CEN15MA290

NTSB accident investigation · Airbus Helicopters AS350B3E · Frisco, CO · July 3, 2015

Accident · FatalClass 1 · MajorFinal report
Date
July 3, 2015, 13:39 local (19:39 UTC)
Place
Frisco, CO
Injuries
1 fatal, 2 serious
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N390LGAirbus Helicopters AS350B3E
Defining event
Takeoff: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report May 9, 2017
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Central Region
Parties
Turbomeca, Air Methods Corporation, BEA, OPEIU - Local 109, Airbus, FAA Denver FSDO, FAA AVP-100
Safety recommendations
Yes
FAA report
20150703023559A
Case key
91489

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

On this page

Probable cause

Airbus Helicopters' dual-hydraulic AS350 B3e helicopter's (1) preflight hydraulic check, which depleted hydraulic pressure in the tail rotor hydraulic circuit, and (2) lack of salient alerting to the pilot that hydraulic pressure was not restored before takeoff. Such alerting might have cued the pilot to his failure to reset the yaw servo hydraulic switch to its correct position during the preflight hydraulic check, which resulted in a lack of hydraulic boost to the pedal controls, high pedal forces, and a subsequent loss of control after takeoff. Contributing to the accident was the pilot's failure to perform a hover check after liftoff, which would have alerted him to the pedal control anomaly at an altitude that could have allowed him to safely land the helicopter. Contributing to the severity of the injuries was the helicopter's fuel system, which was not crash resistant and facilitated a fuel-fed postcrash fire.

Findings · 11

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.

Design: equipment designOrganizational issues › Development · ManufacturerAmerican Eurocopter AS350B3: 1 caseAll aircraft: 35 casesProbable cause
Design: design of document/infoOrganizational issues › Development · ManufacturerAmerican Eurocopter AS350B3: 1 caseAll aircraft: 11 casesProbable cause
Hydraulic power systemAircraft › Aircraft systems · DesignAmerican Eurocopter AS350B3: 1 caseAll aircraft: 22 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotAmerican Eurocopter AS350B3: 1 caseAll aircraft: 792 casesProbable cause
Fuel systemAircraft › Aircraft systems · DesignAmerican Eurocopter AS350B3: 1 caseAll aircraft: 181 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

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-17/01. On July 3, 2015, about 1339 mountain daylight time, an Airbus Helicopters AS350 B3e helicopter, N390LG, registered to and operated by Air Methods Corporation, lifted off from the Summit Medical Center Heliport, Frisco, Colorado, and then crashed into a parking lot; the impact point was located 360 feet southwest of the ground-based helipad. The pilot was fatally injured, and the two flight nurses were seriously injured. The helicopter was destroyed by impact forces and a postcrash fire. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135 on a company flight plan. Visual meteorological conditions prevailed at the time of the accident.

Factual narrative

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-17/01. On July 3, 2015, about 1339 mountain daylight time, an Airbus Helicopters AS350 B3e helicopter, N390LG, registered to and operated by Air Methods Corporation, lifted off from the Summit Medical Center Heliport, Frisco, Colorado, and then crashed into a parking lot; the impact point was located 360 feet southwest of the ground-based helipad. The pilot was fatally injured, and the two flight nurses were seriously injured. The helicopter was destroyed by impact forces and a postcrash fire. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135 on a company flight plan. Visual meteorological conditions prevailed at the time of the accident.

Aircraft

Registration
N390LG
Reported as
Airbus Helicopters AS350B3E
Category
Helicopter
Serial number
7595
Built
2013
Airframe hours
487.4
Engine
Turbomeca Arriel 2D, 802 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Air Methods Corp
Registered owner
Air Methods Corp
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · July 2, 2015
Departed
91CO · Frisco, CO
Destination
Gypsum, CO
Flight plan
Company VFR
Airport
91CO · Summit Medical Center, runway H1, 100 × 100 ft, concrete
Equipment
Electronic primary flight display, Electronic multifunction display, Data recorder, Onboard weather, Video recording device, Satellite tracking device

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
64
Injuries
Fatal
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
March 22, 2015
Seat
Front
Restraint
3-point
Toxicology
Performed
Flight hours
13,231 total · 5,231 in this make and model · 13,131 as pilot in command · 20 in the last 90 days · 12 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 19 knots, gusting 24
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 28 °F
Altimeter
30.62 inHg
Observed at
KCCU, 7 nm away

Docket · 53

The files NTSB released with the investigation on August 17, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 95.8 MB in all.

Airworthiness Group Chairman's Factual ReportItem 1 · .PDF · 16 photos · 3.4 MBAirworthiness Attachment 1 - SIN 2776-S-29Item 2 · .PDF · 851 KBAirworthiness Attachment 2 - SB AS350-67.00.64Item 3 · .PDF · 1.6 MBAirworthiness Attachment 3 - SB AS360-67.00.66Item 4 · .PDF · 3.7 MBAirworthiness Attachment 4 - AD 2015-22-53Item 5 · .PDF · 146 KBAirworthiness Group Chairman's Factual Report ErrataItem 6 · .PDF · 32 KBHuman Performance FactualItem 7 · .PDF · 167 KBHuman Performance Attachment 1 - Interview SummariesItem 8 · .PDF · 278 KBHuman Performance Attachment 2 - Interview TranscriptsItem 9 · .PDF · 949 KBHuman Performance Attachment 3 - AS350B3e ChecklistsItem 10 · .PDF · 429 KBHuman Performance Attachment 4 - GOM Risk Assessment ProgramItem 11 · .PDF · 214 KBHuman Performance Attachment 5 - AS350 Differences Training TableItem 12 · .PDF · 172 KBHuman Performance Attachment 6 - Test Plan and ResultsItem 13 · .PDF · 230 KBAirbus SIN-2992-S-00Item 14 · .PDF · 532 KBMeteorology Group Chairman's Factual ReportItem 15 · .PDF · 12.8 MBMeteorology Attachment 1 - Visible Satellite LoopItem 16 · .PDF · 88 KBMeteorology Attachment 2 - Radar Loop for KFTG (0.9)Item 17 · .PDF · 88 KBMeteorology Attachment 3 - Radar Loop for KFTG (1.3)Item 18 · .PDF · 88 KBMeteorology Attachment 4 - WRF Hortizontal Speed Animation (North to South)Item 19 · .PDF · 88 KBMeteorology Attachment 5 - WRF Horizontal Speed Animation (West to East)Item 20 · .PDF · 88 KBMeteorology Attachment 6 - WRF Vertical Speed Animation (North to South)Item 21 · .PDF · 88 KBMeteorology Attachment 7 - WRF Vertical Speed Animation (West to East)Item 22 · .PDF · 88 KBMeteorology Attachment 8 - WRF Relative Humidity Animation (West to East)Item 23 · .PDF · 88 KBPerformance StudyItem 24 · .PDF · 4 photos · 1.8 MBVideo StudyItem 25 · .PDF · 3 photos · 132 KBOnboard Image Recorder Factual ReportItem 26 · .PDF · 9 photos · 830 KBOnboard Image Recorder Attachment 1 - University ReportItem 27 · .PDF · 5.5 MBOnboard Image Recorder Attachment 2 - CT Scan Report (Appareo)Item 28 · .PDF · 758 KBDigital Engine Control Unit Factual ReportItem 29 · .PDF · 6 photos · 419 KBFlight Data Monitoring Data - Specialist's StudyItem 30 · .PDF · 187 KBMaterials Laboratory Report - Collective SwitchesItem 31 · .PDF · 831 KBComputed Tomography Specialist's Factual ReportItem 32 · .PDF · 24 photos · 7.9 MBSurvival Factors 6 – Survival Factors Group Chairman’s Factual ReportItem 33 · .PDF · 2.1 MBMedical Factual ReportItem 34 · .PDF · 175 KBToxicological Report - MahanyItem 35 · .PDF · 171 KBInjury Factual ReportItem 36 · .PDF · 357 KBWitness StatementsItem 37 · .PDF · 965 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 38 · .PDF · 1.1 MBFlight for Life Morning Briefing TranscriptItem 39 · .PDF · 39 KBOCC TranscriptsItem 40 · .PDF · 53 KBAir Methods Mechanic StatementItem 41 · .PDF · 73 KBMaintenance RecordsItem 42 · .PDF · 43.0 MBStatement of Party Representatives to NTSB InvestigationItem 43 · .PDF · 169 KBSafety Recommendation Transmittal Letter A-16-008-010Item 44 · .PDF · 34 KBSafety Recommendation Report A-16-008 through A-16-011Item 45 · .PDF · 125 KBSafety Recommendation Transmittal Letter A-16-011Item 46 · .PDF · 30 KBErrata Medical Factual ReportItem 47 · .PDF · 423 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 48 · .PDF · 47 KBAir Methods SubmissionItem 49 · .PDF · 429 KBAirbus Helicopter SubmissionItem 50 · .PDF · 203 KBProfessional Helicopter Pilots Association International SubmissionItem 51 · .PDF · 86 KBASR-16-02 correctedItem 52 · .PDF · 65 KBNTSB - Adopted Board ReportItem 53 · .PDF · 5 photos · 1.8 MB

FAA reports on this event · 1

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