Leonardo could have averted Leicester City Football Club helicopter disaster, says AAIB
On Tuesday (September 5th), the Air Accident Investigation Branch (AAIB) published its comprehensive report into the helicopter crash at Leicester City Football Club’s stadium in October 2018.
The crash tragically took the lives of all five on board: then Leicester City owner and Chairman Vichai Srivaddhanaprabha, pilots Eric Swaffer and Izabela Roza Lechowicz, as well as Kaveporn Punpare and Nusara Suknamai.
The detailed 209-page report raises serious concerns about the safety of the crashed helicopter, and the actions of its manufacturer, the Italian multinational, Leonardo S.p.A. The report sets out a tragic sequence of failures. These failures led to the helicopter’s tail rotor control system disconnecting, and the aircraft spinning out of control.
The report is clear that there was nothing the pilot could have done to prevent the crash.
The AAIB was able to identify the source of the catastrophic failure and crash. This was that a critical duplex bearing, which connected the control shaft running along the length of the tail to the rotor blades, seized. This seizure of the bearing was the result of fatigue, cracking, pitting, shearing, friction, grease degradation and heat generation.
The report identified clear deficits by Leonardo, including the inactions listed below, which led to the bearing seizure and tragic crash:
Not sharing critical flight test results with the company which made the duplex bearing, in order to confirm that the bearing that they had chosen was actually suitable for use in the tail rotor. Had Leonardo shared the results, the bearing may not have been chosen.
Not requiring the routine inspection of critical parts removed from service (such as the duplex bearing) to confirm that they were in the condition that they expected them to be in based on their design. Had Leonardo done so, they would have found that the bearings were more damaged than expected and ought to have concluded that they needed to change their original design.
Not fully considering possible risk reduction and mitigation measures for the duplex bearing - which had been identified as a critical component by Leonardo during the design phase. It was recognised by Leonardo, the report notes, that if the bearing failed it could lead to the death of multiple occupants onboard. Had they included one of those mitigation measures, simply changing the thread direction of a key component, it is likely that the severity of the accident would have been reduced and all those onboard may still be alive.
Former Leicester City owner Vichai Srivaddhanaprabha purchased what he believed to be a state-of-the-art helicopter. Leonardo’s non-performance of key measures, identified by the AAIB report, raise serious questions about the safety of company’s aircraft.
The release of the AAIB report has brought the families of those lost in the crash both comfort and pain in equal measure. The families thank the AAIB for their thorough investigation and detailed report.
Aiyawatt Srivaddhanaprabha, who lost his father, Vichai Srivaddhanaprabha, commented: “I am deeply saddened by the course of events. Almost five years after my father’s passing, this report provides concerning evidence against Leonardo. My father trusted that he had bought a safe helicopter from a world-renowned manufacturer. Had he known what we know now he would never have risked his life in this machine. The pain this causes me and my family is immeasurable and as a family we continue to struggle every day with our grief at the loss of my father. He was a great inspiration to me personally and we all loved him very much.”
The families of three of those lost in the crash - Vichai Srivaddhanaprabha, Eric Swaffer, and Izabela Lechowicz - have retained leading litigation specialists’ Stewarts. The family of Vichai Srivaddhanaprabha are now considering their legal recourse against Leonardo. Litigation has already been commenced in Italy on behalf of the families of Eric and Izabela.
Eric and Izabela were life partners and soulmates. Both were recognised and highly respected throughout the global aviation industry for their exemplary piloting skills. Both were also qualified instructors and examiners on a range of aircraft. Eric spent most of his career lobbying and advising on matters of safety in the rotary wing industry.
The report confirms beyond any doubt that there was nothing either Eric or Izabela could have done to prevent this disaster. The AAIB report stresses that effective control of the aircraft was impossible following the loss of the tail rotor. Having always believed this to be the case, for the families, it has been important for the memories of Izabela and particularly Eric, who was piloting the helicopter, that their names have been cleared of any possible implication in the accident.
Peter Neenan, a partner in the aviation team at Stewarts, commented: “This report is a frightening tale of missed opportunities.
“The report confirms that the helicopter manufacturer, Leonardo, did not accurately model the forces affecting the helicopter during their design, did not provide the right information to the bearing manufacturer, did not then measure the forces actually affecting the helicopter, did not involve the bearing manufacturer to validate their assumptions despite not having the software needed to model the forces on the bearing, did not implement a routine inspection requirement for these bearings to identify and replace them during their degeneration prior to any risk of seizure and did not require discarded bearings to be examined to see whether their design assumptions were valid.
“This was all done in circumstances where Leonardo had recognised that the duplex bearing was a critical component, and that the failure of this component could be catastrophic for the helicopter and likely to result in the death of those onboard.
“Nevertheless, and despite that concerning warning, they then also did not implement sufficient mitigation measures within the wider tail rotor control system to avoid a catastrophic loss of control of the helicopter from such a failure. Some of those measures would have been as simple as changing the thread direction on component parts, a measure that they had already implemented for an earlier variant of this helicopter, the AW139.
“This was an accident waiting to happen.”
BlueSky Business Aviation News | 7th September 2023 | Issue #714