ANC98TA162

NTSB accident investigation · Hughes 369D · Homer, AK · September 27, 1998

Accident · Serious injuriesFinal report
Date
September 27, 1998, 08:25 local (16:25 UTC)
Place
Homer, AK
Injuries
1 serious, 2 uninjured
Damage
Minor damage
Phase of flight
Standing
Aircraft
N1091PHughes 369D
Weather
Visual (VMC) · Day
Status
Completed · report February 16, 2001
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19980927037959A
Case key
44043

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The passenger not following the instructions given by the pilot. Contributing factors were the rising terrain and the pilot's diverted attention during the toe in landing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Propeller/rotor contact to personStanding - engine(s) operating
Terrain condition - risingFactor
Instructions,written/verbal - not followedPassengerCause
Diverted attentionPilot in commandFactor
Unsuitable terrain or takeoff/landing/taxi area - selectedPilot in command

Analysis

The helicopter was engaged in a partial power toe in landing to disembark two passengers. The passenger on the left side walked uphill, and was struck by the main rotor blades, sustaining serious injuries. The helicopter sustained minor damage to the rotor system, and the pilot relocated to a safe landing site. According to the other passenger and the pilot, the passengers had been briefed to not walk uphill when exiting the helicopter. The pilot stated that his attention was diverted between the passengers on each side of the helicopter, and maintaining the helicopter's position.

Factual narrative

On September 27, 1998, at 0825 Alaska daylight time, a Hughes 369D helicopter, N1091P, sustained minor damage to two main rotor blades when they struck a disembarking passenger during a toe-in landing to a remote beach site. The passenger who was struck by the rotating blades sustained serious injuries. The commercial pilot and the one other passenger were not injured. The government flight was being operated on an end-use contract by the U. S. Bureau of Land Management to conduct land surveys. The helicopter was owned by Temsco Helicopters, Inc., of Ketchikan, Alaska. The flight was conducted under 14 CFR Part 135, and had departed the Research Motor Vessel (M/V) Nancy H at 0755, to transport the two passengers to a remote beach site. Visual meteorological conditions prevailed at the time of the accident, and a flight plan was filed with the M/V Nancy H.

The pilot told the NTSB investigator-in-charge (IIC) during a telephone interview on September 27, that while performing a partial power toe-in landing, he signaled the passengers that they could exit the helicopter. The pilot said his attention was diverted between the passengers on each side of the helicopter, and maintaining the helicopter's position. The first passenger exited off the front of the left skid, and walked uphill into the turning rotor blades, sustaining serious injuries to his back and head. The helicopter immediately began to vibrate violently, and the pilot relocated the helicopter to a landing site about 800 feet away. He stated that the helicopter's vibration after the impact with the passenger activated the emergency locator transmitter (ELT).

Interviews by the NTSB IIC with the pilot and uninjured passenger revealed that by 1100, no rescuers had arrived. The pilot removed the ELT from the helicopter and moved it away from the steep cliff face next to where he had landed. At 1130, the US Coast Guard began a search resulting from satellite receipt of an ELT signal. At 1146, the M/V Nancy H reported the helicopter overdue to the Coast Guard. At 1257, the helicopter was located, and the occupants were rescued at 1329.

Both the pilot and the uninjured passenger told the NTSB IIC that the passengers had been briefed to not walk uphill from under the turning rotors. Both men also told the IIC that there was no level ground to land the helicopter, and the only way to disembark the passengers was by performing a toe-in landing, keeping partial power on the rotor system, and allowing the passengers to climb off the skids.

The helicopter was contracted for, and both passengers were employed by, the surveying company. The surveying company was retained by the Port Graham Native Corporation, Port Graham, Alaska, to perform cadastral land surveys, with funds provided by the United States Department of Interior, Bureau of Land Management, under the Indian Self Determination Act (Public Law P.L. 93-638).

Aircraft

Registration
N1091P
Reported as
Hughes 369D
Category
Helicopter
Serial number
683D
Airframe hours
7,528
Engine
Allison 250-C20B, 420 horsepower, turbo shaft
Damage
Minor damage
Flight
Public use
Operator
Bureau Of Land Management
Registered owner
Temsco Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 8, 1998 · 60 hours before
Departed
M/V Nancy H.
Flight plan
Company VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
26
Certificate
Commercial
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
3,000 total · 1,200 in this make and model · 2,900 as pilot in command · 210 in the last 90 days · 55 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
20 statute miles
Lowest ceiling
None
Temperature
55 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.