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‘Helicopter giant knew of fatal maintenance schedules before ...

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‘Helicopter giant knew of fatal maintenance schedules before Netcare crash’

Bell denies all accusations as US lawsuit unearths accident report which shows crash was ‘preventable, foreseeable’

Senior reporter
The burning wreckage of the Netcare aero medical helicopter which crashed in KwaZulu-Natal in January 2021.
PYRE The burning wreckage of the Netcare aero medical helicopter which crashed in KwaZulu-Natal in January 2021.
Image: Richard O'Brien

The manufacturers of a Netcare aero ambulance helicopter that crashed in January 2021 must have been aware of a critical maintenance warning to prevent structural faults in its rotor blades components as far back as 2018, according to documents filed in a US court.

Global helicopter manufacturing giant Bell Textron stands accused by the family of the pilot of only acting on that information six months after the deadly accident in SA and at least three years after a similar crash in Angola. Bell denies all the accusations.

It would have taken 13 hours and cost R13,652 ($900) to carry out the life-saving maintenance on critical rotor components of the Netcare helicopter that crashed in KwaZulu-Natal, wiping out a team of specialist doctors who were attending to a Covid-19 emergency.

Sunday Times Daily has seen a 2018 Angolan aviation accident report, contained in public documents from a lawsuit currently before a Texas federal court, which indicates it took Bell until July 2021 to release the required updated maintenance schedules and procedures for the aircraft’s main rotor pitch link clevises and rod ends.

This aviation accident report investigated a 2016 Bell-430 helicopter crash in Angola. It was compiled by the Angolan Accident Investigation Commission and signed off on August 28 2018. The report is accessible through court documents filed in a case brought by the family of the pilot, Mark Stoxreiter, who was killed in the KwaZulu-Natal crash.

In August 2021, Canadian aviation authorities released a report saying the cause of both accidents was “similar”. Bell is based in Canada and Texas.

The Stoxreiter family’s lawyers argue the aviation reports show that Bell was made aware of the fault by Angolan authorities but only acted after the same Bell-430 model crashed years later in SA.

In papers filed in the Texas federal court, Stoxreiter’s family state that Bell conducted and supervised the examination of the Bell-430 which crashed in Angola and conducted metallurgical tests of the components of the crashed wreckage.

“Specifically, as it relates to the Angola crash investigation, Bell was on specific notice of a concern over, without limitation, its maintenance and inspection protocols and whether Bell should alter its maintenance and inspection protocols in light of the investigation, indicating one or both of these parts failed or some mechanical problem.

“Bell refused, instead blaming the Angola accident on failed maintenance.”

Approached for comment by Sunday Times Daily, Bell spokesperson Grace Dieb declined to respond  (*see the full list of questions to Bell at the end of the article) citing the ongoing litigation with the Stoxreiter family.

According to Bell’s responding court papers, it had examined the components of the Angolan crash but denied it had refused to take action following the crash, issue warnings or that the Angola crash involved a sudden, catastrophic mechanical failure.

The company refuted the Stoxreiter family’s claims it was negligent and responsible the Netcare crash, stating it had no control over the event.

“Bell asserts the accident and plaintiffs’ alleged damages were solely caused by the fault and negligence of other persons ...”

It said the court case should be argued in SA and claimed it was not responsible for maintaining maintenance and operating manuals and procedures for all Bell-430s. It also denied being involved in an “extreme degree of risk” by omitting and failing to issue an airworthiness directive, considering the probability and magnitude of the potential harm.

Bell dismissed the following claims:

  • that the Angolan authorities had placed the company on notice over concerns over its maintenance and inspection protocols;
  • that it should alter its maintenance and inspection protocols;
  • that it had had the opportunity to suggest further inspections and revise and reduce life cycle recommendations for relevant parts; and
  • that the second accident resulted from any type of design or manufacturing defect in design, maintenance or life cycle protocol which might have been addressed by revised warnings, inspections and part replacement protocols or that the service notice meant that the components lifecycle be reduced from 10,000 hours to 5,000 hours.

However the Angolan aviation report obtained by Sunday Times Daily shows five recommendations made to Bell after its investigation into the 2016 crash.

An extract from the Angolan aviation report signed off in 2018 and issuing safety instructions to Bell.
CHECK LIST An extract from the Angolan aviation report signed off in 2018 and issuing safety instructions to Bell.
Image: Supplied

Structural fault in rotor blade components

The Stoxretiers’ court case against Bell is based on warning reports around the maintenance of components linked to the rotor blades — the main rotor pitch link clevises and rod ends — and faults which subsequently develop. 

The Stoxreiter family’s lawyers argue they have proof that a fault which developed in those parts caused the Netcare crash. This is based on aviation advisories from Bell, which the company issued in July 2021, and those which both the Canadian and US aviation authorities issued in August and December 2021.

The parts, assembled into a component known as a pitch link assembly, are critical for the operation of a helicopter. Sitting in the cockpit, a pilot has their hands on controls which are linked to the main rotor blades. One of the controls increases the power of the engine, while the other increases the pitch of the blades allowing the helicopter to move forwards, backwards, left and right.

A break in the link sees the pilot lose control of one or more of the blades, often with fatal consequences.

The pitch link assembly on a Bell-430 helicopter.
SUM OF THE PARTS The pitch link assembly on a Bell-430 helicopter.
Image: Bell

Despite the fatal Bell-430 helicopter crash off the coast of Angola, and being alerted by that country’s civil aviation authorities that crucial updates needed to be made to the assembly’s maintenance schedule, which operators of the helicopter worldwide must be alerted to, Bell only updated the helicopter’s maintenance programme in July 2021.

The update was only issued after ZT-RRT, the Bell-430 helicopter Netcare used as an aero ambulance, crashed in KwaZulu-Natal in January 2021.

The Netcare aero medical helicopter which crashed in KwaZulu-Natal.
PRE-FLIGHT The Netcare aero medical helicopter which crashed in KwaZulu-Natal.
Image: Netcare

On-board was Stoxreiter, a National Airways Corporation pilot (whose family is now suing the manufacturers); anaesthetist Dr Kgopotso Rudolf Mononyane; cardiologist surgeon Dr Curnick Siyabonga Mahlangu; specialist theatre nurse for cardiothoracic and transplant Mpho Xaba; and Sinjin Joshua Farrance, an advanced life support paramedic at Netcare 911.

Mononyane, Mahlangu, and Xaba were based at Netcare Milpark Hospital.

The team was en route to Hillcrest Hospital south of Pietermaritzburg, to transfer a critically ill patient to Netcare Milpark Hospital in Johannesburg for specialised care, when the helicopter crashed into a farmer’s field close to the N3 near Colenso.

The remains of the Netcare aero ambulance helicopter which crashed en route from Johannesburg to Hillcrest Hospital in KZN to ferry a critically ill patient to Milpark hospital.
DEBRIS The remains of the Netcare aero ambulance helicopter which crashed en route from Johannesburg to Hillcrest Hospital in KZN to ferry a critically ill patient to Milpark hospital.
Image: SA Civil Aviation Authority

Earlier in the day members of the team had helped treat former minister in the presidency Jackson Mthembu, who died of Covid-19.

Sunday Times Daily has a copy of Bell’s update, as well as compulsory updates issued by the Canadian and US aviation authorities.

Bell’s update warns of the risk of accelerated “wear and damage” to the components, instructs that a critical greasing regime of the parts be followed, a specialised magnifying glass and UV light be used to inspect the components for fractures and that the assembly be overhauled every 5,000 flying hours, if a problem is found.

Before the advisory was issued Bell had recommended the components be overhauled after 10,000 flying hours.

The warning which Bell issued six months after the Netcare aero ambulance crash and five years after a similar Bell-430 helicopter crashed in Angola. Despite knowing about maintenance schedule issues, following warnings from the Angolan aviation authorities in 2018 the manufacturer only issued the warning in July 2021.
ALERT The warning which Bell issued six months after the Netcare aero ambulance crash and five years after a similar Bell-430 helicopter crashed in Angola. Despite knowing about maintenance schedule issues, following warnings from the Angolan aviation authorities in 2018 the manufacturer only issued the warning in July 2021.
Image: Bell

The Canadian aviation authority report states: “In January 2021, a model 430 helicopter experienced an in-flight failure of a main rotor pitch link clevis resulting in loss of control of the helicopter and fatal injury to the five occupants onboard. The main rotor pitch link clevis part fractured at the exposed thread area above the nut and the fracture was consistent with fatigue damage.

“A similar accident previously occurred in September 2016 on a model 430 helicopter where the main rotor pitch link clevis was found to have fractured at the neck area via fatigue damage that originated at a corrosion pit.

“This condition, if not corrected, could lead to crack initiation at the main rotor pitch link clevis neck or threaded area and consequent failure of the main rotor pitch link, resulting in loss of control of the helicopter.”

Bell reached settlement in similar case

A preliminary SA Civil Aviation Authority report into the Netcare accident revealed that the helicopter, which was previously operated in Angola and brought into SA in 2018, disintegrated in midair.

The report states: “A witness stated that he saw a red and white helicopter spinning around with objects being flung out of the helicopter ... The objects that were flung out of the helicopter were some airframe parts that were severed by one or more of the helicopter’s main rotor blade(s) while spinning out of control, as well as some airframe parts that broke off during the accident sequence.”

In 2016 former SA Air Force pilot, James 'Jimmy' Horsley was flying five Angolan workers to an oil rig platform when the helicopter crashed into the sea. All six on board died.
FATAL In 2016 former SA Air Force pilot, James 'Jimmy' Horsley was flying five Angolan workers to an oil rig platform when the helicopter crashed into the sea. All six on board died.
Image: Horsley family

The Stoxreiter family’s lawsuit is based on a similar and successful civil suit brought against Bell by the family of James “Jimmy” Horsley, the pilot of the Bell-430 which crashed into the Atlantic Ocean off Angola after disintegrating in midair.

Horsley, 51, flew for Heli Malongo, which chartered helicopters to the international petroleum company Chevron to ferry the company’s staff to its offshore oil rigs. Horsley, a former SA Air Force pilot, and his five passengers were killed.

His family and Bell reached a settlement in July 2021. The Texas federal court ruled the settlement’s terms be sealed.

Sunday Times Daily has learnt from Horsley’s lawyers that evidence filed in the Texas federal court in that lawsuit, which included the Angolan aviation authority report, will be used by the Stoxreiter family in their lawsuit, which they launched in November 2021.

The case is expected to go to trial in April 2023, said Manuel Solis, who along with Benny Agosto is representing Stoxreiter’s family and his estate.

Solis said the maintenance programme for the component took “13 hours and cost (R13,652) $900.

It is not that the entire helicopter needs to be rebuilt, but it is critical maintenance that must be done. Bell should have issued warnings three years earlier. If they had, the SA deaths could have been prevented.
Manuel Solis, who is representing Stoxreiter’s family and his estate

“It is not that the entire helicopter needs to be rebuilt, but it is critical maintenance that must be done. Bell should have issued warnings three years earlier. If they had, the SA deaths could have been prevented.”

The Angolan accident report, which Sunday Times Daily has seen, rules out pilot error.

The 53-page document, which was sent to Bell, states Horsley was “physically and mentally sound”; had not been involved in previous accidents; and was “technically experienced”. The aircraft was well maintained in line with Bell’s now defunct maintenance schedule; its rotor components were serviced three days before the crash; its communications systems were working; and weather conditions along the route were good with visibility up to 6km.

The report found that during the flight the helicopter’s cockpit voice recorder “recorded instantaneous noise that exceeded the normal level of functioning noise of the engines” before suddenly stopping.

It found that the pitch link clevis for one of the blades was “fractured via material fatigue” which occurred because of corrosion.

“The universal bearing was seized as a result of corrosion with no notable amount of grease inside.”

The report states the blades collided with the cockpit destroying the aircraft.

“Since the aircraft take-off until the time of its crash, there were no recorded reports of emergency situations that could jeopardise the techno-operational requirements of the referred aircraft.

“The material failure, which resulted in the aircraft’s sudden crash, deprived the pilot of any opportunity for efficient management of the available resources to avoid the occurrence. The material factor was significant to the accident.”

The investigators ordered Bell review diagrams of the main rotor pitch link clevis; evaluate and review the inspection and maintenance procedures related to the operation of main rotor components, in particular the main rotors pitch link clevis for the blades; review, in terms of safety, its recommendations issued on the 10,000 hour maintenance requirements; issue safety recommendations for the Bell-430 and use instruments to carry out, at predetermined times, non destructive tests to the main rotors pitch link clevis for the blades replacement.

Former National Airways Corporation pilot Mark Stoxreiter.
ON-BOARD Former National Airways Corporation pilot Mark Stoxreiter.
Image: supplied

Solis said they believed the Netcare accident “was preventable and foreseeable, as it was so similar to the Angolan accident”.

He said in both accidents the helicopters disintegrated in midair almost instantaneously and without warning.

“This case [the Netcare crash], which will be a monumental battle, is about ensuring accountability. This second accident was 100% preventable. Bell did a terrible job in looking into what happened in the first accident. We believe if they had done a better job, those onboard the SA helicopter would still be alive today.

“We are taking Bell back to court because we want to prevent further accidents like this from happening again.”

Solis said though the accidents happened in Angola and SA, because the accident involved an American company, under US law they could bring the case to court in the US.

“We will be able to show that this accident was exactly the same as the Angolan accident, and that it was preventable.

“We want to show Bell that they are accountable for the SA deaths because they did not take action and change procedures.”

We will be able to show that this accident was exactly the same as the Angolan accident, and that it was preventable. We want to show Bell that they are accountable for the SA deaths because they did not take action and change procedures.
Lawyer Manuel Solis

Agosto said the case was about product liability and companies’ accountability for the products they sell globally.

“It is clear the problem from 2016 resurfaced in 2021, which is now key in holding Bell to account. Documents from the Angolan case show how Bell was warned by the Angolan authorities of the problem with Chevron urging action.

“Bell knew of the issue but did not act, which points to negligence. We believe Bell simply pushed this under the carpet and hid the warnings until after the SA crash when they, and the US and Canadian aviation authorities, issued the aviation directive for the maintenance of the components.

“Had that warning been issued before January 2021, the lives in SA could have been saved.”

He said they were gathering further evidence and that their aviation accident experts would inspect the Netcare helicopter wreckage within the next three months.

“Our lawyers in SA will be in discussions next week with the company which has the wreckage. We want answers as to why Bell took so long to put out the warnings and advisories, which is a standard practice in the aviation industry when something goes wrong.

“You want to warn aircraft operators, pilots and maintenance crews globally in time so they have the opportunity to change maintenance plans and procedures and change the necessary parts out.

“We will be proving negligence because Bell had been given notice, was aware of this issue and failed to warn about it until after the SA accident.”

SACAA spokesperson Marie Bray said the investigation into the Netcare crash was not concluded.

“The report is in the approval stage, and is expected to be released in the next two months.

“Full cooperation was received from the manufacturer during the investigation process. Other accidents involving the make and model were duly considered.” 


‘My dad loved flying and did everything by the book’

James 'Jimmy Horsley with his daughter Jade and son Shane.
FAMILY MAN James 'Jimmy Horsley with his daughter Jade and son Shane.
Image: Horsley family

The day she learnt that another Bell-430 helicopter, similar to the one her father had died in Angola, had crashed killing all on-board, Jade Horsley went cold.

“The day of my dad’s crash is etched in my mind. When I heard of the Netcare crash it brought everything back. Dad’s body was only found at sea nine days after the accident. Not knowing where he was or whether he was injured or dead was horrendous.”

She said her father, whose passion was flying, was a stickler when it came to safety.

“He loved his job, never took chances and did everything by the book.”

Horsley said learning that the Netcare helicopter was the same model her father flew was heartbreaking.

“It should not have happened again. When we learnt that my father’s helicopter crashed not because of pilot error, it was hard to comprehend.”

I’m a mom with young children. Every day I have to get up and carry on for my children no matter how difficult it is.
Candice Stoxreiter

Stoxreiter’s wife Candice said the past year had been excruciatingly painful for her and her family.

“I’m a mom with young children. Every day I have to get up and carry on for my children no matter how difficult it is. My husband was my children’s hero.

“I am just grateful that I got to say goodbye to Mark the day he flew, because our children did not. The last time they saw him was the day before.”

She said, until the Netcare helicopter crash, she had not heard of the Angolan helicopter accident, or that Bell had been warned before by that country’s aviation authorities that there was a manufacturing and maintenance issue with certain parts.

“You have so much pain that you are dealing with. When you receive news like that, it is difficult to understand. I was in total disbelief.”

She said she was assisted by various people in getting in touch with the lawyers who had helped Horsley’s family.

“We wanted to pursue legal action in SA, but were advised that it would be near impossible. 

“Mark, who was an exceptional pilot, was a perfectionist when it came to safety and never took chances. If he had known there was a potential safety issue he would never have taken off in the helicopter that day. It is clear from the information from the Angolan crash, and what has been obtained from the Netcare accident to date, that it was not pilot error.”

*The questions Bell declined to answer:

1) When was Bell made aware of the findings of the Angolan accident investigation report involving the Bell 430 (aircraft registration D2-EYI), which was operated by Heli Malongo?

2) The Angolan accident report recommended Bell do the following:

* Review, in functional terms, the project diagram of the main rotor pitch link clevis for the orange blade of the aircrafts type Bell, model Be11430, of its manufacture;

* Evaluate and, if possible, review the inspection and maintenance procedures related to the operation and main rotor components replacement, in particular for the main rotors pitch link clevis for the blades and the respective universal bearings;

* Review, in terms of safety, its recommendations issued on the requirements being observed with relation to the established time margins (10,000 hours) for the main rotor pitch link clevis for the blades replacement of the aircraft type Bell, model Bell 430;

* Conceive instruments of imperative character, that obligate to carry out, in periods of determined times, non destructive tests (NDT) to the main rotors pitch link clevis for the blades replacement of the aircraft type Bell, model Bell 430;

* Issue safety recommendations to the aircrafts Bell 430 that make possible the identification of eventual evidences of the universal bearing malfunctioning, establishing also the respective tolerance margins, and taking in account the identified deficiencies values.

In regards to these recommendations did Bell do this and was this done before the Netcare air ambulance aircraft crash, which occurred in SA and if not why not?

3) How many safety recommendations, which were raised in the Angolan accident report around the main rotors pitch link clevis, did Bell issue before the Netcare air ambulance crash on January 21 2021?

4) What prompted Bell to issue the the Bell Textron ALERT SERVICE BULLETIN 430-21-60 on July 13 2021 and why was it only issued on the July 13 2021 and not before?

5) What was Bell’s response to Chevron executives’ insistence that the fault lay with the main rotors pitch link clevis and not the maintenance of the Heli Malongo aircraft?

6) What was Bell’s response to the Angolan government’s accident report and did Bell dispute the findings of the report?

7) Is Bell aware of the South African Civil Aviation Authority preliminary report into the Netcare Air Ambulance Bell430 crash on January 21 2021 and what are the company’s views on the preliminary findings?

8) Can Bell explain why it entered into a settlement agreement with the family of the pilot of D2-EYI and not go to trial?

9) Will Bell be defending itself in regards to the matter of the ESTATE OF MARK STOXREITER and others v BELL TEXTRON or will the company be pushing to enter into a similar settlement agreement as it did with the family of the pilot of D2-EYI?

10) What are Bell’s comments on the FAA Airworthiness Directives in regards to the Bell 430?

11) What are Bell’s comments on the Transport Canada Airworthiness Directive Number: CF-2021-26 in regards to the Bell430?

12) What is Bell’s response to claims that if it had issued the ALERT SERVICE BULLETIN 430-21-60 before the January 21 2021 Netcare air ambulance accident, this accident and the deaths of those onboard the helicopter could have been prevented?

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