Agusta AW139 Safety Record

The inflight loss of collective control of the helicopter due to thermal damage of a collective control torque tube that abraded with misrouted electrical wiring, which resulted in an electrical short and inflight fire. Contributing to the accident were the incorrectly manufactured wiring support strip assembly that misrouted electrical wires near the collective control torque tube, the ambiguity of the support strip assembly drawing that allowed for its incorrect manufacturing, the inadequate quality control processes to identify the incorrectly manufactured support strip assembly, and the helicopter manufacturer’s inadequate assembly instructions that allowed the misrouting of the electrical wiring, due to the incorrectly manufactured strip assembly, on the helicopter production line.

The pilots’ decision to takeoff over water in dark night conditions with no external visual reference, which resulted in spatial disorientation and subsequent collision with the water. Also causal was the pilots’ failure to adequately monitor their instruments and respond to multiple EGPWS warnings to arrest the helicopter’s descent. Contributing to the pilots’ decision was external pressure to complete the flight. Contributing to the accident was the pilots’ lack of night flying experience from the island and their inadequate crew resource management.