CEN18LA306

NTSB accident investigation · Bell 47G 3B · Custer, SD · August 2, 2018

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
August 2, 2018, 09:20 local (15:20 UTC)
Place
Custer, SD
Injuries
1 minor, 2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N347BHBell 47G 3B
Defining event
Approach: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA
FAA report
20180802009539A
Case key
97971

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 mismanagement of rotor RPM and subsequent forced landing on uneven terrain which led to a dynamic rollover.

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.

Action: delayed actionPersonnel issues › Action/decision · PilotBell 47G-3B: 1 caseAll aircraft: 894 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-rated pilot and flight instructor were completing familiarization training in the accident helicopter. After successful training flights the morning of the accident, the flight instructor decided to remove the dual controls from the helicopter, and one additional passenger was loaded before practicing hovering and a low-rpm recovery. On approach to land during the accident flight, about 100 feet above ground level (agl), the pilot noticed the rotor rpms drop below the normal operating range. The pilot increased throttle but was unable to recover rotor rpms within the normal range. The flight instructor stated that the helicopter lost a lot of altitude quickly and there was no time to recover. The pilot attempted a forced landing on the side of a roadway but caught the right skid on uneven ground, which led to a dynamic rollover and substantially damaged the tail section and tail rotor. The flight instructor stated that the engine had no mechanical anomalies before the flight and that the engine had “performed well” during both the accident flight and previous flights. The helicopter likely lost power and altitude due to the pilot’s mismanagement of rotor rpm resulting in the pilot having to attempt a forced landing on uneven terrain and a subsequent dynamic rollover.

Factual narrative

On August 2, 2018, about 0920 mountain daylight time, a Bell 47G 3B helicopter, N347BH, was substantially damaged when it was involved in an accident near Custer, South Dakota. The pilot and passenger were not injured; the flight instructor received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The commercial-rated pilot and flight instructor completed several training flights in the accident helicopter before the accident flight to familiarize the pilot with Bell 47 helicopters. On the morning of the accident, the pilot completed hover practice and three circuits in the pattern at Crazy Horse Heliport (0SD9), Custer, South Dakota. Because the instructor did not intervene during the pattern work, the dual flight controls were removed to allow for additional occupants and for the accident pilot to practice flying with a heavier load like the pilot would encounter during future tour flight operations. After picking up a passenger, the pilot and flight instructor practiced hovering and a low-rpm recovery. The helicopter departed 0SD9 and followed a left traffic pattern. On the approach to land, about 100 feet agl, the pilot stated she noticed the rotor rpms drop below the normal operating range. She increased throttle but was unable to recover rotor rpms within normal range. The flight instructor stated that the helicopter lost a lot of altitude quickly and there was no time to recover. He also explained that the turbocharger on the engine had “some lag, the rotor rpm does not come back up with only opening the throttle but lowering the collective at that time was not an option due to the low altitude.” The helicopter continued to descend toward the ground with oncoming traffic on the road. The pilot executed a forced landing in a grassy area on the side of a highway. However, the right skid caught on uneven ground and the helicopter rolled over to the right on the sloping terrain, which substantially damaged the tail section and tail rotor. The flight instructor stated that the engine did not “shutter,” “kick,” or demonstrate another anomaly before or during the event and that the engine “performed well.” He also recalled that the engine did not have issues on any of the previous flights.

Aircraft

Registration
N347BH
Reported as
Bell 47G 3B (No Series)
Category
Helicopter
Serial number
2771
Built
1962
Airframe hours
1,998.1
Engine
Lycoming TVO-435D1B, 270 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Black Hill Aerial Adventure
Registered owner
Dakota Rotors
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 1, 2018 · 47.8 hours before
Departed
OSD9 · Custer, SD
Destination
Same as departure
Airport
OSD9 · Crazy Horse Base

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
32
Injuries
None
Certificates
Commercial, Flight instructor
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
May 23, 2018
Seat
Left
Restraint
4-point
Flight hours
1,063 total · 2 in this make and model · 884 as pilot in command · 176 in the last 90 days · 86 in the last 30 days · 7 in the last 24 hours
Role
Pilot-rated passenger
Injuries
Minor
Certificates
Flight instructor, Foreign, Commercial
Seat
Center
Restraint
Lap only
Flight hours
1,100 total

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 3 knots
Visibility
10 statute miles
Temperature
75 °F, dew point 32 °F
Altimeter
30.07 inHg
Observed at
KCUT, 405 nm away

Docket · 4

The files NTSB released with the investigation on April 19, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.2 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.

Other investigations on N347BH · 1

Matched to the same aircraft by N-number and date.