Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0266, written 30 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 May 2025 |
|---|---|
| Reference | 2025-0266 |
| Deceased | Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara Suknamai and Kaveporn Punpare |
| Coroner | Catherine Mason |
| Coroner area | Leicester City and South Leicestershire |
| Category | Accident at Work and Health and Safety related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
HM Senior Coroner for Leicester City & South Leicestershire INQUESTS INTO THE DEATHS ARISING FROM THE HELICOPTER CRASH AT KING POWER STADIUM ON 27 OCTOBER 2018 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. European Union Aviation Safety Authority (EASA) Postfach 10 12 53 50452 Cologne Germany (By email to: 2. The Civil Aviation Authority (The CAA) Aviation House Beehive Ringroad Crawley West Sussex RH6 0YR (By email to: 1 CORONER ) ) I am Professor Catherine Mason, Senior Coroner for the coroner area of Leicester City and South Leicestershire. 2 CORONER’S LEGAL POWERS I make this report under: (a) Paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 (https://www.legislation.gov.uk/ukpga/2009/25/schedule/5); and (b) Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (https://www.legislation.gov.uk/uksi/2013/1629/part/7/made). 3 INVESTIGATION AND INQUESTS 1 On 6 November 2018, I commenced an investigation into the deaths of the five people who lost their lives in the helicopter crash at King Power Stadium, Leicester, on 27 October 2018. The names of the five people were Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara Suknamai and Kaveporn Punpare. The investigation concluded at the end of an inquests hearing on 28 January 2025. The conclusions at the end of the hearing were in summary as follows: (a) The medical cause of death for each of the five people other than Izabela Lechowicz was: 1a. Inhalation of the products of combustion, while the medical cause of death for Ms Lechowicz was: 1a. Head and chest injuries. (b) The jury returned a short-form conclusion of death by accident for each the of those who died, supplemented with a narrative setting out circumstances of death (as set out in the next section of this report). 4 CIRCUMSTANCES OF THE DEATHS The jury returned a supplementary narrative as to the circumstances of the deaths, as follows: “On the 27th October 2018, an Agusta Westland 169 helicopter, registration G- It was piloted by Eric VSKP, departed the King Power stadium in Leicester. Swaffer Vichai passengers Srivaddhanaprabha, Nusara Suknamai and Kaveporn Punpare. The destination was Stansted Airport in the UK and the helicopter departed at 8.37pm British Summer Time. Lechowicz, carrying Izabela and After the helicopter reached the appropriate take-off decision point, the pilot initiated a right turn. The helicopter spun out of control and crash landed at 8.38pm British Summer Time in the car park of the King Power Stadium, Leicester. The helicopter hit a 0.5 metre high concrete step, rupturing the fuel tank, and came to rest on its left side with no means of escape. Izabela Lechowicz sustained head and chest injuries on impact, which proved fatal. Leaking fuel ignited, resulting in rapid spread of fire. Vichai Srivaddhanaprabha, Eric Swaffer, Nusara Suknamai and Kaveporn Punpare died due to inhalation of the products of combustion. The subsequent AAIB [Air Accidents Investigation Branch] investigation concluded that due to likely rolling contact fatigue, the tail rotor duplex bearing seized, commencing a sequence of events leading to the crash of the helicopter. This included rotation and detachment of the actuator control shaft, loss of yaw control and uncontrollable spinning. the tail rotor control system became uncontrollable. In effect, It The helicopter had all appropriate airworthiness and maintenance certificates. was found that the pilot, Eric Swaffer, took all appropriate and available options to him, to try and regain control of the helicopter.” 5 CORONER’S CONCERNS During the course of the inquests, the evidence revealed matters giving rise to 2 concerns. action is taken. In my opinion there is a risk that future deaths could occur unless In the circumstances it is my statutory duty to report to you. The matters of concern set out below all relate to the systems and procedures for design and safety supervision of aircraft, specifically helicopters. They are founded upon specialist technical evidence given to the court during the inquests. They take full account of action taken by EASA to date of which the court is aware. I should stress at the outset that the matters of concern set out below remain valid irrespective of whether the AAIB’s causal explanation of the accident is correct. Each one is based on a safety concern which exists even if the points raised by EASA in response to that causal explanation have merit. It should also be stressed that none of these matters of concern should be interpreted as levelling implicit criticism at the aircraft or component manufacturers involved in this case. They are all concerned with achieving safety improvements for the future. Given the potentially catastrophic consequences of failure of an individual component or system in a helicopter, I hope that this report will be considered carefully. The MATTERS OF CONCERN are as follows: (1) Provision of system and flight-testing data by aircraft manufacturers to suppliers In the inquests, the AAIB investigation team explained that they had recommended that EASA amend Certification Specification 29.602 to require type design manufacturers to provide the results of all relevant system and flight testing to any supplier who retains the sole expertise to assess the performance and reliability of components identified as critical parts within a specific system application, to verify that such components can safely meet to the certification This was AAIB safety overall of recommendation SR-2023-018. the in-serve operational demands, prior system. the As (AAIB Principal Inspector) explained in his evidence, in this case the bearing manufacturer (SKF Aerospace) was the only party which could fully assess the contact pressures that loads experienced tests generated on the duplex bearing which ultimately during flight it would have been a desirable failed. He further explained that improvement the aircraft to the design and certification process if manufacturer had been required to provide system and flight-testing data it could have used its unique to the bearing manufacturer, so that expertise to identify risks arising from in-service use. explained that EASA had responded to this recommendation the relevant regulations required the by saying that another part of aircraft type certificate holder to be responsible for demonstration of for showing that critical parts and systems met compliance (i.e. this was an inadequate performance requirements). He said that the safety response, because it did not meet recommendation by introducing the specific improvement proposed. the intent of 3 of SKF gave evidence in relation to this safety recommendation. He said that the data his company would receive from manufacturers if the recommendation were implemented would be useful to SKF. He said that his company would not find it difficult to manage being provided with data as required. He noted that data of this kind had been made available in relation to the duplex bearing as a result of the AAIB investigation. In these circumstances, I am concerned by EASA’s rejection of the AAIB safety recommendation, which would appear to propose a meaningful improvement to requirements for aircraft design work. (2) Requirements for Certification Specification to address rolling contact fatigue failure In the inquests, the AAIB investigation team explained that they had recommended that EASA introduce further requirements to Certification Specification 29 so as specifically to address premature rolling contact fatigue failure as a failure mechanism across the full bearing operating spectrum and service life of bearings used in safety-critical applications. This was AAIB safety recommendation SR-2023-019. explained in evidence that this safety recommendation was not prescriptive. It asked EASA to propose requirements which would address risks of premature rolling contact fatigue in bearings, the form of failure which the AAIB concluded had caused the catastrophic accident in this case. As explained, EASA is undertaking work which looks at the fatigue tolerance of principal structural elements and at the possibility of changing acceptable means of compliance (AMC) for those items. As part of this work, EASA is considering adding clarification and detail which might meet the AAIB recommendation. This reflects the position stated by EASA in its letter of 6 February 2024. I am concerned that an issue raised by the AAIB to the effect that CS-29 and/or AMC may be improved to address risks of rolling contact fatigue failure in critical part bearings has not been addressed by EASA by a time over 18 months after the AAIB report on this crash was issued. (3) Airworthiness status and control of life limits for non-structural critical parts of aircraft designs already in service In the inquests, the AAIB investigation team explained that they had recommended that EASA should define the airworthiness status of life limits on non-structural critical parts and how they should be controlled in service. They said that they had recommended this in relation to aircraft designs not yet in service (safety recommendation SR-2023-020) and in relation to aircraft designs already in service (safety recommendation SR-2023-021). in his evidence pointed out that this recommendation did not raise an issue of causal relevance to this particular accident, but that it was nevertheless important to ensure greater clarity as regards the life limits of non-structural critical parts. 4 He said that new AMC introduced by Amendment 11 of Certification Specification 29 had adequately addressed the recommendation in relation to aircraft designs to be put into service in future, but that EASA had decided not to make any changes which would secure the requisite additional clarity in relation to designs already in service. As he put it “those aircraft already in service will not benefit from the Amendment 11 changes to life control.” In these circumstances, I am concerned that EASA has not implemented the recommendation in relation to designs already in service. Although said that EASA had explained that it considered that issues with non-structural critical parts would be picked up as part of continued airworthiness review, that does not strike me as a response which meets the recommendation. (4) Comprehensive programme for assessment of critical parts after removal from service In the inquests, the AAIB investigation team explained that they had recommended that EASA amend CS 29.602 to require aircraft manufacturers to implement a comprehensive programme for assessing critical parts after removal from service. AAIB safety recommendation SR-2023-022 addressed this topic for aircraft yet to be put into service, while safety recommendation SR-2023-023 addressed the topic for designs already in service. As explained this recommendation, it was “for EASA to require a closed-loop system for critical components removed from helicopters so that anything that is removed that is classified as a critical part has to ensure some form of… assessment programme carried out on it that… it is progressing throughout its service life in the manner that was expected at the design stage using the design assumptions.” He told the court that such a system would have meant that, when duplex bearings were removed from the AW-169 helicopter at the end of their service life, at least a sample would have been reviewed by Leonardo and/or SKF to verify design assumptions. responded positively I understand it, EASA has to the As recommendation as regarding aircraft designs yet to be put into service. It has published a notice of proposed amendment to CS 29 with a view to implementing a Continued Integrity Verification Programme (CIVP). This work is still ongoing. However, EASA has indicated to the AAIB that it does not intend to make any regulatory change for in-service aircraft, because existing procedures are sufficient. to benefit told the court that this response from EASA did not allow in- service helicopters He acknowledged that there were some existing requirements which could identify adverse trends or deficiencies in relation to critical parts (such as the duplex bearing which failed in this case) but he stressed that they were not prescriptive enough, given the safety issues underlying the recommendations. from the proposed CIVP. the safety recommendation with retrospective effect which the AAIB had made, and which EASA was resisting, “would be very beneficial” (although he of SKF told the court that 5 commented that his company was already acting in accordance with the recommendation at least for some components). I am concerned that EASA does not intend making changes which would from the proposed new CIVP allow in-service helicopters to benefit requirements. (5) Guidance and minimum standards for the calculation of design load spectrums for non-structural critical parts In the inquests, the AAIB investigation team told the court that they had recommended that EASA amend CS 29.602 so as to provide guidance and set minimum standards for calculating design load spectrums for non-structural critical parts (like the duplex bearing which failed in this accident). Under this recommendation, the standards would have to include highest individual operating loads and combination of dynamic operating loads, as well as the longest duration of exposure for such loads that could be experienced in operation. This was safety recommendation SR-2023-024. it, put this recommendation represented an attempt to As ensure that the design process took into account what the AAIB had learned from this investigation. He acknowledged that major manufacturers would have procedures for considering design load spectrums for parts such as the bearing which failed in this case. However, his concern was to have a comprehensive and uniform set of standards for such safety-critical parts. According to the latest information provided by the AAIB, EASA has issued a Certification Memorandum (CM)-RTS-003, which gives guidance on demonstration of compliance with applicable CS-27 and CS-29 requirements for hybrid bearings (i.e. bearings involving steel races and ceramic balls). EASA claims that this adequately addresses the findings from the accident. The AAIB does not consider this an adequate response. It points out that there is no guidance or requirement to calculate loads for non- structural critical parts (such as the tail rotor bearing), as distinct from a principal structural element (such as the entire tail rotor). It further notes that Certification Memorandum (CM)-RTS-003 focusses on issues with one type of bearing and does not address the broader issue raised by this recommendation. I am concerned that EASA has responded to this AAIB recommendation by citing action it has taken which does not appear to meet the AAIB’s concerns. (6) Failure modes analysis at a system level In the inquests, the AAIB investigation team explained that they had recommended that EASA make amendments to requirements in CS-29 and to AMC in order to stress that, where potentially catastrophic failure modes are identified, the wider system should be reviewed for practical mitigation options, such as early warning systems and failure-tolerant design, rather than relying solely on statistical analysis to address the risk. This was safety recommendation SR-2023-025. 6 explained that, in the present case, it may have been helpful to consider failure modes in relation to the tail rotor bearing and actuator as a single or conjoined system. He said that, if this had been done, “it may have been possible to mitigate the catastrophic nature of the tail rotor duplex bearing failure”. He told the court that EASA’s initial response to the recommendation had the points the AAIB had raised and had not not covered any of addressed the intent of the recommendation at all. of He said that, after further engagement, EASA had given a more comprehensive reply which stated that Amendment 11 to CS-29 and the sufficiently provision the recommendation. However, said that even that reply had quoted features of CS-29 which did not meet the requirements of the recommendation. There remained no provision for failure analysis to be conducted at a system level. guidance material addressed In those circumstances, the AAIB assessed EASA’s response to the recommendation as not being adequate. I am concerned that the AAIB’s apparently sensible suggestion of requiring failure modes analysis to be conducted at a system level continues to be rejected. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths, and I believe that each of EASA and the CAA have power to take such action. to make regulatory changes and issue guidance as EASA has power recommended by the AAIB under the various safety recommendations referenced above. These would affect helicopters in use in the UK at present and helicopters which may be in use in the UK in the future. Meanwhile, as of the CAA told the court, the CAA has power to set certification specification requirements for helicopters which would affect the ability of a particular design of aircraft to be used in the UK. Furthermore, the CAA has a role in seeking to work with EASA and other international regulators to secure appropriate action to improve safety. 7 YOUR RESPONSE A response to this report should be provided within 56 days of the date of this report, namely by 25th July 2025. As coroner, I am able to extend the period if appropriate. Your response should contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you should explain why no action is proposed. 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons in the inquest, namely (i) the families of those who died; (ii) 7 King Power International Group; (iii) Starspeed Ltd; (iv) Leicester City FC; (v) Sloane Helicopters Ltd; (vi) Gama Aviation plc; (vii) Leonardo SpA; (viii) SKF Aerospace; (xi) AIG Pacific Insurance Pte Ltd; and (xii) the AAIB. (x) Shell Aviation Ltd; (ix) Microtecnica Srl; I have also sent it to the Secretary of State for Transport ( as a person who may find it useful or of interest. ), I am also under a duty to send a copy of your response to the Chief Coroner and all Interested Persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish this report and/or any response to it in complete, redacted or summary forms. She may send a copy of this report and/or any response to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 30 May 2025 8
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Professor Catherine E Mason H.M. Senior Coroner for Leicester City & South Leicestershire H.M. Coroner’s Office Town Hall Town Hall Square Leicester LE1 9BG By email only: 25 July 2025 IN THE MATTER OF AN INQUEST INTO THE DEATHS ARISING FROM THE HELICOPTER CRASH AT KING POWER STADIUM ON 27 OCTOBER 2018 CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO PARAGRAPH 7 OF SCHEDULE 5 TO THE CORONERS AND JUSTICE ACT 2009 AND REGULATIONS 28 AND 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Introduction The UK Civil Aviation Authority wishes to express its sincere condolences to the families, friends, and loved ones of those who lost their lives in this tragic accident. The CAA has carefully considered the Regulation 28 Report and the matters of concern raised by the Senior Coroner. Response Following this tragic accident, the CAA analysed the Safety Recommendations (SRs) issued to EASA by the Air Accident Investigation Branch (AAIB) to understand the intent of the SRs and to consider what actions are within the CAA’s power to address within the UK. The CAA gave a detailed account of these actions to the Senior Coroner in the course of the inquest. The CAA: a. has adopted updates to Acceptable Means of Compliance to CS-27 and CS-29 relating to rolling contact fatigue in critical bearings classified as Principal Structural Elements; b. has initiated rulemaking projects to update the UK regulatory framework to: Civil Aviation Authority Aviation House, Beehive Ring Road, Crawley West Sussex RH6 0YR www.caa.co.uk i. ii. clarify how the airworthiness status and life limits of critical parts should be defined and published to operators of the aircraft type; ensure the removal of defective critical parts from service and their return to the Type Certificate Holder (TCH) of the aircraft for analysis, to better understand the performance of critical parts in service; iii. extend the scope of existing required safety assessments of the rotor and rotor drive system to minimise the hazard severity resulting from component failure; c. is developing a Certification Memorandum (“CM”) which will clarify that applicable data from the supplier of critical bearings (including installation and operating limitations, bearing design specification, and applicable best practice) should be recorded and assessed by the TCH of the aircraft prior to certification. This CM will apply to all critical bearings, including both metallic and hybrid designs. The CAA will share this CM with EASA for discussion; d. will consider EASA’s final proposals in relation to the Continued Integrity Verification Programme (CIVP) once they are issued and will reflect those provisions in the equivalent UK regulatory provisions if appropriate to do so; e. will continue its work to ensure that industry can better identify critical parts and notify any failure to meet their design life to the CAA through the Mandatory Occurrence Reporting (MOR) system; and f. will continue to explore an internationally harmonised approach to the treatment of critical parts by maintenance organisations to ensure such parts are properly identified, controlled, managed, stored and released to service throughout the global aviation industry. The CAA also continues to work with its international counterparts, including EASA, as advised to the Senior Coroner during the inquest, to consider what actions might be taken to address the Senior Coroner’s concerns and ensure ongoing high safety standards for helicopters. The CAA and EASA met to discuss these issues on 2 July 2025, and a further meeting is planned for the autumn at which these discussions will continue. The CAA will also raise these issues with other international counterparts, such as the FAA, as appropriate. As the Senior Coroner has noted, divergence of regulatory standards is generally undesirable in the context of civil aviation. For this reason, the CAA will continue this process of international engagement with the aim of achieving an internationally harmonised approach to the question of critical bearing design and certification, and the identification, handling, maintenance and analysis of critical parts. If international harmonisation cannot be achieved in due course, the CAA will consider whether it would be appropriate nonetheless to exercise its own powers to amend UK certification specifications or other regulatory provisions unilaterally. While this process of international discussion is ongoing, the CAA will continue to have a range of powers available to ensure high standards of safety in helicopters operating in the UK, and will use these powers if necessary and appropriate to do so. These powers include: a. powers to issue Airworthiness Directives, requiring action to be taken to ensure an aircraft remains safe to operate; Civil Aviation Authority Aviation House, Beehive Ring Road, Crawley West Sussex RH6 0YR www.caa.co.uk b. powers to validate new aircraft types being brought onto the UK register, and to require additional assurances or actions to enable the CAA to be satisfied that the aircraft is safe to operate in the UK; c. powers to ground aircraft if an unsafe condition is found to exist. The CAA considers that these actions address the Senior Coroner’s concerns as they may apply within the UK. The CAA remains committed to maintaining high standards of aircraft safety within the UK and contributing to similarly high standards globally. The CAA will continue to engage with EASA and other international counterparts, and to assess the UK’s regulatory framework, to address the lessons from this tragic accident. The Civil Aviation Authority Civil Aviation Authority Aviation House, Beehive Ring Road, Crawley West Sussex RH6 0YR www.caa.co.uk
Acting Resources and Support Director Resources and Support Directorate Cologne, as per the e-signature Professor Catherine E. Mason LL.B (Hons) His Majesty’s Senior Coroner Leicester City & South Leicestershire Town Hall Town Square Leicester LE1 9BG Sent by e-mail only Subject: Attachment: Inquest into the Deaths arising from the Helicopter Crash at King Power Stadium on 27 October 2018 – Regulation 28 Report to prevent future deaths Annex recalling the EASA replies to AAIB safety recommendations 2023-018, 2023-019, 2023-021, 2023- 023, 2023-024 and 2023-025 Dear Prof. Mason, We would like to express our sincere appreciation for the investigation into the helicopter crash at King Power Stadium on 27 October 2018. We acknowledge the significant effort and dedication that has gone into this inquest, and we are grateful for providing the European Union Aviation Safety Agency (EASA) with the opportunity to respond to the concerns formulated in the Prevention of Future Death Report arising from this tragic event. As you are aware, EASA assisted the Air Accidents Investigation Branch (AAIB) of the UK in the safety investigation into this accident in accordance with the provisions of Regulation (EU) No 996/2010. As mentioned in our previous submissions, there has been some topics on which we could not reach a common understanding, and that included the root cause of the accident (cf. ‘Appendix K of the AAIB Final Report). Nevertheless, we understand the importance of these safety recommendations and have approached them with the utmost seriousness and consideration. Our decision regarding these recommendations were not taken lightly. They have been carefully produced according to a formal internal procedure that involved various subject matter experts from within the Agency, as well as management review. In the context of aircraft certification, it is crucial to ensure harmonization of certification requirements applied by aviation authorities around the world, with the primary objective of ensuring aviation safety. EASA is committed to working closely with other regulatory bodies, including the UK Civil Aviation Authority (CAA), to achieve this goal. In fact, we have been in contact with the UK CAA and are aware that they are exploring certain concepts related to some of the safety recommendations proposed by the AAIB. We are open to engaging in consultation with UK CAA to assess the merits of these proposals and to discuss potential ways forward. However, at this point, EASA maintains its position as already communicated in response to the AAIB's safety recommendations. For the sake of convenience, the latest responses to those recommendation that are reconfirmed in point 5 of the PFD as ‘Coroner’s Concerns’ are recalled in the annex to this letter. We believe that our positions, as outlined in the annex, address the safety recommendations TE.GEN.00101-010 An agency of the European Union Postal address: Postfach 10 12 53, 50452 Cologne, Germany Visiting address: Konrad-Adenauer-Ufer 3, 50668 Cologne, Germany ISO 9001 Certified Tel.: E-mail: Web: www.easa.europa.eu Page 1 of 8 raised by the investigation. At the same time, EASA is working on other improvements to the rotorcraft certification process to address lessons learned beyond AAIB’s safety recommendations. The Agency is committed to ensuring that any regulatory changes are proportionate, effective, and aligned with international best practices. Once again, we would like to express our gratitude for the opportunity to respond to the Coroner's PFD report. We remain committed to working with all stakeholders to identify areas for improvement and to implement measures that enhance aviation safety. We trust that this letter clarifies EASA’s position in this matter and we thank you for your attention. Yours sincerely, (electronically signed) TE.GEN.00101-010 An agency of the European Union Postal address: Postfach 10 12 53, 50452 Cologne, Germany Visiting address: Konrad-Adenauer-Ufer 3, 50668 Cologne, Germany ISO 9001 Certified Tel.: +49 221 89990 3000 E-mail: arthur.beckand@easa.europa.eu Web: www.easa.europa.eu Page 2 of 8 Annex recalling the EASA replies to AAIB safety recommendations 2023-018, 2023-019, 2023-021, 2023-023, 2023-024 and 2023-025 AAIB reference 2023-018: “It is recommended that the European Union Aviation Safety Agency amend Certification Specification 29.602 to require type design manufacturers to provide the results of all relevant system and flight testing to any supplier who retains the sole expertise to assess the performance and reliability of components identified as critical parts within a specific system application, to verify that such components can safely meet the in-service operational demands, prior to the certification of the overall system.” [EASA reference: UNKG-2023-001] Final EASA reply sent on 06/02/2024: “Pursuant to point 21.A.20 of Annex I (Part 21) to Regulation (EU) No 748/2012, the applicant for aircraft type certification is responsible for the demonstration of compliance with the type certification basis (that includes certification specifications), and to record justifications of compliance within the compliance documents as referred to in the certification programme. This implies ensuring that parts and systems reach minimum performance and reliability targets. Therefore, the applicant is responsible for providing any information such as, but not limited to, test results to its suppliers to ensure a final airworthy design. This principle is not specific to certain products and should not be repeated in each Certification Specification where a supplier could be affected. The European Union Aviation Safety Agency (EASA) considers that the above-mentioned regulatory framework, including Certification Specifications, is adequate and does not envisage creating new prescriptive requirements.” AAIB reference 2023-019: “It is recommended that the European Union Aviation Safety Agency introduce additional requirements to Certification Specification 29 to specifically address premature rolling contact fatigue failure across the full operating spectrum and service life of bearings used in safety critical applications.” [EASA reference: UNKG-2023-002] Interim reply sent on 06/02/2024: “Point CS 29.571 (Fatigue Tolerance Evaluation of Metallic Structure) paragraph (d) of Certification Specification for Large Rotorcraft (CS-29) specifies the following with regard to Principle Structure Elements (PSE): “Each PSE must be identified. Structure to be considered must include the rotors, rotor drive systems between the engines and rotor hubs, controls, fuselage, fixed and movable control surfaces, engine and transmission mountings, landing gear, and their related primary attachments.” The European Union Aviation Safety Agency (EASA) considers that this includes critical components within the rotor control mechanism, such as the tail rotor duplex bearing of the AW169. TE.GEN.00101-010 An agency of the European Union Postal address: Postfach 10 12 53, 50452 Cologne, Germany Visiting address: Konrad-Adenauer-Ufer 3, 50668 Cologne, Germany ISO 9001 Certified Tel.: +49 221 89990 3000 E-mail: arthur.beckand@easa.europa.eu Web: www.easa.europa.eu Page 3 of 8 Acceptable Means of Compliance AMC1 29.571 (introduced with Amendment 11 of CS-29) addresses Rolling Contact Fatigue (RCF) which should be included, when applicable, in the fatigue tolerance evaluation of Principle Structure Elements (PSE). This AMC describes possible steps to be taken to minimise the risk of crack initiation due to RCF on PSEs (and in particular for integrated bearing races). A fail-safe approach is recommended wherever possible, such that cracking of the affected structural element(s) is detected prior to its residual strength capability falling below the required levels prescribed in CS 29.571(f). In addition to following a fail-safe approach, inspection and retirement times may be needed in order to ensure that the assumptions supporting the fail-safety and detection of failure remain valid throughout the operational life of the component. EASA is however reviewing the opportunity to clarify the scope of application of AMC1 29.571, and similarly of AMC1 27.571, to ensure that critical bearings are always considered. A proposed amendment of CS-27 and CS-29 is planned to be included in the next Notice of Proposed Amendment under rulemaking task RMT.0128 ‘Regular update of the Certification Specifications for Very Light Rotorcraft (CS-VLR), Small Rotorcraft (CS-27), and Large Rotorcraft (CS-29)’.” AAIB reference 2023-021: “It is recommended that the European Union Aviation Safety Agency define the airworthiness status of life limits and how they should be controlled for existing non-structural critical parts approved to Certification Specification 29.602 requirements, already in service.” [EASA reference: UNKG-2023-004] Final reply sent on 22/03/2024: “In accordance with point 21.A.7 of Annex I (Part 21) to Regulation (EU) No 748/2012, the Type Certificate Holder (TCH) must provide Instructions for Continued Airworthiness (ICA) for critical parts, either structural or non-structural, and, in case of large rotorcraft, the preparation of ICA must be performed in compliance with the Certification Specification (CS) 29.1529. The ICA applicable to critical parts may be included within the Airworthiness Limitation Section (ALS) of the ICA and/or in other appropriate Sections. Retirement Times or Operational Time Limits provided in the ICA are necessary for the safe operation of the aircraft and they have to be implemented in the Aircraft Maintenance Programme (AMP) to obtain approval by the Competent Authority [ref. point M.A.302(d)(2) of Annex I (Part M) to Regulation (EU) No 1321/2014]. This requirement is applicable to both ALS and other Sections of the ICA. In addition, point 21.A.3A of Annex I (Part 21) to Regulation (EU) No 748/2012 contains the necessary provisions for ensuring the collection, investigation and analysis of occurrence reports to identify the necessary mitigations in terms of changes to the design and/or to the ICA to prevent or minimize the possibility of such occurrences in the future, as necessary. This includes, as per point 21.A.3A(a)(1), the identification of adverse trends or deficiencies that cause or might cause adverse effects on the continuing airworthiness of the product. The ‘analysis’ is not limited to those occurrences that require the involvement of the European Union Aviation Safety Agency (EASA) under point 21.A.3A(e). TE.GEN.00101-010 An agency of the European Union Postal address: Postfach 10 12 53, 50452 Cologne, Germany Visiting address: Konrad-Adenauer-Ufer 3, 50668 Cologne, Germany ISO 9001 Certified Tel.: +49 221 89990 3000 E-mail: arthur.beckand@easa.europa.eu Web: www.easa.europa.eu Page 4 of 8 Taking into account the information above, the EASA considers that the necessary regulatory framework is already in place and, therefore, EASA does not intend to re-define or re-evaluate the airworthiness status of ICA for critical parts, either structural or non-structural, already in service.” AAIB reference 2023-023: “It is recommended that the European Union Aviation Safety Agency require manufacturers to retrospectively implement a comprehensive post removal from service assessment programme for critical parts, approved to Certification Specification 29.602 requirements, already in service. The findings from this should be used to ensure that the reliability and life assumptions in the certification risk analysis for the critical part or the system in which it operates remain valid.” [EASA reference: UNKG-2023-006] Final reply sent on 22/03/2024: “Point 21.A.3A of Annex I (Part 21) to Regulation (EU) No 748/2012 defines the obligations applicable to the Type Certificate Holders (TCHs) to establish and maintain a system for collecting, investigating and analysing occurrence reports. This includes, as per point 21.A.3A(a)(1), identification of adverse trends or deficiencies that might cause adverse effects on the continuing airworthiness of the product. In addition, acceptable means of compliance AMC1 21.A.3A(a) clarifies that, for parts whose failure could lead to an unsafe condition (and critical parts are candidates as they could have catastrophic effect upon the rotorcraft), the ‘analysis’ function of the system should ensure that reports and information sent, or available, to the Design Approval Holder (DAH) are fully investigated so that the exact nature of any event and its effect on continuing airworthiness is understood. This may then result in changes to the design and/or to the Instructions for Continued Airworthiness (ICA), and/or in establishing a mitigation plan to prevent or minimize the possibility of such occurrences in the future, as necessary. The ‘analysis’ is not limited to those occurrences that require the involvement of the European Union Aviation Safety Agency (EASA) under point 21.A.3A(e). EASA considers that obligations outlined in 21.A.3A already indicate that the TCH shall collect, investigate and analyse reports and information [including the early rejection of parts from service as mentioned in guidance material GM1 21.A.3A(a) and 21.A.3A(b) Reporting system] that might question the certification assumptions for critical parts and when necessary, define design changes and implement mitigation plans. Therefore, EASA considers that the necessary regulatory framework is already in place to address the intent of this Safety Recommendation (SR) and, therefore, there is no need to retrospectively implement a comprehensive post removal from service assessment programme for critical parts already in service.” TE.GEN.00101-010 An agency of the European Union Postal address: Postfach 10 12 53, 50452 Cologne, Germany Visiting address: Konrad-Adenauer-Ufer 3, 50668 Cologne, Germany ISO 9001 Certified Tel.: +49 221 89990 3000 E-mail: arthur.beckand@easa.europa.eu Web: www.easa.europa.eu Page 5 of 8 AAIB reference 2023-024: “It is recommended that the European Union Aviation Safety Agency amend Certification Specification 29.602 to provide guidance and set minimum standards for the calculation of design load spectrums for non-structural critical parts. They must encompass, with an appropriate and defined safety margin, the highest individual operating load and combination of dynamic operating loads, and the longest duration of exposure to such loads that can be experienced in operation.” [EASA reference: UNKG-2023-007] Final reply sent on 24/03/2025: “The accident investigation report mentions a non-conservative loads calculation at the time of certification as a root cause of the bearing failure. The European Union Aviation Safety Agency (EASA) does not share this single factor conclusion, considering that other possible detrimental factors may also have contributed to the bearing failure. The methodology for loads calculation as used by Leonardo is not novel or unusual and does not require complete reconsideration by means of new, prescriptive certification specifications. However, as lessons learned from this accident, EASA considers that future approvals of hybrid bearing with ceramic balls will deserve more attention as regards to the failure mechanics and the sensitivity of the bearing to its working conditions (including abnormal conditions originated by e.g. manufacturing defects, degraded lubrication, improper maintenance, etc..) in order to better cope with a wider range of scenarios. Consequently, EASA issued Certification Memorandum (CM)-RTS-003 titled ‘Hybrid Bearings’ on 13 Dec 2024 to provide specific guidance related to the demonstration of compliance with applicable CS- 27 and CS-29 certification specifications for hybrid bearings (combination of steel races with ceramic ball is available on EASA’s website at: https://www.easa.europa.eu/en/document- bearings). This library/product-certification-consultations/hybrid-bearings EASA considers that this action adequately addresses findings from this accident by highlighting relevant aspects to be addressed during the certification process of rotorcraft featuring hybrid bearings.” TE.GEN.00101-010 An agency of the European Union Postal address: Postfach 10 12 53, 50452 Cologne, Germany Visiting address: Konrad-Adenauer-Ufer 3, 50668 Cologne, Germany ISO 9001 Certified Tel.: +49 221 89990 3000 E-mail: arthur.beckand@easa.europa.eu Web: www.easa.europa.eu Page 6 of 8 AAIB reference 2023-025: “It is recommended that the European Union Aviation Safety Agency amend the relevant requirements of Certification Specification 29 and their Acceptable Means of Compliance (AMC) to emphasise that where potentially catastrophic failure modes are identified, rather than rely solely on statistical analysis to address the risk, the wider system should also be reviewed for practical mitigation options, such as early warning systems and failure tolerant design, in order to mitigate the severity of the outcome as well as the likelihood of occurrence.” [EASA reference: UNKG-2023-008] Final reply sent on 19/07/2024: “The European Union Aviation Safety Agency (EASA) considers that practical mitigation options such as early warning systems and failure tolerant designs are relevant means to achieve adequate safety levels in rotorcraft designs. According to CS-29 Amdt 11 (Certification Specifications, Acceptable Means of Compliance (AMC) and Guidance Material for Large Rotorcraft), CS 29.571 (Fatigue tolerance evaluation of metallic structure) and AMC1 29.571 (dealing with rolling contact fatigue (RCF)) address the need to take into account the impact of RCF and minimise the risk of crack initiation resulting from RCF on Principal Structural Elements (PSEs). In addition, AMC1 29.571 states that ‘as it is difficult to totally preclude cracking initiated by RCF, a fail-safe approach is recommended wherever possible, such that cracking of the affected structural element(s) is detected prior to its residual strength capability falling below the required levels prescribed in CS 29.571(f)’. Hence AMC1 29.571 clearly introduces the notion of fail- safe designs and of means of detection to fulfil the objective of preventing failure as a result of RCF. This regulatory material was relatively new at the date of publication of the accident investigation report and it appeared, in EASA’s view, not to have been considered. Nevertheless, additional CS-29 provisions help to meet the intent of this safety recommendation: (1) The design assessments specified by CS 29.547(b) (Strength requirements - Main and tail rotor structure) and CS 29.917(b) (Powerplant – Rotor Drive System - Design) require the identification of all failures in rotors and rotor drive systems that will prevent continued safe flight or safe landing, as well as the means to minimise the likelihood of their occurrence. As per Federal Aviation Administration (FAA) Advisory Circular (AC) 29-2C Change 7 (recognised as AMC to CS-29) sections 29.547 and 29.917, ‘a design assessment […] should be carried out in order to substantiate that the system is of a safe design and that compensating provisions are made available to prevent failures classified as hazardous and catastrophic[…]’. The listed compensating provisions include design features (such as redundancies and safety factors) and the use of safety devices or vibration health monitoring systems, which cover the means proposed by the AAIB in this safety recommendation. Other compensating provisions such as inspections or checks, as well as preventive maintenance are also listed. (2) Since some years EASA has recognised the need to clearly identify those continuing airworthiness tasks which are listed as compensating provisions in the aforementioned design assessments and are also considered key to ensuring that the hazardous and catastrophic failures of the design are either adequately mitigated or their probability of occurrence has been adequately minimised. EASA considers that these continuing airworthiness tasks should be: TE.GEN.00101-010 An agency of the European Union Postal address: Postfach 10 12 53, 50452 Cologne, Germany Visiting address: Konrad-Adenauer-Ufer 3, 50668 Cologne, Germany ISO 9001 Certified Tel.: +49 221 89990 3000 E-mail: arthur.beckand@easa.europa.eu Web: www.easa.europa.eu Page 7 of 8 (i) (ii) considered as candidates for Certification Maintenance Requirements (CMRs) in accordance with AMC 25-19 of CS-25 (Certification Specifications and Acceptable Means of Compliance for Large Aeroplanes). EASA currently addresses the application of the CS-25 CMR concept to support the demonstration of compliance with large rotorcraft certification specifications requiring safety assessment and design assessment, including CS 29.547(b) and CS 29.917(b), through a Means of Compliance Certification Review Item. Therein applicants are requested to detail the criteria and methods to demonstrate the adequacy of these CMRs. evaluated for the need of dedicated certification testing to demonstrate adequate performance and suitable intervals. EASA is currently considering the possibility of introducing new AMC to CS 29.927(a) (Additional tests) to address this aspect. This would clarify the need to support inspection intervals and retirement times with appropriate directly applicable data. In conclusion, while the relevance of a full assessment of the design and a detailed evaluation of the failure scenarios is agreed and already present in CS-29, EASA considers that mandating design measures to systematically mitigate the outcome of catastrophic failures could be counterproductive. This could lead to impractical and overly complex solutions, that negatively impact the reliability of rotors and rotor drive systems. Based on the above, EASA considers that the necessary elements are in place to ensure that hazardous and catastrophic failures are adequately addressed during certification, by adequately mitigating such failures and/or minimising their probability of occurrence, thus, ensuring adequate safety levels.” Electronically signed on 14/07/2025 09:19 (UTC+02) in accordance with Article 11 of Commission Decision (EU) 2021/2121 An agency of the European Union Page 8 of 8 Postal address: Postfach 10 12 53, 50452 Cologne, Germany Visiting address: Konrad-Adenauer-Ufer 3, 50668 Cologne, Germany ISO 9001 Certified Tel.: +49 221 89990 3000 E-mail: arthur.beckand@easa.europa.eu Web: www.easa.europa.eu TE.GEN.00101-010
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