CEN18LA290

NTSB accident investigation · Bell 206 · Todd Mission, TX · July 20, 2018

Accident · Minor injuriesLimited investigationFinal report
Date
July 20, 2018, 12:15 local (17:15 UTC)
Place
Todd Mission, TX
Injuries
2 minor, 2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N352CTBell 206
Defining event
Takeoff: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report September 14, 2020
Report
Approved by Office Director
NTSB office
Central Region
Parties
Rolls-Royce, FAA Houston FSDO, Transportation Safety Board of Canada, Bell Helicopter
FAA report
20180720018729A
Case key
97855

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 passenger’s inadvertent interference with the tail rotor pedals, which resulted in a loss of helicopter control during takeoff and the subsequent impact with terrain.

Findings · 3

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.

Rotorcraft flight control: tail rotor control systemAircraft › Aircraft propeller/rotor · Unintentional use/operationBell 206B: 2 casesAll aircraft: 13 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PassengerBell 206B: 11 casesAll aircraft: 1,386 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleBell 206B: 8 casesAll aircraft: 3,958 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 pilot landed the helicopter on a grass field so that the three passengers could switch seat positions during the local personal flight. As the helicopter took off from the field, it began to rotate to the right. Once airborne, the helicopter spun several revolutions to the right. The pilot reported that she applied full left pedal with no response from the helicopter. The left skid impacted the ground, and the helicopter rolled to the left and came to rest on the left side of the fuselage. The helicopter sustained substantial damage to the main rotor system, the fuselage, the tailboom, and the tail rotor system. A postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The cyclic, collective, and the two tail rotor pedals were installed on the left side of the helicopter. The passenger in the front left seat was asked if he had his feet on top of the tail rotor pedals; he reported "that or on the floor" and then stated that he was not sure. Postaccident passenger interference testing in a flight training device revealed performance similar to the helicopter's accident sequence. Although the pilot had briefed the passengers about not touching any of the flight controls, it is likely that, during the takeoff, the passenger had his feet either on or up against the tail rotor pedals, which resulted in the helicopter's rotation to the right and the subsequent loss of control.

Factual narrative

On July 20, 2018, about 1215 central daylight time, a Bell 206B, N325CT, sustained substantial damage when it was involved in an accident near Todd Mission, Texas. The private pilot and one passenger sustained minor injuries and two passengers sustained no injury. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. After flying in the local area and refueling, the pilot landed on a grass field to facilitate the passengers switching their seat positions in the helicopter. During the seat-switching process, the pilot reduced the throttle to the flight idle position. After the passengers switched seats and secured their restraint systems, with one passenger stationed in the front left seat, and two passengers stationed in the cabin, the pilot increased the throttle to 100 percent and lifted the helicopter off from the field. A review of accident sequence video footage shows that the helicopter began to rotate right during the takeoff. The pilot reported that about 10 ft above ground level with about 5 kts of forward airspeed and a heading of about 270°, the helicopter spun four 360° revolutions to the right. The pilot reported she applied full left pedal with no response from the helicopter. During the loss of control sequence, the pilot observed the torque gauge "jump" and she heard a "whining" noise emit from the engine. Prior to the impact with terrain, the pilot reduced the throttle to the flight idle position. The left skid impacted the ground, the helicopter rolled to the left, and came to rest on the left side of the fuselage. The pilot executed an emergency shutdown and the occupants egressed from the helicopter without further incident. The helicopter sustained substantial damage to the main rotor system, the fuselage, the tailboom, and the tail rotor system. A postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The helicopter had the cyclic, collective, and the two tail rotor pedals installed in the left side of the helicopter. The pilot reported that she briefed all of the passengers about not touching any of the flight controls. The passenger in the front left seat was asked if he had his feet on top of the tail rotor pedals as a footrest. He stated "that or on the floor," and then stated that he was not sure. The passenger further reported that the pilot did give a passenger safety briefing about not touching any of the flight controls. Postaccident testing was conducted in a Bell 206B flight training device. Wind conditions were replicated for the accident site. The National Transportation Safety Board (NTSB) investigator-in-charge (IIC) rested his feet on top of the tail rotor pedals for two flight iterations with no force applied and with medium force applied. When the Bell chief training pilot (CTP) attempted to takeoff for both iterations, the helicopter started to immediately rotate tothe right. The CTP had a hard time maintaining directional control due to the interference of the feet on the tail rotor pedals. The NTSB IIC also placed the tips of his feet on the floorboards up against the tail rotor pedals. When the CTP attempted to takeoff for the third iteration, the helicopter started to immediately rotate to the right. The CTP had a hard time maintaining directional control due to the interference of the feet up against the tail rotor pedals. A review of the Bell 206B rotorcraft flight manual found no guidance regarding the carrying of passengers in the cockpit and the interference of flight controls. The Federal Aviation Administration Helicopter Flying Handbook (FAA-H-8083-21B) discusses operations when carrying passengers in the cockpit and states, "If possible, remove front passenger flight controls and ensure all passenger personal items, such as cameras and mobile phones are secure."

Aircraft

Registration
N352CT
Reported as
Bell 206 (B)
Category
Helicopter
Serial number
340
Built
1969
Airframe hours
7,102.6
Engine
Rolls-Royce 250-C20, 400 horsepower, turbo shaft
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 23, 2017
Departed
DWH · Houston, TX
Destination
Pinehurst, TX
Equipment
Electronic primary flight display

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
73
Injuries
Minor
Certificate
Private
Medical
Class 3, With waivers/limitations
Last flight review
January 10, 2018
Seat
Right
Restraint
4-point
Flight hours
3,780 total

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 73 °F
Altimeter
29.97 inHg
Observed at
KDWH, 19 nm away

Docket · 9

The files NTSB released with the investigation on June 26, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 366 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.