CEN11LA339

NTSB accident investigation · MD Helicopter 369E · Victoria, TX · May 16, 2011

Accident · No injuriesLimited investigationFinal report
Date
May 16, 2011, 13:05 local (18:05 UTC)
Place
Victoria, TX
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N4278TMD Helicopter 369E
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report November 7, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, MD Helicopters Inc, Rolls-Royce
FAA report
20110516013289A
Case key
79110

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 pilot’s failure to ensure that the governor limit switch was properly set, which resulted in reduced engine power.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: lack of actionPersonnel issues › Action/decision · PilotMD Helicopters 369E: 1 caseAll aircraft: 792 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Shortly after departure, the pilot observed the engine-out caution light and received an audible alarm. The pilot then saw the automatic re-ignition light illuminate. Since the engine appeared to be operating at a reduced power setting, the pilot elected to perform a run-on landing. During the landing, the helicopter encountered a ditch, and the tail rotor struck the ground. A postaccident examination of the helicopter found that the fuel control governor limit switch, located on the pilot's collective, was set near the minimum limit (low power setting). No other anomalies were found with the airframe. The engine was removed and run on a testing system with no defects noted. According to the helicopter manufacturer, the warnings and power reduction that the pilot observed were consistent with the position of the limit switch as found. Therefore, it is likely that the reduction in engine power resulted from the improper setting of the governor limit switch.

Factual narrative

On May 16, 2011, about 1305 central daylight time, an MD Helicopters 369E, N4278T, was substantially damaged during a forced landing near Victoria, Texas. The commercial pilot and three passengers were not injured. The helicopter was registered to Wells Fargo Bank Northwest N/A Trustee and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. The helicopter's tailboom section sustained substantial damage. Visual meteorological conditions prevailed for the flight, which operated without a flight plan. The flight had departed the Victoria Regional Airport (KVCT), Victoria, Texas, about 1255, destined for the William P. Hobby Airport (KHOU), Houston, Texas. According to the pilot, after refueling, the helicopter departed for Houston. Approximately 5 minutes into the flight the pilot observed the engine out caution light and received an audible alarm. The pilot then saw the automatic re-ignition light illuminate. Since the engine appeared to operate at a reduced power setting, the pilot elected to perform a run-on landing, in an open area. Upon touchdown, the helicopter settled into uneven terrain and the tailboom contacted the rising terrain. Ground contact of the tail rotor stinger and tail rotor blades resulted in significant damage to the tailboom, tail rotor blades and tail rotor drive system. Damage to the helicopter and impact signatures were consistent with the helicopter landing with little to no forward movement. A postaccident examination found the fuel control governor switch located on the pilot's collective was set near the minimum limit. According to the helicopter manufacturer, along with reduced total engine power, the associated warning of a minimum governor setting would be an engine out caution light, audible warning, and re-ignition light illumination. Also found was the trim setting set to the full forward/nose down limit. The helicopter's engine was removed and sent to Rolls-Royce for a test run. The engine was started and produced rated power without anomalies. A follow-up interview with the pilot revealed a student helicopter pilot and had performed the pilot procedures through engine start. The commercial pilot then assumed control of the helicopter. The pilot added that during the loss of the engine power, he confirmed full throttle and activated the governor switch. He stated that he did not actuate the trim to the full nose forward position. The exact position of the switches at the time of the accident could not be determined.

Aircraft

Registration
N4278T
Reported as
MD Helicopter 369E
Category
Helicopter
Serial number
0605E
Airframe hours
80
Engine
Rolls Royce 250-C20B, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Other work use · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · February 28, 2011
Departed
KVCT · Victoria, TX
Destination
KHOU · Houston, TX

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
48
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
September 14, 2010
Seat
Right
Flight hours
5,699 total · 5 in this make and model · 5,401 as pilot in command · 62 in the last 90 days · 26 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 48 °F
Altimeter
30.00 inHg
Observed at
KVCT

Docket · 5

The files NTSB released with the investigation on August 1, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 984 KB in all.

FAA reports on this event · 1

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