# NTSB CEN11LA339: MD Helicopter 369E, N4278T, Victoria, TX, May 16, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 16, 2011, 13:05 local (18:05 UTC) - Place: Victoria, TX - Coordinates: 28.884445, -96.838607 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.8844&lon=-96.8386&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report November 7, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, MD Helicopters Inc, Rolls-Royce - NTSB case key (mKey): 79110 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA339 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/79110/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=79110 - Page: https://openairdocs.org/ntsb/CEN11LA339 ## Probable cause The pilot’s failure to ensure that the governor limit switch was properly set, which resulted in reduced engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel controlling system](https://openairdocs.org/ntsb-findings/01057320): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [MD Helicopters 369E, 1 case](https://openairdocs.org/ntsb-findings/01057320/cases.md?model=3030008), [All aircraft, 59 cases](https://openairdocs.org/ntsb-findings/01057320/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [MD Helicopters 369E, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=3030008), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [MD Helicopters 369E, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=3030008), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Autorotation: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [MD Helicopters 369E, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=3030008), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [MD Helicopters 369E, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=3030008), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N4278T-2012-11-26), registration cancelled 2012-11-26, S/N 0605E, built 2010 (OpenAirDocs) - Reported make and model: MD HELICOPTER 369E - Registry model: [MD Helicopters 369E](https://openairdocs.org/model/md-helicopters-369e) (registry code 3030008) (OpenAirDocs) - Registry engine: [Allison 250-C20R/2](https://openairdocs.org/engine/allison-250-c20r-2) (registry code 03092, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 0605E - Airframe hours: 80 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20110516013289A](https://openairdocs.org/incident/20110516013289A), May 16, 2011: Md Helicopters Inc 369E, Victoria, TX, Substantial damage. Aircraft departed Victoria, Texas (kvct). Pilot reported to tower he had lost partial power and was down in a field with no injuries. Total flight time… ## Docket (5 files) The files NTSB released with the investigation on August 1, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=79110. 984 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 559 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40368596&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement: Follow-up pilot statement (item 2, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40368597&FileExtension=.PDF&FileName=Witness%20Statement%3A%20Follow-up%20pilot%20statement-Master.PDF - Pilot Statement to FAA FSDO (item 3, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370429&FileExtension=.PDF&FileName=Pilot%20Statement%20to%20FAA%20FSDO-Master.PDF - Photo 1: Rear view of helicopter (item 4, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370430&FileExtension=.PDF&FileName=Photo%201%3A%20Rear%20view%20of%20helicopter-Master.PDF - Photo 2: Photo of helicopter skid (item 5, .PDF, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370431&FileExtension=.PDF&FileName=Photo%202%3A%20Photo%20of%20helicopter%20skid-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.