Source: http://jdasolutions.aero/blog/ntsb-faa-taken-preliminary-actions-nyc-doors-open-initial-thoughts-questions/
Timestamp: 2020-02-23 10:20:46
Document Index: 387642782

Matched Legal Cases: ['art 91', 'art 91', 'art 91', 'art 91', 'art 91', '§91', 'art 91', 'art 91']

Early NTSB report & FAA order provide insights
NTSB and FAA have taken preliminary actions on the NYC Doors Open—initial thoughts and questions
TOPICS:Emergency OrderharnessesPart 91 FlightPreliminary Report
Posted By: Mike Rioux March 28, 2018
NTSB Issues Preliminary Report For Liberty Helicopters Accident
Pilot Said He Provided Safety Briefing That Included Emergency Evacuation Procedure
Harnesses for Open Door Flight not FAA approved
Operations Under Part 91
Float System deployed asymmetrically
Based on the March 11 crash of a 2013 Airbus Helicopters AS350B2 in the East River in New York City that resulted in the drowning of five passengers who were wearing supplemental harnesses:
the FAA has taken an initial step, N 8900.456, Emergency Order of Prohibition Pertaining to “Doors-Off” Flight Operations for Compensation or Hire.
the NTSB has issued an Aviation Accident Preliminary Report [ERA18MA099][1] and an Urgent Safety Recommendation to Prohibit Flights that Use Unsafe Harness Systems
Focusing on those actions, which provide a clear statement of the facts, here are a few initial observations:
The operator of the flight in question was advertising the Open Door Flights to the General Public, but was flown under 14 CFR Part 91
As evidenced by the cover of this post and a review of the internet, Open Door Photographic Helicopters were heavily promoted by Liberty Helicopters, Inc., the operator and., FlyNYON, the provider of “a crowdsourced aerial experience.”
The Board determined that the accident flight was operated under the provisions of 14 CFR Part 91, the less restrictive rules for General Operations. Although the Report did not explain what exception allowed the flight to operate under Part 91, the operator may have relied on an LOA issued under 14 CFR §91.147.
The harness used did not have FAA approval
Here is the ERA18MA099 description of the pilot’s pre-flight safety review about the harness:
…the pilot checked his passengers' harnesses and put their life vests on. He pointed out where the cutting tool
was located on their harness and explained how to use it. He then seated the passengers and secured their harness
tethers to hard points on the helicopter. After the passengers were seated, loading personnel assisted them with
putting on the helicopter's restraints (For the purpose of this report, "restraint" refers to the seabelt and
shoulder harness installed by the helicopter manufacturer, and "harness" refers to the system provided by FlyNYON).
Before he started the helicopter, the pilot provided a safety briefing that included which of the passengers was going
to remove their restraints and which would remain buckled in their restraints during the flight. He asked the passengers
to confirm what sights they wanted to see, and they put their headsets on. He finished the safety briefing and again explained
how to use the cutting tool to cut the seatbelts.
a. A chart purporting (unconfirmed) to show the harness:
b. YouTube demonstration of the harness
https://www.youtube.com/watch?v=IcTOk-IsL8w
NOTE: excellent explanation of how the harness was tethered to hard points and how the harness might have interacted with the emergency fuel shutoff lever.
c. the description of the seat belts and restraint systems after examination:
Examination of the seats and restraint systems revealed that the five passengers onboard the helicopter were provided with
airframe manufacturer-installed restraints, as well as a full body harness. The harness system was not installed by the
helicopter manufacturer and was comprised of off-the-shelf components consisting of a nylon fall-protection harness that was
attached at the occupants' back by a locking carabiner to a lanyard. The lanyard was composed of multiple woven fabric loops,
and the opposite end of the lanyard was secured by another locking carabiner to a hard point on the helicopter. A small pouch
was attached to the harness and contained a cutting tool. Under normal circumstances, at the end of each flight, FlyNYON personnel
would unscrew the locking carabiner located on the back of the passengers' harnesses so that the passengers could egress.
3. N 8900.456 references Emergency Order of Prohibition, Order No. FAA-2018-0243
…which prohibits the use of supplemental passenger restraint systems that cannot be released quickly in an emergency during
flight operations for compensation or hire with the doors open or removed (hereinafter, “doors-off flights” or “doors-off
flight operations”). The order is applicable to operators and pilots who conduct “doors-off” flights for compensation or hire.
Additionally, the order prohibits passenger-carrying “doors-off” operations for compensation or hire unless the passengers are
at all times properly secured using Federal Aviation Administration (FAA)-approved restraints. The order was effective immediately
a. The order specifies what the Aviation Safety Inspectors/Technicians must do immediately:
All ASIs and ASTs who have oversight responsibility of operators or pilots that conduct “doors-off” flights for compensation or
hire are required to immediately convey the information contained in the Emergency Order of Prohibition, Order No. FAA-2018-0243,
to those operators or pilots. Pilots and operators must cease the conduct of “doors-off” operations for compensation or hire with
the use of supplemental passenger restraint systems, unless the supplemental passenger restraint system has been installed on the
aircraft pursuant to an FAA approval.
b. The order also admonishes operators and pilots that violation of this FAA order is subject to certificate actions and/or civil penalties (i.e. this is not a matter to be discussed under cooperation and compliance!!!)
4. ERA18MA099 also noted an asymmetric deploying of the floats, which obviously added to the passengers’ inability to escape
Examination of the emergency float system revealed that the three floats installed on the left landing gear skid appeared to be
more inflated than the floats on the right landing gear skid. The emergency floats' left pressurized gas cylinder gauge indicated
about 0 psi, while the right pressurized gas cylinder gauge indicated about 4,000 psi. A functional check was performed by actuating
the cyclic trigger (which is what is used to activate the floats). The trigger mechanism was smooth with no evidence of binding.
Continuity of the float system control was established between the trigger, dual cable block, and the activation cable clevis connection.
When the trigger was released, the dual cable block returned to its normal position (via spring within the junction box) but the upper
and lower turnbuckles remained in their actuated positions.
Policy Questions highlighted by these preliminary assessments
Should any operator which advertises as heavily as in this case be allowed to operate under Part 91?
Does Liberty’s and/or FlyNYON’s (it is unclear whether one or both bear responsibility for its use) reliance on the Supplemental Harness System demonstrate the level of Safety Culture which is expected of all aviators? [NOTE: Safety Culture is not readily discerned from afar, but the statement[2] on Liberty’s consumer webpage does not convey the necessary concern about flight safety.]
So how is an ASI/AST to assess supplemental passenger restraint systems? Clearly a cutting tool is not enough and a carabiner in the back does not constitute “quick release”; so, what mechanism and/or time period qualify as “quick release”?
Until a standard is set for quick release, many Part 91 and 135 operators will not be permitted to fly without the doors—right?
HAI has urged that the FAA ban “Open Doors” Flights:
Maybe that’s the right answer.
[1] This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.
[2] Liberty Helicopter Safety and Security
In order to make your helicopter flight a pleasant and safe experience, we need your assistance in the flight preparation process. Helping us in this process will ensure a safe, fun and memorable experience.
Liberty Helicopters will not fly anyone without a valid form of photo identification. US residents must bring valid photo id. Non US residents must bring government issued passport.
Upon entering the building you and your party will be scanned by a metal detector by one of our security representatives. Once security has been completed you will check in at the ticket counter where you will present your voucher and identification. Once that is complete you will enter an area to watch a safety video and be given a floatation device. Our flight coordinator will then explain our weight and balance loading procedure. For your safety and the weight and balance of the helicopter, you may or may not be seated next to everyone in your party.
Prior to boarding the helicopter our ramp staff will take a digital photo of you and your party in front of the helicopter. You will have the option to purchase this photo after your flight. Once your photo has been taken our ramp staff will direct you to your seat and secure you inside the helicopter. (Please Note: The main responsibility of our ramp staff is to keep you safe while boarding and exiting the helicopter and ramp area).
When your tour has been completed DO NOT attempt to open helicopter doors the ramp staff will assist you in exiting the helicopter. You will then be safely guided back to the interior of the heliport.
Don’t forget to purchase your digital photo that was taken before flight. This is a perfect way to remember your “Once in a Lifetime Experience” with Liberty Helicopters.
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