The helicopter, a Rotorway Executive 162F (G-JDHN), was in a stable cruise when the pilot heard a very loud noise which may have been caused by unburnt fuel igniting in the exhaust. This resulted in the helicopter reacting in a way that the pilot could not rationalise in the short time available, so he successfully autorotated to land in a field. At the end of the ground run, the left skid caught on uneven ground and the helicopter rolled over onto its left side. Both the pilot and passenger managed to escape with minor injuries.

It is suspected that defects in the cylinder 3 exhaust valve sealing may have been the cause of unburnt fuel in the exhaust system

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During an experimental flight near Cranfield Airport of a modified Piper PA-46-350P (G-HYZA), an electrically powered aircraft with electrical power from hydrogen fuel cells, suffered a loss of power to the electrical motors. This meant a forced landing was carried out, which severely damaged the aircraft, the crew were unharmed.

The loss of power occurred during an interruption of the power supply when, as part of the test procedure, the battery was selected to OFF with the intention of leaving the electrical motors solely powered by the hydrogen fuel cell. During this interruption, the windmilling propeller on the aircraft generated voltage that was high enough to operate the inverter protection system. This then locked out the power to the motors and the pilot and observer were unable to reset the system and restore electrical power.

A number of factors contributed to the accident:

• Sufficient ground testing had not been carried out to determine the effect of the back voltage from a windmilling propellor on the inverter protection system.

• The emergency procedure to clear an inverter lock out after the protection system operated was ineffective.

• An investigation had not been carried out into a previous loss of power resulting from an inverter lock out, which occurred three flights prior to the accident flight.

• The risk assessment had not been reviewed following the loss of propulsion on two previous flights.

• Ad hoc changes were made to the flight test plan, including the position where the electrical power source was switched, without the knowledge of the competent person.

• The competent person’s involvement was restricted in a number of areas due to issues within the organisational relationships, the fast tempo of the project, other work commitments and restrictions from the COVID-19 pandemic.

• The operator’s chief executive and the flight test director took on the day-to-day management responsibility for much of the programme. However neither individual had the necessary safety and flight test experience for that role and their focus was primarily on meeting key project targets.

Five Safety Recommendations are made, and the operator has also taken Safety Action to address a number of findings from the accident.

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Publishing the report, David Neal said:

I welcome the publication of this report, which looks at the Home Office’s introduction of GPS electronic monitoring (‘tagging’) of Foreign National Offenders (FNOs) following the introduction of the Home Secretary’s duty in August 2021.

The purpose of tagging is to reduce absconding and increase the number of FNOs removed. This inspection found that the service is still in the first 6 months of roll out and so cannot yet demonstrate it is achieving these aims.

The Home Office’s Electronic Monitoring Hub (the ‘Hub’) had a positive workplace culture and were a strong team, but their efforts were blunted by cumbersome and overlong recruitment processes, and an underestimation of the scale of legal challenge. Staffing shortfalls resulted in delays to the 3-monthly reviews of those who are on a tag and a lack of use of formal sanctions for breaches, which threatens to undermine the effectiveness of the whole programme.

The Hub needs to have a clear plan for what can be achieved as the Home Office expands its use of electronic monitoring, including the delayed introduction of non-fitted devices, which is a key part of its strategy. A comprehensive training package for both existing and new staff, alongside the implementation of quality assurance processes and more effective performance management of the supplier, are required to help drive continuous improvement.

Further work is also needed to develop robust and assured data. Currently, there are inconsistencies in data across the Hub’s areas of activity, and no data quality framework is in place to ensure that information (including sensitive details of FNO movements) is being properly managed.

I made five recommendations in this report. I am pleased that the Home Office accepted all of these recommendations in full and that work is already underway to tackle the issues raised.

Over the years, MAIB has seen many incidents where seafarers have been struck by mooring lines, unfortunately in some cases resulting in serious injury or death. Our Annual Report recently highlighted that such incidents continue to occur despite well published guidance on the subject. Even though there have been many advances in technology and automation in the shipping industry, mooring decks remain a place where people need to work in proximity to heavy lines under tension and interaction is unavoidable. Therefore, it is important that the safety guidance is followed. Below, we have emphasised three key components for safer mooring operations.

Equipment

Making sure the right equipment is used and then maintained in good condition is essential to keeping safe on mooring decks. Mooring lines need to be regularly inspected to make sure that wear and tear has not degraded the line, there are no hard spots on synthetic lines and no signs of contamination by oils and greases. The lead of each mooring line needs to be considered carefully to avoid placing additional stress on the lines or introducing chafe points. Inappropriate or poorly maintained equipment has previously contributed to incidents where lines have parted or released under tension and struck crew members, therefore meticulously checking equipment for anything untoward is critical for the safety of the crew.

Planning and Briefing

Planning is important when conducting any mooring deck operations. The risk assessment and control measures should be reviewed for each new operation and planning should take account of the expected mooring configuration, paying particular attention to the potential risk of snapback. Areas where mooring deck operations take place need to be kept tidy and mooring lines should be closely monitored on all berths – this is vitally important when there is a large range of tide. Planning effectively also involves making sure that all seafarers are adequately briefed on the mooring configurations, that they know what to do, and that they are positioned on parts of the deck that are less dangerous. Enough crew should be on deck to conduct the job safely, but too many crew should be avoided as it can unnecessarily place others at risk.

Communication

Finally, crew communication is of the utmost importance when working on mooring decks, because it has the potential to be extremely hazardous if people are not able to interact clearly. Everybody involved in an operation needs to communicate effectively, but must also consider the number of circuits in use: too many voices on the same circuit can cause confusion and risk over-talking; however, using separate circuits can leave some crew in the dark. Ultimately, effective communication can be the difference between being safe and putting people at risk, therefore it is important that the mooring plan ensures that good communications can be maintained between all parties involved in the mooring operation.

For more information, head to the Code of Safe Working Practices for Merchant Seafarers (COSWP) guidance and consult your safety management system (SMS).