The East River Crash: Lessons Learned

Phyllis Utter Top Story

This year’s HAI Safety Symposium began on a somber note, with a moment of silence for those affected by the Jan. 26 crash in Calabasas, California, a stark reminder of the hazards our industry must work to manage and mitigate. The 2020 symposium, which each year kicks off HAI HELI-EXPO, featured a panel discussion of the lessons learned from the East River crash in New York nearly two years ago.

The panel was moderated by Rick Kenin of Boston MedFlight and featured Jim Viola, HAI president and CEO; Tim LeBaron, deputy director, National Transportation Safety Board (NTSB) regional operations; Todd Gunther, senior air safety investigator, NTSB Eastern Region (pictured, right); Clint Johnson, chief, NTSB Alaska Regional Office and advisor, HAI Safety Working Group; and Pat Hempen, director, FAA Office of Accident Investigation.

Gunther, NTSB’s lead investigator for the East River accident, began the presentation by briefing attendees about the events of March 11, 2018, when an Airbus Helicopters AS350 B2 lost power and landed in New York City’s East River. The Part 91 photo flight was operated by Liberty Helicopters under a contractual agreement with NYONair.

About 16 minutes into the flight, the aircraft lost engine power, and the pilot deployed the emergency floats and made an autorotative landing into the East River. Eleven seconds after landing, the aircraft inverted into the river. All five passengers drowned, and the pilot escaped with minor injuries.

The symposium panel members next discussed some points the NTSB had determined were critical factors in the accident.

Harnesses. The passengers and pilot were provided with FAA-approved restraints; however, in order to facilitate their movement around the aircraft during the doors-off flight, passengers also wore fall-protection harnesses. A D-ring located on the back of the harnesses connected the passengers via a locking carabiner to a tether that attached to a hard point on the aircraft. 

During a preflight safety briefing, passengers were told they could release the harnesses by using the quick-release feature or the cutting tool contained in a pouch on the harness. (The carabiners, however, had no quick-release feature.) The NTSB determined that passengers would have great difficulty using either method to quickly release themselves from the harnesses. 

None of the passengers incurred significant injuries during the aircraft’s descent; their inability to rapidly extricate themselves from the aircraft was a critical factor in their deaths. After ditching, the pilot was able to remove his FAA-approved restraints and exit the aircraft.

The East River accident revealed gaps in the FAA’s guidance that inhibited the ability of FAA personnel to evaluate this type of operation. The FAA has letters of authorization (LoAs) with 468 Part 91 operators permitting aerial tour operations. Because of the East River investigation, the FAA has increased its inspections of Part 91 air tour operators with LoAs from 10% to 30% per year. 

In addition, the FAA has increased its requirements for SPRS (supplemental passenger restraint systems) used during doors-off flights. In order to qualify for an LoA permitting the use of an SPRS, the operator must demonstrate, among other requirements, that passengers can release themselves from the restraints with minimum difficulty and quickly exit the aircraft without assistance from another person and without using a cutting tool.

Fuel-Shutoff Lever. There is strong evidence from the East River accident that the strap on a passenger’s fall-protection harness interfered with the aircraft’s floor-mounted fuel-shutoff lever; when the pilot attempted to restart the engine, he reported finding the fuel-shutoff lever in the “up,” or “off,” position. Gunther reported that the principal concern during the design of the AS350 fuel-shutoff lever was preventing the pilot from mistaking it for another engine control, and so it has a different shape and color than adjacent levers. Preventing inadvertent activation by someone other than the pilot was controlled through operational measures such as preflight briefings and the securing of loose items. 

The NTSB recommends that rather than relying on operational measures, design modifications to the fuel-shutoff lever would prevent similar accidents in the future. Several members of the audience who fly public transport missions, such as helicopter air ambulances or air tours, described adopting measures such as installing cages around flight-critical controls to prevent similar accidents. Airbus representative Seth Buttner confirmed that Airbus will offer an engineering change to the AS350 that will provide a gate around the fuel-shutoff lever.

Additional recommendations were made regarding floats and operational-control issues.

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