – Extracts From the G-TIGH Investigation 127
B21 – Extracts From the G-TIGK Investigation 129
B22 – Extracts From the G-HAUG Investigation 130
B23 – Extracts From the LN-OPG Investigation 133
B24 – Extracts From the G-BJVX Investigation 135
B25 – Extracts From the G-JSAR Investigation 138
B26 – Extracts From the G-BLUN Investigation 140
B27 – Extracts From the G-REDU Investigation 142
B28 – Extracts From the G-REDL Investigation 144
B29 – Extracts From the G-REDW Investigation 145
B30 – Extracts From the G-CHCN Investigation 148
January 2014 Page 6

CAP 1144 Chapter 1: Executive summary
Chapter 1
1
Executive summary
The UK CAA has been aware of issues related to failed and inadvertent
deployments of Automatically Deployable Emergency Locator Transmitters
(ADELTs) and, as a result, has been actively monitoring issues associated with
ADELTs. As a result of this monitoring the UK CAA initiated a further review
of ADELT performance, the sole intent of which was to make a number of
recommendations related to ADELT performance, based on the knowledge
gained over 26 years with the aim of increasing the likelihood of helicopter
occupants being located and rescued in the event of an accident or incident.
The review was performed in two phases; a review of Mandatory Occurrence

Reports (MORs) related to ADELT incidents (to determine a base set of
performance issues) followed by a review of a number of accident reports.
The review of accident reports covered a period of 26 years and included the
accidents referenced in the Helicopter Airworthiness Review Panel (HARP)
Report – CAP 4911. This was supplemented by some accidents that occurred after
publication of the HARP report to check whether the data gathered from a review
of MORs was consistent with the information contained in accident reports.”
All the accidents reports that were reviewed related to accidents/incidents that
occurred in the North and Irish Seas.
The aim of this review was to address four basic questions:
What are the main causes of degraded ADELT functionality?
Is the ability of an ADELT to function correctly significantly affected by the

helicopter tail boom becoming detached?
Is the ability of an ADELT to function correctly significantly affected by

helicopter inversion?
Have recent improvements in ADELT system designs improved ADELT reliability?
Analysis of the MORs and accident investigation reports reviewed during this
investigation demonstrates that there are a number of common issues associated
with the deployment or non-deployment of an ADELT. The review concluded that
ADELT functionality is influenced by:
The location of the ADELT on the aircraft
1 CAP 491 can be found on the CAA website.
January 2014 Page 7

CAP 1144 Chapter 1: Executive summary
The location of ADELT related sensors in the aircraft
The location of the power supplies for ADELTs and their supporting sensors
Flight deck and maintenance human factors issues
The level of clarity and completeness of maintenance instructions
The review concluded that there is probably no one “perfect” ADELT installation.
Any ADELT installation design is likely to have to be a compromise to achieve the
best possible resolution of issues associated with equipment selection, location
and maintenance.
Finally, this report concludes that, while some previously identified ADELT issues
have been resolved with no further occurrences, some have either recurred
despite the system and installation designs being amended, or have only been
partly resolved.
These conclusions were re-reviewed in the light of more recent helicopter

accidents in the North Sea (G-REDW and G-CHCN). Although no new
recommendations are proposed following these accidents, the information gained
from a review of publicly available data related to these accidents supports the
conclusions of this report.
The review includes a number of recommendations related to location

of the ADELT, ADELT related sensors and ADELT sensor power supplies.
If adopted, these have the potential to optimise installation designs and
maximise the likelihood of the ADELT deploying and transmitting appropriately.
Recommendations are also made regarding human factors issues and
maintenance issues that have the potential to reduce the number of inadvertent
deployments of ADELTs.
In addition to the ADELT related lessons and recommendations, discussions with

the AAIB identified that there are some helicopter flight recorder installations that
place the flight recorders in parts of the tailboom that are likely to become detached
during or after an accident. As a result, this report contains one general flight
recommendation that flight recorders are also located away from these areas.
January 2014 Page 8

CAP 1144 Chapter 2: Acknowledgements
Chapter 2
2
Acknowledgements
The following people and organisations supported this review:
Bond Helicopters (Aberdeen) and CHC Scotia (Aberdeen) were consulted as

part of this review and provided information on the general issues they had
experienced relating to poor performance of ADELTs.
Bristow Helicopters (Aberdeen) were also consulted as part of this review and
provided information on the general issues they had experienced. In addition,
Bristow kindly gave permission to photograph their aircraft equipped with
ADELTs to illustrate possible ADELT locations.
Caledonian Airborne Systems were also consulted as part of this review and
provided information on the general issues they had experienced. In addition,
they provided information on ADELT design issues.
The UK AAIB were also consulted as part of this review, provided access
to reports that are publicly available but not on their website and provided
information about ADELT issues that are generally encountered during
accident/incident investigations.
The AAIB Denmark provided information on an accident report that was only
available in Danish.
CAA SARG technical staff from the Airworthiness and Flight Operations
Capability Teams.
The author is grateful to these people and organisations for their invaluable
support during this review.
January 2014 Page 9

CAP 1144 Chapter 3: Introduction
Chapter 3
3
Introduction
The UK CAA has been aware of issues related to failed and inadvertent
deployments of Automatically Deployable Emergency Locator Transmitters
(ADELTs) for several years, as the following extract from CAP 641 “Report of the
Review of Helicopter Offshore Safety and Survival” [Ref 37] shows:
“ADELT does not have a good record of satisfactory operation in crashes …

Thus, whereas finding a ditched helicopter has never been a problem, it might
not always be easy to locate the scene of a crash which has occurred with
little warning some distance away from an offshore platform, particularly if the
aircraft has not remained on the surface.”
This review was performed to identify the most likely causes of ADELT
malfunctions and make a number of recommendations solely aimed at increasing
the likelihood of helicopter occupants being located and rescued in the event of
an accident or incident. It covered a period of 26 years from 1986 to 2012 and
used the UK CAA’s Mandatory Occurrence Report (MOR) database and publicly
available air accident investigation reports as its primary sources of information.
In addition, this review made reference to the HARP (Helicopter Airworthiness

Review Panel) report of 1984 (CAP 491 [Ref 35]) to ensure that it was aligned
with the other helicopter research reports collated in CAP 491. Specifically, this
review addressed the same set of accident reports covered by the HARP report to
determine whether any ADELT related lessons could be learned from evaluating
them. A number of other accident reports (related to accidents that occurred after
the publication of the HARP report) were also investigated with the same intent.
The helicopter operators in Aberdeen (Bristow, Bond and CHC), Caledonian

Airborne Systems and the UK AAIB also provided input to this review. The UK AAIB
provided copies of publicly available accident reports which were not published on
their website and general information about the damage helicopters have been
subjected to during an accident. AAIB Denmark also provided information about
an accident report that was only available in Danish. Bristow, Bond, CHC and
Caledonian Airborne Systems commented on the initial drafts of this report and to
provide input on the types of ADELT related issues they have experienced.
The review was performed in two stages; a review of the UK CAA MORs to
determine a base set of ADELT issues and a subsequent review of the data
related to the accidents listed in the HARP report and other, more recent,
January 2014 Page 10

accident reports to determine whether this information confirmed the findings

derived from the review of MORs.
The review of the CAA MORs resulted in the identification of five categories of
ADELT issues:
Failure To Deploy
Inadvertent Deployment
Performance
Other
Unclassified
These categories are defined in section four of this report (Definitions and
Acronyms).
The categories of ADELT issues identified by the review of MORs are used in this
review as the Primary Classifications (i.e. the initial categories used to sort the
MOR data).
Each of the four relevant primary categories (i.e. excluding ‘unclassified’) were
subjected to further analysis, which resulted in the allocation of Secondary
Classifications, intended to indicate the most likely cause of the ADELT issue
under consideration. The secondary classifications listed below are also defined in
section 4 of this report.
Design
External Event
Human Factors
In-Flight Damage
Installation
Maintenance
Manufacturing
Performance
Note 1: The issues identified as unclassified have been included in these charts
for completeness but have not been subjected to any further analysis.
Note 2: Automatically deployable beacons are generally referred to as

Automatically Deployable Emergency Locator Transmitters (ADELTs) or Crash

Position Indicators (CPIs). This report has simplified the terminology used such
that reference is only made to ADELTs. In all cases, the use of the term ADELT(s)
should be interpreted as referring to both ADELTs and CPIs.
Figure 1 below provides an overview of the prevalence of each type of ADELT

issue over the 26 year period.
It should be noted that, as a result of the time span this review covers, some of
the rotorcraft types that appear in this document have since been retired, along
with their ADELT installations. However, as the lessons associated with the ADELT
issues raised may still be relevant, they have been addressed in this report.
Figure 1 – Top Level ADELT Distribution
From the data available, it appears that the most common issue related to
ADELTs is “inadvertent deployment”, closely followed by “systematic” and “other”.
However, care should be taken when using this set of data to draw conclusions
related to the overall distribution of different types of ADELT issues because:
Although the majority of “failure to deploy” issues relate to aircraft accidents or

incidents, this review has classified some events as “failure to deploy” on the
basis that the issues identified were likely to result in a failure to deploy, even
though an actual failure to deploy had not occurred.

Although the conclusions related to the distribution of ADELT issues drawn

in this review appear to be sound, based on the data available, they are taken
from a statistically small dataset and, were a wider dataset available, those
conclusions may have been different.
The report will address each type of ADELT issue identified in this review and
discuss the most common causes for each.
A number of recommendations have been made as a result of these analyses and

these are identified in Section 11 of this report (Recommendations).
As detailed earlier, this review has also covered a number of accident reports.
However, only publicly available accident reports or interim bulletins associated
with accidents/incidents were reviewed as part of this research. Accidents
involving public transport rotorcraft for which an accident report or interim
bulletin was not publicly available while this report was in preparation have been
specifically excluded from this report.
Some interim bulletins were used to evaluate data associated with accidents still
under investigation and, where use of these bulletins was necessary, permission
to use the data was obtained from the relevant investigation agencies and
operators. Although the review of recent accident investigation bulletins has not
changed the conclusions of this report, the data obtained from these reports
supports the conclusions drawn.
The list was discussed with CAA specialists, the AAIB, North Sea Operators and
an ADELT manufacturer before being finalised and an agreement was reached
that the final list was suitably representative.
The list of accidents that has been considered is:
Reg Year Pub Pub UK Ditched ADELT Tail boom Rotorcraft

avail transport register refs separation inversion
report
G-ATSC 8 Mar 1976 Y Y Y Y N N Y
G-BBHN 1 Oct 1977 Y Y Y Y N Y Y
G-BIJF 12 Aug 1981 Y Y Y N Y N Y
G-ASWI 13 Aug 1981 Y Y Y Y N N
G-BDIL 14 Sep 1982 Y Y Y N Y N N
G-ASNL 11 Mar 1983 Y Y Y Y N Y but N/A1 Y but N/A1
G-BEON 16 Jul 1983 Y Y Y N Y N Y


report
G-BARJ 24 Dec 1983 Y Y Y N N N Y
OY-HMC 2 Jan 1984 Y Y N Y N Y Y
G-BISO 2 May 1984 Y Y Y Y N N Y
G-AZOM 24 Jul 1984 Y Y Y Y N N Y
G-BJJR 20 Nov 1984 Y Y Y N N N N
G-BKFN 15 May 1986 Y Y Y Y N N N
G-BWFC 6 Nov 1986 Y Y Y N Y N N
G-BEID 13 Jul 1988 Y Y Y Y Y N Y but N/A2
G-BDII 17 Oct 1988 Y Y Y N N N Y
G-BDES 10 Nov 1988 Y Y Y Y Y Y Y
G-BGKJ 25 Apr 1989 Y Y Y Y N N N
G-BEWL 25 Jul 1990 Y Y Y N N N N
G-TIGH 14 Mar 1992 Y Y Y N Y Y Y
G-TIGK 19 Jan 1995 Y Y Y Y Y N N
G-HAUG 12 Dec 1996 Y Y Y N Y N N
LN-OPG 8 Sept 1997 Y Y N N Y Y N
G-BJVX 16 Jul 2002 Y Y Y N N N N
G-JSAR 21 Nov 2006 Y Y Y Y Y N N
G-BLUN 27 Dec 2006 Y Y Y N N Y N
G-REDU 18 Feb 2009 Y Y Y N Y Y N
G-REDL 1 April 2009 Y Y Y N N3 N4 N4
G-REDW 10 Oct 2012 Y Y Y Y Y N N
G-CHCN 22 Oct 2012 Y Y Y Y Y N N


report
1 This resulted from damage inflicted during the attempt to recover the rotorcraft.
2 The inversion occurred as a result of a fire that destroyed most of the fuselage.
3 This full report in to this accident has not been published yet.
4 The aircraft was destroyed on impact.
Table 1 List of reviewed accident reports
Note 3: CAP 641 (Report of the Review of Helicopter Offshore Safety and
Survival, dated February 1995) draws a distinction between ditching and crashing,
where ditching is understood to be a controlled descent into water and crashing
is understood to be an uncontrolled descent into water. This review has used the
same distinction in order to assess whether ADELT performance or the likelihood
of either tail boom separation or rotorcraft inversion are affected by whether the
rotorcraft crashes or ditches.
Each accident report has been subject to primary and secondary assessments.
The primary assessment was performed to determine whether the performance

of the ADELT was specifically addressed and whether any ADELT related
recommendations were made.
The secondary assessment was used to determine whether the rotorcraft tail
boom separated from the main fuselage and whether the rotorcraft inverted. This
assessment was performed to support the analysis of the effect of tail boom
separation and rotorcraft inversion on ADELT performance – see Sections 9 and
10 of this report.
Extracts from the listed accident reports are provided in Appendix B to this report.
Although the whole accident report is not provided, the following information is
provided for each accident:
The aircraft type
The basic accident details (location, date and time)
The synopsis of the accident
Any comments on the ADELT plus any associated findings and

recommendations
Any comments on tail boom separation plus finding and recommendations
Any comments on rotorcraft inversion plus findings and recommendations

The CAA response to any ADELT recommendations
An indication of where the full accident report can be found

CAP 1144 Chapter 4: Definitions and acronyms
Chapter 4
4
Definitions and acronyms
Term Definition
ADELT Automatically Deployable Emergency Location Transmitter. This is an
Emergency Locator Transmitter (ELT) that has been designed to be ejected
from an aircraft and to automatically transmit its location to aid Search and
Rescue (SAR) activities.
CPI Crash Position Indicator. This is a marketing term for a specific manufacturer’s
ADELT.
Crash An uncontrolled descent into water. Definition taken from CAP 641 [Ref 37].
Design This term has been used as a secondary classification to indicate that the
most likely cause of an ADELT event is related to a design issue that either
caused the equipment to fail or directly resulted in a human factors event.
Ditching A controlled descent into water. Definition taken from CAP 641 [Ref 37].
External Event This term has been used as a secondary classification to indicate either that:
The MOR under consideration is not related to ADELT event but

merely refers to an ADELT in the explanatory text (e.g. a spurious PLB
transmission – see MOR 200604317), or that
The ADELT event in question resulted from an external event that was not
related to the ADELT design, manufacture, installation, maintenance or
usage. An example of this is a ship pitching (see MOR 199302109).
Failure to This term has been used as a primary classification to refer to either:
Deploy Issues that directly resulted in a failure to deploy, or
Issues whose end result was most likely to be a failure to deploy

Hostile A hostile environment is defined as:
Environment (a) an environment in which:
(i) a safe forced landing cannot be accomplished because the surface is
inadequate;
(ii) the helicopter occupants cannot be adequately protected from the
elements;
(iii) search and rescue response/capability is not provided consistent with
anticipated exposure; or
(iv) there is an unacceptable risk of endangering persons or property on
the ground;
(b) in any case, the following areas:
(i) for overwater operations, the open sea areas north of 45N and south of
45S designated by the authority of the State concerned;
(ii) those parts of a congested area without adequate safe forced landing
areas;

Term Definition
Human This term has been used as a secondary classification to indicate that the
Factors most likely cause of an ADELT event is related to a human factors issue that
was not directly triggered by a design issue (e.g. a switch being deliberately
activated but in the wrong direction).
In-Flight This term has been used as a secondary classification to indicate that the
Damage most likely cause of an ADELT event is related to damage that occurs in flight.
Inadvertent This term has been used as a primary classification to refer to either:
Deployment
Issues that directly resulted in an inadvertent deployment, or
Issues whose end result was most likely to be an inadvertent deployment.

Installation This term has been used as a secondary classification to indicate that the
most likely cause of an ADELT event is related to an installation issue.
Maintenance This term has been used as a secondary classification to indicate that the
most likely cause of an ADELT event is related to a maintenance error.
Manufacturing This term has been used as a secondary classification to indicate that the
most likely cause of an ADELT event is related to a manufacturing issue.
Not Applicable This term has been used as a secondary classification used solely when the
primary classification is Unclassified. In this case, the MOR data is not rele-
vant to this review and a secondary classification is not applicable.
Other This term has been used as a primary classification to refer to MOR records
that specifically call out an ADELT or CPI but do not directly relate to failure
to deploy, inadvertent activation or systematic issues. This type of event has
been investigated to determine if there are lessons to be learnt from these
reports that could be used to reduce future occurrences of the other three
types of issue.
Performance This term has been used as a primary classification to refer to issues that
affected ADELT/CPI functionality/capability but that did not/were not likely to
result in a failure to deploy or an inadvertent deployment.
Personal Term used to identify a type of personal ELT that, in general, does not hold an
Locator aviation equipment approval.
Beacon (PLB)
Sensor A number of different types of sensor can be used in conjunction with an
ADELT to activate its deployment mechanism. These are:
Frangible Switches – These are used to detect that parts of an airframe have
become damaged (buckled).
G Switches – These are acceleration activated sensors used to detect that an

aircraft has impacted with either terrain or water.
Hydrostatic Switches – These are water activated sensors used to detect

that an aircraft has landed or crashed on water.
Saline Switches – These are salt water activated sensors used to detect that
an aircraft has crashed or landed on salt water. These are sometimes used
in preference to hydrostatic switches to avoid inadvertent deployment of an
ADELT whilst an aircraft is being cleaned.

Term Definition
Unclassified This term has been used as a primary classification to refer to MOR reports
that were identified by the search of the CAA MOR database but which do not
actually relate to either ADELTs or CPIs.
These records were identified by the search of the MOR database as a result
of the term CPI being used in two different senses within the MOR database;
1) Crash Position Indicator (relevant to this research) and 2) Control Position
Indicator (not relevant to this review).
Unknown This term has been used as a secondary classification to indicate that the
most likely cause of an ADELT event cannot be determined from the available
information.
Wear This term has been used as a secondary classification to indicate that the
most likely cause of an ADELT event is related to a part (or parts) wearing.
Acronym Expansion
AAIB Air Accident Investigation Branch (UK)
AAIU Air Accident Investigation Unit (Ireland)
AD Airworthiness Directive
ADELT Automatically Deployable Emergency Location Transmitter.
CAA Civil Aviation Authority (UK)
CAP Civil Aviation Publication (UK)
CFIT Controlled Flight Into Terrain
CPI Crash Position Indicator
MOR Mandatory Occurrence Report, raised under the auspices of CAP 382
PLB Personal Locator Beacon

CAP 1144 Chapter 5: Evaluation of failures to deploy
Chapter 5
5
Evaluation of failures to deploy
5.1 Introduction
This chapter provides a detailed analysis of the MORs related to Failure to Deploy.
Table 2 provides a tabulated summary of the MORs related to Failure to Deploy
and the associated reasons for those failures. The text that follows Table 2
provides the analysis of those MORs and, where applicable, the relevant accident
investigation reports.
Classification No of Top level Detailed cause Reference to main MOR

MORs identified Table (Annex A).
cause
Annex MOR number
A Ref
Design Issues 11 Equipment Sensor location M11 198802141
location M12 198803491
Electrical power
M14 198803829
Location
M15 198804052
ADELT Location
Human factors N/A M101 201212866
Sensor selection N/A M37 199605710
Vibration N/A M20 198903806
M25 199102308
M26 199102388
Water ingress N/A M28 199201636
Wiring issues N/A M42 199902037
M11 199802141
M12 198803491
M14 198803829
M15 198804052
Installation issues 1 N/A N/A M89 200911410
Manufacturing 1 N/A N/A M39 199704615
issues
Wear 1 N/A N/A M64 200509195
Unknown 4 N/A N/A M44 200003812
M48 200200339
M83 200901483
M97 201204951
Table 2 – MORs associated with failure to deploy

The data contained in Table 2 shows that there are 18 MORs related to non-
deployment of ADELTs and CPIs which can be split in to five basic types:
Design issues
Installation issues
Manufacturing issues
Wear
Unknown
5.2 Design issues

There are five types of design issue related to the ‘Failure To Deploy’
classification:
Equipment location
Sensor selection
Vibration
Water ingress
Wiring issues
5.2.1 Equipment location

MORs 198802141 (M11), 198803491 (M12), 198803829 (M14) and 198804052
(M15) relate to a series of ditchings where the ADELTs failed to deploy as a result
of equipment location issues.
These incidents were subject to both AAIB recommendations and a mandatory

AD [Ref 30]. As such, the immediate lessons that could be drawn can be seen to
have been implemented.
Despite this, discussions with operators and a review of recent accident reports
have shown that location of ADELTs, ADELT sensors and ADELT related power
supplies is still of concern and has the potential to result in additional non-
deployments.
The issues associated with location of ADELTs, ADELT sensors, and electrical
power supplies are discussed below.

5.2.2 ADELT location

Analysis of both MORs and accident reports has identified that the location
of an ADELT (e.g on the tail boom or close to the passenger cabin) can have a
significant effect on whether an ADELT will survive an accident/incident such that
it will be able to perform its intended function.
If the ADELT is located on the tail boom of a helicopter it is more susceptible to

damage that results from being struck by rotor blades, separation of the tail boom
from the rest of the fuselage or the tail rotor drive breaking2.
Locating the ADELT forward of the tail boom will protect it from this type of
damage. However, any alternative location for an ADELT must be carefully
considered to avoid:
Potential conflict with the main rotors,
Compromising any emergency exits.
The design of the ADELT can also have a bearing on this issue. If an ADELT is
shaped in to an aerofoil an inappropriate location may lead to it flying upwards into
the main rotors on initial deployment.
As a result of these issues the following recommendations are made:
Recommendation 1a – It is recommended that EASA develop guidance

material to assist designers of future ADELTs/CPIs and aircraft ADELT/CPI
installations to demonstrate compliance with CS XX:1301, 1309, 1529 and 1581.
This guidance material should address the issues associated with determination
of the appropriate location of an ADELT/CPI with respect to the transport joint
and the main rotors to maximise the likelihood of deployment and transmission.
Recommendation 1b – It is recommended that EASA develop guidance

This guidance material should address the issues associated with installations
that could compromise emergency exits or any safety related functions or parts
of the aircraft to ensure that overall airworthiness is maintained and that the
likelihood of passenger survival is not decreased.
5.2.3 Sensor location

Analysis of currently available data indicates that some sensor locations are less
likely to result in ADELT deployment than others.
2 Section 9 of this report discusses the likelihood of tail boom separation in more detail.

Some hydrostatic/saline sensors are located near the roof of the passenger cabin
which means that the rotorcraft would have to invert (capsize) or substantially
submerge before the sensor would be activated.
Currently a significant proportion of rotorcraft do invert after ditching or crashing

into water3 but this does not always happen and the current flotation system
technologies are being improved to further reduce the probability of rotorcraft
inversion (see reference 35). This implies that future improvements in flotation
technology may render roof mounted hydrostatic/saline sensors less effective.
As a result, the following is recommended:
Recommendation 1c – It is recommended that EASA develop guidance

installations to demonstrate compliance with CS XX:1301, 1309, 1529 and
1581. This guidance material should address the issues associated with the
appropriate selection and location of activation sensors to take account of the
functional capabilities and the intended role of the aircraft (e.g. environments
where the aircraft will be operated, especially if hostile, and whether the aircraft
has flotation equipment).
5.2.4 Electrical power location

The evaluation of MORs and accident reports, together with discussions with
AAIB, indicate that there have been a number of occasions where an ADELT has
failed to deploy as a result of the electrical power supply to the related sensors
becoming immersed in water. This has resulted in the sensors failing before they
can be triggered.
Investigation of these incidents has shown that the electrical power supply for
these sensors is installed towards the base of the main fuselage, resulting in the
rapid immersion and consequent failure of the power supply once the rotorcraft
enters the water.
It should be noted that, if the power supply is located such that it will be
immersed as the rotorcraft settles in the water, failure of the power supply can
also occur in the event of a controlled ditching.
Incidents such as this are still occurring and loss of power supplies resulting from
immersion in sea water is considered to be an ongoing problem. It is accepted
that it isn’t likely to be possible to address all types of event with one solution
and, as a result, the following recommendation is made:
3 Section 10 of this report discusses the likelihood of rotorcraft inversion in more detail.

Recommendation 1d – It is recommended that EASA develop guidance

installations to demonstrate compliance with CS XX*:1301, 1309, 1529 and
location and type of power supplies for all elements of an ADELT/CPI system
to maximise the likelihood of ADELT deployment and transmission during an
accident or incident.
* XX refers to the set of aviation certification specifications, e.g., CS-23/25
5.2.5 Human factors

MOR 201212866 (M101) relates to deployment failure that resulted from a lack
of knowledge of the subtleties of the ADELT system installed in the rotorcraft
concerned4. In this particular case the flight crew were unaware that manually
triggering the ADELT system before ditching would prevent it from being
automatically deployed until the system had been reset. This was a subtlety of
operation that was not intuitively obvious and which was not documented in the
flight manual.
There are a number of obvious human factors issues associated with the
interface between a flight crew and an ADELT system (e.g. non-guarded switches
which allow inadvertent triggering) and these are being addressed by the ADELT
design community. However, it is important to ensure that all aspects associated
with the human/ADELT system interface are addressed in the flight manual,
particularly those which relate to functionality that is not intuitively obvious. As a
result of these issues the following recommendation is made:
Recommendation 1e1 – It is recommended that EASA develop guidance

This guidance material should address mitigation of any relevant factors issues
including flight deck human factors issues (such as inadvertent activation/
arming).
5.2.6 Sensor selection

MOR 199605710 (M37) and AAIU Report 01/98 refer to a fatal CFIT accident. One
of the conclusions of the accident report was that the ADELT related sensors
were of the wrong type to result in ADELT activation5. The automatic activation
4 The extract from the relevant AAIB accident investigation bulletin is provided in Appendix B B29
5 The extract from AAIU accident investigation report AAIU Report 01/98 [Ref 21] is provided in
Appendix B22

of the ADELT trigger mechanisms was only supported by hydrostatic sensors. As

the aircraft crashed on land the ADELT sensors would not have been triggered.
It is accepted that the most common function of an ADELT is to be deployed

over water, but it should be noted that many rotorcraft that operate in the North
or Irish Seas fly over a hostile environment prior to reaching the sea. This being
the case, it seems advisable to recommend that ADELTs are not solely triggered
by hydrostatic or saline sensors. However, the simple addition of a standard ‘g’
switch is not likely to be acceptable as the data associated with flight recorders
shows that standard ‘g’ switches can be triggered by events other than a crash
(e.g. a lightning strike or a ground handling incident). If an ADELT were fitted with
a standard ‘g’ switch, incidents such as lightning strikes could result in the ADELT
being inappropriately deployed. Guidance on the required performance of ‘g’
switches can be found in EUROCAE ED-62.
No additional recommendations are made as a result of the findings associated

with MOR 199605710 (M37) and the associated AAIU accident investigation.
However, attention is drawn to recommendation 1c, which is reproduced below:

5.2.7 Vibration
MORs 198903806 (M20), 199102308 (M25) and 199102388 (M26) refer to
failures to deploy that resulted from vibration induced burring.
The material used to form the back of the ADELT was not sufficiently robust
to withstand the vibration levels associated with a rotorcraft. As a result, burrs
formed on the edges of the ADELT locator slots preventing the ADELT deploying
even when the deployment mechanism was activated.
A modification was developed to rectify this situation and no further incidents

of this type of non-deployment have been seen since that modification was
incorporated. This type of incident is not considered relevant to the current
ADELT/CPI non-deployment issues and, as such, no recommendations are made.

5.2.8 Water ingress

MOR 199201636 (M28) refers to an incidence of corrosion that could have
resulted in a failure to deploy. This appears to have been an isolated incident as
no further MORs related to this type of ADELT failure mechanism have been
raised during this investigation. However, given the environment that most
ADELT systems are operated in (e.g. the North and Irish Seas), it is accepted
that corrosion is a problem that could recur. As a result, a number of aircraft
maintenance manuals were inspected and it was found that not all maintenance
manuals cover the whole ADELT system – several of the manuals inspected
focussed on the deployable beacon and provided little or no guidance on the
maintenance/inspection requirements for other parts of the system. As a result
the following is recommended:
Recommendation 1f – It is recommended that EASA develop guidance

This guidance material should address the issues associated with the type and
frequency of required maintenance tasks to ensure that all elements of the
ADELT/CPI system are appropriately maintained.
5.2.9 Wiring Issues

Evaluation of accident reports6 indicates that damage to wiring has the potential
to result in a failure to deploy. In addition, MOR 199902037 (M42) relates to a
wiring issue that rendered a submersion actuator defective. Although this did not
actually result in a failure to deploy, had the ADELT been needed whilst this fault
was undetected, it would have done.
In addition:
Wiring is discussed as a contributory factor in MORs 198802141 (M11),

198803491 (M12), 198803829 (M14) and 198804052 (M15). These MORs are also
discussed above in terms of sensor/electrical power location.
An inspection of available ADELT and CPI Component Maintenance Manuals

has identified that checks of the submersion actuator functional integrity are not
specified.
No additional recommendations are made; however, attention is drawn to

recommendations 1d and 1f, which are reproduced below.
6 See Appendices B1 to B30

Recommendation 1d – It is recommended that EASA develop guidance

installations to demonstrate compliance with CS XX*:1301, 1309, 1529 and
location and type of power supplies for all elements of an ADELT/CPI system
to maximise the likelihood of ADELT deployment and transmission during an
accident or incident.
* XX refers to the set of aviation certification specifications, e.g., CS-23/25

ADELTs are located in a manner designed to avoid interactions with the main or
tail rotors in the event of inadvertent deployment.
The data reviewed during this review shows that the tail boom of a rotorcraft can
become detached during an accident or incident7 with the result that the wiring
between the crash sensors and the ADELT is disrupted or physically broken.
No additional recommendations have been made related to this issue;

however, attention is drawn to recommendations 1a and 1d, where
recommendation 1a is reproduced below.
Recommendation 1a – It is recommended that EASA develop guidance

This guidance material should address the issues associated with determination
of the appropriate location of an ADELT/CPI with respect to the transport joint
and the main rotors to maximise the likelihood of deployment and transmission.
Discussions with AAIB identified that the ADELT issues associated with being
located toward the aft end of the tail boom may also apply to flight recorders and
so the following recommendation is made:
7 Where the reference to accident or incident includes “tail bumps”

Recommendation 5 – It is recommended that designers of flight recorders and

aircraft flight recorder installations consider re-locating rotorcraft flight recorders
into a part of the rotorcraft that is not subject to tail break issues.
5.3 Installation issues

Analysis of MOR data (specifically MOR 200911410 (M89)) indicates that chafed
wiring has the potential to prevent the deployment of an ADELT.
As noted previously, an inspection of maintenance manuals has identified that

not all maintenance manuals address the complete ADELT system installed on an
aircraft.
No additional recommendations have been made with respect to this issue;

however, attention is drawn to recommendation 1f, which is reproduced
below:

5.4 Manufacturing
MOR 199704615 (M39) refers to a manufacturing issue that could have resulted
in a failure to deploy.
There is only one incidence of this type of report in the list of ADELT MORs
and so this is considered to be an isolated event that does not merit a specific
recommendation.
5.5 Wear
MOR 200509195 (M64) refers to a failure to deploy that resulted from wearing of
the main cases and pistons.
There is only one incidence of this type of report in the list of ADELT MORs
and so this is considered to be an isolated event that does not merit a specific
recommendation; however, attention is drawn to recommendation 1f.

5.6 Unknown
MORs 200003812, 20020339 and 200901483 have been classified as unknown
as it was not possible to determine a probable cause for those events from the
information available.

CAP 1144 Chapter 6: Evaluation of inadvertent deployments
Chapter 6
6
Evaluation of inadvertent deployments
6.1 Introduction
This chapter provides a detailed analysis of the MORs classified as ‘Inadvertent
Deployment’. Table 3 provides a tabulated summary of the MORs related to
inadvertent deployment and the associated reasons for those failures. The text
that follows Table 3 provides the analysis of those MORs and, where applicable,
the relevant accident investigation reports.

cause
Annex MOR number
A Ref
Design issues 15 Design induced N/A M38 199704478
human factors
M40 199704980
M41 199705986
M43 199902336
M54 200504249
M56 200505413
M59 200506741
M65 200509296
Robustness Vibration, M13 198803736
distortion, liners
& seals M55 200504764
M66 200510704
M78 200700568
Location & M8 198702572
water ingres
M75 200608951
M76 200609183
Human 3 N/A N/A M71 200602977
factors
M96 201202777
M100 201209986


cause
Annex MOR number
A Ref
Installation 4 N/A N/A M33 199301925
issues
M67 200600119
M68 200600623
M84 200904571
Maintenance 7 Incorrect N/A M23 199101360
issues assembly
Excess N/A M19 198902218
stressing of
components
Micro-switch N/A M57 200506099
alignment
Waterproofing N/A M53 200406853
M93 201114478
M94 201115065
M95 201115066


cause
Annex MOR number
A Ref
Unknown 24 N/A N/A M9 198801119
M10 198801871
M21 199003325
M29 199204060
M35 199403142
M36 199601053
M58 200506258
M60 200508162
M61 200508382
M63 200509194
M69 200600712
M70 200602281
M77 200611448
M79 200701969
M80 200702096
M85 200907497
M86 200909638
M87 200910882
M91 201012411
M92 201101188
M98 201205512
M99 201206384
M102 201215354
M103 201301229
Table 3

The data contained in Table 3 shows that there are 53 MORs related to
inadvertent deployment of ADELTs and CPIs which can be split into five basic
types:
Design issues
Human factors issues
Installation issues
Maintenance issues
Unknown
6.2 Design issues

There are two types of issue related to the ‘Design’ classification:
Design induced human factors errors
Robustness faults
6.2.1 Design induced human factors errors

MORs 199704478 (M38), 199704980 (M40), 199705986 (M41), 199902336 (M43),
200504249 (M54), 200505413 (M56), 200506741 (M59) and 200509296 (M65) relate
to inadvertent activation of switches. It is noted that some rotorcraft cockpits and
consoles have limited space as a result of the types of operation they are used for. It
is also true that some types of rotorcraft operation require specific types of clothing
(e.g. gloves) which can make correct manipulation of switches harder. However, this
is a human factors issue that could be at least partly addressed by design (e.g. careful
consideration of switch location and the design of switch guards).
No additional recommendations are raised. However, attention is drawn to

Recommendation 1f, which is reproduced below.


6.2.2 Robustness Faults

Robustness can be split into two categories:
Vibration, distortion, liners & seals
Location/water ingress
6.2.3 Vibration, distortion, liners & seals

MOR 198803736 (M13) refers to an incidence of damage related to distortion and
vibration that could have led to an inadvertent deployment.
MOR 200504764 (M55) refers to an inadvertent deployment that resulted from

vibration.
MOR 200510704 refers to a faulty seal that resulted in an inadvertent activation.
MOR 200700568 (M78) refers to an overly compressed ADELT liner that resulted
in an inadvertent activation.
Each of these is indicative of an initial equipment design that may not have been
sufficiently robust to survive the intended environment.
No additional recommendations are made but attention is drawn to

Recommendation 1c, as reproduced below.

6.2.4 Location & water ingress

MORs 198702572 (M8), 200608951 (M75) and 200609183 (M76) refer to
incidents of water/moisture ingress, some of which can be directly attributed to
the location of the part in question.
In addition, discussion with operators has identified that there have been
numerous occasions when their own internal occurrence monitors have reported
sensor location as a contributory cause of inadvertent deployment.

Some of these internal reports relate to inadvertent activation whilst cleaning or

taxiing a rotorcraft. These have been triggered by locating a hydrostatic switch (as
opposed to a saline switch) in the undercarriage bay of a rotorcraft.
Clearly, when a rotorcraft is parked or taxiing, its undercarriage is down and

the undercarriage bay is open. This means that water can be sprayed onto the
hydrostatic sensors in sufficient quantities for a sufficient duration to trigger the
hydrostatic switch and deploy the ADELT/CPI.
A number of other internal reports refer to ADELTS being inadvertently deployed

as a result of saline switches being located in the undercarriage bay of a rotorcraft
and being activated by salt spray.
No additional recommendations are made; however, attention is drawn to

Recommendation 1c, which is reproduced below.

6.3 Human factors

MOR 200602977 (M71) refers to an incident where an ADELT was inadvertently
deployed as a result of an incorrect switch movement. MOR 201202777 (M96)
refers to an incident of an ADELT being deployed as a result of the battery being
inadvertently selected on during pre-start checks. MOR 201209986 (M100) refers
to an inadvertent deployment of an ADELT as a result of the device being in the
incorrect setting whilst being tested.
These MORs all refer to incorrect operation of the ADELT system as a result of
human error and, although no additional recommendations are made, attention is
drawn to Recommendation 1e, which is reproduced below.

Recommendation 1e – It is recommended that EASA develop guidance

This guidance material should address the issues associated with Mitigation of
any relevant human factors issues including:
1. Flight deck human factors issues (such as inadvertent activation/arming) and
2. Maintenance human factors issues (such as misleading or incomplete

maintenance instructions).

MORs 199301925, 200600119, 200600623 and 200904571 refer to a set of
installation issues predominantly related to wiring (incorrect wiring and damaged
wiring).
While these are indicative of common wiring issues, they do not appear to be
indicative of a specific ADELT issue. However, clear and complete maintenance
instructions may assist in the detection and mitigation of these issues.
No additional recommendations are made, however, attention is drawn to

Recommendation 1f.
6.5 Maintenance issues

There are four types of maintenance issue related to the ‘Inadvertent
Deployment’ classification:
Incorrect assembly
Excess stressing of components
Micro-switch alignment
Waterproofing
MOR 199101360 refers to an incidence of incorrect assembly. MOR 198902218

refers to an incidence of excess stressing of components. MOR 200506099
refers to an incidence of micro-switch misalignment.
Each of these MORs appears to relate to recognised types of maintenance errors

and omissions and, as they are spread over a sixteen year period, they do not
appear to indicate an ADELT specific set of issues. However, clear and complete
maintenance instructions could assist in the detection and mitigation of this type
of issue.

MOR 200406853 refers to an incidence of water ingress resulting from a required

maintenance action (the application of silicone grease) being omitted. Although
there is only one MOR that specifically refers to the need to apply silicon grease
to assist in waterproofing, omission of tasks is a common human factors
issue that could be at least partially mitigated by the use of clear and complete
maintenance instructions. As a result, the following recommendation is made:

including maintenance human factors issues (such as misleading or incomplete
6.6 Unknown
MORs 198801119, 198801871, 199003325, 199204060, 199403142, 199601053,
200509194, 200600712, 200611448, 200701969, 200702096, 200907497,
200506258, 200508162, 200508382, 200602281, 200909638, 200910882,
201012411, 201101188, 201205512, 201206384, 201215354 and 201301229
have been classified as unknown as it was not possible to determine a probable
cause for those events from the information available.

CAP 1144 Chapter 7: Evaluation of performance issues
Chapter 7
7
Evaluation of performance issues
7.1 Introduction
This chapter provides a detailed analysis of the MORs classified as ‘Performance
Issues’. Table 4 provides a tabulated summary of the MORs related to
performance issues and the associated reasons for those failures. The text that
follows Table 4 provides the analysis of those MORs and, where applicable, the
relevant accident investigation reports.

cause Annex MOR number
A Ref
Design issues 6 Design induced N/A M52 200308245
human factors
Robustness Switch failures M4 198700070
M22 199100076
Susceptibility M17 198804209
to vibration and
wear M27 199102551
M45 200007694
Maintenance 8 Antenna issues N/A M30 199204092
issues 198701090
Error/omissions N/A M5
M16 198804208
M24 199102275
M62 200509166
M82 200808505
M90 201005028
Excessive loads N/A M6 198701136
Manufacturing 1 N/A N/A M3 198604297
issues
Unknown 2 N/A N/A M49 200200339
M51 200303770
Table 4

The data contained in Table 4 shows that there are 17 MORs related to ADELTs
and CPIs performance issues which can be split into four basic types:
Design Issues
Maintenance issues
Manufacturing issues
Unknown
7.2 Design issues

There are two types of design issue related to the ‘Performance’ classification:
Robustness
Design induced human factors
7.2.1 Robustness
Robustness can be split into two categories:
Switch failures
Susceptibility to vibration/wear
Switch failures
MORs 198700070 (M4) and 199100076 (M22) relate to switch failures. Although
there is limited information available related to these failures it seems possible
that these failures occurred as a result of the design providing an inadequate level
of robustness against the environment the switches were installed in.
Susceptibility to vibration/wear
MORs 198804209 (M17), 199102551 (M27) and 200007694 (M45) refer to either
vibration damage or wear and are potentially indicative of designs that were
inadequately robust against the predictable installed environment.
Switch failures and vibration/wear induced damage can have an impact on ADELT
performance. Although no additional recommendations have been made attention
is drawn to Recommendation 1c, which is reproduced below.


7.2.2 Design induced human factors

MOR 200308245 (M52) refers to an incident where an incorrect electrical
connector was used. This type of maintenance human factor can be directly
addressed by design (e.g. by ensuring that the design of any relevant connectors
minimises the possibility of mistakes).
No additional recommendations have been made but attention is drawn to

Recommendation 1e2, which is reproduced below.

including maintenance human factors issues (such as misleading or incomplete
7.3 Maintenance issues

There are three types of maintenance issue related to the MORs classified as
‘Performance’:
Antenna issues
Errors/omissions
Excessive loads
7.3.1 Antenna issues

MOR 199204092 (M30) refers to unexpected antenna behaviour – cracking
noises when the antenna was flexed.
There is only one incident of this type among the ADELT MOR reports and so its
occurrence is statistically low. However, poor antenna performance may result in

degraded ADELT performance and appropriate maintenance requirements have

the potential to help in the resolution of these issues.
No additional recommendations are made but attention is drawn to

Recommendation 1f, which is reproduced below.

7.3.2 Errors/omissions
MORs 198701090 (M5), 198804208 (M16), 199102275 (M24), 200509166 (M62),
200808505 (M82) and 2010005208 (M90) all refer to maintenance errors and
omissions.
Each of these MORs appears to relate to recognised types of maintenance

errors and omissions. They are spread over a twenty three year period, and
do not appear to indicate an ADELT specific set of issues. However, analysis
of MORs and accident reports and discussions with operators indicated that
correct maintenance and storage of ADELT batteries was fundamental to ADELT
performance. Battery maintenance and storage issues are not limited to ADELTs
but it was noted that there have been problems with some ADELT batteries that
resulted in the labels being difficult to read or the storage instructions being
difficult to follow. As a result, the following is recommended:
Recommendation 1g – It is recommended that EASA develop guidance

This guidance material should address the issues associated with labelling
on ADELT/CPI component parts (e.g. batteries) to ensure that any necessary
labels (e.g. usage instructions or battery shelf life information) are appropriately
visible, unambiguous and permanent to minimise the possibility of incorrect
usage.
Attention is also drawn to Recommendation 1f.
7.3.3 Excessive loads

MOR 198701136 (M6) refers to an incident of ADELT damage that may have
occurred as a result of excessive loads being applied during maintenance.

A fleet alert bulletin was issued to address this incident and no further incidents
of this type have been reported since this bulletin was issued.
This type of incident is not considered relevant to the current set of performance
issues but attention is drawn to Recommendation 1f, which is reproduced below.

7.4 Manufacturing issues

MOR 198604297 (M3) refers to an event where a battery exploded during
the installation of an ADELT. The event appears to have occurred as a result
of the use of faulty components. Although this infers the presence of some
generic production control issues, these issues do not directly relate to ADELT
design, installation, maintenance or use and, as such, no ADELT related
recommendations have been made as a result of this MOR.
7.5 Unknown
MORs 200200339 (M49) and 200303770 (M51) have been classified as unknown
as it was not possible to determine a probable cause for those events from the
information available.

CAP 1144 Chapter 8: Evaluation of other events
Chapter 8
8
Evaluation of other events
8.1 Introduction
This chapter provides a detailed analysis of the MORs classified as ‘Other’. Table
5 provides a tabulated summary of the MORs related to other issues and the
associated reasons for those failures. The text that follows Table 5 provides the
analysis of those MORs and, where applicable, the relevant accident investigation
reports.
Classification No of Top level identified cause Reference to main MOR Table

MORs (Annex A).
Annex A Ref MOR number
Design 3 Robustness M7 198702571
M88 200911082
Spurious warnings M32 199301513
External 5 In-flight damage M34 199302109
events
M50 200207646
PLB transmissions M72 200604317
M73 200606089
Aircraft events M81 200708324
Installation 1 N/A M74 200607680
issues
Unknown 2 N/A M31 199204953
M47 200108341
Table 5

The data contained in Table 5 shows that there are 11 MORs related to other
issues which can be split into four basic types:
Design Issues
External events
Installation issues
Unknown
8.2 Design issues

There are two types of design issue related to the ‘Other’ classification:
Robustness
Spurious warnings
8.2.1 Robustness
MORs 198702571 (M7) and 200911082 (M88) refer to incidents of damage to the
ADELT casing and the ADELT support brackets respectively.
It is possible that the root cause of the ADELT case crack and the cracked support
brackets was a maintenance issue but, since this is not referenced in either MOR,
it seems reasonable to assume that the root cause was either a design that was
not able to withstand the levels of vibration likely to occur on a helicopter or a
manufacturing error that resulted in an ADELT that was vulnerable to damage.
No additional ADELT related recommendations have been made as a result

of these two MORs but as some cracking issues can be identified via routine
maintenance attention is drawn to recommendation 1f, which is reproduced
below.

8.2.2 Spurious warnings

MOR 199301513 (M32) refers to a spurious illumination of the ADELT DEPLOY
light. There is currently only one direct reference to spurious warnings among
the ADELT MORs and so this incident is not currently deemed to be statistically

significant. However, a recent accident has identified additional human factors

issues that have resulted in an ADELT failing to deploy.
As a result of the continuing presence of human factors issues in ADELT

system/installation designs, attention is drawn to recommendation 1e, which is
reproduced below.


8.3 External events

There are three types of external event associated with the ‘Other’ classification:
In-flight damage
Plb transmissions
Aircraft events
8.3.1 In-flight damage

MOR 200207646 (M50) refers to a collision with the deck edge netting of an oil
rig, resulting in damage to the aircraft’s ADELT.
MOR 199302109 (M34) refers to an event where a ship pitched whilst a

helicopter was hovering over its helideck, resulting in damage to the helicopter’s
ADELT.
In each case it might be possible to determine whether that the location of the
ADELT could have affected the likelihood of it being damaged if more information
was available regarding the location of the ADELT (i.e. was it fitted to the end of
the tail boom or was it located close to the passenger cabin). However, in the
absence of this information, no ADELT related recommendations can be made.

8.3.2 PLB Transmissions

There are two MORs (200604317 (M72) and 200606089 (M73)) that refer to PLB
transmissions. Neither of these MORs refers to an actual ADELT event and no
ADELT related recommendations can be made.
8.3.3 Aircraft events

MOR 200708324 (M81) refers to a non-ADELT-related issue. As such this MOR
has not resulted in any recommendations.

MOR 200607680 (M74) refers to an event where the ADELT switch guard was
found to be detached. While this could have resulted in a human factors related
inadvertent deployment of the ADELT, only one incident of this appears in the
available data.
Despite the limited number of reports related damage to switch guards, human
factors issues continue to contribute to ADELT failures and, as such, attention is
drawn to recommendation 1e, which is reproduced below.


8.5 Unknown
MOR 200108341 (M47) has been classified as unknown as it was not possible to
determine a probable cause for the event from the information available.

CAP 1144 Chapter 9: Tail boom separation issues
Chapter 9
9
Tail boom separation issues
Analysis of the accident data considered in this review (see Table 1 for a summary
of this data) shows that seven of the accidents resulted in a separation of the
helicopter tail boom. Of these seven tail boom separations, four occurred in
accidents where reference to the ADELT was also made, indicating that nearly
60% of tail boom separations were linked to accidents where a reference to the
ADELT was made. The implication of this is that separation of the tail boom has a
high probability of degrading ADELT functionality.
Additional technical discussions were held with operators and accident

investigators to validate this result. These discussions identified that, where an
ADELT is located aft of the transport joint (see figures 1 and 2), any disruption
of the tail rotor drive shaft has the potential to disrupt or disconnect the ADELT
wiring (see also the AAIB Reports in to G-REDU, Appendix C27).
A review of accident reports and discussions with accident investigators and

operators has also identified that, when a tail boom does become detached, it
usually becomes detached at, or just aft of, the transport joint. In these cases, if
an ADELT is located aft of the transport joint, it is reasonable to predict that the
ADELT has the potential to become detached from its sensors and power supply
before it can be deployed.
The analysis of the accident data used for this review also considered whether
there was any link between controlled ditching and the incidence of tail boom
separation. The data indicates that a controlled ditching is slightly less likely to
result in a separation of the tail boom, but when this is viewed against the overall
dataset, it does not change any of the recommendations of this report. As a crash
can result in loss of the tail boom it is still preferable, where possible, to locate an
ADELT forward of the transport joint.

Figure 1
Figure 2
Figures 1 and 2 show an ADELT installation that is aft of the transport joint and
more susceptible to the effects of a tail boom separation, e.g. damage to or
breaking of wiring.

Figure 3
Figure 4
Figures 3 and 4 show an ADELT installation that is forward of the transport joint
and, as such, is less likely to be damaged or loss in the event of a tail boom
separation.

CAP 1144 Chapter 10: Rotorcraft inversion considerations
Chapter 10
10
Rotorcraft inversion considerations
The analysis of accident and MOR data detailed in previous chapters (see Table
1 for a summary of this data) identified that some ADELT installations had been
designed such that water/saline switches were located in an area of the cabin that
appeared to pre-suppose that the helicopter would become inverted in the event
of an accident.
There is compelling data to support this pre-supposition (see below) but, if ADELT
performance is to be improved, the continuing validity of this supposition should
be questioned.
Analysis of the accident data considered in this review shows that four of the
eleven accidents that resulted in inversion of the helicopter also made reference
to the ADELT.
This indicates that approximately 36% of the inversions assessed as part of this
review were related to an ADELT reference. The analysis of the data also shows
that 50% of ditchings result in the helicopter becoming inverted.
A further review of rotorcraft inversion data was performed to validate this

conclusion.
CAP 641 (Report of the Review of Helicopter Offshore Safety and Survival –
1994) was reviewed and the following comments were noted:
“Experience has shown that in the offshore environment, surface conditions

are very often such that, despite the correct functioning of flotation gear, the
aircraft will very soon capsize.”
“...we recognise the extreme difficulty of persuading a helicopter, with its

inherently high centre of gravity, to remain upright on anything but the
calmest of seas”
“Experience has shown that a severe crash is often followed by rapid

inversion and submersion of the aircraft,”
“Improved flotation would make a major contribution to the prospects of

safe escape after a crash. Although the scope for such improvement may
be extremely limited in the case of aircraft now in service, and the probably
catastrophic consequences of inadvertent deployment in flight of a high-

CAP 1144 Chapter 10: Rotorcraft inversion considerations
mounted device would need careful consideration, it remains a possibility

which should not be neglected in the current study on flotation and stability.”
The United States Federal Aviation Administration commissioned a report on

“Rotorcraft Ditchings and Water-Related Impacts” [Ref 39]. This study analysed 77
helicopter impacts with water from 1982 to 1989 in terms of occupant injury and
death, and reached a number of conclusions including:
“Flotation equipment, as is currently deployed and used, does not adequately

keep the occupiable area of the rotorcraft upright and afloat.”
Most of the accidents included in the FAA commissioned study involved relatively
small helicopters (for example, the Jet Ranger) which were not representative of
the types in general use for UK offshore operations. However, the authors of CAP
641 found that there was “nothing in the conclusions of this study that conflicted
with our own views of the principal hazards in a helicopter crash and the methods
of countering them.”
CAP 641 made several recommendations including:
“The CAA should accelerate and/or coordinate current studies into helicopter
crashworthiness, flotation and stability parameters and the automatic activation
of flotation gear, as indicated in Paragraphs 8.7, 9.6 and 10.3. Particular account
should be taken of the need to improve provision for flotation after a severe
impact, including the possibility of installing extra flotation devices specifically to
cater for a crash, as suggested in Paragraph 10.9.”
The data above appears to provide substantial support for the supposition that a
helicopter is likely to become inverted in the event of an accident over water, but
there are three points which should be considered before reaching a final conclusion.
Both of these documents were published over a decade ago and may not be
representative of rotorcraft that have been designed since their publication.
CAP 641 specifically recommends that the possibility of “...installing extra

flotation devices” be investigated.
A lot of work has already been put in to developing rotorcraft flotation systems
since the publication of CAP 641, and this work continues to be progressed
and improved.
When the points listed above are taken into account, it becomes apparent that the
validity of any pre-supposition that a rotorcraft will become inverted after descent
onto the water may be open to question. As such, when developing ADELT sensor
installations, rather than pre-supposing rotorcraft inversion, it would be better to
investigate the effectiveness of any installed flotation systems first.

CAP 1144 Chapter 11: Recommendations
Chapter 11
11
Recommendations
The analysis of ADELT/CPI data documented in this report has resulted in the
following recommendations:
No. Recommendation
1 It is recommended that EASA develop guidance material to assist designers of future
ADELTs/CPIs and aircraft ADELT/CPI installations to demonstrate compliance with
CS XX:1301, 1309, 1529 and 1581. This guidance material should address the issues
associated with:
a) Determination of the appropriate location of an ADELT/CPI with respect to

the transport joint and the main rotors to maximise the likelihood of ADELT
deployment and transmission.
b) Installations that could compromise emergency exits or any safety related

functions or parts of the aircraft to ensure that overall airworthiness is
maintained and that the likelihood of passenger survival is not decreased.
c) Appropriate selection and location of activation sensors to take account of the

d) The location and type of power supplies for all elements of an ADELT/CPI
system to maximise the likelihood of ADELT deployment and transmission
during an accident or incident.
e) Mitigation of any relevant human factors issues including:
i) Flight deck human factors issues (such as inadvertent activation/arming) and
ii) Maintenance human factors issues (such as misleading or incomplete

f) The type and frequency of required maintenance tasks to ensure that all
elements of the ADELT/CPI system are appropriately maintained.
g) Labelling on ADELT/CPI component parts (e.g. batteries) to ensure that any

necessary labels (e.g. usage instructions or battery shelf life information) are
appropriately visible, unambiguous and permanent to minimise the possibility of
incorrect usage.
2 In the light of the recent accidents in the North Sea where ADELTs/CPIs failed to deploy,
it is recommended that EASA consider the need to re-evaluate current ADELT installations
that are being carried by rotorcraft known to be operating in a hostile environment.

CAP 1144 Chapter 11: Recommendations
No. Recommendation
3 In the light of the recent accidents in the North Sea where ADELTs/CPIs failed to deploy,
it is recommended that, where rotorcraft are being operated in a hostile environment, the
operators of those rotorcraft include an evaluation of the suitability of their current ADELT/
CPI installations for the intended function and operational environment of their rotorcraft
as part of their SMS risk assessment process.
4 It is recommended that EASA develop specific design requirements for ADELTs (e.g. an
ETSO) based on the content of CAA Specification 16, ED-62A and the recommendations
of this report.
5 It is recommended that designers of flight recorders and aircraft flight recorder
installations consider re-locating rotorcraft flight recorders into a part of the rotorcraft that
is not subject to tail break issues and/or consider the use of deployable memory.

CAP 1144 Chapter 12: References
Chapter 12
12
References
No. Report Source

1 Aircraft Accident Report 4/85: AAIB
Report on the accident to British Airways S-61N in the North Sea 75 NM

East of Aberdeen on 11 March 1983
Report on the accident to Westland Wessex 60 G-ASWI 12 miles ENE of

Bacton, Norfolk on 13 August 1981
Report on the accident in the North Sea, north east of the River Humber
estuary on 8 March 1976
4 Aircraft Accident Report 3/85 AAIB
G-AZOM
G-BARJ
Report on the accident in the North Sea, North East of Aberdeen on 1

October 1977
Report on the accident to Sikorsky S61N, G-BDES in the North Sea 90 nm

north east of Aberdeen on 10 November 1988
Report on the accident to the Sikorsky S61N helicopter G-BDII near Handa
Island off the north-west coast of Scotland on 17 October 1988
Report on the accident to Bell 212, G-BDIL 14 miles from the Murchison
platform on 14 September 1982
Report on the accident to Sikorsky S-61N, G-BEID 29 nm north east of

Sumburgh, Shetland Isles on 13 July 1988
Report on the accident to British Airways Sikorsky S-61N, G-BEON in the

sea near St Mary’s aerodrome, Isles of Scilly on 16 July 1983

No. Report Source

Report on the accident to Sikorsky S-61N, G_BEWL at Brent Spar, East

Shetland Basin n 25 July 1990
No Supporting Title Provided

Report on the accident to Bell 212 G-BIJF in the North Sea, south east of the
Dunlin Alpha platform, on 12 August 1981
Report on the accident to Boeing Vertol (BV) 234 LR G-BISO in the East
Shetland Basin of the North Sea on 2 May 1984
Report on the accident to Bell 212 G-BJJR, in the North Sea 50 miles east of
the Humber on 20 November 1984
17 Aircraft Supplemental Accident Report S3/2002. AAIB
Report on the accident to Bell 214 ST G-BKFN in the North Sea 14 miles
North East of Fraserburgh, Scotland on 15 May 1986
19 AAIB Special Bulletin S1/2007 AAIB
Report on the accident to Boeing Vertol 234 LR, G-BWFC 2.5 Miles east of
Sumburgh, Shetland Isles on 6 November 1986
21 Aircraft Accident Report 01/98: AAIU
Report on the accident to Sikorsky S-76B G-HAUG at Omeath, Co. Louth 12

December 1996
Report on the accident to Aerospatiale AS332L Super Puma, G-TIGK, in

North Sea 6nm south-west of Brae Alpha Oil Production Platform on 19
January 1995
24 Air Accident Investigation Board, Norway (AAIB/N) Report 47/2001 AAIB/N
Report on the air accident 8 September 1997 in the Norwegian Sea, approx
100 nm west north west of Bronnoysund, involving Eurocopter AS 332L1
Super Puma, LN-OPG, operated by Helicopter Service AS
25 OY-HMC AIB
(Denmark)
26 AAIB Report 1/2011 AAIB
G-REDU

No. Report Source

27 AAIB Special Bulletin 5/2009 AAIB
G-REDL
G-REDW
G-REDW & CHCN

G-CHCN
No Report Source Date

31 EUROCAE ED-62 Minimum Operational Performance EUROCAE May 1990
Specification For Emergency Locator Transmitters.
32 CAP 476 Amdt 287 Issue 6 Mandatory Aircraft Modifications CAA January
and Inspections Summary 2003
33 CAA AD 058-12-88 CAA December
1988
34 CAP 476 Mandatory Aircraft Modifications and Inspections CAA September
Summary Issue 287 2004
35 CAP 491 Helicopter Airworthiness Review Panel (HARP) CAA 1984
Report
36 CAP 594 Air Accidents Investigation Branch (AAIB) CAA 1991
Recommendations: Progress Report 1991
37 CAP 641 Report of the Review of Helicopter Offshore Safety CAA 1995
and Survival
38 CAS/CPT 600/SB-01 Caledonian 1988
Airborne
Systems
39 Rotorcraft Ditchings and Water-Related Impacts. FAA October
1993

CAP 1144
January 2014
Appendix A
List of MORs
No MOR MOR title Aircraft Primary Secondary MOR details

classification classification
M1 197603439 Occurrence: VC10 Super Unclassified N/A OCCURRED WITH NR1 AP ENGAGED. RUDDER APPLICATION
WHEN ‘NAV’ COMFIRMED BY RUDDER INDICES YAW DAMPER & CPI NR 1
SELECTED A C AUTOPILOT HAD BEEN DEFECTED ON 18.7.76 FOR DISCONNECTING
YAWED SHARPLY IN TURNS. RUDDER DEFLECTION ON CPI APPROX 1/6 RIGHT. YAW
TO RIGHT DAMPER INDICATED ALL FULL SCALE RIGHT. NR 1 AUTOPILOT
DISCONNECTED ON HANDWHEEL. OPERATION NORMAL WITH NR
2. CAA CLOSURE; 3 AXIS RATE GYRO CHANGED CURED FAULT.NO
FURTHER RECURRENCE TO DATE.NO FURTHER ACTION.
M2 198100684 Occurrence: B747 Unclassified N/A THIS A/C HAD AN A.D.D STATING THAT IT REQUIRED 1.5 DIVISIONS OF
RUDDER TRIM LH RUDDER TRIM IN CRUISE. SUBSEQUENT DEFECT RAISED SAID A/C
FAULT NOT DID NOT REQUIRE TRIM BUT CPI SHOWS 2 DEG LEFT DEFLECTION
RECTIFIED ALSO ON LOWER RUDDER.SYSTEM LUBRICATED BUT DEFECT COULD
APU FAULT NOT BE CLEARED.A/C HAD BEEN FLYING IN THIS CONDITION SINCE
19TH FEB.ALSO, APU HAD BEEN U/S FOR 1 WEEK CAA CLOSURE-NO
CAA ACTION REQUIRED. MAINT MANUAL TRIM LIMITS ARE 2 UNITS.
HOWEVER PCU INPUT ROD & LOWER PCU CHANGED.RUDDER TRAVEL
WAS WITHIN LIMITS AT ALL TIMES.
M3 198604297 ADELT BEACON SA365 Dauphin Performance Manufacture DURING INSTALLATION OF ADELT BEACON MOD, BATT EXPLODED.
DEPLOYMENT P/N: 00,23,1071; S/N: 8607575. NIL HOURS. ADDNL INFO: EXPLOSION
BATTERY OCCURRED AFTER CONTROL PANEL REMOVED WHEN OPERATION
EXPLODED. OF TEST SWITCH FAILED TO PRODUCE ANY CURRENT. 7.5AMP C/
BREAKER BETWEEN ADELT TERMINAL FOUND TO HAVE LOW
RESISTANCE BUT THIS WAS PROBABLY RESULT OF EXPLOSION.
OTHERWISE NO FAULT FOUND. CAA CLOSURE: EXAM OF
BATTERY REMAINS INDICATES USE OF FAULTY COMPONENTS AT
CONSTRUCTION, POSSIBLY LEADING TO SHORT CIRCUIT DURING
INSTALLATION. BATTERIES REMOVED FROM ALL ADELT SYSTEMS
PENDING APPROVAL OF REDESIGNED BATTERY. MEANWHILE
SYSTEMS CONNECTED TO A/C BATTERY. SAFT ASB 1/87 & VARIOUS
LOCAL MODS REFER.
Appendix A: List of MORs
Page 57
CAP 1144
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M4 198700070 Occurrence: AUTO Sikorsky S61 Performance Design NO VOLTAGE PRESENT ON PIN ‘’A’’ OF THE ‘’ADELT’’ CARRIER
DEPLOYABLE DISCONNECT.(BOTH WITH MANUAL DEPLOY & SHORTING OUT AUTO
LOCATOR DEPLOY SWITCHES).SEE ALSO 87/00154C CAA CLOSURE:”ARM”
TRANSMITTER SWITCH RETND TO OHAUL AGENCY WHO REPORT FAILURE DUE
MALFN ARM/OFF JAMMED CONTACT WIPER.LOW FAILURE RATE OF COMPONENT
SWITCH FAILED (1.5%) CONSIDERED TO BE ACCEPTABLE.BIH SPECIAL CHECK
SC100/S-2001 COMPLETED WITH TOTAL OF TWO SWITCHES FOUND
DEFECTIVE.OTHER ABERDEEN -BASED OPRS ADVISED OF DEFECT.
M5 198701090 Occurrence: Sikorsky S76 Performance Maintenance POSSIBLY WORN THROUGH BY RESTRAINT. P/N 92900000-02 (00-
PART OF ADELT 23-1085). CAA CLOSURE: FLEET CHECK CARRIED OUT-NO OTHER
BEACON A/C AFFECTED. CONSIDERED TO BE A RANDOM OCCURRENCE
ANTENNA POSSIBLY AS RESULT OF ANTENNA BEING STRAIGHTENED AFTER
MISSING AN ACCIDENTAL BENDING THUS CREATING A WEAK POINT.AS A
DETACHED 6MM PRECAUTIONARY MEASURE BCAL TELEX 12251/JH ISSUED REQUIRING
FRM ATTACH PT APPLICATION OF”RAYCHEM”PROTECTIVE HEAT- SHRINK SLEEVING
WORN THROUGH OVER ANTENNA AT THIS POINT.
M6 198701136 Occurrence: Sikorsky S61 Performance Maintenance CAUSE UNKNOWN BUT DAILY AMBIENT TEMPS BETWEEN +28/34DEG
ADELT BEACON C.P/N 92900000-01B. ADDNL INFO:AFTER INVESTGN THE MFR HAS
WITH 2 IN CONCLUDED THAT DAMAGE WAS CAUSED BY THE APPLICATION
CRACK AROUND OF AN EXCESSIVE LOAD POSSIBLY DURING MAINTENANCE.A FLEET
ELECTRONIC ALERT BULLETIN IS TO BE ISSUED REMIND- ING STAFF OF THE CARE
BOARDS NEEDED IN HANDLG THIS EQUIPMENT.
HOUSING
M7 198702571 Occurrence: SA332 Super Other Design “ADELT” CASING CRACKED AFT OF TEST SWITCH FLEET CHECK NO
“ADELT” CASING Puma OTHER INCIDENTS. ACTION WILL BE TAKEN ON OCC 87/02572H
CRACKED AFT
OF TEST SWITCH
FLEET CHECK
NO OTHER
INCIDENTS
M8 198702572 Occurrence: Bolkow 105 Inadvertent Design SEE OCC 87/02571X CAA CLOSURE:MOISTURE CONTAMINATION
“ADELT” Deployment CONFIRMED.LOCAL MOD INTRODUCED TO ‘POT’ SUBMERSION
DEPLOYED ACTUATOR CONNECTORS. CREWS ADVISED TO REPORT ANY
AT 40FT AGL WARNING LIGHTS IMMEDIATELY.
SUBMERSN
SWITCH
MALFUNCTION
FLUID INGRESS
Page 58
CAP 1144
January 2014
M9 198801119 Occurrence: Sikorsky S76 Inadvertent Unknown Same As Title

ADELT BEACON Deployment
SEPARATED INFLT Note: This has been given a secondary classification of unknown as it is
DEPLOY SYST not possible to determine whether the screws were loose as a result of
INTACT SUSPECT vibration or maintenance error.
MOUNT SCREWS
LOOSE
M10 198801871 Occurrence: Bolkow 105 Inadvertent Unknown BEACON RECOVERED & FOUND BROKEN IN TWO. NO FAULT
ADELT BEACON Deployment FOUND IN FIRING MECHANISM. UNIT RETURNED TO MFR.SEE ALSO
FIRED WHEN 87/02572. CAA CLOSURE: ADELT SQUIB FIRING LINES CHANGED AS A
UNDERSLUNG PRECAUTION. NO FURTHER SIMILAR OCCURRENCES REPORTED TO
LOAD RELEASED DATE (31 JULY 91). NO FURTHER CAA ACTION PROPOSED.
ARM SWITCH IN
“OFF” POSN
M11 198802141 Occurrence: Sikorsky S61 Failure To Design See Text For MOR 198804052 (M15)
ADELT BEACON Deploy
FAILED TO Note: See the text for MOR 198804052 (M15). This has been included as a
DEPLOY IN separate event because it was recorded separately via MOR 198802141
EMERGENCY
SITUATION 3
DITCHINGS
M12 198803491 Occurrence: Sikorsky S61 Failure To Design See Text For MOR 198804052 (M15)
ADELT BEACON Deploy
FAILED TO Note: See the text for MOR 198804052 (M15). This has been included as a
DEPLOY IN separate event because it was recorded separately via MOR 198802141
EMERGENCY
SITUATION 3
DITCHINGS
M13 198803736 Occurrence: Bell 214 Inadvertent Design SEE ALSO 87/00154,87/02572 & OPEN OCC 88/01871.SEE DIGEST
ADELT BEACON Deployment D/88/45. INVESTGN REVEALED PIN HAD PROBABLY SHEARED AS
DEPLOYED IN RESULT OF PROGRESSIVE DISTORTION SUFFERED THROUGH
WORKSHOP TURNING MOTION DURING LOADING & SUBSEQUENT IN- SERVICE
FIRING PIN VIBRATION.WITHOUT PIN IN PLACE ONLY VERY SLIGHT DISTURBANCE
SHEARED CAN CAUSE BEACON TO EJECT.
BY PISTON
MOVEMENT
Page 59
CAP 1144
January 2014
M14 198803829 Occurrence: Sikorsky S61 Failure To Design See Text For MOR 198804052
ADELT BEACON Deploy
FAILED TO (M15)
DEPLOY IN
Note: See the text for MOR 198804052 (M15). This has been included as a
EMERGENCY
separate event because it was recorded separately via MOR 198802141
SITUATION 3
DITCHINGS
M15 198804052 Occurrence: Sikorsky S61 Failure To Design OCCS 88/02141, 88/03491 & 88/03829 REFER. CAA CLOSURE:SB CAS/
ADELT BEACON Deploy CPT 600/SB-1 HAS BEEN MADE MANDATORY UNDER CAA AD058-12-
FAILED TO 88.LTO 914 ALSO REFERS.
DEPLOY IN
EMERGENCY Note: Caledonian Airborne Systems Service Bulletin CAS/CPT 600/SB-01.
SITUATION 3 was raised to require the re-wiring of control panel p/n 00-23-1065 and
DITCHINGS the relocation of the deployment battery and Submersion Actuator. CAP
476 Amdt 287, Issue 6 dated Jan 2003 shows that CAA AD 058-12-88
Mandated Caledonian Airborne Systems Service Bulletin CAS/CPT 600/
SB-01 and required implementation not later than 31 March 1989. See
Appendix I for more information.
M16 198804208 Occurrence: Bell 212 Performance Maintenance MISSING SCREW & WASHER FOUND INSIDE BUOY.FLEET CHECK
ADELT BEACON CARRIED OUT-NO OTHER A/C AFFECTED. SEE OCC 88/04052,
RESTRAINT 88/02141,88/03491 & 88/03819.
PLATE LOOSE
POSS SHORT
CIRCUIT SCREWS
UNDONE/LOST
M17 198804209 Occurrence: Bell 212 Performance Design RESULTS OF FLEET CHECK SHOWED OTHER A/C TO BE SIMILARLY
ADELT BEACON AFFECTED. BELIEVED THAT HEAT & STRONG UV LIGHT EXPERIENCD
CAP CRACKED DURING OPERATIONS IN ARABIAN GULF MAY BE CONTRIBUTORY
IN 3 PLACES AT FACTORS.MFR INFORMED & DAILY INSPCN INTRODUCED.SEE OCC
ATTACHMENT 88/04052
THREAD
Page 60
CAP 1144
January 2014
M18 198901193 Occurrence: 4 B747 Unclassified N/A CPI INDICATED 3 DEGS UPPER RIGHT RUDDER INPUT WAS PRESENT.
5 DIVS OF LH WHEN UPPER YAW DAMPER DISCONNECTED,THE RUDDER TRIM
RUDDER TRIM COULD BE RETURNED TO ZERO & ALL INDICATIONS NORMAL. ADD
REQUIRED FOR RAISED.
STRAIGHT &
LEVEL YAW TRIM
DAMPER MALFN
M19 198902218 Occurrence: Sikorsky S61 Inadvertent Maintenance SEE ALSO 88/03736.INSPN OF DEPLOYMENT PISTON & SHEAR PIN
ADELT BEACON Deployment INDICATED THAT ROTATION OF MAIN CASE OF THE ADELT WHILST
DEPLOYED UNDER SPRING PRESSURE CAUSED SHEAR PIN TO FAIL.IT WAS NOT
WHILE BEING DETERMINED WHETHER EXCESS STRESS TO SHEAR PIN OCCURRED
REMOVED FROM DURING ASSEMBLY OR DISASSEMBLY. CAA CLOSURE: MAINT
A/C SHEAR PIN MANUAL AMENDED TO HIGHLIGHT THE NEED TO AVOID MAIN CASE
BROKEN ROTATION DURING LOADING/UNLOADING.
Note: The secondary classification has been set to Maintenance because

the MOR details indicate that the final cause may have been determined to
be maintenance
M20 198903806 Occurrence: Sikorsky S76 Failure To Design LOCKING SPHERES OF DEPLOYMENT MECH FOUND TO HAVE
ADELT Deploy DEFORMED THE EDGES OF THEIR LOCATING HOLES FORMING
SQUIB FIRED BURRS ON MAIN CASE WHICH BECAME SEIZED WITHIN RETAINING
INADVERTENTLY SLEEVE.BIH SPECIAL CHECK 100/S-2015 RAISED TO RECTIFY &
DURING WIRING MONITOR THE DEFECT.MAINT MANUAL AMENDMENT PLANNED
CHECK BUT PENDING PROPOSED MODIFICATION BY MANUFACTURER.SEE ALSO
BEACON DID NOT 88/04052. CAA CLOSURE: HAZARD NOW ADEQUATELY CONTROLLED
DEPLOY BY INTRODUCTION OF MORE FREQUENT INSPNS. MAINT MANUAL
AMENDMENT CMM 25-60-02 REFERS.
Note: This has been classified as failure to deploy rather than a

Performance issue as the most probable end result of the chafed wiring
would have been a failure to deploy. The secondary classification has been
set to Design because the root cause seems to be an insufficiently robust
design to deal with a known high vibration environment.
Page 61
CAP 1144
January 2014
M21 199003325 Other Occurrence: Sikorsky S76 Inadvertent Unknown ATC REPORTED THAT NO ADELT BEACON SIGNALS HAD BEEN
“ADELT Deployment RECEIVED. ON INVSTGN DEPLOYMENT MECH WAS STILL IN PLACE
DEPLOYED” BUT ITS BATTERY STUD HAD SHEARED ALLOWING INNER & OUTER
LIGHT CAME ON SPRINGS TO RELEASE THE BEACON WITHOUT ACTIVATING THE SQUIB
IN CRUISE. ON CIRCUIT. SEE ALSO 87/00154, 87/02572 & 88/01119. CAA CLOSURE:
ARRIVAL ADELT CONSIDERED ISOLATED INCIDENT.
WAS MISSING
FROM A/C.
M22 199100076 Other Occurrence: Sikorsky S76 Performance Design ADELT BUOY FOUND TO HAVE INTERNAL FAULT. BUOY (CALEDONIAN
ADELT AIRBORNE PN:00-23-1087) DESPATCHED WITH BATTERY
COMMENCED DISCONNECTED TO MFR FOR INVSTGN. INSPN REVEALED BEACON
TRANSMITTING WAS TRANSMITTING A LOW POWER TEST SIGNAL ONLY DUE TO A
IN CRUISE DEFECTIVE TEST SWITCH WHICH HAD WORN. THE WEAR HAS BEEN
WITH AUDIO ATTRIBUTED TO A/C VIBRATION. CAA CLOSURE: HAZARD CONSIDERED
BREAKTHROUGH TO BE ACCEPTABLE PROVIDING FREQUENCY OF OCCURRENCE
ON A/C REMAINS LOW.
INTERCOMM.
M23 199101360 Other Occurrence: Sikorsky S76 Inadvertent Maintenance CAA CLOSURE: OCCURRENCE ATTRIBUTED TO INCORRECT ASSY OF
ADELT BEACON Deployment BEACON AT INSTALLATION. REVIEW OF MAINT MANUAL SHOWED
DEPLOYED THAT ASSY INSTRS ARE CLEAR. OPRS FLEET CHECK COMPLETED.
UNSELECTED.
M24 199102275 Other Occurrence: Sikorsky S76 Performance Maintenance FOUND DURING ANNUAL INSPN. FURTHER DIS-ASSEMBLY OF
ADELT BEACON MECHANISM FAILED TO REVEAL ANY EVIDENCE OF THE MISSING
DEPLOYMENT SPHERE AS EITHER DEBRIS OR CORROSION RESIDUE. SEE OPEN OCC
MECHANISM 91/02308.
FOUND TO
CONTAIN ONLY 3
OF ITS 4 LOCKING
SPHERES.
Page 62
CAP 1144
January 2014
M25 199102308 Other Occurrence: Sikorsky S76 Failure To Design SEE ALSO 91/02275 & 91/02388. FAILURE TO DEPLOY ATTRIBUTED TO
ADELT Deploy VIBN INDUCED BURRING OF ADELT MAIN CASE. MFR NOW MAKES
DEPLOYMENT CASES FROM A SLIGHTLY HARDER MATERIAL & WILL SUPPLY THESE
MECHANISM IN DUE COURSE. OPR HAS INCREASED FREQUENCY OF BEACON
FAILED TO REMOVAL TO 3 MONTHLY INTERVALS (PREVIOUSLY 6 MONTHS).
SEPARATE MFR HAS INTRODUCED A MAIN CASE OF HARDER MATERIAL. CAA
AFTER PISTON CLOSURE: HAZARD ADEQUATELY CONTROLLED BY MFR & OPR
REMOVED. ONE ACTIONS.
LOCKING SPHERE
REMAINED Note: This has been classified as failure to deploy rather than a
LODGED IN CASE. Performance issue as the most probable end result of vibration induced
burring would have been a failure to deploy.
M26 199102388 Other Occurrence: Sikorsky S76 Failure To Design ONCE SPHERES WERE FREED ADELT WOULD STILL NOT SEPARATE
DURING MAINT Deploy DUE BURRING OF SPHERE RETENTION HOLES. SEE ALSO 91/02275
CHECK ADELT & 91/02308. MFR HAS INTRODUCED A MAIN CASE OF HARDER
DEPLOYMENT MATERIAL & OPR HAS INCREASED PERIODICY OF INSPECTION. CAA
MECH LOCKING CLOSURE: HAZARD ADEQUATELY CONTROLLED BY MFR & OPR
SPHERES WOULD ACTIONS.
NOT DISENGAGE.
Performance issue as the most probable end result of vibration induced
burring would have been a failure to deploy.
M27 199102551 Other Occurrence: Sikorsky S76 Performance Design BEACON CHANGED.
ADELT BEACON
CASING CRACKED Note: The secondary classification has been set to Design because,
ABOVE BEACON without further information, inadequate robustness to vibration appears to
TEST SWITCHES. be the most likely cause. Further discussion with the operators is needed
to definitively rule out maintenance action as a cause.
Page 63
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January 2014
M28 199201636 Other Occurrence: Bolkow 105 Failure To Design FOUND DURING EQUIPMENT REMOVAL FOR A/C MODIFICATIONS.
SEVERE Deploy CORROSION IN FORM OF HEAVY GREEN/WHITE DEPOSITS. ONE FIXED
CORROSION OF RECEPTACLE CONTACT PIN CORRODED COMPLETELY THROUGH &
ADELT BEACON REMAINED IN SOCKET OF THE FREE CONNECTOR ON REMOVAL.
SUBMERSION EVIDENCE OF ELECTRICAL ARCING BETWEEN THE CONTACTS
ACTUATOR ALSO FOUND. CAA CLOSURE: FLEET CHECK REVEALED NO OTHER
CONNECTOR. INSTALLATIONS AFFECTED. MAINTENANCE SCHEDULE AMENDED TO
REQUIRE ANNUAL INSPECTION

Performance issue as the most probable end result of the corrosion would
have been a failure to deploy. The secondary classification has been set
to Design because the most likely cause of corrosion is water ingress.
Further discussion with the operators is necessary to definitively preclude
maintenance action as a root cause of the corrosion.
M29 199204060 Other Occurrence: Bolkow 105 Inadvertent Unknown BEACON CHECKED, GREEN POWER LIGHT FOUND ILLUMINATED.
INADVERTENT Deployment TEST SWITCH DEPRESSED AND RELEASED, BEACON DEACTIVATED.
ACTIVATION OF CYCLING SWITCH CLEARED DEFECT. CAUSE NOT DETERMINED.
ADELT BEACON. CAA CLOSURE: RANDOM OCCURRENCE. HAZARD IS ACCEPTABLE
SEARCH & PROVIDED FREQUENCY REMAINS LOW
RESCUE A/C
ARRIVED TO
ADVISE OF
SITUATION.
M30 199204092 Other Occurrence: SA365 Dauphin Performance Maintenance FOUND DURING POST FLT INSPECTION. ANTENNA PN:606-150-001.
CRACKING NOISE CAA CLOSURE: MODIFIED ANTENNA ON TRIAL, WILL BE RETROFITTED
HEARD WHEN ON ATTRITION BASIS. HAZARD CONSIDERED ACCEPTABLE PROVIDING
ADELT ANTENNA FREQUENCY OF OCCURRENCE REMAINS LOW
FLEXED.
ANTENNA Note: The secondary classification has been set to maintenance but further
BROKEN discussions with the operator are necessary to determine the correctness
INTERNALLY, of this classification
EFFECTIVENESS
CONSIDERED
DEGRADED.
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M31 199204953 Other Occurrence: SA365 Dauphin Other Unknown ACCESS PANEL HINGE RIVETS HAD PULLED THROUGH KEVLAR
RH AUXILIARY FUEL TANK BOX ALLOWING COMPLETE HINGE ASSY TO DETACH
FUEL TANK WITH ACCESS PANEL. ADELT BEACON LABEL TORN TOGETHER
FILLER ACCESS WITH SLIGHT SCRATCHING ON ADELT BODY. ADELT ASSESSED
PANEL FOUND SERVICEABLE. FLEET CHECK CARRIED OUT. MINOR MOD RAISED TO
MISSING AFTER REPLACE UNUSED PANELS WITH BLANKING PLATES. CAA CLOSURE:
SHUTDOWN ON HAZARD ADEQUATELY CONTROLLED BY REPORTERS ACTIONS.
POST FLT INSPN.
M32 199301513 Other Occurrence: Sikorsky S61 Other Design SPURIOUS WARNING. CAA CLOSURE-HAZARD ACCEPTABLE PROVIDED
ADELT FREQUENCY OF OCCURRENCE REMAINS LOW.
DEPLOY LIGHT
ILLUMINATED
FOR 30
SECONDS. ADELT
SWITCHED OFF &
FLT CONTINUED.
ADELT FOUND TO
BE IN POSITION
AFTER LANDING.
M33 199301925 Other Occurrence: Sikorsky S76 Inadvertent Installation CAA CLOSURE-Fleet check carried out-satis. Considered isolated failure of
Adelt beacon Deployment release mechanism
missing. Separated
at sleeve retaining Note: The secondary classification has been set to Installation as this
assy. Squib had appears to be an isolated event and so cannot be classified as design.
not fired.
M34 199302109 Other Occurrence: Sikorsky S76 Other External Note: Raise Question – Was rest of aircraft damaged?
As a/c brought Event
to hover over
ship helideck,
ship pitched
substantially,
resulting in ADELT
beacon damage.
Page 65
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January 2014
M35 199403142 Other Occurrence: SA365 Dauphin Inadvertent Unknown The cockpit control was not armed & deployment switch was still wire
Adelt beacon Deployment locked ‘off’
deployed onto
helideck, during
refuel, when
master switches
selected ‘on’.
M36 199601053 Other Occurrence: SA365 Dauphin Inadvertent Unknown
ADELT deployed Deployment
at approx 200ft
on take off
following hovering
manoeuvres during
CofA air test.
Page 66
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January 2014
M37 199605710 UK Reportable Sikorsky S76 Failure To Design Investigation by Irish authorities. Having completed a training detail in
Accident: A/c Deploy the vicinity of Aldergrove Airport, the a/c departed for a 20 minute return
crashed on high flight to its home base at Ballyedmond. The approach was executed using
ground in bad a locally produced, GPS-based approach procedure. Having commenced
weather. All 3 on its descent, in preparation for landing at Ballyedmond, the a/c struck the
board killed. north face of the Carlingford Mountains at 960ft amsl. All 3 occupants
suffered fatal injuries. The investigation found that the circumstances
of the accident were consistent with controlled flight into terrain. The
primary cause of the accident was assessed as being a loss of situational
awareness, which prompted a decision to deviate from the programmed
route by delaying the turn on to the final segment of the approach to
the missed approach point & subsequent failure to monitor the a/c’s
rate of turn once initiated. The Irish AAIU Aircraft Accident Report 01/98
contains 9 Safety Recommendations, 5 of which are addressed to the
CAA & relate to: i) establishment of a special category for corporate
operations; ii) regulation of night & IMC operations by non-instrument
rated pilots; iii) external vetting of corporate operations; iv) use of GPS; v)
ADELT specifications. CAA Closure: CAA responses to the 5 AAIU Safety
Recommendations were communicated by letter dated 27 Aug 98.
Note: This was a fatal accident related to CFIT, which was investigated by
the AAIU. One of the conclusions of the investigation was that the ADELT
had probably not been armed but, even if it had been armed, the beacon
would not have been activated as it relied hydrostatic sensors being
immersed in water and the accident occurred inland. See Appendix G for
more information.
M38 199704478 Other Occurrence: SA332 Super Inadvertent Design Note: In the absence of any other information the secondary classification
On selecting Puma Deployment has been set to Design as the most likely cause is a design induced human
121.25mhz a factor.
distress beacon
transmission
was picked up.
It transpired
that subject a/
cs ADELT had
been inadvertently
activated. A/c
returned.
Page 67
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M39 199704615 Other Occurrence: A/C Equipment Failure To Manufacture Connector electrode tubes were loose & connector securing screws
ADELT submersion Deploy missing. Defect would prevent beacon deploying automatically in event of
actuator water landing. Actuator, Walter Kidde, PN K38215. Second unit found with
inoperative due similar defect. See Digest 97/D/10. Mfr informed. Fleet check carried out
defective electrical & more frequent inspections introduced. CAA Closure: Hazard adequately
connector. controlled by reporter’s action.

Performance issue as the most probable end result of the defective
connector would have been a failure to deploy.
M40 199704980 Other Occurrence: Sikorsky S76 Inadvertent Design No defect found when aircraft checked at base. Deployment attributed
ADELT deployed Deployment to possible inadvertent switch operation by pilot’s gloved hand when
light came switching to arm. Although deploy switch is guarded, the guard does not
on when arm extend over switch. Alternative guard which covers switch recommended
switch selected. by operator
Helideck crew
confirmed ADELT
had deployed –
a/c shutdown.
ADELT & spring
plunger removed &
stowed.
M41 199705986 Other Occurrence: SA365 Dauphin Inadvertent Design Note: The secondary classification has been set to Design because it
Emergency beacon Deployment seems possible that the test switch had been inadvertently activated
signal heard by making it a design induced human factor.
crew breaking in
on VOR frequency
& strong on
121.5mhz. Source
not found, but
on return Adelt
test switch found
active.
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M42 199902037 Other Occurrence: SA365 Dauphin Failure To Design Tests revealed no continuity between pin A & outer tube, although there
ADELT submersion Deploy was continuity between pin B & inner tube. Defect would prevent beacon
actuator deploying automatically in event of water landing. Actuator, Walter Kidde,
inoperative due to PN K38215. See also 97/04615. Defect addressed by embodiment of mod
defective electrical no 19513.
connection.
Note: This has been classified as failure to deploy rather than a systematic
issue as the most probable end result of the defective connector would
have been a failure to deploy. The secondary classification has been set
to design because a modification has been developed to addressed this,
indicating a design issue.
M43 199902336 Other Occurrence: SA332 Super Inadvertent Design Whilst extracting pocket computer from flight bag situated above
Inadvertent Puma Deployment the document box, it fell on the ADELT control panel with a forward
deployment of movement, deploying the ADELT. ATC advised. It should be noted that
ADELT. when deployed the ADELT must have been damaged on impact as it
did not transmit. On inspection of ADELT control panel it was possible
to select the guarded ‘DEPLOY’ switch to ‘DEPLOY’ without lifting the
switch – the DEPLOY switch is proud of the side protection guards & was
showing signs of previous impacts. Due to the exposed location of the
ADELT panel opr suggests a more robust guarded switch (ie as per the
EXIS lights) to prevent any further occurrences. Beacon, beacon battery,
system battery & ADELT control panel changed & tested satis. Crews
advised of care to be exercised in cockpit. Opr’s investigation ongoing.
Note: The secondary classification has been set to design as this MOR is
indicative of a design induced human factor.
M44 200003812 ADELT beacon Sikorsky S76 Failure To Unknown A/c returned to base with tech log defect of squib light inoperative.
failed to deploy. Deploy Squib found to have blown but ADELT beacon had not deployed. A/c
systems checked, no fault found. Complete ADELT assembly changed.
Manufacturer advised.
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M45 200007694 ADELT submersion SA365 Dauphin Performance Design Actuator PN K38215 changed. See also 1999/02037. Failure attributed
actuator failed to effects of fenestron vibration on submersion actuator. Previously
continuity test introduced measures, including repositioning of actuator and more frequent
– pin A not inspections, do not appear to have resolved the problem. The possibility of
connected to outer introducing an alternate actuator is being considered.
tube electrode.
Tubes also loose.
M46 200105325 Maintenance DHC8 Unclassified N/A During Certificate of Maintenance Review (CMR) task D83-6110/09E1
overrun. appeared to have overrun by 1,035hrs. On investigation it would appear
that the PCU was not compliant with AD CF 96/2520 – PCU replaced. See
also 200102767 and 200105103. The operators investigation concluded
that:- ‘The ASR was raised on 28 July 2001 as a consequence of a
maintenance review, presumably by the CMR signatory. At issue was
the evidence in AMICOS that task D83-611/09E1 had overrun its “not
to exceed” period by 1,035 flying hours. This task is the performance
of Critical Parts Inspection to the Propeller Control Unit that had been
mandated by FAA AD 96-25-20 (the ASR refers incorrectly to Canadian AD
CF 96/2520 which does not exist)’. The AMICOS system has now been
replaced by a maintenance planning system known as OASES. At the time
there were a number of Quality issues and NCRs raised on the subject of
AD control at that time, which lead ultimately to Quality performing a 100%
check of all ADs on the DHC8 fleet. Following this check a complete AD
statement was produced for each aircraft. The Quality manager confirms
that the aircraft is now fully compliant with AD 96-25-20 and the Surveyor
has verified that the quoted task due dates are as follows: Nr1 PCU P/N
782490A47 S/N 960143, TSO 8,935 flying hours, CPI inspection due
in1,565 flying hours. Nr2 PCU P/N 782490A47 S/N 950539, TSO 2,553
flying hours, CPI inspection due in 7,947 flying hours. This information is
correctly forecast in OASES under task D83-6110/09E1. CAA Closure: The
hazard is adequately controlled by the actions stated above.
M47 200108341 ADELT deployed Sikorsky S76 Other Unknown
light illuminated
shortly after
departure. Aircraft
returned.
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M48 200200339 Smoke/fumes SA332 Super Failure To Unknown Shortly after take off a strong “ozone” smell was noticed, accompanied
in cockpit. PAN Puma Deploy by tendrils of smoke from the rear of the centre console. The smoke
declared. Aircraft stopped after approx 5 seconds and no services were lost. A PAN was
returned. declared, the aircraft returned to base and landed safely. The defect
was traced to the emergency floatation control panel. A cockpit water
leak had deposited drips of water onto the centre console, in the vicinity
of this control panel. The water had then contaminated the “Liteflow”
lighting plate of the controller. This caused a short circuit of one of the
filaments, which subsequently caused the plastic plate to overheat and
give off the fumes and smoke experienced by the crew. The floatation
control panel was replaced and the emergency floatation system, along
with the AFDS system, was fully functioned and found to be satisfactory.
During the investigation, the ADELT control unit was also found to be
water contaminated. This controller was replaced as a precaution and
full functional checks of the ADELT deployment system carried out
satisfactorily. Investigation of the cockpit water leak resulted in the
structure above the windscreen transparencies being resealed. The ram air
vent was also disassembled and then fully resealed on reassembly.
Note: This has been classified as both Failure To Deploy (as the most
probably end result of the water contamination would have been a failure
to deploy) and Systemic (as the MOR indicates a maintenance issue was
highlighted by a system failure). The secondary classification has been set
to Unknown because it is not possible to determine whether this occurred
as a result of a design issue, a random failure or a maintenance error.
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M49 200200339 Smoke/fumes SA332 Super Performance Unknown Shortly after take off a strong “ozone” smell was noticed, accompanied
in cockpit. PAN Puma by tendrils of smoke from the rear of the centre console. The smoke
declared. Aircraft stopped after approx 5 seconds and no services were lost. A PAN was
returned. declared, the aircraft returned to base and landed safely. The defect
was traced to the emergency floatation control panel. A cockpit water
leak had deposited drips of water onto the centre console, in the vicinity
of this control panel. The water had then contaminated the “Liteflow”
lighting plate of the controller. This caused a short circuit of one of the
filaments, which subsequently caused the plastic plate to overheat and
give off the fumes and smoke experienced by the crew. The floatation
control panel was replaced and the emergency floatation system, along
with the AFDS system, was fully functioned and found to be satisfactory.
During the investigation, the ADELT control unit was also found to be
water contaminated. This controller was replaced as a precaution and
full functional checks of the ADELT deployment system carried out
satisfactorily. Investigation of the cockpit water leak resulted in the
structure above the windscreen transparencies being resealed. The ram air
vent was also disassembled and then fully resealed on reassembly.
Note: This has been classified as both Failure To Deploy (as the most
probably end result of the water contamination would have been a failure
to deploy) and Systemic (as the MOR indicates a maintenance issue was
highlighted by a system failure). The secondary classification has been set
to Unknown because it is not possible to determine whether this occurred
as a result of a design issue, a random failure or a maintenance error.
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M50 200207646 Serious Incident: Sikorsky S76 Other External The helicopter was making a short positioning flight between rigs in the
ADELT found Event southern North Sea. It was almost dark and intermittent rain showers were
damaged after affecting the area. The windscreen was clear but the chin windows were
landing on partly misted. The wind direction, reported as 190deg/24kt, necessitated
offshore platform. the approach being flown by the co-pilot from the LH seat. He aimed
Possible collision for the centre of the marked circle on the helideck, in accordance with
with deck edge company SOPs. The captain lost sight of the landing area in the last
netting support. 100ft of the descent but was content that the approach was being flown
AAIB AARF within normal parameters. Touchdown was uneventful but, after landing,
investigation. the HLO reported that the aircraft’s Automatic Deployable Emergency
Locator Transmitter (ADELT), fitted to the rear fuselage, was damaged.
An operator’s investigation established that the ADELT struck the deck-
edge safety netting, and then the seaward side of the cable tray, during
the landing. It was concluded that the helicopter had crossed the helideck
below the safe profile either because it “had been flown on a too
shallow approach with a small flare, or flown on a normal sight picture
approach with too hard a flare”. A contributory factor may have been
the helicopter’s centre of gravity which was 80% towards the aft limit
and would have required a higher than normal nose attitude in the flare.
It was recommended that, in future, the non-handling pilot should bring
attitudes of 10deg nose-up or more to the attention of the handling pilot
when the helicopter is within 30ft of the surface. Further recommendations
include a review of the aiming point for the approach (other aircraft in the
operator’s fleet aim at the far side of the landing circle) and an investigation
into possible solutions to the chin window misting problem. Finally,
consideration is to be given to the fitting of an approved modification to
reposition the ADELT from its present position under the tail to the right
side of the fuselage, aft of the baggage bay. See AAIB Bulletin 4/2003, ref:
EW/G2002/10/16. CAA Closure: The hazard is adequately controlled by the
actions stated above.
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M51 200303770 Automatic Sikorsky S76 Performance Unknown Note: This could have resulted from a number of causes (maintenance,
Deployable wear, human factors...) and, from the data available it isn’t possible, to
Emergency determine which is most likely
Locator Transmitter
(ADELT) aerial
found to have
broken off and be
missing at shut
down. Nothing
noted during
preceding flight.
Page 74
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January 2014
M52 200308245 ADELT system SA332 Super Performance Design A scheduled ADELT system battery replacement was being undertaken.
replacement Puma The replacement battery was withdrawn from stock and, after a voltage
battery supplied check, was fitted into the beacon carrier. The battery’s electrical connector
with incorrect was connected to the carrier receptacle, the beacon was reloaded and
connection socket. the assembly refitted to the airframe. However, when the ADELT system
checks were carried out, the green ‘Battery’ LED on the ADELT control
panel would not illuminate when the test button was pressed. The defect
was investigated and traced to the replacement system battery electrical
connector being a 3-socket type, while the beacon carrier receptacle was a
4-pin type. Although the connectors had different numbers of pins/sockets,
because the connector shell sizes and keyway orientation were identical,
the connectors would connect together easily. It did not register when the
battery voltage was checked that the connector had 3 sockets instead of
4. The correct 4-socket connector is wired A and C for battery power, as is
the incorrect 3-socket connector. The result being that the correct voltage
was obtained from the detailed connections, so no query was raised in
the engineer’s mind. The connectors going together easily further masked
the problem. The battery that had been withdrawn from bonded stores
had the correct part number (00-23-1099). The entire stock holding of this
battery was investigated and two others were found to have the incorrect
type of connector fitted. These batteries were quarantined pending further
investigation. A replacement battery of the correct configuration was
installed and system checks established serviceability. The operator has
subsequently amended its procedures and no further problems have been
reported. CAA Closure: The hazard is acceptable provided the frequency
remains low.
Note: The secondary classification has been set to Design because the
design of the connector allowed a maintenance human factors error to
occur.
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January 2014
M53 200406853 Inadvertent SA332 Super Inadvertent Maintenance Following a normal landing, while carrying out the landing checklist,
discharge of Crash Puma Deployment the red ‘CPI Discharge’ caption was observed to be flashing. The crew
Position Indicator delayed disembarkation and held the deck crew clear of aircraft while
(CPI). Water the emergency checklist, MEL and Bond ESE guide were consulted. The
activated switch co-pilot made visual confirmation of CPI deployment and the passengers
did not seem to were then disembarked. It was reported that a rig worker had sighted a red
have any silicone object detach from the aircraft on finals. This was confirmed as the CPI and
grease coating and collected by the safety boat. ATC were informed that the aircraft was safe
was permanently and stood down the SAR. The crew confirmed that the CPI switches in the
“on”, therefore cockpit were still guarded. Extensive investi-gations were conducted by the
developed a fault. operator and the manufacturer of the beacon. All aircraft system tests that
were carried out concluded that a water activated switch was the cause
of the CPI discharge. When the water activated switch was removed and
inspected it was noted that there did not seem to be any silicone grease
coating, as compared to two other in-service switches on fleet aircraft.
Electrical testing of the switch indicated that it was permanently switched
“on” and therefore had developed a fault. CAA Closure: No further CAA
action required at this time.
M54 200504249 Accidental Sikorsky S76 Inadvertent Design During the transit between two offshore platforms the Captain dropped
deployment of Deployment an unopened can of drink, which landed on the centre console behind
ADELT. the ADELT panel. In attempting to catch the can, the Captain believes
he caught the deploy switch, as the ADELT deploy caption illuminated
immediately. The crew informed Anglia Radar and listened out on 121.5 but
heard nothing. On landing the Captain checked the ADELT cradle and found
that the ADELT had indeed deployed. Clearance was obtained to return to
base without passengers. See also 200504764.
Note: The secondary classification has been set to design because this
MOR is indicative of a design induced human factor.
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M55 200504764 Uncommanded Sikorsky S76 Inadvertent Design On approach to the rig, an uncommanded transmission of the ADELT
operation of Deployment occurred which, following landing, could not be reset from either inside
Automatic or outside the aircraft. Rescue Co-ordination Centre advised of false
Deployable transmission and the unit was switched off. Engineering investigation
Emergency found the beacon had rotated in the carrier and dragged the deploy switch
Locator Transmitter actuating arm, causing the deploy microswitch to operate. Switch arm
(ADELT). reset/adjusted and the aircraft returned to service. See also 200505413 and
200506099.
M56 200505413 Inadvertent Sikorsky S76 Inadvertent Design As soon as the ADELT was armed, whilst the aircraft was parked on the
operation of Deployment stand, it began transmitting. The ADELT was switched off and reset. The
Automatically reporter confirms that this has previously occurred with the modified
Deployed ADELT equipment and suggests that the modification to install guards on
Emergency the switches should be introduced as a priority. The reporter also suggests
Locator Transmitter that the necessity of having apparently surplus switches on the ADELT
(ADELT). OEM should be investigated. The beacon manufacturer has issued two service
has issued two bulletins which address this issue. The operator has a programme to
SBs on this embody these modifications. See also 200504764, 200506099, 200509296
subject and the and 200510704. CAA Closure: The hazard is adequately controlled by the
subject operator actions stated above.
has planned
embodiment. Note: The secondary classification has been set to design because the
design of the installation allowed a human factors error (inadvertent
switching) to occur.
M57 200506099 Uncommanded Sikorsky S76 Inadvertent Maintenance Inbound to Norwich at 20 DME the ADELT started to transmit and could
operation of Deployment not be reset from the cockpit. Anglia Radar and D&D informed. On
Automatic inspection the deploy/transmit microswitch was found mis-aligned and
Deployable was adjusted accordingly. The reporter suggests that such inadvertent
Emergency transmissions be monitored in case of a fault with the model of ADELT
Locator Transmitter (CPT 900) in use. See also 200504764. Investigation being progressed
(ADELT) in flight. under 200505413.
M58 200506258 Inadvertent SA332 Super Inadvertent Unknown During the pre-flight external inspection, after power had been applied to
deployment of Puma Deployment the aircraft, the CPI was found to be deployed at the side of the aircraft.
Crash Position The ground controller was contacted on 121.7 and it was established
Indicator (CPI). that the beacon was transmitting. The reset procedure was carried out
Modification and the ground controller confirmed that the transmissions had stopped.
programme Modification programme incorporated across the fleet, since when there
initiated. has been no recurrence. Other operators informed accordingly. See also
200406853, 200508162, 200508382 and 200602281. CAA Closure: The
hazard is adequately controlled by the actions stated above.
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M59 200506741 Accidental SA332 Super Inadvertent Design After shutdown the ADELT safety device was given to the ground crew to
activation of Puma Deployment be fitted. Shortly afterwards the ADELT control box in the cockpit indicated
ADELT. that the beacon had been activated. A message was passed to the ground
crew to check the switches on the beacon. The ‘on’ switch had been
accidentally knocked, activating the beacon. A notice was subsequently
posted asking for caution to be exercised when fitting or removing the
ADELT strap.
Note: The secondary classification has been set to design because the
design of the installation allowed a human factors error (inadvertent
switching) to occur.
M60 200508162 Inadvertent SA332 Super Inadvertent Unknown After arriving on stand the ground crew informed the crew that the CPI
deployment of Puma Deployment was missing from the aircraft. The CPI controller was checked and all the
Crash Position switches were found in the correct position. At that point the CPI deployed
Indicator (CPI). light was observed to be flashing. The light had not been seen before
because of the glare of the sun through the window. ATC were informed
and, on arrival at engineering, Kinloss informed ops that the beacon was
on the airfield. The beacon was then recovered. See also 200406853 and
200506258.
Note: Need to check other referenced MORs

M61 200508382 Inadvertent in- SA332 Super Inadvertent Unknown During cruise a flashing green light was noted on the CPI panel. Activation
flight activation Puma Deployment of the CPI was confirmed from the emergency frequency, Kinloss and
of Crash Position other aircraft in the vicinity. The aircraft returned and an uneventful landing
Indicator (CPI). carried out. See also 200508162, 200406853. CAA Closure: Investigation
Aircraft returned. being progressed under 200506258.

M62 200509166 Inadvertent Sikorsky S76 Performance Maintenance During scheduled maintenance of the ADELT system, specifically the
discharge of ohmic resistance check of the ADELT deployment squib, connection of the
ADELT deployment safety ohm-meter to the firing and ground line connector pins resulted in a
squib. small bang and the unexpected deployment of the ADELT transmitter. The
transmitter itself was restrained within the carrier by the safety harness.
An engineering notice was raised to remind personnel of the relevant
safety and maintenance requirements.
Note: The secondary classification has been set to maintenance because

the MOR details indicate that the event was triggered by a maintenance
error.
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M63 200509194 Uncommanded Sikorsky S76 Inadvertent Unknown Enroute the ADELT amber D/XMT light started flashing and was unable
operation of Deployment to be reset using the control panel. ATC advised. Once the aircraft landed
Automatically on the offshore installation the beacon was reset using the beacon reset
Deployed switch. The aircraft returned to base and engineering were informed. Total
Emergency aircraft hours 19019.
Locator Transmitter
(ADELT) deployed
light during flight.
M64 200509195 ADELT activation. SA332 Super Failure To Wear During the electrical Part ‘E’ section of an ‘A’ check, it was noticed the
Investigation found Puma Deploy squib light failed to illuminate during the self test of the ADELT panel.
that the cause Investigation found the squib had detonated although the beacon had not
was due to wear deployed. Investigation found that the cause was wear in the main cases
in the release and pistons, which are now in excess of 15 years old. A proposal for an SB
mechanism. An SB has been sent to EASA to form part of a proposed AD. CAA Closure: The
is in press. hazard is adequately controlled by existing requirements, procedures and
documentation.
Note: The secondary classification has been set to Wear because, with the
data available, it isn’t possible to determine whether an earlier maintenance
check should have spotted the wear or whether the original design was
insufficiently robust.
M65 200509296 Uncommanded Sikorsky S76 Inadvertent Design On landing, the engineer was able to cancel the transmission by external
ADELT activation Deployment manipulation of the ADELT housing. Investigation being progressed under
in flight. Recurring 200505413
problem.
Note: This MOR refers back to MOR 200505413 which has a secondary
classification of Design. In the absence of additional information this MOR
has been given the same classification.
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M66 200510704 Inadvertent ADELT Sikorsky S76 Inadvertent Design ADELT appeared to deploy and transmit on 121.5 during the cruise, causing
transmission. Deployment break through on VHF 2 – 122.95 and 123.62. The flight crew decided
Investigation has against a reset and set the unit to ‘Off’, although it continued to transmit.
resulted in an ATC were advised and the flight continued to its planned destination.
improved method The ADELT on the subject aircraft was fitted with a weatherseal (p/n:
of setting up BC84-015) which has been found to allow the beacon to rotate, thereby
the switch and a activating the microswitch and causing the beacon to transmit. The
revised manual. weatherseal was replaced with an older part (p/n: C85-015-1) which
maintains a better grip. A check to ensure the beacon is firm in its carrier
is to be included in pre-flight walk arounds, whilst the introduction of creep
marks is also being considered. Investigation has resulted in the design
organisation introducing an improved method of setting up the switch. The
operators have been issued with a troubleshooting manual. An amendment
to the maintenance manual has been raised to improve the continuing
airworthiness instructions and incorporate the above information. See
also 200505413. CAA Closure: The hazard is adequately controlled by the
actions stated above
Page 80
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M67 200600119 Uncommanded SA365 Dauphin Inadvertent Installation During the approach to land on the Leman 27B rig, a brief squib sound
operation of Deployment was heard through the headset. On landing, the ADELT deployed light
Automatic was noted to be illuminated and inspection found the ADELT (p/n 070-
Deployable 0900-001) missing. Aircraft returned to the main platform and shut down.
Emergency Technical/operations advice was sought. It was noted that the ADELT
Locator Transmitter arm switch was in the armed position and the deploy switch was in the
(ADELT) during ‘OFF’ position. ADELT recovered from the sea adjacent to the Leman
approach to rig. 27B rig. Investigation revealed that the associated loom was in very poor
condition with chafed submersion actuator wiring. In addition, the firing
line to the squib wire (ident ELT4EZO) was found to be unscreened efglass
cable instead of screened raychem. The deployment battery, submersion
actuator and multi-axis G switch were not located in the correct positions
as stated in CPT-600/SB-09. There is ongoing investigation under
200509195. CAA Closure: No further CAA action required at this time
Note: This MOR refers back to MOR 200509195 which has a secondary
classification of Wear. However, MOR 200509195 refers to wearing of
main cases and pistons whilst this MOR refers to a wiring problem. As a
result the secondary classification of this MOR has been set to Installation
rather than simply matching it to the referenced MOR.
M68 200600623 Uncommanded SA365 Dauphin Inadvertent Installation ADELT deployed during landing, when selected from ‘ARM’ to ‘SAFE’.
operation of Deployment Investigation under 200600119
Automatic
Deployable Note: This MOR refers back to MOR 200600119 which has a secondary
Emergency classification of Installation. In the absence of additional information this
Locator Transmitter MOR has been given the same secondary classification
(ADELT).
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M69 200600712 Uncommanded Sikorsky S76 Inadvertent Unknown At approximately 10nm to run to the Leman field, the ADELT deploy light
operation of Deployment started flashing, attempt to reset was unsuccessfully so a decision was
Automatic made to reset the beacon itself once on the deck of the Leman C. On
Deployable deck it was found that the ADELT had deployed. Anglia radar advised and
Emergency aircraft returned to base without passengers. Investigation carried out and
Locator Transmitter crew de-briefed with reference procedures for ADELT re-set. The ADELT
(ADELT) light was flashing and the crew had attempted to re-set it by moving the
during cruise. deploy ‘XMT/RST’ switch to ‘XMT/RST’. The light then changed to ‘Steady
Investigation has On’ and on landing it was found that the ADELT had been deployed. During
resulted in an the attempted re-set the P1 stated that he was very careful not to move
improved method the switch ‘fwd’ at all, only aft to the ‘XMT/RST’ position. It should be
of setting up noted that the ‘DPL/ARM’, ‘XMT/ARM’ switch was left in the ‘DPL/ARM’
the switch and a position. The complete system was checked by avionics and a replacement
revised manual. ADELT etc fitted. Discussions have been held with Q and S and Fleet
Support and a number of procedures/modifications have been suggested.
The operator states that it is extremely probable that the beacon deployed
because it was commanded to do so by an inadvertent and microscopic
forward selection of the 3 position switch from ‘OFF to DEPLOY’ (Fwd
= Deploy, Centre = Off, Rearward = Reset). It is for this very reason that
the operations circular issued approximately a year ago requires a second
switch to be selected to a different position (designed to enable the
beacon to transmit but remain in the carrier) before the deploy/reset switch
is touched. The crew did not remember to do this. Nevertheless this is
tertiary to the event; the switch would not have been touched if the beacon
had not started to transmit without cause. Inadvertent activation of the
CPT900 beacon is a significant problem that is being actively pursued with
the OEM Avionics Type Engineer. Investigation has resulted in the design
organisation introducing an improved method of setting up the switch. The
operators have been issued with a troubleshooting manual. An amendment
to the maintenance manual has been raised to improve the continuing
airworthiness instructions and incorporate the above information. CAA
Closure: The hazard is adequately controlled by the actions stated above
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M70 200602281 Crash Position SA332 Super Inadvertent Unknown While parked and awaiting departure, a beacon noise (pinger) was heard
Indicator (CPI) Puma Deployment through VHF1, which was tuned to 122.375. Investigation found the CPI
activated. Beacon Green/Test transmit light flashing. The reset button was pressed resulting
found lying on the in the light extinguishing for a moment before illuminating again. The
ground. transmit toggle switch was cycled and the reset button pressed, both
without success, after which the red ‘deployed’ light illuminated. The flight
was abandoned and the aircraft returned to the stand. On the way back
to the stand, the beacon was seen to be lying on the ground, which was
retrieved by airport staff. Investigation being progressed under 200506258.
See also 200508162.

M71 200602977 ADELT Bell 214 Inadvertent Human It was reported that transmissions were being received from a Bristow
transmissions Deployment Factors 406MHz ADELT beacon. Investigation revealed that the ADELT beacon
traced to aircraft installed on the subject aircraft, which was parked in the hangar, had
in hangar. During initiated transmissions by itself. Whilst carrying out the reset procedure
reset procedure, from the cockpit controller, the switch positions were inadvertently made
beacon was in the wrong sense (forward instead of aft), resulting in the beacon being
inadvertently fired fired from its carrier on to the floor of the hangar. The safety strap had
in the hangar. previously been removed to access the beacon switch although attempts
to carry out a reset at the beacon were unsuccessful. No injuries were
incurred and there was no damage to the aircraft or ground equipment but
the beacon itself was damaged on striking the floor.
M72 200604317 Spurious SARBE SA332 Super Other External A 121.5 MHz SARBE (distress) transmission was noticed on ‘homer’
transmission due Puma Event when the aircraft was on AUK A platform. All passengers’ LSJs were
to inadvertent checked, together with two crew LSJs and ADELT but no obvious source
activation of of transmission was found. The aircraft departed and the SARBE indication
passenger’s remained for the duration of the flight – ATC were informed. Passengers
Personal Locator LSJs were checked again on arrival and a PLB transmitter was found
Beacon (PLB) on activated on one of the lifejackets. See also 200305618.
lifejacket (LSJ).
Note: This MOR refers to a transmission from a Personal Locator Beacon
(PLB) and not a transmission from an ADELT.
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M73 200606089 Personal Locator Sikorsky S76 Other External During pre-start checks, a PLB transmission was heard on 121.5 MHz.
Beacon (PLB) Event Aircraft Automatically Deployable Emergency Locator Beacon (ADELT)
transmitting. and crew beacons were checked and found satisfactory. Passengers were
then offloaded and their PLBs checked, with one found to be transmitting.
Beacon reset, passengers re-boarded and the flight departed. The reporter
notes that the PLBs are low power, but when triggered they render radio
reception by the aircraft on 121.5 and close frequencies impossible. See
also 200403785.
Note: This MOR refers to a transmission from a Personal Locator Beacon

(PLB) and not a transmission from an ADELT.
M74 200607680 ADELT “switch Sikorsky S76 Other Installation On departure from the Viking PA, the HLO reported something had fallen
guard” cover from the a/c into the sea. On the next landing the HLO inspected the a/c
separated from a/c prior to touchdown and crew inspected the a/c on landing. Nothing was
and fell into sea on found missing. On arrival back at base, it was discovered that the ADELT
take off. “switch guard” cover was missing.
Note: The secondary classification has been set to Installation as it seems

likely that the switch guard fixings had failed in some way.
M75 200608951 Crash Position Eurocopter Inadvertent Design On arrival, crew noticed a green flashing ‘CPI Gone’ warning on the
Indicator (CPI) EC225 Deployment CPI panel. On shutdown, CPI found to be no longer attached to the a/c.
uncommanded Operator found evidence of water in the immersion sensors (water-
deployment. activated switches) on their a/c. EASA have issued AD 2006-0300, which
states that immersion sensor p/n 50323, which is declared unfit for flight,
is replaced with a new immersion sensor, p/n 503232. See also 200609183
and 200609668. CAA Closure: The hazard is adequately controlled by
existing requirements, procedures and documentation.
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M76 200609183 After ATC reported Eurocopter Inadvertent Design After ATC reported that the a/c’s emergency beacon was transmitting, it
that the a/c’s EC225 Deployment was discovered that an uncommanded in-flight deployment of the Crash
emergency Position Indicator (CPI) had occurred. See also 200609668. Investigation
beacon was progressed under 200608951
transmitting, it was
discovered that an Note: This MOR refers back to MOR 200608951 which has a secondary
uncommanded in- classification of Design. In the absence of additional information, this MOR
flight deployment has been given the same secondary classification.
of the Crash
Position Indicator
(CPI) had occurred.
M77 200611448 During cruise, the Sikorsky S76 Inadvertent Unknown After landing the beacon was reset manually, the fault cleared and did not
ADELT light began Deployment recur. See also 200509296.
to flash and the
associated aural
warning sounded.
Attempts to
reset the system
in flight were
unsuccessful.
M78 200700568 Uncommanded Sikorsky S61 Inadvertent Design ADELT started to transmit (heard through headsets) and white deploy/
operation of Deployment transmit light illuminated. Investigation revealed that this is the third
Automatic occurrence of beacon activation caused by the foam liner in neck of beacon
Deployable carrier becoming flattened over time, subsequently allowing enough play
Emergency to momentarily activate the microswitch. Reporter comments that some
Locator Transmitter additional support is needed in lower half of carrier neck to prevent foam
(ADELT) during from flattening. ADELT p/n 070-0900-001, TSN 1098.46hrs, TSO 107.55hrs.
take-off. Aircraft The carrier, p/n 00-23-1063, has been replaced and withdrawn from
returned. service. CAA Closure: The hazard is acceptable provided the frequency
Microswitch remains low.
activated by
flattened foam
liner.
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January 2014
M79 200701969 Inadvertent ADELT SA332 Super Inadvertent Unknown Deployed/transmit light on ADELT panel was seen to be flashing and the
transmission after Puma Deployment emergency morse ident heard through the headphones. Reset button on
landing offshore. ADELT beacon was operated and indications of transmission stopped.
Amsterdam ATC were informed of the incident but had not received an
emergency signal, it was revealed later that a signal had been received by
Aberdeen ATC. System inspected and reset with no fault apparent. See
also 200702096 same aircraft.
M80 200702096 Inadvertent ADELT SA332 Super Inadvertent Unknown Deployed/transmit light on ADELT panel was seen to be flashing and the
transmission prior Puma Deployment emergency morse ident heard through the headphones. Reset button on
to landing offshore. ADELT beacon was operated and indications of transmission stopped.
System inspected and reset with no fault found. See also 200701969 same
aircraft, two days earlier.
M81 200708324 Following standard SA332 Super Other External Some evidence of unburned fuel around the engine exhaust area. The
shutdown, the Puma Event airport fire service were notified by the line office. Upon investigation, it
co-pilot observed was observed that the engine door non slip material in the vicinity of the
smoke and flames module 4 was showing signs of overheating and had in fact separated from
from engine the actual engine door. It was further observed that the adhesive backing
bay area when of the non slip had run and dripped onto the module 4 casing and the
fitting the ADELT exhaust pipe. It was suspected that it was the adhesive from this non slip
safety device. No material that had ignited during the engine shut down, therefore the door
abnormal flight was stripped of the material and it was discovered not of the ‘metallised’
deck indications. type. The non slip for the interior of the engine doors should be of the
‘metallised’ type, which has tolerance of the engine bay temperature. In
operator stock, there was the non ‘metallised’ type for which use should
be restricted to the exterior steps etc. They are difficult to tell apart, and a
section was placed on the nr2 engine door to renew a torn one. The heat
of the engine bay caused the adhesive to run and come in contact with
the exhaust and module 4 casing area which led to the event. The non
‘metallised’ non slip material is to be removed from stock and disposed of.
All non slip material will now be of the ‘metallised’ type to prevent further
recurrence. The aircraft was subjected to extensive ground runs and
engine shut downs and no repetition of the shut down incident reoccurred.
CAA Closure: The hazard is adequately controlled by the actions stated
above.
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January 2014
M82 200808505 During Captain’s SA332 Super Performance Maintenance Investigation revealed that, having completed and signed off their pre-
pre-flight walk Puma flight inspection, the engineers realised that they had overlooked a
round, the ADELT recently introduced monthly check of the ADELT battery validity date. This
inspection panel date can be viewed by opening the ADELT inspection panel, which the
was found open engineer then omitted to close. Appropriate advice given by engineering
and hanging management.
loose with all four
fasteners undone.
Page 87
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January 2014
M83 200901483 UK Reportable Eurocopter Failure To Unknown Shortly before commencing the approach, the crew were informed that
Accident: A/c EC225 Deploy weather conditions had deteriorated, with visibility reducing to 0.5nm and
descended into cloud base to 500ft. At a range of approx 13nm, the platform was sighted
the sea close to and the crew agreed to descend to 500ft and conduct a visual approach
offshore platform. using weather radar to assist with range information. A further descent
All 18 occupants was then initiated but on passing 400ft the helicopter entered a bank of
rescued. A/c fog. The a/c returned to 500ft where the gas flare and platform lights could
remained afloat be seen but not the helideck, which has an elevation of 166ft. At a distance
but tail cone of 0.75nm from the platform, the commander disengaged the autopilot
separated and hold modes to fly the helicopter manually. The crew then suspended the
sank. Subject ‘Check Height’ audio warning. The helicopter commenced a turn to the
to AAIB Field left and began to descend and reduce speed. When it rolled out of the
investigation. turn visibility appeared to have reduced but the crew could still see the
bright glow of the gas flre. The co-pilot was visual with what he believed
was the platform’s helideck lighting as well as the platform lights and the
commander was visual with what he believed were the platform lights
but could not identify the helideck. Shortly after that the aircraft landed
heavily on the surface of the sea. All the passengers and crew survived
the accident with a few minor injuries and were rescued within two hours.
The helicopter’s tail boom detached from the main structure on impact and
subsequently sank. The remainder of the fuselage continued to float but
later became inverted before being recovered from the sea. The tail boom,
containing the CVFDR and TAWS computer, was located on the seabed and
was also recovered along with some other items of wreckage, including
the left main door. During the course of the investigation it was established
that the aircraft’s automatically deployable Crash Position Indicator (CPI)
had failed to release/transmit. In addition, the crew had failed to extend
the antennae on their lifejacket Personal Locator Beacons (PLBs) or liferaft
Emergency Locator Transmitters (ELTs) and that signals from these devices
were suppressed by transmissions from the passenger’s Wrist Watch
Personal Locator Beacons (WWPLBs). Four Safety Recommendations
(2009-064 to -067) are made on this subject. See AAIB Special Bulletins
S3/2009 and S4/2009. CAA Closure: CAA FACTOR F9/2009, detailing the
CAA responses to the four AAIB Safety Recommendations, was issued on
12 August 2009. Any further CAA action required will be progressed via the
‘Annual Review of AAIB Recommendations’ procedure.
Note: This MOR relates to an accident that is still under investigation by

the AAIB. To date there have been no safety recommendations related
to ADELTS made as a result of this recommendation. See Appendix K for
more information.
Page 88
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January 2014
M84 200904571 Inadvertent ADELT SA365 Dauphin Inadvertent Installation The ADELT switch appeared to be in the transmit/reset position, but when
deployment. Deployment the switch was moved to the off position the ADELT deployed.
Note: The secondary classification has been set to Installation because the
MOR details imply that the switch may have been incorrectly wired.
M85 200907497 ADELT beacon SA365 Dauphin Inadvertent Unknown On raising collective to contain Nr during a standard 360deg autorotation
transmission in Deployment from 1500ft ‘ADELT D’PLYD/XMT illuminated with associated audio
flight. through headset indicating ADELT was transmitting. ATC notified.
M86 200909638 Uncommanded Eurocopter Inadvertent Unknown Uncommanded Crash Position Indicator (CPI) deployment as the aircraft
Crash Position EC225 Deployment was towed into the hangar.
Indicator (CPI)
deployment as the
aircraft was towed
into the hangar.
M87 200910882 Uncommanded SA332 Super Inadvertent Unknown Outbound in the cruise an audio ELT tone sounded together with flashing
Crash Position Puma Deployment green ‘TX/TEST’ light. System successfully reset as per SOPs and flight
Indicator (CPI) continued without further incident. Inbound in the cruise warnings recurred
deployment in and again system initially successfully reset. However fault recurred
flight. several times and eventually the red ‘Beacon Gone’ light illuminated and
continued flashing until shut down. Post flight inspection confirmed that
CPI had been deployed.
M88 200911082 ADELT support SA365 Dauphin Other Design On removal of the tail cone cowling to inspect the nav light wiring, two
brackets cracked. cracks were noticed on the LH side of the rear doubler skin. On removal
of the ADELT carrier from the rear fuselage, the support spacers between
the carrier and the support brackets in the tail fell off. The two ‘U’ channels
fitted in the tail to support the carrier had failed allowing the weight of
the carrier to be taken by the rear doubler skin causing it to crack. CAA
Closure: Due to failure of the ADELT support channels, inspection of this
area is to be carried out at 500hrs from repair.
Page 89
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January 2014
M89 200911410 Crash Position Agusta AB139 Failure To Installation During landing gear leg replacement, both wires were noticed to be chafed
Indicator Deploy and exposed. Reporter comments that if both wires had totally separated
(CPI) beacon it would have prevented automatic deployment of CPI when in water, or
submersion switch moisture ingress or contact of wires could have caused deployment of
wiring chafed. beacon.
Note: This has been classified as Failure To Deploy as the most probable
end result of the chafed wiring would have been a failure to deploy
M90 201005028 CPI SIU battery SA332 Super Performance Maintenance Control unit and beacon lights were flashing slowly. Upon replacing the
housing and Puma battery on the SIU, the battery and housing were found rattling around, as
battery found one of the bolts was loose inside. SIU battery had become loose causing
loose. the control panel to indicate ‘Beacon Gone’. Fleet check for battery security
initiated.
M91 201012411 During cruise, SA365 Dauphin Inadvertent Unknown During cruise, Crash Position Indicator (CPI) activated. System reset and no
Crash Position Deployment further activation occurred.
Indicator (CPI)
activated. System
reset and no
further activation
occurred.
M92 201101188 When ADELT SIKORSKY S76 Inadvertent Unknown Fault found with internal mechanism of unit.
switched Deployment
during post Note: This has been given a secondary classification of unknown as it is
landing checks not possible to determine whether the fault was a production fault or a
emergency beacon design fault.
transmissions
heard over
intercom. ADELT
switched off for
return sector.
Unit removed for
inspection.
Page 90
CAP 1144
January 2014
M93 201114478 Crash position AEROSPATIALE Inadvertent Maintenance During flight the CPI beacon lights flashed. Both switches were in the
indicator (CPI) AS332 Deployment guarded position. Engineering checks carried out on arrival. Corrosion was
beacon self found on ADELT unit connector. CPI and deployment systems replaced.
deployed in flight.
M94 201115065 Uncommanded AEROSPATIALE Inadvertent Maintenance Shortly after take-off, the CPT900 ADELT began transmitting. 121.5MHz
ELT activation. SA365 Deployment transmissions were received on the VHF radio and the ‘deployed/
ADELT connector transmit’ light was seen to be flashing. Eight attempts were made to
contaminated. reset the unit using the cockpit controls. It did eventually reset with no
further occurrences. Subsequent investigations found moisture ingress
in the ADELT unit/airframe electrical plug. Plug cleaned and refitted with
satisfactory results.
M95 201115066 Uncommanded AEROSPATIALE Inadvertent Maintenance Three minutes after take-off, the ELT was heard transmitting on the
ELT activation. SA365 Deployment VHF radio. control unit used to rest system but after 30secs it began
ADELT connector transmitting again. Two attempts were required to reset it. A/c returned.
contaminated. ADELT carrier assembly removed and moisture evident on connector which
was subsequently dried and refitted. Access panel sealed against further
moisture ingress.
M96 201202777 CPI beacon SIKORSKY S92 Inadvertent Human ATC and engineering informed. Beacon replaced.
deployed when A Deployment Factors
battery selected Note: This has been given a secondary classification of human factors
on during pre- because of the reference to the battery being selected on
start checks. Blue
‘Deployed’ light
illuminated and
aural warning
activated.
Page 91
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January 2014
M97 201204951 Serious Incident: EUROCOPTER Failure To Unknown The crew of the helicopter carried out a controlled ditching following
Pilot reported EC225 Deploy indications of a failure of the main gearbox (MGB) lubrication system and,
a gear problem subsequently, a warning indicating failure of the emergency lubrication
and intention to system. All passengers and crew evacuated the helicopter into a life raft
ditch in the North and were subsequently rescued. Two passengers sustained minor injuries.
Sea. Reported A further Special Bulletin details the progress made in identifying the failure
as gearbox oil mechanism that caused the 360deg circumferential crack, in the bevel
pressure warning. gear vertical shaft in the helicopter’s main gearbox, which was identified in
14 POB, no the early stages of the investigation and published in AAIB Special Bulletin
injuries. Damage S2/2012. It also details progress on the investigation into the indicated
to be advised. failure of the main gearbox emergency lubrication system published in
AAIB Field AAIB Special Bulletin S3/2012. Latest Special Bulletin contains information
investigation. about the helicopter’s main gearbox (MGB) lubrication system and the
results of an investigation into the indication of a failure of the emergency
lubrication system, after it was activated by the crew. It follows publication
of two earlier Special Bulletins on this accident. This was the first occasion
that the EC225 LP MGB emergency lubrication system had been operated
in-service. One Safety Recommendation, nr 2012-034 addressed to the
European Aviation Safety Agency. AAIB Special Bulletin S5/2012. A further
Special Bulletin has been published containing information on the progress
of the investigation into the emergency lubrication systems and the
Crash Position Indicators (CPI). AAIB Special Bulletin: S2/2013, Ref: EW/
C2012/05/01.
Note: This has been given a secondary classification of unknown because

the accident investigation was unable to provide a definitive reason for the
failure to deploy. See Also Appendix XXXX
M98 201205512 Uncommanded AEROSPATIALE Inadvertent Unknown After the last flight of the day it was noticed that the CPI was missing.
deployment of SA365 Deployment No cockpit indications were present. ATC conducted a search of the main
the Crash Position runways and taxiways. ARCC were informed and confirmed that they had
Indicator (CPI). not, and were not, receiving any transmissions from the device. Local
police informed.
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January 2014
M99 201206384 Uncommanded AEROSPATIALE Inadvertent Unknown CPI deployment light was recognised on shutting down. CPI confirmed
deployment of SA365 Deployment missing. Time and position of deployment not known.
Crash Position
Indicator.
M100 201209986 Inadvertent EUROCOPTER Inadvertent Human CPI was not in the correct setting whilst being tested and a signal was
deployment of EC135 Deployment Factors transmitted and recorded by MCC Kinloss.
crash position
indicator (CPI). Notes: This has been given a secondary classification of human factors
because of the reference to the CPI being in the incorrect setting during
testing
M101 201212866 UK Reportable EUROCOPTER Failure To Design The crew of the helicopter carried out a controlled ditching following
Accident. MAYDAY EC225 Deploy indications of a failure of the main gearbox (MGB) lubrication system and,
declared due to subsequently, a warning indicating failure of the emergency lubrication
failure of main system. All passengers and crew evacuated the helicopter and were
rotor gearbox subsequently rescued without injury. AAIB Special Bulletin S6/2012, Ref:
emergency EW/C2012/10/03. A further Special Bulletin contains information on the
lubrication system. progress of the investigation into identifying the cause of the 360deg
A/c ditched in circumferential crack in the bevel gear vertical shaft on the subject a/c.
sea but remained It also compares the findings with those recorded previously on another
upright with EC225 LP accident involving a similar failure and provides a further update
flotation devices on the investigation into both accidents. One Safety Recommendation, nr
inflated. 19 POB 2012-034 addressed to the European Aviation Safety Agency. AAIB Special
no injuries. Subject Bulletin S7/2012. A further Special Bulletin has been published containing
to AAIB Field information on the progress of the investigation into the emergency
Investigation. lubrication systems and the Crash Position Indicators (CPI). AAIB Special
Bulletin AAIB Bulletin: S2/2013, Ref: EW/C2012/10/03.
Notes: This has been given a secondary classification of design because

the accident investigation identified a design issue that resulted in the
system being designed not to deploy in the event of the crew manually
selecting transmit. See Also Appendix XXXXX
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January 2014
M102 201215354 ADELT transmitting SIKORSKY S76 Inadvertent Unknown The fault occurred initially on power up of a/c with the flashing light in the
inadvertently. C Deployment cockpit indicating the ADELT was transmitting. A reset was performed
before departure and all transmission indications ceased. However,
on approach to the platform ATC informed that the ADELT was again
transmitting. No cockpit indications reflected this. Reset once more on
arrival and unit switched off for the return flight. Engineering assistance
sought, unable to reproduce the fault but suspected intermittent operation
of G-switch so this part was replaced and a/c released to service.
Notes: This has been given a secondary classification of unknown as it

is not clear whether the G-Switch was responsible for the intermittent
transmissions and it is also unclear whether this was an installation,
maintenance or wear problem
M103 201301229 Crash position AEROSPATIALE Inadvertent Unknown During fault finding into a CPI defect, the beacon deployed. At the time, the
indicator (CPI) AS332 L2 Deployment a/c power was off and the CPI was selected off.
beacon deployed
in hangar. Notes: This has been given a secondary classification of unknown because
it isn’t possible to determine whether the deployment was related to the
fault that was being investigated, an inadvertent action on behalf of the
investigator or another, unspecified cause.
Page 94
CAP 1144 Appendix B: Accident investigation reports
Appendix B
B
Accident investigation reports
B1 – Extracts From the G-ATSC Investigation
B1.1 Aircraft Type

Wessex 60 Series 1
B1.2 Accident Information

The accident occurred in the North Sea, 35nm north east of the River Humber
estuary at 13:17hrs on 8 March 1976.
B1.3 Synopsis – Extracted From AAIB Report 11/76 [Ref 3]

The accident happened with both engines stopped in rapid succession shortly
after the helicopter had taken off from a gas rig platform in the North Sea. A
successful ditching was carried out and all the occupants of the aircraft were able
to escape unhurt and board the life raft. After some 25 minutes they were picked
up by a rig support vessel.
The accident was caused by the ingestion of the engine intake cover which the
pilot had omitted to remove before take-off.
B1.4 Background To AAIB Recommendation Relating To ADELT

No reference was made to ADELTs and there were no ADELT related
recommendations made.
B1.5 Tail Break Information

None as a result of the accident, the aircraft was destroyed by the effects of
immersion and movement on the seabed.
B1.6 Rotorcraft Inversion Information

Section 1.1 (History of flight) of the report states that:
“The port wheel flotation bag failed about one hour after the aircraft had entered
the water, allowing it to roll over and float with the tail rotor clear of the surface.
The aircraft sank later that evening in 90 feet of water whilst an attempt was

being made to tow it ashore. It was successfully salvaged and bought ashore 12
days later.”
B1.7 CAA Response to ADELT Recommendations

No ADELT related recommendations were made.
B1.8 Location of the Accident Report

This accident report can be found on the United Kingdom Air Accident
Investigation Branch website using the following link:
www.aaib.gov.uk.uk
B2 – Extracts From the G-BBHN Investigation
B2.1 Aircraft Type

S61N

The accident occurred in the North Sea, 48 nautical miles NE of Aberdeen at
14:18 hrs on 1 October 1977.

The accident occurred when the helicopter made an emergency landing in very
rough seas and capsized almost immediately after touchdown. The liferaft could
not be deployed, however all three occupants were rescued by another helicopter
after 53 minutes immersion, uninjured but suffering from the effects of exposure.
The floating wreckage was salvaged three days later.
It is concluded that this accident was caused by the helicopter alighting on open
water in very rough seas which were beyond the sea keeping capabilities of the
aircraft, because the commander believed that a major structural failure was
imminent. It is probable that a main rotor blade pocket had become partially raised
and disbonded causing very severe vibration.

There were no ADELT related recommendations, however, it was noted in the
report that none of the aircraft involved in the rescue were fitted with equipment
that would have allowed them to home to either 121.5MHz or 243MHz. Finding
xv “Although personal locator beacons were available to the crew, none of the
helicopters or surface vessels deployed was equipped to home on to their beacon

transmissions, had a search operation been necessary” reflects this. As a result,

even if ADELTs had been available they would have had no effect.

The tail boom separated in upward bending at a position immediately aft of the
transport joint. As this is not attributed to the salvage operation, it is assumed to
have occurred during the accident.

Section 1.1 of the report notes that “At the time of the ditching the wind was
assessed as being 30 to 40 knots with heavy seas and wave heights of 20 to 30
feet.”
The text continues “The commander had considered keeping the rotors turning
after touchdown but when he saw the “wall of water” ahead he realised that the
rotor would not survive.”
The text further continues “The helicopter climbed the face of the advancing
wave, which was very steep, achieving a pitch angle of about 30o and on reaching
the crest the bow lifted clear. According to eye witnesses in RJ the wave carried
the machine backwards and it yawed about 30o to the left under the influence of
wind and wave. As HN rolled to the left the slowly turning rotor blades dug in to
the water and it capsized almost immediately.”


www.aaib.gov.uk.uk

B3 – Extracts From the G-BIJF Investigation
B3.1 Aircraft Type

Bell 212
B 3.2 Accident Information

The accident occurred in the North Sea, approximately 1.3 miles south east of the
Dunlin Alpha Platform at 04:35 hours on 12 August 1981.
B 3.3 Synopsis – Extracted From AAIB Report 10/82 [Ref 14]

The accident occurred during a daytime flight, planned for VMC, between the
Brent Field and the Dunlin platform in the North Sea. The helicopter encountered
an area of reduced visibility and continued towards the Dunlin at a height of
200 feet until a decision was made to return to the Brent Field. During the turn,
control of the helicopter was lost after the aircraft pitched 20o nose up and
climbed to 300 feet with zero airspeed. It began yawing rapidly to the right and
descending and struck the sea in an essentially level attitude. The single fatality
and 13 survivors were retrieved by another helicopter and a rig support vessel
after some 44 minutes. The wreckage was salvaged by the rig support vessel the
same day.

Section 1.6.5 of the report states that the emergency board was fitted with a
BE369 floating SARBE beacon operating on 121.5MHz and 243MHz. This is not
the same thing as an ADELT but it might have been useful in attracting attention
except that this section of the report goes on to say that “Neither the emergency
board or any of the equipment attached to it was recovered during salvage”.
Section 2.6 of the report states that:
“Of the two emergency radio beacons in the accident helicopter the BE369
beacon was lost thus leaving available to the survivors on the SARBE Mk5 in the
lifejacket of the commander. If the commander had been incapacitated by the
impact there would have been no emergency beacon to guide rescue ships and
aircraft to the wreckage. A way to overcome this failing would be to require public
transport helicopters of this size to be fitted with an emergency beacon which is
automatically deployed on immersion in water, or by impact forces”.
The observation above led to finding ix:
“Had the aircraft been fitted with an automatically deployed emergency beacon
and if all the stand-by vessels had been fitted with the associated homing

equipment the nearest stand-by vessel should have been able to reach the
survivors within 15 minutes”.
This, in turn, led to recommendation 4.3:
“Public transport helicopters be fitted with an emergency beacon which is

automatically deployed on immersion in water or by impact forces.”

The tail did not become detached during this accident.

“The aircraft hit the water hard and immediately inverted with the cockpit and
cabin immediately filling with water”.
B3.7 CAA Response to ADELT Recommendations – Extracted

From Factor F1 1987
The Air Navigation Order, Schedule 5, has been amended to give effect to this
recommendation from 1st November 1986.

www.aaib.gov.uk.uk
B4 – Extracts From the G-ASWI Investigation
B4.1 Aircraft Type

Westland Wessex 60

The accident occurred 12 miles ENE of Bacton, Norfolk at 15:42 hrs on 13 August
1981

The helicopter was flying from the Leman Bank gas field to Bacton, Norfolk,
when it suffered a complete loss of power to the main rotor gearbox. In the late

stages of the ensuing autorotation the helicopter went out of control and crashed
into the sea, all thirteen men on board being killed.
There was insufficient evidence to permit the cause of either the loss of power
or the loss of control to be established. However, the report discusses possible
causes and ten safety recommendations are made.

Section 1.6.4 (Safety equipment) of the report states that:
“A Burndept Model BE 369 portable electronic flotation distress beacon was

mounted inside the cabin on the starboard side immediately aft of the door”
Section 1.15 (Survival aspects) of the report states that:
“The RAF search and rescue Sea King took off from Coltishall at 1547 hrs and
was directed by ATC along a vector of 050oM towards the accident area. Shortly
before crossing the coast the Sea King detected a crash locator beacon signal
on 121.5MHz, homed on to it, and spotted wreckage when 1 1/2 miles distant.
The Sea King recovered the bodies of six passengers and the cabin attendant
as well as items of floating wreckage. The bodies of the Commander and four
passengers were recovered during the next fortnight but that of one passenger
was never found. The Sea King also recovered WI’s BE369 emergency beacon
which had floated away from the aircraft transmitting on 121.5 and 243 MHz.”
Section 2.4.3 (Automatic survival radio beacon) of the report states that:
“In different circumstances WI’s impact with the water might have been a much
less violent one, survived by severely injured occupants unable to operate the
survival beacons carried and in need of prompt location and transport to hospital.
Fortuitously, the Burndept 369 beacon carried in the cabin cleared the wreckage,
floated and transmitted a signal. The rescue Sea King was thus able to quickly
locate the accident site.
This raises the question of whether offshore helicopters should be equipped

with an automatic survival radio beacon. The main case for the automatic survival
radio beacon in aircraft rests on increasing the chances of survivors being
rescued before they deteriorate so much that they die. Such a beacon, activated
by immersion or by impact forces, would give an increased probability that the
electronic distress signals will be transmitted. It would be of especial value
where the crew are unable to switch on the manually operated survival beacons
now carried, due to injury or other reason. Passengers carried in aircraft over
hostile survival environments are especially at risk, and this applies to helicopters
operating around the British Isles. The use of automatically operated survival

beacons in helicopters operating offshore can also be invaluable in the location

of wreckage for accident investigation, as the underwater sonar location beacon
carried by helicopters still entails a surface vessel search at short range. The CAA
was therefore recommended to consider requiring helicopters operating offshore
to be fitted with an automatic survival radio beacon.”
These comments led to recommendation 4.8 which states that:
“Public transport helicopters be fitted with a survival radio beacon which is


None – the aircraft was destroyed on impact

None – the aircraft was destroyed on impact.

From Factor F4 1984
A draft specification for automatically deployable emergency location transmitters
has been prepared. Apart from flight crew activation it is envisaged that the
equipment will be deployed by the action of crash sensors (frangible and/or inertia
switches) and a hydraulic pressure switch. The industry is being consulted on the
proposals.

www.aaib.gov.uk.uk

B5 – Extracts From the G-BARJ Investigation
B5.1 Aircraft Type

Bell 212

The accident occurred in the Brent oil field on the 24th December 1983 at 12:00
hrs.

The aircraft had been on a winching training flight in the Brent field. It had been
necessary to restrict the crew to one pilot and winch operator in order to remain
below the maximum single engined hover weight. The wind was less than 10
knots and there was a 4-5 metre irregular swell with the occasional larger wave.
After completing 4 practice drum lifts the aircraft obtained clearance to carry
out practise winching over the deck of the HUDDERSFIELD TOWN – the Brent
Charlie stand-by vessel. The winching area at the stern of the vessel was a 20
feet diameter yellow circle which was bordered around its aft edge by a fixed
guard rail containing nine stanchions 3 1/2 feet high positioned 4 1/1 feet apart
with three rails between each. The aircraft winch was located (as usual) in the
forward starboard position and the winch operator was sitting in the forward
cabin doorway with the door locked open. As the stern of the vessel was
approached the winch hook was lowered with a ballast weight attached to it
with a piece of flat webbing approximately one foot long. A satisfactory hover
was maintained at a height of 20-30 feet for a period of 1-2 minutes with the
hook over the centre of the winching area. The stern of the vessel then began
to corkscrew in a larger swell and the deck rose allowing two turns of the cable
to collect on the deck. The winch operator winched in and as the stern dropped
in to a deep trough the cable swung aft allowing the hook to contact the guard
rail which was not protected by canvas “dodgers”. The ballast weight and cord
wrapped around the middle guard rail and immediately pulled taut, causing
the aircraft to roll to the right and pitch nose-down until the pilot had full left
cyclic applied. The aircraft dived in to the sea alongside the vessel in an attitude
approximately 45o down. Both the crew and a witness on the ship estimated that
the elapsed time between the cable attaching to the rail and the aircraft hitting
the sea was approximately 3-4 seconds.
The helicopter immediately inverted with the emergency flotation equipment

partially inflated.


There were no ADELT related recommendations.

The tail boom did not become detached.

The aircraft was destroyed in impact with the sea.
B5.7 CAA Response to ADELT Recommendations.


www.aaib.gov.uk
B6 – Extracts From the G-ASNL Investigation
B6.1 Aircraft Type

Sikorsky S-61N

The accident occurred in the north sea, 75 nm north east of Aberdeen at 14:43
hrs on 11th March 1983

The accident occurred during a routine flight from the Piper and Claymore
platforms to Aberdeen. Shortly after departure from the Claymore Platform
the crew heard a loud bang, and experienced vibration from the main rotor
transmission. At the same time the crew observed that the No 1 engine had run
down and stopped. The crew transmitted a MAYDAY distress call and announced
their intention to make a precautionary landing alighting on the water. A controlled
ditching was completed without incident and the helicopter floated in a stable
manner with the emergency flotation gear inflated. During deployment, both
liferafts carried on board the helicopter were punctured and rendered unusable
by sharp projections on the hull of the helicopter. A Royal Air Force Sea King
helicopter arrived on the scene one hour after the ditching and the passengers

and crew were winched on board and flown to Aberdeen. An attempt at recovery
of the helicopter by an oil company support vessel resulted in the helicopter being
damaged and subsequently sinking. It was later recovered from the sea bed and
examined at the Accident Investigation Branch, Farnborough.
The report concludes that the accident was caused by a failure, in fatigue, of a
spur gear in the main rotor transmission gearbox which resulted in a rupture of
the gearbox casing and loss of the transmission lubrication oil.

There were no AAIB references to ADELTs or recommendations regarding
ADELTs, however, it is notable that it took an hour for a rescue helicopter to arrive
and it is possible that a functioning ADELT may have reduced these times.
Although a specification for ADELTs was not available in 1983, it is notable that
some aircraft were carrying “portable electronic flotation distress beacons” (see
Appendix B2 – extracts from the G-ASWI investigation). This implies that the
industry was already of the opinion that location devices would aid search and
rescue.
By 1984, a draft specification for ADELTs had been developed. This would appear
to indicate that the industry and the UK CAA agreed with the premise that
reliable, automatically deployable, emergency location systems had the potential
to increase the likelihood of rescue and, therefore, survival.

The tail boom did eventually become detached from the rotorcraft but this was
a result of damage inflicted during the recovery attempt and so the tail boom
detachment is not relevant to this report.

The rotorcraft did eventually sink, although it is not clear whether it became
inverted before it sank. Either way, the rotorcraft sank as a result of damage
inflicted during the recovery attempt and so sinking event is not relevant to this
report.



www.aaib.gov.uk
B7 – Extracts From the G-BEON Investigation
B7.1 Aircraft Type

S61N

The accident occurred in the sea near St. Mary’s Aerodrome, Isles of Scilly, at
about 11:35 hrs on July 16 1983.

G-BEON was on a scheduled service from Penzance to the Isles of Scilly, and
was being operated in accordance with the Visual Flight Rules (VFR). Whilst it
was on the approach to St Mary’s aerodrome the helicopter gradually descended
from its intended height of 250 feet without either pilot being aware of this, and
flew in to the water.
Nineteen of the 23 passengers, and 1 of the 3 crew members lost their lives. St
Mary’s lifeboat attended the scene and picked up the 6 survivors.

Section 2.8.2 of the report states that:
“Apart from flotation aspects another severe handicap incurred by the survivors
in the water was that the helicopter sank together with the dual frequency
BE369 beacon and the BE375 PLB’s carried in the lifejackets of the three crew
members. This accident again illustrates the value of equipping helicopters which
operate offshore with a survival radio beacon which is automatically deployed by
immersion in water or by impact forces. Recommendations to this effect were
made in AAIB reports 10/82 [G-BIJF], 4/83 [G-ASWI] and 2/84 [G-BDIL]”.
This assertion led to recommendation 4.5:
“Public transport helicopters be fitted with a survival radio beacon which is



The aircraft was destroyed as a result of the impact.

The final paragraph of section 1.1 of the report states that:
“During the impact both sponsons broke off together with the inflatable flotation
gear, water entered the cockpit forcibly, and the aircraft’s hull was disrupted in
such a way as to cause water to burst open the two freight-bay hatches in the
floor. The fuselage rolled over, filled with water, and quickly sank”.

From Factor F3 1986
This recommendation has been accepted. All helicopters engaged on public
transport flights beyond 10 Minutes flying time from land will be required to be
equipped with an automatically deployable emergency locator transmitter.
This will be implemented by 1 October 1986. The transmitters will be dual

frequency (121.5 and 243 MHz), and as an option may also be fitted with a radar
transponder.

www.aaib.gov.uk
B8 – Extracts From the G-BDIL Investigation
B8.1 Aircraft Type

Bell 212

The accident occurred in the North Sea, 030o (T) 14 miles from the Murchison
platform at 0242 hrs on September 14 1982.

The accident occurred during a night Search and Rescue (SAR) flight and
was reported to the Accidents Investigation Branch on 14 September. The
investigation commenced the same day.

The Baffin Seal seismic survey vessel, operating 5 to 10 miles north of the
Murchison platform, had reported that a man had been injured in an accident on
board. At approximately 0200 hrs the Brent Field helicopter unit was alerted to
take a doctor and medical attendant to the Baffin Sea and, because the helideck
of the vessel was obstructed, a winch was fitted to the aircraft and a full SAR
crew was carried. The aircraft took off at 0225 hrs and some minutes later
was seen to pass close to the Murchison platform at low level and disappear
on a north easterly heading in driving rain and poor visibility. The aircraft was in
radio contact with the Baffin Seal on marine VHF and had given its position as
‘FIVE MILES NORTH OF THE MURCHISON PLATFORM LETTING DOWN TO
SURFACE CONTACT’. Soon after this at approximately 0242 hrs contact with
the helicopter was lost on all frequencies. Small items of wreckage and two
bodies were recovered later that day in an area 17 to 22 miles north east of the
Murchison. The bulk of the wreckage was eventually recovered from the sea bed
at a depth of 1,120 feet in a position of 030o (T) 14 miles from the Murchison. All
six occupants died.

Section 1.6.4(iv) of the report states that:
“The aircraft was carrying in the cabin a BE 369 floating SARBE beacon for
operation on 121.5 MHz and 243MHz. The beacon was recovered from the sea
bed with the main bulk of the wreckage”.
Section 1.6.4(vi) of the report states that:
“An automatically deployable survival radio beacon was not required by United
Kingdom regulations and neither was one fitted.”
Although the aircraft was not equipped with an ADELT, it should be noted that
section 1.15.1 of the report states that “The accident was not survivable” and so
the absence of an ADELT would have had no material impact on the likelihood of
victims surviving this specific accident.
“It is obviously an advantage if those engaged in a search can be directed at

an early stage to the correct area. Quite apart from greatly aiding the rescue of
potential survivors, this would make it possible to reduce the resources required,
time involved and therefore the cost of the search operation. One problem is
that helicopters engaged in offshore operations are frequently out of range of
ATC radar coverage. If a data link system is developed whereby the aircraft’s
position is periodically transmitted to ATC, this could be used to provide accurate
information on a missing aircraft’s last known position. An alternative solution

would be to fit to helicopters an automatically deployed survival radio beacon

which could be homed on by the searching forces.”
The result of these comments was recommendation 4.4 which states that:
“Public transport helicopters to be fitted with a survival radio beacon which is

automatically deployed on immersion in water or by impact forces”.

The aircraft was destroyed on impact with the sea.

The aircraft was destroyed on impact with the sea.

from Factor F8 1984
A draft specification for automatically deployable emergency location transmitters
has been prepared. Apart from the flight crew activation it is envisaged that the
equipment will be deployed by the action of crash sensors (frangible and/or inertia
switches) and a hydraulic pressure switch. The industry is being consulted on the
proposals.

www.aaib.gov.uk.uk
B9 – Extracts From the OY-HMC Investigation
B9.1 Aircraft Type

Aerospatiale AS332L Super Puma

The helicopter was ditched at night 22nm east of the Dan-B Platform, in the North
Sea on the 2nd of January 1984.
B9.3 Synopsis – Extracted From AIB Denmark Report

HCL1/84‑0-001 [Ref 25]
None available – original report in Danish.

B9.4 Background To AAIB/N Recommendation Relating To

ADELT

The helicopter was ditched at night in adverse weather conditions and the tail
boom became separated either during or after ditching.

The helicopter ditched with a high nose attitude and both the tail boom and the
left hand float separated. As a result the helicopter capsized and floated, partially
submerged for approximately 10 nm before it sank.


There is only a Danish copy of this report; the information above was provided as
a courtesy by AIB Denmark. The basic information related to this accident was
provided in bulletin form in the AIB Denmark annual report of 1984.
B10 – Extracts From the G-BISO Investigation
B10.1 Aircraft Type

Boeing Vertol (BV) 234 LR

The accident occurred in the East Shetland Basin of the North Sea, 8 miles west
north west of the Cormorant Alpha rig at 1241 hours on 2 May 1984.

The aircraft was engaged on a flight from the Polycastle Rig in the Magnus Field
to Aberdeen carrying a full load of 44 passengers, one cabin attendant and two
flight deck crew. Shortly after establishing in the cruise at 120 knots (kt) a violent
disturbance was experienced. There then followed a series of disturbances, with
changes in aircraft altitude, normal acceleration(‘g’) and rotor speed, associated
with fluctuations in the No 2 flight control hydraulic boost system pressure.

After implementing the “Emergency Check List Drill, Flight Boost Hydraulic
Pressure Low” and attempting to regain control of the aircraft by changes in
speed and height, the crew elected to ditch, fearing all control might be lost.
A successful ditching was achieved 8 miles west north west of the Cormorant
Alpha Rig. With the aircraft on a north easterly heading, into wind and swell, an
attempt was made to water taxi towards the North Cormorant Rig. However,
when the aircraft was found to be taking on water and sinking, an evacuation of
the passengers commenced. After all the passengers and the cabin attendant
were clear, the engines and rotors were stopped, following which the two pilots
evacuated the aircraft. Shortly afterwards the aircraft capsized. It remained
floating inverted until its recovery. All crew and passengers were rescued by other
helicopters or surface vessels.

The report contains no ADELT references and no ADELT related

The tail boom did not break during this accident.

The report synopsis states that:
“After all the passengers and the cabin attendance were clear, the engines
and rotors were stopped, following which the two pilots evacuated the aircraft.
Shortly afterwards the aircraft capsized”.
In addition, finding 17 of the report states that:
“The aircraft ditched undamaged on an almost calm sea, but capsized 82 minutes
after touchdown...”.

There were no ADELT related recommendations for the CAA to respond to.

www.aaib.gov.uk

B11 – Extracts From the G-AZOM Investigation
B11.1 Aircraft Type

Bolkow B105D

The accident occurred 5.5 nms due east of Skegness on July 24 1984 at
approximately 12:02 hours.

The purpose of the 30 minute flight was to ferry two passengers from Strubby
heliport, in Lincolnshire, to Bacton gas terminal in Norfolk. The weather was
good and the Commander decided to conduct the flight at 1000 feet amsl, flying
visually on a direct track from Strubby to Bacton. At approximately 1155hrs, with
one of the passengers in the front left (P2) seat, the aircraft lifted off for Bacton.
The departure was normal and the commander levelled the aircraft at 1000 feet
amsl and established a cruise speed of 110 kts.
When the aircraft was about 5nm off the coast of Skegness the Commander
heard a “dull bang” from the back and the yaw pedals gave a “twitch”. His
immediate impression was that something was wrong with the tail rotor and
he decided to descend so as to be closer to the surface and also to turn right
towards Skegness. At this juncture there was no apparent loss of yaw control so
the Commander established the aircraft in a 70kt powered descent, turning to
the right. During this descent he felt further vibrations and so decided to alight
on the sea. Accordingly, he inflated the helicopter floats and called Strubby to
announce he was going to ditch but did not transmit a full distress message. He
also told passengers to don their lifejackets. By this time it was apparent that
the yaw pedals, although still effective, were losing sensitivity. Nevertheless, the
Commander flared successfully but, as power was applied in order to reduce the
descent rate, all yaw control was lost and the helicopter performed 2 or 3 (360o)
turns to the right, before hitting the water.
As a result of rotating in to the surface of the sea one of the four floats detached
and the aircraft immediately rolled on to its right side. It stabilised for sufficient
time to allow the front seat passenger to jettison his door, through which all three
occupants escaped. Very shortly after that the aircraft rolled upside down.

There are no references to ADELTS in this report.



The helicopter did invert as a result of one of the floats becoming detached.

There were no ADELT recommendations for the CAA to respond to.

www.aaib.gov.uk
B12 – Extracts From the G-BJJR Investigation
B12.1 Aircraft Type

Bell 212

The accident occurred 50 miles NE of the Humber at 19:19 hrs on 20 November
1984.

The helicopter departed from its base at North Denes near Great Yarmouth at
1757 hrs to carry out various transport tasks on several rigs in the southern North
Sea. Its final task was to collect 7 passengers from the rig Cecile Provine and
transport them back to Great Yarmouth. During the night approach to this rig, in
reasonable weather conditions, the helicopter crashed in to the sea 200 metres
north of the rig and both crew members perished. Most of the wreckage was
recovered from the sea bed in two diving operations during the next few weeks.

The report contains no ADELT references.

Not applicable the aircraft was destroyed by the impact with the sea.


Not applicable the aircraft was destroyed by the impact with the sea and sank.


www.aaib.gov.uk
B13 – Extracts From the G-BKFN Investigation
B13.1 Aircraft Type

Bell 214 ST

The accident occurred 14 miles NE of Fraserburgh at 11:00 hrs on 15 May 1986.

The accident occurred during a flight from Sumburgh in the Shetland Isles to
Aberdeen. A partial loss of collective control resulted in the crew being unable
to maintain height and the helicopter was forced to ditch 14 miles north east of
Fraserburgh, Scotland. The crew and passengers were able to evacuate safely
and were picked up by a fishing vessel that was in the area. The helicopter was
subsequently recovered and taken to the operator’s base in Aberdeen.

The report contains no ADELT references.

None – The aircraft floated after a successful ditching.

None – The aircraft floated after a successful ditching.



www.aaib.gov.uk
B14 – Extracts From the G-BWFC Investigation
B14.1 Aircraft Type

Boeing Vertol (BV) 234 LR

The accident occurred approximately 2.5 miles east of Sumburgh, Shetland Isles
(Latitude: 59o 53.5’ North, Longitude 001o 12’ West) at approximately 11:31 hrs
on November 6 1986.

The accident happened when the helicopter was approaching to land at
Sumburgh Airport, Shetland Isles on returning from the Brent oilfield in the East
Shetland Basin. Whilst descending from a height of 1,000 feet and at a range
of about 2.5 miles from the helicopter runway at Sumburgh, the helicopter
suffered a catastrophic failure of the forward transmission which in turn led to
de-synchronisation of the twin rotors such that the forward and aft rotor blades
collided. As a result the aft pylon, complete with the aft transmission and rotor
system, detached from the fuselage. The aircraft struck the sea in a tail down
attitude with considerable force, broke up and sank.

“The aircraft was fitted with an automatically deployable emergency location

transmitter (ADELT) mounted externally in the left rear side of the fuselage
and incorporating a VHF/UHF emergency transmitter and an X band radar
transponder. Release could be initiated by pilot selection or automatically either
by frangible or water sensing switches. Impact damage to the aft part of the
aircraft was particularly severe and the ADELT was found broken up and rendered
inoperative.”

“Fortunately, the Coastguard helicopter was able to rescue them after about
10 minutes in the sea, albeit suffering from hypothermia. Has this aircraft not
sighted the wreckage, the chances of rescue arriving in time could have been
crucially dependent on the functioning of the ADELT, but this was destroyed
by the impact. Since the accident, it has been proposed to modify ADELT
installations to include an independent power supply within the fuselage mounted
housing so that deployment is not jeopardised by an interruption of the aircraft’s
power supply. However, in this case the ADELT was located in a position which
happened to take the brunt of the impact and it was not considered that any
sensible redesign could ensure that the ADELT would survive such an impact.”
These statements led to safety recommendation 4.3 which states that:
“It has been recommended that requirements relating to the ADELT equipment,
including location, crashworthiness, protection and power supplies, be reviewed
in the light of this accident.”

There is no specific tail break information because the rotorcraft disintegrated on
impact with the water. However, section 1.12.3 of this report notes that:
“There were marks which indicated that rotor blade contact with the cockpit
section had occurred, but with relatively little velocity. No other evidence was
found that any rotor blades had struck the fuselage, but structural disintegration
of the cabin was such that this possibility could not be dismissed.”

There is no rotorcraft inversion information, the rotorcraft disintegrated on impact
with the water.

From “Annual Progress Report on Responses to AAIB
Safety Recommendations 1990”
“The Authority accepts this Recommendation. The requirements relating to the
ADELT equipment have been reviewed and amendments have been drafted:
these will shortly be circulated for Industry comment. Action has also been taken,
in conjunction with the operators and the ADELT system manufacturer, to modify
the installations already in service so as to improve the ability of the system
to survive an accident. This includes the repositioning, within the equipment

housing, of the independent power source which ejects the transmitter on

activation.
Status – September 1990 – Closed
Technical consultation with industry on the content of Issue 2 of CAA

Specification No 16 “Automatically Deployable Emergency Locator Transmitters
for Helicopters” is complete and all appropriate ADELT installations have been
modified. The formal publication of the specification is proceeding.”
NOTE: Issue 2 of CAA Specification was published on December 1 1991.

www.aaib.gov.uk
B15 – Extracts From the G-BEID Investigation
B15.1 Aircraft Type

Sikorsky S61N

The accident occurred in the North Sea, 11nm from the Shetland Island coast at
1431 hrs on 13 July 1988.
B15.3 Synopsis – Extracted From AAIB Report 3/90

Whilst operating a passenger flight from a North Sea rig to Sumburgh, the crew
heard an unusual noise which was almost immediately followed by a fire warning
on No 2 engine, and shortly thereafter by a fire warning on No 1 engine. Three
minutes after the initial noise a controlled ditching was carried out 11 nm from
the Shetland Island coast onto an almost calm sea. By this time the cabin had
filled with smoke. All twenty one occupants evacuated successfully into liferafts
and were winched into a Search and Rescue helicopter. After a fierce fire had
consumed much of the floating aircraft, the remains broke up and sank.

The following text has been extracted from Section 1.6.2.9 of the AAIB report:
“A modification was incorporated in BIH S-61N Helicopters in 1987 to provide an

Automatically Deployable Emergency Location Transmitter (ADELT)...The ADELT

was mounted in an external plinth located about midway up the right/rear sidewall
of the fuselage and deployed by springs when released from a mechanical latch
by an electrically fired explosive cartridge. The electrical source for the cartridge
was originally a dedicated 12 volt lithium battery, but this had been removed from
S-61Ns and the supply taken from an aircraft essential busbar. Cartridge activation
could initiated by any of three frangible switches, triggered by impact forces in a
heavy touchdown situation; or by manual operation of a guarded Deploy Switch in
the cockpit, with the ADELT Arm Switch in its normal in-flight ‘Arm’ position.”
Section 1.12.7 of the AAIB report states that: “The remains of the ADELT, which
was severely fire damaged, were found in the ADELT housing. Examination
showed that the deployment cartridge had not fired, but under test it operated at
an electrical current that was within limts.”
Section 1.15.4 of the AAIB report states that: “The ADELT did not deploy and
the crew reported that they had not operated the Deploy Switch. The operator’s
Operations Manual contained a description of the ADELT, which stated that in the
event of a controlled ditching a manual release of the ADELT would be carried
out, but there was no reference to this in the Emergency Drills in the Operations
Manual or the Emergency/Abnormal Checklist.”
Section 2.2 of the AAIB report states that “The crew omission of ADELT manual
deployment selection before leaving the aircraft was possibly related to a general
climate of feeling that deployment would be automatic in case of a ditching,
in line with the title of the equipment. Infact, in a gentle ditching where the
frangible switches remained intact the ADELT would not automatically deploy
unless the aircraft capsized or took on large quantities of water, sufficient to
cover the immersion switch in the plinth, well above the cabin floor level. A
major contributory factor may well also have been the lack of any mention of the
ADELT in the emergency drills. Had ID’s ditching circumstances been somewhat
less favourable, the occupant’s survival could have depended on the ADELT. It is
considered unsatisfactory that, two years after its incorporation throughout the
operators fleet, a simple revision of a Checklist card had not been made. The
CAA, in the course of their flight standards monitoring function, had drawn the
operator’s attention to this omission, but the operator had failed to take action to
rectify this. ”

The issues listed above led to the following finding (number 10):
“The Automatically Deployable Emergency Location Transmitter did not deploy.

Manual deployment selection by the crew was not required by drills, and
conditions for automatic deployment were not met until after the ADELT had
been disabled by fire damage”.
This led to the following Recommendation (number 4.10):
“Conduct a review of S-61N emergency procedures for crews to ensure that the
procedure for deployment of the ADELT, by manual selection from the cockpit,
are included in crew checklists and carried out in simulated training.”

This was an aircraft fire that did not result in a tail break.

Section 1.3 of the report states that “Approximately one hour after the ditching,
when the fire had destroyed most of the fuselage structure above floor level, the
remnants of the aircraft capsized and floated with only the tail boom above the
sea surface” Although the aircraft did eventually capsize, this would appear to be
the result of the fire and is not deemed applicable to this review.
B15.7 CAA Response to ADELT Recommendation – Extracted

From CAP 594 [Ref 37]
The Authority accepts this Recommendation. The operator has reviewed its
emergency procedures and manual deployment of the ADELT is now included on
the emergency checklist.
Simulator training procedures have been revised in respect of ADELT operation

following emergency landing. These actions are being reviewed for the other
S-61 operator as part of the Authority’s normal monitoring function.
Action has been taken to review S61 operators’ Check-lists and emergency drills,
and these have been amended to include manual selection of the ADELT and
these procedures are included in simulator training.
B15.8 Location of Accident Report

www.aaib.gov.uk

B16 – Extracts From the G-BDII Investigation
B16.1 Aircraft Type

S61N

The accident occurred near Handa island, of the NW coast of Scotland at 20:40
hrs on 17 October 1988.

The accident occurred during a Search and Rescue (SAR) mission, centred off
the northwest coast of Scotland … The duty SAR crew were called out from their
base at Stornoway to conduct a Search and Rescue flight for the two occupants
of a small fishing boat, which had capsized somewhere in the area of Handa
island. Towards the end of the search, whilst performing a hover manoeuvre, a
crew member commented that the helicopter was travelling backwards very fast.
The commander’s attempted recovery from this manoeuvre resulted in the

aircraft striking the sea and immediately rolling over. All four crew members
eventually boarded the liferaft and were later rescued by a Sea King SAR
helicopter from RAF Lossiemouth which returned them to Stornoway.


The tail boom did not separate from the helicopter.

The report states that “The helicopter immediately rolled inverted and settled into
a nose-down attitude, sinking slowly”.


www.aaib.gov.uk

B17 – Extracts From the G-BDES Investigation
B17.1 Aircraft Type

Sikorsky S61N

The accident occurred in the North Sea 90 nm north east of Aberdeen at 08:50
hours on 10 November 1988.

The Sikorsky S61N, G-BDES, was tasked on a non scheduled public transport
service from Aberdeen to three oil installations in the North Sea 100 nm north
east of Aberdeen and return. The outbound and two short inter-rig sectors were
completed without incident and, after refuelling, the aircraft was prepared for the
return to Aberdeen.
With a crew of two and eleven passengers on board G-BDES was lifted to a
low hover and the engines and controls checked before commencing the climb.
Whilst established in the cruise the crew and passengers became aware of an
unusual, initially slight, buzzing noise. This noise increased in volume and the
commander decided to land as soon as possible and turned towards a suitably
equipped platform. The noise continued to get louder associated with increasing
vibration. Following loss of the main transmission oil pressure, restored by
use of the Emergency Lubrication Pump, a sudden change in the level of both
noise and vibration associated with rapidly fluctuating engine indications forced
the commander to execute an immediate ditching. Shortly afterwards G-BDES
inverted.
The crew and the passengers evacuated the aircraft and were rescued without
serious injury.

The following text has been extracted from Section 1.17.1 of the AAIB report:
“The ADELT installation was examined at the AAIB facility at Farnborough. Most
of the system wiring, the control panel, the two forward frangible switches, the
saline switch and the lithium battery were not recovered and could not therefore
be examined. The ADELT unit was badly disrupted; examination revealed that
the pyrotechnic squib had not fired. An acceptance and firing check carried out
on the squib proved it to be serviceable. The rear frangible switch was found
to be serviceable but had not operated. The crew did not attempt to deploy the

ADELT using the flight deck ADELT DEPLOY switch. A Service Bulletin (CAS/CPT
600/SB-01)had been issued by the ADELT manufacturer to provide alternative
deployment activation means in the event of a failure of the aircraft power supply
or system wiring. This was made mandatory by CAA Airworthiness Directive
058-12-88 for compliance not later than 31 March 1989 but had not been
implemented on G-BDES.”
The issues listed in section 1.17.1 led to the following finding (number xvi):
“The Automatically Deployable Emergency Locator Transmitter failed to operate

but it was not possible to establish a reason”.
“The Civil Aviation Authority review the design and installation of the
Automatically Deployed Emergency Locator Transmitter system on helicopters in
order to ensure reliable operation.”

Section 1.12.1 of the AAIB report states that:
“At 1616 hrs a report was received from MSV Tharos that the aircraft’s tail had
broken off and had sunk at a position 58o27.4’N and 000o9.2’W”.
There were no findings or recommendations associated with this.

Section 1.1 of the AAIB report states that:
“The commander announced his intention to ditch the aircraft and the co-pilot
transmitted an abbreviated MAYDAY. There was insufficient height to turn into
wind. Speed was reduced to below 20 kt IAS at which point the commander felt
that her was losing yaw control. The ditching was cushioned by use of collective
control and the aircraft contacted the water in a slightly nose-up attitude with no
bank. On impact the commander lowered the collective lever; the co-pilot shut
down engines and attempted to deploy the flotation system. The ditching had
occurred in a trough between two very large waves. The front of the aircraft was
immediately engulfed by a wave and shortly afterwards G-BDES rolled to the right
and inverted. A summary of pre-impact timing is at Appendix 1.”

The predicted weather conditions were reported as:
1.7 Meteorological information
1.7.1 Synoptic situation
A strong to gale south-westerly airstream covered the area with frontal

troughs lying north-south over western Scotland and moving east at about
25 kt.
1.7.2 Forecast weather
Surface wind: 200oC/35 kt.
The actual weather conditions were reported as:
1.7.3 Actual weather conditions
An aftercast by the Meteorological Office gave the following conditions for
the ditching area:-
Surface wind: 190oC/25-30 kt with gusts to 40 kt.
The inversion of the rotorcraft led to the following finding:
“On ditching, the front of the aircraft was immediately engulfed by a wave, it
rolled to the right and inverted.”
This finding led to the following recommendation:
“The Civil Aviation Authority give further consideration to the problems of escape
from inverted helicopters, given the likelihood of rapid capsize following ditching,
when approving helicopters for offshore operations.”
B17.7 CAA Response To ADELT Recommendation – Extracted

From CAP 594
The CAA accepts this Recommendation. Wiring errors are known to have
prevented the deployment of an ADELT of the type installed on G-BDES
(Caledonian Airborne Systems CPT 600 system) in another accident involving an
S61N. However, because of the disruption to the ADELT system on G-BDES it
has not been possible to establish whether similar wiring errors existed.
CAA issued Airworthiness Directive 058-12-88 in December 1988 which required

the modification of all CAS CPT 600 ADELT Systems, in accordance with
Caledonian Airborne Systems Service Bulletin CAS/CPT 600/SB-01 by 31 March
1989. The modifications included replacement of the deployment battery with a

different type, relocation of the deployment battery and submersion actuator, and
changes to the control panel and airframe wiring.
CAA also issued a Letter to Owners/Operators No. 914 dated 10 February 1989
which recommended that the ADELT activation circuit wiring should also be
checked during the embodiment of CAA AD -58-12-88 and periodically thereafter.
A number of other detail changes, including the clarification in the CPT 600
Maintenance Manual of accept/reject criteria for airframe vibration induced wear
in the deployment mechanism, have since been introduced to improve the
reliability of the ADELT system.
B17.8 Location of Accident Report

www.aaib.gov.uk
B18 – Extracts From the G-BGKJ Investigation
B18.1 Aircraft Type

Bolkow 105D

The accident occurred near Scatsta Aerodrome, Shetland Isles at 1432 hrs on
April 25.

The helicopter departed at about 1345 hrs and carried out an oil pollution
reconnaissance flight to the northwest. At 1415 hrs the commander called
Scatsta Tower and was passed the weather, which was surface wind 030o/15
kt, visibility 5000 metres in rain, cloud base 1000 feet and temperature 3o. As
there appeared to be extensive low cloud between his position, north of Esha
Ness lighthouse and his base at Sella Ness he elected to carry out an NDB
approach to runway 24 at Scatsta, intending to break right for the helicopter pad,
which was about half a mile to the northeast of the runway threshold. At 1422
hrs the controller advised that it had started to snow and decided to monitor the
approach on radar.
Shortly after 1422 hrs and just prior to entering cloud at 2500 feet, 7nm on
a bearing of 300o from the “SS” NDB, the commander carried out the initial
approach checks and switched on the engine anti-ice system. He noted an

increase in the turbine outlet temperature on both engines. On entering the cloud
he encountered sleet which appeared to turn to water as it made contact with
the windscreen. A visual check of the airframe showed no signs of ice accretion
and the outside air temperature (OAT) gauge was reported to have read 1oC.
Although he could not see the OAT gauge, the observer’s report of the inflight
conditions was similar to that of the commander. At 1425 hrs the controller
advised that the heaviest weather returns, on the radar, were on the 24 approach
at 2.5 to 3 nm. The aircraft passed the beacon at 1426 hrs, descended to 2000
feet, carried out a righthand positioning turn and overflew the beacon at 1429
hrs to commence the outbound leg. Once established outbound it descended to
1700 feet. The commander noted that the inflight conditions were the same as
previously reported. After 1 minute 40 seconds he turned right and established
on the inbound track of 243o.
At 1431 hrs the controller advised that the range from touchdown was 5.5 nm.
Shortly after this transmission, the commander heard a dull thud and the aircraft
yawed to the left. He noticed the number one engine N2 decrease, heard the
associated audio warning and saw the central panel RPM warning light. As N2
passed 60% the aircraft again yawed to the left and the number two engine N2
decreased. The collective lever was lowered immediately. The call “Mayday,
Mayday, Mayday. Golf Kilo Juliet double engine failure” was recorded at
1431:47.3hrs.
Autorotation was established at 75 kt, and the aircraft was turned on to a heading
of 020o, the last known surface wind direction. The commanded glanced away
from his instruments, momentarily, to select the float inflation switch. When he
did not hear the floats inflate he looked down and saw that he had inadvertently
selected fuel jettison. Both guarded switches were on the same centre panel,
separated only by the windscreen wiper switch. Leaving the fuel jettison
selected, he then successfully inflated the floats. At 150 feet the surface of the
sea was visible but there was no forward vision. The flare was started at 50 feet
on the radar altimeter, and the landing was cushioned by the use of collective
pitch. Although the landing did not feel heavy, the commander noted that there
was some forward speed and the right front and both rear float bags became
partially detached. Shortly after 1432 hrs the commander informed Scatsta Air
Traffic Control that they were on the water and were vacating the aircraft. He
then carried out shutdown checks, deselected the fuel jettison, and initiated the
evacuation. The aircraft had taken up a marked list to the rear right.

The accident synopsis notes that “the ADELT beacon had been automatically
activated”.


The tail boom did not become detached from the rest of the aircraft but the
synopsis states that:
“...the rear of the main fuselage had buckled around the tail boom attachment in
a way that indicated that the boom had been strained downwards.”

The aircraft did not become inverted as a result of the accident.

There were no ADELT related recommendations for CAA to respond to.

www.aaib.gov.uk
B19 – Extracts From the G-BEWL Investigation
B19.1 Aircraft Type

S61N

The accident occurred at Brent Spar, East Shetland Basin at 0944 hrs on 25 July
1990.

The accident occurred whilst the helicopter was manoeuvring to land on the
Brent Spar, a permanently moored semi-submersible offshore storage and tanker
loading unit. After the helicopter had approached to a hovering position adjacent
to the helideck, several witnesses realised that it was positioned dangerously
close to a part of the installation’s crane structure. The tail rotor blade tips
contacted a handrail surrounding the anemometer mast which was attached
to the crane ‘A’ frame after which the helicopter crashed onto the helideck
and almost immediately fell over the side of the deck and into the sea. Seven
survivors were rescued from the sea having made their escape from the sinking
helicopter. Six occupants including the crew perished.


“The ADELT beacon appears to have deployed normally under the initiation of
the saline switch, however, given the circumstances of the accident, in which
the ditched helicopter was located immediately, the ADELT had little or no part
to play in the SAR phase. When the beacon was examined by the manufacturer
it was found to operate correctly, both in respect of the radio homing signals
and in response to radar interrogation. Battery power was found to be lower
than expected and this would have affected the radio signal strength. The radar
response was at full strength, due to lower voltage requirements. Examination of
the battery revealed no defect and it was unclear why its capacity was low. At the
time of the accident, the battery had consumed some 70% of its service life and,
depending on the frequency and duration of in service checks, may have been
approaching replacement. Also, even when not activated, storage in the vertical
or near vertical position would cause some current drain due to latching of the
attitude sensing circuitry. This may have been the case before installation or in
the period following recovery.”
Although the ADELT was operational, it is worth taking note of the issues related
to storage which may have led to transmissions of limited time – see the main
report. This fact led to conclusion number xiv which stated that:
“The ADELT beacon, if it had been required by rescue agencies, was unlikely to
have provided assistance for any length of time or over any great distance due to
its depleted internal batteries.”
Although potential degradation of ADELT performance was specifically

mentioned, no recommendations were made related to ADELTs. Despite this,
Recommendation Systematic 03, related to maintenance and storage of ADELTs
and ADELT batteries, should be considered.

The helicopter was destroyed as a result of the accident.

The helicopter was destroyed as a result of the accident.



www.aaib.gov.uk
B20 – Extracts From the G-TIGH Investigation
B20.1 Aircraft Type

AS 332L Super Puma

The accident occurred in the northern North Sea, approximately 500m east of the
Cormorant ‘A’ Oil Production Platform in the East Shetland Basin at 19:50 hours
on 14 March 1992.
B20.3 Synopsis – Extracted From AAIB Report 2/93

The accident occurred at night during a shuttle of personnel from an oil
production platform to a nearby accommodation ‘Flotel’. The crew had been
similarly engaged with other shuttle tasks since leaving Sumburgh nearly four
hours earlier. Weather conditions were severe with winds gusting up to 55 kts,
snow showers and very rough seas. However, the helicopter was being operated
within its specified wind limits. Having embarked 15 passengers, the helicopter
lifted from the platform helideck, transitioned forwards and almost immediately
began a right turn towards the ‘Flotel’. Climbing to a height of 250 feet and whilst
turning downwind, the handling pilot, who was also the aircraft commander,
reduced power and raised the nose of the helicopter such that the airspeed
reduced to zero and a rate of descent built up. Once he was aware of the
descent, which was also advised by his co-pilot and the Automatic Voice Alerting
Device (AVAD), he applied full power but the descent could not be arrested
before the helicopter struck the sea. Down draughts and incipient Vortex Ring
state may have exacerbated the situation.
The helicopter rolled on to its right side before inverting and sinking within
a minute or two. All but five of the occupants managed to escape from the
helicopter before it sank. Of the twelve survivors in the sea, only six were
recovered alive; the others perished in the hostile sea environment, some of
them having survived for a considerable time. The rescue operation, using
ships and helicopters, began almost at once but was severely hampered by the
conditions. The wreckage of the helicopter and its Combined Voice and Flight
Data Recorder (CVFDR) were recovered some 30 hours later.


Section 1.6.1.4 of the report states that:
“The ADELT system fitted on GH consisted of the beacon itself, a launching

spring, a pyrotechnic squib and a lithium battery, all in a carrier mounted on the
left-hand side of the rear fuselage. The launching system could be initiated by any
one of three signals; a cockpit switch, a saline switch in the carrier or any one of
three frangible ‘crash’ switches mounted in the airframe, close to the skin.”
“The ADELT beacon had been successfully deployed in the accident. The
pyrotechnic deployment squib in the fuselage-mounted ADELT carrier had
fired, the aircraft ADELT wiring was intact and the saline switch was functional.
The glass bowls of the two forward ‘frangible’ switches were intact, despite
deformation around the right-hand switch but the rear ‘frangible’ switch had been
fractured in the impact by displacement of the aircraft skin. Thus it appeared the
rear ‘frangible’ switch had initiated the deployment of the beacon and that, if this
had not occurred, the saline switch would have done so shortly afterwards.
Examination of the ELT beacon itself showed the unit to be fully serviceable and,
when activated, still to give a satisfactory signal”.

“The damage to the helicopter’s tail boom indicates that it also failed structurally
at impact, pivoting forward and to the right.”

“The helicopter rolled on to its right side before inverting and sinking within a
minute or two”.

There were not ADELT related recommendations for CAA to respond to.

www.aaib.gov.uk

B21 – Extracts From the G-TIGK Investigation
B21.1 Aircraft Type

Aerospatiale AS332L Super Puma (Tiger).

The accident occurred in the North Sea, 6nm south-west of the Brae Alpha Oil
Production Platform at about 12:40 hours on 19 January 1995.

The helicopter was conducting a charter flight, ferrying 16 maintenance engineers
from Aberdeen to the Brae oilfield. Having just passed a position 120 nm on the
062o radial from the Aberdeen VHF omnirange (VOR) radio beacon, and whilst
beginning its descent from 3,000 feet above mean sea level (amsl), the helicopter
was struck by lightning. This resulted in severe vibration which, a few minutes
later, developed into a loss of tail rotor control, necessitating an immediate
ditching in heavy seas. The ditching was executed successfully and the helicopter
remained upright enabling the passengers and crew to board a heliraft, from
which they were subsequently rescued. There were no injuries sustained and the
passengers and crew were later returned to Aberdeen by helicopter and ship.

Section 1.6.6.2 of the report states:
“The ADELT system fitted to G-TIGK consisted of the beacon, a launching spring,
a pyrotechnic ‘squib’ and a lithium battery; all were in a carrier mounted externally
on the left-hand side of the rear fuselage (Appendix B, Figure 4). The launching
system could be initiated by any one of three signals from: a cockpit switch, a
saline switch in the carrier, or from any one of three frangible ‘crash switches’
mounted in the airframe, close to the skin. Although the ADELT eventually
radiated successfully, it is not known whether it deployed on ditching, during the
subsequent period of floating, or from the sea bed.”
Section 1.18.10 of the report states:
“Two external plats which acted as load spreaders for pairs of bolts securing an
internal bracket (which supported the shroud mounted ADELT unit) were curled
up at their edges” and
“A number of avionic units appeared to have been damaged, or rendered

inoperative, by the strike. These included one starter-generator and/or the
generator control unit, the automatic direction finding (ADF) loop aerial and

receiver, the P1 station box, the anti –collision beacon power supply unit, a further
power supply unit, the ADELT unit and elements of its deployment system,
together with the FDR acquisition unit. It appeared that high voltage currents
had passed through a large number of avionic units and although the remained
generally operative, their future life may have been greatly reduced.
The ADELT unit was mounted at the extreme rear of the aircraft with its antenna
pointing aft. The latter component had completely disappeared. This suggested
that the discharge had travelled between the outboard trailing edge of the
damaged main rotor and the ADELT antenna”.
Although the report text identifies a lack of certainty regarding when the ADELT
started to transmit there were no ADELT related safety recommendations.
This may be because of the potential system damage identified by subsequent
sections of the report. Although there were no ADELT related recommendations,
it should be noted that the location of the ADELT and its antenna are identified as
a possible cause of damage to the ADELT. This is another example of an ADELT
system becoming damaged as a result of the location of its various parts.


The helicopter did not invert as a result of the accident, but it did sink as a result
of the flotation bags being punctured during the salvage activities. This has not
been counted as a helicopter inversion for the purposes of this paper because the
inversion was not a direct result of the accident.

There were no ADELT related Recommendations for the CAA to respond to.

www.aaib.gov.uk
B22 – Extracts From the G-HAUG Investigation
B22.1 Aircraft Type

Sikorsky S-76B


The accident occurred in the Carlingford Mountains, approximately 2 miles SE of
Omeath at 18:16hrs on 12 December 1996.
B22.3 Synopsis – Extracted From AAIU Report 01/98 [Ref 21]

G-HAUG departed Belfast International – Aldergrove Airport on 12 December
at 18:03 hrs to return to its home base at Ballyedmond, Co. Down, Northern
Ireland. This would normally be a flight of some 20 minutes duration. The
approach to the home base was executed using a locally produced GPS based
approach procedure. Having commenced its descent, in preparation for landing at
Ballyendmond, the helicopter struck the north face of the Carlingford Mountains
at 960 feet above sea level, approximately 2 miles SE of the village of Omeath,
Co. Louth, at 18:16 hrs. All three occupants suffered fatal injuries.
The investigation found that the circumstances of the accident were consistent
with controlled flight into terrain.

The following text has been extracted from Section 1.6.9 of the AAIU report:
“The ADELT system is a distress beacon that can be either manually or

automatically ejected from the aircraft. Automatic ejection is accomplished by
impact sensitive switches mounted in the aircraft. The ADELT fitted to G-HAUG
was a Series CPT-600 manufactured by Caledonian Airborne Systems. This
item of equipment was fitted as an option on G-HAUG; there was no regulatory
requirement to fit this item to the aircraft.
When ejected, the beacon is only automatically activated when it is immersed

in water. The buoyant beacon then transmits on 121.50 MHz and 243 MHz,
which are international distress frequencies. The beacon is also equipped with a
transponder, which transmits an encoded signal between 9.3 and 9.5 GHz.
On G-HAUG, the ADELT beacon was housed in a special fairing underneath the
tail boom, and was configured to be ejected rearward on receipt of a signal from
the crew or from the crash switches”
Section 1.6.12 of the AAIU report notes that the aircraft was serviced on 22
October and that “A 3-month inspection of the ADELT was carried out, the
ADELT beacon was tested and its battery was replaced.”
Section 1.15.3 of the AAIU report states that: “G-HAUG was equipped with an
ADELT Emergency Location Transmitter as described in para 1.6.9. This unit did
not eject from the aircraft in the accident. The aerial of the beacon had become

detached from the beacon during the impact. After the accident, the beacon
assembly was returned to the UK for testing and was found to function correctly.”
Section 2.19.1 of the AAIU report states that: “It is probable that the ADELT
was not armed, and for this reason did not deploy. However even if it had been
armed and had deployed, it would not have transmitted, as the beacon must
be immersed in water to activate the beacon battery. If the accident had been
survivable, and ELT beacon which could have functioned without immersion in
water may have facilitated the location of the aircraft. Some countries required
ELT beacons to function in such on-land situations.”
The issues listed in section 1.17.1above led to the following finding (number
3.1.26):
“In the case of this accident, because of the severity of the impact, the non-
functioning of the ADELT had no effect on the survivability of those on board.
However it did fail in its function to assist the SAR teams in their efforts to locate
the accident site. If the impact had been less severe, the fact that the ADELT
would not have functioned as it was not immersed in water, could have adversely
affected the prospects for survival of those on board”.
“The UK CAA should consider amending the certification specification for ADELTs
to ensure that these devices are capable of functioning following overland
accidents.”

None – this was a CFIT related accident in which the whole aircraft was destroyed.

None – this was a CFIT accident.

From Response to Irish AAIU
When the provision of ADELTs is required by the UK operating rules, they must
be approved to the requirements of EUROCAE Minimum Operating Performance
Specification ED62, which superceded CAA Specification 16. Both these
specifications already require that ADELTS are activated automatically by the
deployment means when the automatic deployment occurs, whether on land or
water. The Authority therefore considers that the existing specifications already
satisfy this Recommendation.


This accident report can be found on the website of the Air Accident Investigation
Unit, Ireland website using the following link:
www.aaiu.ie
B23 – Extracts From the LN-OPG Investigation
B23.1 Aircraft Type

Aerospatiale AS332L Super Puma

The accident occurred in the Nowegian Sea, approximately 100 nm west of
Bronnoysund on 8 September 1997 at approximately 06:56 hours
B23.3 Synopsis – Extracted From AAIB/N Report 47/2001 [Ref 24]

On 8 September 1997 at 0600 hours, the helicopter took off from Bronnoysund
Airport on course for the oil production vessel “Norne”. On board were a crew
of two pilots and 10 passengers. The flight proceeded as normal on a standard
IFR flight plan at an altitude of 2,000 ft until 0650 hours when the crew observed
a short illumination of the overspeed (OVSP) light. The crew had no reason to
assume that this was a serious warning signal. The helicopter approached the
Norne, and the crew made contact with the Transocean Prospect oil rig, which
was operating the radio station for the area. Communications with the Bodo
Air Traffic Control Centre (ATCC) were then terminated. A short time after this,
the crew observed what they assumed to be further abnormal indicators in the
cockpit. The ongoing fault in the axle between the right motor adn the mean
gearbox now became critical. This led to the R/H and the L/H power turbines
burst (were torn apart). This meant that vital flight control rods were cut and the
helicopter went completely out of control. Everyone onboard was killed when the
helicopter hit the surface of the sea.
B23.4 Background To AAIB/N Recommendation Relating To ADELT

“The aircraft was equipped with an externally mounted Emergency Locator

Transmitter of the ADELT type. No signal from this transmitter was ever
received.”
Sections 1.15.1.3 and 1.15.1.4 of the report state:

“The helicopter had an Emergency Locator Transmitter of the Automatical

Deployable Emergency Locator Transmitter (ADELT) type, model CPT 600. This
was mounted the L/H sponson on the helicopter and could be actuated either
manually or automatically. On actuation, it is released by a spring so that it is
discharged upward and backward. During the impact with the surface of the sea,
the Emergency Location Transmitter was so damaged that it neither was ejected
not did it begin to transmit.
On the basis of experience from the British sector of the North Sea, HS advised
against type approval and use of this Emergency Locator Transmitter when the
type came on to the Norwegian market. However, the type was approved and
installed into helicopters belonging to AS Morefly. On its takeover of this fleet of
helicopters, HS also became a user of the type.”
“The Emergency Locator Transmitter that was installed in LN-OPG did not
contribute to locating the helicopter wreckage. This was due to it being destroyed
when the helicopter hit the surface of the sea. In the opinon of the AAIB/N,
the Emergency Locator Transmitter in question is vulnerable to loadings in
conjunction with accidents and is positioned in a confined area that means even
minor damage might prevent it from releasing. An assessment should therefore
be made as to whether it is suitable for its purpose.
Section 3.1.6.c of the report states that:
“The helicopter’s Emergency Locator Transmitter (type ADELT) was smashed

in the impact with the surface of the sea and consequently did not transmit any
emergency signals. The Emergency Locator Transmitter was therefore of no
assistance in warning of the accident or determining the site of the accident.”
These statements led to the following recommendation (number 42/2001) to the

Norwegian Civil Aviation Authority (Luftfartstilsynet)
“In collaboration with the Norwegian Post and Telecommunications Authority

[Post-og Teletilsynet], the Norwegian Civil Aviation Authority [Luftfartstilsynet]
should assess whether Emergency Locator Transmitters of the ADELT
type, model CPT 600, should be approved for use in Norwegian aircraft.
(Recommendation nr. 42/2001)

“The helicopters tail was raised as the first section.”

“The helicopter’s tail, including the tail rotor, had separated at main frame 9000,
but were found right next to the cabin. The tail boom was bent to the right in
middle...”.

“In the opinion of the AAIB/N, the helicopter fell almost vertically after breaking
up in the air. The impact with the surface of the sea caused such great damage
to the helicopter that it sank after a very short time. This may explain why all the
parts were found within a relatively limited area on the seabed.

No ADELT related recommendations were made to the UK CAA.

This accident report can be found on the Air Accident Investigation Branch
Norway website using the following link:
www.aaib.no
B24 – Extracts From the G-BJVX Investigation
B24.1 Aircraft Type

Sikorsky S76A (Modified)

The accident occurred approximately 0.8nm north west of the Leman
49/26 Foxtrot platform in the Leman Offshore Gas Field of the North Sea at
approximately 18:44 hrs on 16 July 2002.
B24.3 Synopsis – Extracted From AAIBSupplemental Report

S3/2002 [Ref 17]
On the evening of the accident the aircraft departed Norwich to complete a
scheduled flight consisting of six sectors in the southern North Sea offshore gas
fields. The first four sectors were completed without incident but whilst en-route
between the Clipper, an offshore platform, and the Global Santa Fe Monarch, a
drilling rig, the aircraft suffered a catastrophic structural failure. The helicopter’s

main rotor assembly separated almost immediately and the fuselage fell to the
surface about 0.8nm north-west of the Global Santa Fe Monarch which at the
time was attached to the Leman 49/26 Foxtrot platform, a normally unmanned
installation. Witnesses reported hearing a single or double muffled bang or boom,
and seeing the aircraft fall in to the sea. The fuselage disintegrated on impact
and the majority of the structure sank. Fast rescue craft launched from Putford
Achilles, a multipurpose standby vessel, arrived at the scene of the accident
within a few minutes. There were no survivors amongst the nine passengers and
two crew.

“The ADELT beacon fitted to G-BJVX was mounted in a carrier located externally
at the lower rear section of the tail boom. The ADELT could be deployed by
any one of three methods: a cockpit switch; a saline switch in the carrier; and
by either of two frangible ‘crash switches’ mounted in the airframe. The radio
transmitter beacon was a conical shaped sealed self-buoyant unit with an antenna
system mounted in the upper portion.
The current requirements for an ADELT are specified in EUROCAE document

ED-62 dated May 1990. This document supersedes MPS 1/WG4/65,, “Minimum
Performance for Radio Survival Beacons functioning on VHF” dated July 1965.
In respect of current requirements for crash shock resistance, an ADELT should
survive a 500g impulse lasting 4 +/- 1 milliseconds and a 100g impulse lasting
23 +/- 2 milliseconds. Regarding impact shock developed by contact with a hard
surface (eg rock, concrete, steel) the ADELT must survive an impact velocity of
25 metres/sec (80 feet/sec) under laboratory conditions. Calculations indicated
that the speed of water impact was in the order of 140kt (72 metres/sec or 236
feet/sec) with the fuselage in a 37o dive.”
Section 1.12.3.3 states that:
“When recovered the ADELT (Automatically Deployed Emergency Location

Transmitter) beacon did not appear to have deployed when the helicopter struck
the sea surface. It was recovered from the main wreckage site together with its
carrier into which it appeared to be loosely fitted. The beacon launcher had been
torn away from its mounting position at the lower rear part of the tailboom. The
beacon deployment springs mounted within the launcher unit were extended.
The electrically initiated explosive squib was not recovered. The radio transmitter
beacon had been severely damaged during the impact rendering it unserviceable
electrically and non-buoyant.

The launcher unit and the beacon were physically examined and there were no
obvious defects that would have prevented deployment of the beacon.
The mechanical firing mechanism was dismantled and no fault was found with
any of the mechanical parts. The lithium battery was tested and found to be well
below its minimum charge which was consistent with its submersion in water
for a period of time. The electric charge within the battery indicated that there
had not been a defect and that it had not suffered a short circuit. The battery was
found to be well within its service calendar life.
The examination of the launcher mechanism, which did not include the explosive
squib, concluded that there was no evidence of a pre-impact defect or failure that
would have prevented deployment of the beacon.
The launcher and the aircraft mounting bracket were taken to an explosives
laboratory for chemical analysis. The results of this analysis detected traces of the
explosive used in the electrically initiated squib, which indicated that the squib
had fired.”
Section 2.18.1 of the report states:
“The ADELT beacon, a variant of the more generic ELT (Emergency Locater
Transmitter) did not perform its intended functions of automatically marking
the crash position of the helicopter and transmitting on international distress
frequencies. When found, it was on the sea bed still loosely within its carrier.
The launcher squib had fired but the spring ejection mechanism was completely
overpowered by the speed and force of the impact. Calculations indicated that
the speed of water impact was in the order of 140kt with the fuselage in a 37o
dive.
The beacon itself and its ejector mechanism were probably serviceable before
water impact but the equipment specification was probably exceeded by the
unforeseen brutality of the water impact.”
These statements led to finding number 35:
“The ADELT beacon and its ejector mechanism were probably serviceable before
water impact but the equipment’s specification was probably exceeded at water
impact.”
There were no safety recommendations related to the ADELT, presumably

because the cause of its failure to deploy was likely to have been the fact that its
survival specifications were exceeded by the force of the impact.


None, the aircraft was destroyed on impact.

None, the aircraft was destroyed on impact.


www.aaib.gov.uk
B25 – Extracts From the G-JSAR Investigation
B25.1 Aircraft Type

Eurocopter AS332L2 “Super Puma”

The helicopter was forced to make an emergency landing in the North Sea,
approximately 10 nm North West of Den-Helder at 11:28pm on the 21st
November 2006.
B25.3 Synopsis – Extracted From Dutch Safety Board Report

“Emergency landing Bristow AS332L2 search and rescue
helicopter”. [Ref 26]
On the evening of Tuesday 21 November 2006 at 11.28 p.m. a helicopter of
the Eurocopter AS332L2 “Super Puma” type, registration number G-JSAR,
was forced to make an emergency landing in the North Sea, approximately ten
nautical miles to the north-west of Den Helder. The four crew members and
thirteen passengers were rescued from the sea after approximately 1 hour and
carried to Den Helder using different means of transportation. One passenger
was admitted to hospital with mild hypothermia symptoms but discharged after a
few hours; the remaining occupants were uninjured.
The passengers came from production platform K15B belonging to the

Nederlandse Aardolie Maatschappij (NAM). Because of a prolonged power outage

(“black out”) – which had started at 08.00 p.m. that day – they had transferred
to the drilling platform adjacent to the K15B, the Noble George Sauvageau
(hereinafter referred to as the Noble George). After the power outage on the
K15B the work on the Noble George had been halted for some time, but was
resumed when it became clear that no fire had broken out on the K15B – all the
safety provisions on the Noble George were functioning properly. It was decided
to take anyone not needed to work on fixing the power outage to the mainland,
for which the Search and Rescue (SAR) helicopter G-JSAR was deployed. On
the return flight the crew reported fluctuations in the engine revolutions, and
there were also problems with the steering, following which the crew decided
to make an emergency landing. The Coast Guard organised and coordinated the
successful rescue operation.

“The G-JSAR is equipped with an Automatically Deployable Emergency

Locator Transmitter (ADELT). After the helicopter ditched, the ADELT deployed
automatically and started transmitting.”
“...the emergency locator transmitter (ADELT) deployed automatically and started

transmitting.”
Section 7.6 states that:
“The ‘responder radar’ element of the ADELT beacon on the G-JSAR assisted the
rescue ship(s) in locating the area of the ditched aircraft due to returns from this
transponder on their radar screens.”
The ADELT performed as expected and, as a result, no ADELT related



The helicopter did not invert.

There were no ADELT related Recommendations for the CAA to respond to.


This accident report can be found on the Dutch Safety Board website using the
following link:
www.safetyboard.nl
B26 – Extracts From the G-BLUN Investigation
B26.1 Aircraft Type

Aerospatiale SA365N, Dauphin 2

The accident occurred in the Irish Sea, approximately 0.25nm south of the
North Morecambe platform (located within the Morcambe Bay gas field) at
approximately 18:33 hours on 27 December 2006.
B26.3 Synopsis – Extracted From AAIB Special Bulletin S1/2007

[Ref 19]
The helicopter departed Blackpool at 1800 hrs on a scheduled flight consisting
of eight sectors within the Morecambe Bay gas field. The first two sectors were
completed without incident but, when preparing to land on the North Morecambe
platform, in the dark, the helicopter flew past the platform and struck the surface
of the sea. The fuselage disintegrated on impact and the majority of the structure
sank. Two fast response craft from a multipurpose standby vessel, which was
on position close to the platform, arrived at the scene of the accident 16 minutes
later. There were no survivors amongst the five passengers or two crew.

Section 1.15.1 of the report states that “At 1834 hrs, the North Morecambe
Platform ‘Man Overboard’ alarm was activated and reports of a helicopter
ditching were received on a marine radio channel. The Highland Sprite, stationed
approximately one mile to the southwest of the platform, launched two FRCs
towards the reported area. The Liverpool Coastguard Maritime Rescue Co-
ordination Centre (MRCC) initiated full Search and Rescue (SAR) action in liaison
with the Aeronautical Rescue Co-ordination Centre (ARCC) at RAF Kinloss,
initially deploying two rescue helicopters and two allweather lifeboats. The MRCC
incident log records that the transmission from the Automatically Deployable
Emergency Locator Transmitter (ADELT) was first detected, by satellite, at 1835
hrs. This signal, which included a doppler derived position of the beacon, was

updated 30 minutes later when the satellite next passed overhead and at routine
intervals thereafter.”
As the ADELT functioned as intended in this accident, the AAIB made no

recommendations related to ADELTS.

Section 1.12.1 of the report states that “The first items of wreckage to be
recovered were found floating on the surface by the two FRCs launched from
the Highland Sprite, stationed approximately one mile to the south-west of the
platform. Much of the floating debris included engine and transmission cowlings,
fuselage panels, passenger seats and an inflated life raft. The most significant
item recovered at this stage was the tailboom, complete with the fenestron tail
rotor and gearbox. The condition of this wreckage suggested that the helicopter
had impacted the sea at high speed, and that the remainder would be scattered
on the sea bed. This wreckage was recovered to shore on the morning of 29
December 2006.”
“As noted in paragraph 1.12.1, the fenestron tail rotor and its gearbox were still
attached to the tailboom and empennage structure, which had been recovered
floating on the surface by rescue vessels on the night of the accident. A long
section of the tail rotor centre driveshaft had pulled out of its sliding spline
connection with the rear shaft (which was still in-situ) and was later recovered
from the sea bed. The forward end had failed in bending at the same location
where the tailboom had fractured. The remaining section of the centre driveshaft
was found still connected to the forward shaft, which had also broken into two
pieces in bending. Both flexible couplings in the system were intact.”
The rotorcraft was destroyed on impact during this incident so there were no
recommendations related to the failure of the tail boom.

The rotorcraft was destroyed on impact so it did not have chance to invert.


www.aaib.gov.uk

B27 – Extracts From the G-REDU Investigation
B27.1 Aircraft Type

Eurocopter EC225 LP Super Puma

The accident occurred approximately 300m southwest of the ETAP Central
Production Facility Platform helideck in the North Sea at 18:37hrs on 18 February
2009.

“The helicopter departed Aberdeen Airport at 1742hrs on a scheduled flight to
the Eastern Trough Area Project (ETAP). The flight consisted of three sectors,
with the first landing being made, at night, on the ETAP Central Production Facility
Platform. Weather conditions at the platform deteriorated after the aircraft left
Aberdeen; the visibility and cloud base were estimated as being 0.5 nm and 500ft
respectively. At 1835 hrs the flight crew made a visual approach to the platform
during which the helicopter descended and impacted the surface of the sea.
The helicopter remained upright, supported by its flotation equipment which had
inflated automatically. All those on board were able to evacuate the helicopter in
to its liferafts and they were successfully rescue by air and maritime Search and
Rescue (SAR) assets.”

“The helicopter was equipped with an externally mounted, deployable

crashposition indicator (CPI). The CPI was mounted on a panel forming the lower
left side of the aft extension of the baggage hold at the rear of the main cabin.
Deployment could be achieved as a result of any one of the following three
actions:
1. Operation of a g-switch registering more than 6g acceleration in any direction.
2. Manual operation by a crew member from the flight deck.
3. Automatic operation by immersion in water of a water switch, positioned just

above cabin floor level behind the cabin trim and slightly aft of the left main
cabin door aperture.
Regardless of the deployment method, automatic transmission commences

once it has separated from the helicopter. The release system uses a very small

explosive charge and a light spring to project the CPI away from the helicopter.
The CPI subsequently floats and transmits on 406.0 MHz as well as on 121.5 and
243.0 MHz.
The CPI may be switched to a transmit function by the crew whilst the helicopter
is in flight.”
Section 2.5.9 states that:
“The circumstances of this accident, ie the combination of forward speed and

rate of descent, with associated nose-up attitude, resulted in both linear vertical
and nose-down angular pitching accelerations at impact. These, in combination,
created sufficient bending moment at the tail-boom attachment to cause
downward structural failure. This, in turn, led to downward displacement of the
rotating tail-rotor drive shaft. Entanglement with wiring looms and consequent
damage to those incorporating part of the CPI release system, then occurred.
The resulting nose-down attitude of the floating aircraft, following the separation
of the tail-boom, appears to have resulted in the water switch remaining above
the waterline following automatic deployment of the flotation equipment.
The reason for the failure of the CPI to deploy on G-REDU was not fully
determined. It was, however, judged to have been influenced by one or more of
the following factors:
1. The crew release was not utilised – the crew did not report using it and the
release switch was found positioned and gated in the normal flight setting
after salvage.
2. The relatively low linear acceleration imparted to the ‘G’ switch in any
direction during the impact, resulting in the switch failing to trigger.
3. The low position of the CPI unit mounting, both in relation to the floating
waterline and to the initial point of impact of the fuselage with the water,
resulting in water immersion of that unit and associated wiring.”
This extract from the report supports the conclusions indicated by other data
regarding the potential effect of tail boom separation and sensor selection and
location to compromise the functionality of an ADELT.
These observations resulted in the following recommendation:
“Safety Recommendation 2011-071
It is recommended that the European Aviation Safety Agency reviews the

location and design of the components and installation features of Automatically
Deployable Emergency Locator

Transmitters and Crash Position Indicator units, when required to be fitted to

offshore helicopters, to ensure the reliability of operation of such units during and
after water impacts.”

Section 2.5.9 states that:
“The circumstances of this accident, ie the combination of forward speed and

rate of descent, with associated nose-up attitude, resulted in both linear vertical
and nose-down angular pitching accelerations at impact. These, in combination,
created sufficient bending moment at the tail-boom attachment to cause
downward structural failure. This, in turn, led to downward displacement of the
rotating tail-rotor drive shaft. Entanglement with wiring looms and consequent
damage to those incorporating part of the CPI release system, then occurred.”
This clearly demonstrates that damage to the tailboom and/or tail rotor drive shaft
can damage the release system of an ADELT.

“The helicopter remained upright, supported by its flotation equipment which had
inflated automatically.”

The recommendations from this report were aimed at EASA rather than CAA and
so the CAA had no recommendations to respond to.

www.aaib.gov.uk
B28 – Extracts From the G-REDL Investigation
B28.1 Aircraft Type

Eurocopter AS332L2 Super Puma


The accident occurred in the sea approximately 11nm north-east of Peterhead
Scotland at 12:55hrs on 1 April 2009.
B28.3 Synopsis – Extracted From AAIB Special Bulletin 5/2009

[Ref 28]
“Recorded radar information showed the helicopter flying inbound towards
Aberdeen at 2,000 ft and then turning right and descending rapidly. Surface
visibility was good and an eye witness, working on a supply vessel approximately
2 nm from the accident site, heard a helicopter and saw it descend rapidly before
it hit the surface of the sea. Immediately after impact he saw the four main rotor
blades, still connected at their hub, strike the water.”

There were no references to the ADELT in the AAIB Special Bulletins for G-REDL.

None available –the aircraft was destroyed on impact.

None available –the aircraft was destroyed on impact.

No ADELT related recommendations had been made related to G-REDL at the
time when this report was published.

www.aaib.gov.uk
B29 – Extracts From the G-REDW Investigation
B29.1 Aircraft Type

EC225 LP Super Puma


The accident occurred 20nm east of Aberdeen at 11:14hrs on 10 May 2012.

[Ref 29]
“The helicopter was on a scheduled flight from Aberdeen Airport to the Maersk
Resilient platform, in the North Sea, 150 nm east of Aberdeen. On board were
two flight crew and twelve passengers. The helicopter was in the cruise at
3,000 ft with the autopilot engaged and at an approximate speed of 143 KIAS.
Thirtyfour nm east of Aberdeen Airport, the crew were presented with indications
of low pressure in both the main gearbox (MGB) main and standby oil lubrication
systems. This was followed by a chip indication on the Vehicle Monitoring
System (VMS), and the MGB oil temperature starting to increase.
The commander assumed control of the helicopter, reduced speed towards 80

KIAS, turned back towards the coast and initiated a descent. The crew activated
the emergency lubrication system and during the descent the mgbemlub1
caption illuminated on the Central Warning Panel (CWP), for which the associated
procedure is to land immediately. The commander briefed the passengers and
carried out a controlled ditching. The total flight time was 27 minutes.”

Extracted From AAIB Special Bulletin S2/2013 [Ref 30]
Note – the Special Bulletin referenced here applies to both G-REDW and
G-CHCN. Unless specifically stated, any quotations from the report apply to both
aircraft.
The description of the ADELT system states that:
“Both helicopters were equipped with an externallymounted, deployable Type

15-503 crash position indicator (CPI). On G-REDW, the CPI was mounted on the
lower left side of baggage hold at the rear of the main cabin. On G-CHCN the CPI
was mounted on the left side of the tail boom, just aft of the main cabin.
The CPI system consists of the CPI beacon, a beacon release unit, a system
interface unit, a cockpit control panel, a water activated switch and an aircraft
identification unit (Figure 3). These components are located in various positions
around the helicopter, and are connected by wiring which is integrated with the
rest of the helicopter’s wiring looms, and is therefore not specifically protected
against water ingress. The electrical connectors in the CPI system however
conform to an industry standard specification1 which ensures good performance
when submerged in water at shallow depths.

Deployment of the CPI is achieved by any one of the following:
1. A g-switch detecting an acceleration of more than 6 g in any direction
2. Manual operation of the DEPLOY switch on the cockpit control panel
3. Immersion of the water activated switch”
the cockpit control panel. Once selected to TRANSMIT, the CPI will not
automatically deploy either by means of the g-switch or the water activated
switch, unless a system reset, by pressing the TEST/RESET button on the
cockpit control panel, has first been performed. The helicopter manufacturer was
unaware of this feature of the CPI operation and as such no relevant information
was included in the EC225 LP Flight Manual. Nor was this information included in
the Type 15-503 CPI Operating Manual published by the CPI manufacturer.”
The text related specifically to G-REDW states that:
“The CPI on G-REDW did not deploy and remained attached to the helicopter.
Photographic evidence shows that the water level in the cabin whilst the
helicopter was floating was above the level at which the water activated switch
was mounted. The crew did not activate the CPI beacon, either by selecting
TRANSMIT or DEPLOY on the cockpit control panel, prior to the emergency
evacuation. As such, no distress signal was detected from the helicopter during
the accident.”
The discussion section of the report makes the following statement with relation
to G-REDW:
“The CPI on G-REDW did not release automatically; photographs show the
water level in the cabin was above the level of the water activated switch. Whilst
further work is required to support any final conclusions, issues relating to the
continuity of the helicopter wiring when submerged, the design of the water
activated switch and the location of the water activated switch relative to the
water level following the ditching are being investigated as possible causes for
the non-deployment of the CPI”.
No final conclusions in to the causes for the non-deployment of the G-REDW

ADELT were reached during the time that this investigation was being performed,
however, the current investigation in to wiring continuity and location of switches
would indicate that the recommendations contained in this report regarding
maintenance instructions and sensor selection and location have the potential to
improve the reliability of ADELT systems.


None – the tailboom is not reported as becoming detached.

The synopsis of special bulletin S3/2012 states that:
“The helicopter remained upright, supported by the emergency flotation gear”..

No ADELT recommendations have been made at this point, however, any
recommendations that are made will be made to EASA and so there will be no
CAA response to reference.

www.aaib.gov.uk
B30 – Extracts From the G-CHCN Investigation
B30.1 Aircraft Type

EC225 LP Super Puma

The accident occurred in the North Sea approximately 32nm south-west of
Sumburgh, Shetland Islands at approximately 14:25hrs on 22 October 2012.

[Ref 31]
“The helicopter was on a planned flight from Aberdeen International Airport to
the West Phoenix drilling rig, approximately 226 nm to the north.
The crew reported that, whilst in the cruise at about 140 kt and 3,000 ft amsl
with approximately 81% total torque applied, the XMSN (transmission) caption
illuminated on the Central Warning Panel (CWP). They added that the CHIP,
M.P (main pressure), and the S/B.P (standby oil pump pressure) captions on the
Vehicle Management System (VMS) also illuminated and the main gearbox oil
pressure indicated zero. The MGB.P (main gear box oil pressure) caption then
illuminated on the CWP. The crew actioned the ‘Total Loss of MGB (Main Gear

Box) Oil Pressure’ checklist, which required the activation of the MGB emergency
lubrication system (EMLUB). However, within a minute the MGB EMLUB caption
illuminated on the CWP indicating that the emergency lubrication system had
failed. The crew carried out the ‘Emergency Landing – Power ON’ checklist and
successfully ditched the helicopter in the sea, close to a ship. There were no
reported injuries.”

Extracted From AAIB Special Bulletin S2/2013 [Ref 30]
Note – the Special Bulletin referenced here applies to both G-REDW and
G-CHCN. Unless specifically stated, any quotations from the report apply to both
aircraft.
The description of the ADELT system states that:
“Both helicopters were equipped with an externallymounted, deployable Type

15-503 crash position indicator (CPI). On G-REDW, the CPI was mounted on the
lower left side of baggage hold at the rear of the main cabin. On G-CHCN the CPI
was mounted on the left side of the tail boom, just aft of the main cabin.
The CPI system consists of the CPI beacon, a beacon release unit, a system
interface unit, a cockpit control panel, a water activated switch and an aircraft
identification unit (Figure 3). These components are located in various positions
around the helicopter, and are connected by wiring which is integrated with the
rest of the helicopter’s wiring looms, and is therefore not specifically protected
against water ingress. The electrical connectors in the CPI system however
conform to an industry standard specification1 which ensures good performance
when submerged in water at shallow depths.
Deployment of the CPI is achieved by any one of the following:
1. A g-switch detecting an acceleration of more than 6 g in any direction
2. Manual operation of the DEPLOY switch on the cockpit control panel
3. Immersion of the water activated switch”
A further part of this report states that:
“The CPI may be manually switched to a TRANSMIT function (without

deployment) by the crew, via the cockpit control panel. Once selected to
TRANSMIT, the CPI will not automatically deploy either by means of the g-switch
or the water activated switch, unless a system reset, by pressing the TEST/RESET
button on the cockpit control panel, has first been performed. The helicopter
manufacturer was unaware of this feature of the CPI operation and as such no

relevant information was included in the EC225 LP Flight Manual. Nor was this
information included in the Type 15-503 CPI Operating Manual published by the
CPI manufacturer.”
The text related specifically to G-CHCN states that:
“The CPI on G-CHCN was manually selected to TRANSMIT by the flight crew
during the final preparations for the ditching. At 1424 hrs a ‘Detect-only’ alert
was received by the Aeronautical Rescue Coordination Centre (ARCC) at Kinloss,
from a GEO satellite signal. This alert did not provide any positional information,
but did contain the 15-digit hexadecimal code unique to G-CHCN. At 1432 hrs
an unresolved position alert was then received, and at 1453 hrs a further LEO
satellite alert was received, which confirmed the position of G-CHCN. The CPI
beacon remained attached to the helicopter and continued to transmit until it was
recovered to land. Photographic evidence and water damage within the cabin
indicated that the water level was above that of the water activated switch, while
the helicopter was floating.”
Testing of the various system components of the ADELT system installed on

G-CHCN concluded that there were “no defects with these components that
would have prevented the automatic deployment of the CPI beacon, had a manual
TRANSMIT not been selected.”
This conclusion demonstrates that there are still human factors issues associated
with ADELT design which have yet to be resolved and that clearer and more
complete instructions for use of the ADELT system could have prevented the non-
deployment of the ADELT system on CHCN.
The report notes that subsequent to the G-REDU incident, the manufacturer
modified the design of their ADELT system such that it would deploy
automatically, whether or not TRANSMIT had been selected.

None – the tailboom is not reported as becoming detached.

None – the aircraft is not reported as becoming inverted.

No ADELT recommendations have been made at this point, however, any
recommendations that are made will be made to EASA and so there will be no
CAA response to reference.


www.aaib.gov.uk

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Safety and Airspace Regulation Group

ADELT review report

Enquiries regarding the content of this publication should be addressed to:

The latest version of this document is available in electronic format at www.caa.co.uk/publications

ADELT review report

4 Definitions and acronyms 17

5 Evaluation of failures to deploy 20

6 Evaluation of inadvertent deployments 30

January 2014 Page 4

6.3 Human factors 35

7 Evaluation of performance issues 38

8 Evaluation of other events 43

9 Tail boom separation issues 47

10 Rotorcraft inversion considerations 50

January 2014 Page 5

Appendix A List of MORs 57

Appendix B Accident investigation reports 95

January 2014 Page 6

The review was performed in two phases; a review of Mandatory Occurrence

The aim of this review was to address four basic questions:

What are the main causes of degraded ADELT functionality?

Is the ability of an ADELT to function correctly significantly affected by the

Is the ability of an ADELT to function correctly significantly affected by

Have recent improvements in ADELT system designs improved ADELT reliability?

The location of the ADELT on the aircraft

1 CAP 491 can be found on the CAA website.

January 2014 Page 7

The location of ADELT related sensors in the aircraft

Flight deck and maintenance human factors issues

The level of clarity and completeness of maintenance instructions

These conclusions were re-reviewed in the light of more recent helicopter

The review includes a number of recommendations related to location

In addition to the ADELT related lessons and recommendations, discussions with

January 2014 Page 8

The following people and organisations supported this review:

Bond Helicopters (Aberdeen) and CHC Scotia (Aberdeen) were consulted as

January 2014 Page 9

“ADELT does not have a good record of satisfactory operation in crashes …

In addition, this review made reference to the HARP (Helicopter Airworthiness

The helicopter operators in Aberdeen (Bristow, Bond and CHC), Caledonian

January 2014 Page 10

accident reports to determine whether this information confirmed the findings

Note 2: Automatically deployable beacons are generally referred to as

January 2014 Page 11

Figure 1 below provides an overview of the prevalence of each type of ADELT

Figure 1 – Top Level ADELT Distribution

Although the majority of “failure to deploy” issues relate to aircraft accidents or

January 2014 Page 12

Although the conclusions related to the distribution of ADELT issues drawn

A number of recommendations have been made as a result of these analyses and

The list of accidents that has been considered is:

Reg Year Pub Pub UK Ditched ADELT Tail boom Rotorcraft

G-BBHN 1 Oct 1977 Y Y Y Y N Y Y

G-BIJF 12 Aug 1981 Y Y Y N Y N Y

G-ASWI 13 Aug 1981 Y Y Y Y N N

G-BDIL 14 Sep 1982 Y Y Y N Y N N

G-ASNL 11 Mar 1983 Y Y Y Y N Y but N/A1 Y but N/A1

G-BEON 16 Jul 1983 Y Y Y N Y N Y

January 2014 Page 13

What are the main causes of degraded ADELT functionality?

Is the ability of an ADELT to function correctly significantly affected by the

Is the ability of an ADELT to function correctly significantly affected by

Have recent improvements in ADELT system designs improved ADELT reliability?

The location of the ADELT on the aircraft

The location of ADELT related sensors in the aircraft

Flight deck and maintenance human factors issues

The level of clarity and completeness of maintenance instructions

Bond Helicopters (Aberdeen) and CHC Scotia (Aberdeen) were consulted as

Although the majority of “failure to deploy” issues relate to aircraft accidents or

Although the conclusions related to the distribution of ADELT issues drawn

The aircraft type

The basic accident details (location, date and time)

The synopsis of the accident

Any comments on the ADELT plus any associated findings and

Any comments on tail boom separation plus finding and recommendations

Any comments on rotorcraft inversion plus findings and recommendations

The CAA response to any ADELT recommendations

An indication of where the full accident report can be found

The MOR under consideration is not related to ADELT event but

Issues whose end result was most likely to be a failure to deploy

Issues whose end result was most likely to be an inadvertent deployment.

Potential conflict with the main rotors,

Compromising any emergency exits.