CEN16LA386

NTSB accident investigation · Bell 407 · Lawton, OK · September 29, 2016

Accident · Serious injuriesLimited investigationFinal report
Date
September 29, 2016, 06:00 local (11:00 UTC)
Place
Lawton, OK
Injuries
1 serious, 3 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N361SFBell 407
Defining event
Landing: Loss of control in flight
Weather
Visual (VMC) · Night
Status
Completed · report March 18, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
Transportation Safety Board of Canada, Federal Aviation Administration
FAA report
20160929016039A
Case key
94106

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

The pilot's loss of helicopter control during landing, which resulted in a hard landing and collision with a wall.

Findings · 1

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · OtherBell 407: 19 casesAll aircraft: 9,295 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 commercial pilot of the helicopter was approaching to land on a helipad. It was his first landing to this helipad, though he had departed from the helipad the day before. Due to trees and transmission lines near the helipad, the pilot flew a slight right-turning, steep approach. When the helicopter was about 125 ft above the pad and 150 ft to the southwest of it, the pilot commanded left cyclic to stop the right turn. He estimated the helicopter to be 40 knots above effective transitional lift, and in a stable 500 ft per minute descent; there was a headwind. The helicopter did not respond to his control input, and the pilot announced to the crew his intention to go around. He increased left cyclic until the cyclic was against his left leg and the helicopter still did not respond. The pilot lost control of the helicopter and it landed hard, colliding with a wall. Data extracted from the engine control unit (ECU) was consistent with the engine producing the required power and responding to collective control inputs; however, the data indicated that the main rotor speed and torque were exceeded. These exceedances suggested that a large demand for power was commanded by the pilot, likely during the go-around. Examination of the helicopter did not reveal any mechanical anomalies that would have precluded normal operation. The helicopter was in a right bank with 3 crewmembers seated on the right side of the helicopter, one crewmember seated on the left side, and was carrying a near-full fuel load. The distribution of crew members and a high torque setting may have contributed to the pilot's inability to maintain helicopter control; however, the extent to which these factors may have contributed could not be determined.

Factual narrative

On September 29, 2016, about 0600 central daylight time, N361SF, a Bell 407 helicopter, impacted terrain following a loss of control while attempting to land at the Comanche County Memorial Hospital Heliport (18OK), Lawton, Oklahoma. The pilot and 2 crew members had minor injuries. One crew member was seriously injured, and the helicopter was substantially damaged. The helicopter was owned and operated by Survival Flight under the provisions of 14 Code of Federal Regulations Part 135 as a positioning flight. Night visual meteorological conditions prevailed for the flight which operated on a company flight plan.The pilot reported that he approached the helipad from the southwest. It was his first landing to this helipad but had departed from the helipad on the day prior. Due to trees and transmission lines within 40-50 ft of the elevated helipad, the pilot flew a slight right-turning, steep approach. When the helicopter was approximately 125 ft above the pad and 150 ft to the southwest, the pilot commanded left cyclic to stop the right turn. He estimated the helicopter was below 40 knots, but above effective transitional life, with wind off the nose of the helicopter or slightly left, and a stable 500-ft per minute descent. The helicopter did not respond to his control input and the pilot announced his intension to the crew to go-around. He increased left cyclic until it was against his left leg and the helicopter still did not respond. The pilot lost control of the helicopter and it landed hard colliding with a wall. An inspector from the Federal Aviation Administration (FAA) examined the airframe with the assistance of a technical representative from Bell Helicopter. No preimpact anomalies were discovered with the wreckage. The engine control unit (ECU) was removed from the helicopter and sent to Triumph in West Hartford, Connecticut. With oversight from an FAA inspector, data from the unit was downloaded. The data extracted was consistent with the engine producing the required power and responding to collective control inputs. Exceedance information captured by the ECU recorded an exceedance of main rotor speed (Nr) and torque (Q). The unit recorded 10 lines of data with this exceedance which contained information consistent with the accident sequence. Prior to the accident there were 2 spikes in engine parameters. Without changes in collective inputs, demands of flight control inputs could impact a spike on engine demand. On the NTSB Form 6120, the pilot stated that the helicopter was loaded with 3 crew members on the right side of the helicopter, and a near full fuel load. Up to the accident landing, the helicopter had flown for 6 hours including 6 approaches and night landings at other hospitals without incident.

Aircraft

Registration
N361SF
Reported as
Bell 407
Category
Helicopter
Serial number
53490
Built
2001
Airframe hours
2,261.2
Engine
Allison 250-C47B, 813 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Viking Aviation LLC, doing business as Survival Flight Services LLC
Registered owner
Air ER LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · September 24, 2016
Departed
LAW · Lawton, OK
Destination
Lawton, OK
Flight plan
Company VFR
Equipment
Satellite tracking device, Auto-pilot

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
46
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
January 13, 2016
Seat
Front
Restraint
3-point
Flight hours
2,838 total · 140 in this make and model · 2,191 as pilot in command · 37 in the last 90 days · 21 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
360° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 48 °F
Altimeter
30.28 inHg
Observed at
KFSI, 3 nm away

Docket · 5

The files NTSB released with the investigation on April 12, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.6 MB 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.