# NTSB CEN16CA393: Bell 230, N903SH, Fargo, ND, September 30, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 29, 2016, 22:00 local (Sep 30, 2016, 03:00 UTC) - Place: Fargo, ND - Coordinates: 46.884723, -96.785552 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.8847&lon=-96.7856&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 94151 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16CA393 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94151/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94151 - Page: https://openairdocs.org/ntsb/CEN16CA393 ## Probable cause The pilot's failure to maintain clearance from the ground obstacle during the landing with gusting winds present. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Bell 230, 2 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1182149), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Bell 230, 1 case](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=1182149), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Bell 230, 1 case](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=1182149), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) - [Object/animal/substance: pole](https://openairdocs.org/ntsb-findings/03022010): Environmental issues › Physical environment · Awareness of condition (probable cause); cases with it: [Bell 230, 1 case](https://openairdocs.org/ntsb-findings/03022010/cases.md?model=1182149), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Bell 230, 2 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=1182149), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The pilot reported that he performed his approach into the wind. On short final he could feel periodic gusts of wind. The pilot executed the standard approach to the helipad and the helicopter encountered another gust that picked the helicopter's nose up as it was moving over the pad. He maneuvered the helicopter to center it over the pad when he heard a sound like "metal on metal as if the tail rotor had hit something a couple times." The pilot felt no initial feedback in the controls, he felt the helicopter yaw to the left, and the helicopter continued to yaw to the left with his full application of right pedal. He lowered the collective and rolled off the throttle to enter a hovering autorotation and attempted to land it as level as possible. The helicopter landed hard. The operator reported substantial ground damage occurred to the tail rotor gearbox and tail rotor blades and a review of images revealed damage to the tailboom. A nearby fence and light were reported to be damaged. The operator's accident report indicated that there were no mechanical malfunctions with the helicopter. ## Factual narrative The pilot reported that he performed his approach into the wind. On short final he could feel periodic gusts of wind. The pilot executed the standard approach to the helipad and the helicopter encountered another gust that picked the helicopter's nose up as it was moving over the pad. He maneuvered the helicopter to center it over the pad when he heard a sound like "metal on metal as if the tail rotor had hit something a couple times." The pilot felt no initial feedback in the controls, he felt the helicopter yaw to the left, and the helicopter continued to yaw to the left with his full application of right pedal. He lowered the collective and rolled off the throttle to enter a hovering autorotation and attempted to land it as level as possible. The helicopter landed hard. The operator reported substantial ground damage occurred to the tail rotor gearbox and tail rotor blades and a review of images revealed damage to the tailboom. A nearby fence and light were reported to be damaged. The operator's accident report indicated that there were no mechanical malfunctions with the helicopter. ## Aircraft - Registration: [N903SH](https://openairdocs.org/deregistered/N903SH-2016-12-28), registration cancelled 2016-12-28, S/N 23002, built 1994 (OpenAirDocs) - Reported make and model: BELL 230 (NO SERIES) - Registry model: [Bell 230](https://openairdocs.org/model/bell-230) (registry code 1182149) (OpenAirDocs) - Registry engine: [Allison 250-C30 series](https://openairdocs.org/engine/allison-250-c30-series) (registry code 03015, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 23002 - Year built: 1994 - Airframe hours: 9012.4 - Engines: ALLISON 250-C30 SER 650 horsepower turbo shaft; ALLISON 250-C30 SER 650 horsepower turbo shaft - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Sanford Health, doing business as Sanford AirMed - Registered owner: Sanford Health - Airworthiness certificate: Standard, Normal - Last inspection: September 6, 2016 - Departed: KFAR, Fargo, ND - Destination: ND48, Fargo, ND - Flight plan: Company VFR - Airport: ND48, Sanford Health, runway H1, 30 × 30 ft, concrete - Equipment: Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; commercial; airplane ratings: multi-engine land; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review May 3, 2016; seat: right; restraint: 4-point; flight hours: 2,209.1 total, 197.6 in this make and model, 1,589 as pilot in command ## Weather - Conditions: Visual (VMC), Night - Wind: 100° at 10 knots, gusting 20 - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 45 °F - Altimeter: 30.37 inHg - Turbulence: Light - Observed at: KFAR, 3 nm away ## 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 20160929019709A](https://openairdocs.org/incident/20160929019709A), Sep 29, 2016: Bell 230, Fargo, ND, Substantial damage. While executing an approach to the helipad, a gust of wind lifted the nose of the aircraft forcing the tail rotor to make contact with a fence surrounding a… ## Docket (1 files) The files NTSB released with the investigation on November 30, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94151. 2.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446056&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-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.