CEN18LA365

NTSB accident investigation · MD Helicopters MD-369 · Orchard Lake, MI · September 3, 2018

Accident · Serious injuriesLimited investigationFinal report
Date
September 3, 2018, 15:00 local (19:00 UTC)
Place
Orchard Lake, MI
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N1601YMD Helicopters MD-369
Defining event
Takeoff: Collision during takeoff/land
Weather
Visual (VMC) · Day
Status
Completed · report September 14, 2020
Report
Approved by Office Director
NTSB office
Central Region
Parties
MD Helicopters, Boeing, FAA East Michigan FSDO
Case key
98215

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 pilot's failure to maintain helicopter control and terrain clearance while in a hover after performing an evasive maneuver to avoid wildlife.

Findings · 5

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.

Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedMcdonnell Douglas Helicopter 369E: 3 casesAll aircraft: 1,310 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedMcdonnell Douglas Helicopter 369E: 2 casesAll aircraft: 3,958 casesProbable cause
Object/animal/substance: animal(s)/bird(s)Environmental issues › Physical environment · Response/compensationMcdonnell Douglas Helicopter 369E: 1 caseAll aircraft: 358 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 helicopter departed from a wheeled helicopter transportation dolly at the pilot's private heliport and came to an in-ground-effect hover. The pilot indicated that as he was maneuvering the helicopter to the right of the dolly at a hover, a flock of Canada geese "came flying in to the front and right" of the helicopter. The pilot reported "quickly moving" the helicopter back to the right to avoid the birds; that was the last action he could remember until after the impact. The helicopter came to rest on its left side with the main rotor blades separated from the main rotor hub and the tail rotor gearbox separated from the tailboom. The pilot reported there were no preimpact mechanical malfunctions or failures with the helicopter that would have precluded normal operation. The pilot's private heliport was near a lake where Canada geese are known to congregate. It is likely that, while in a hover and attempting to avoid the birds by performing an evasive maneuver, the pilot failed to maintain helicopter control and terrain clearance.

Factual narrative

On September 3, 2018, about 1500 eastern daylight time, a MD Helicopters 369E, N1601Y, sustained substantial damage when it was involved in an accident near Orchard Lake, Michigan. The private pilot sustained serious injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported he was planning a short flight in the local area. The helicopter was stationed on a wheeled helicopter transportation dolly at his private heliport. The helicopter departed from the dolly and came to an in-ground effect hover. As the pilot was maneuvering the helicopter to the right of the dolly at a hover, a flock of Canada geese (Branta canadensis) "came flying in to the front and right" of the helicopter. The pilot reported he remembered "quickly moving" the helicopter back to the right to avoid the birds, and that it was the last action he could recollect until after the impact when the helicopter was laying on its side. The helicopter came to rest on its left side on a flat grass field in front of the heliport, with the main rotor blades separated from the main rotor hub and the tail rotor gearbox separated from the tailboom. The pilot reported there were no preimpact mechanical malfunctions or failures with the airframe and engine that would have precluded normal operation. Emergency services personnel extracted the pilot from the wreckage. The pilot sustained serious injuries to his head and body. A review of the pilot's medical records by the NTSB found the left side of the pilot's face and the right side of the pilot's head sustained impact injuries from the accident sequence. The pilot was not wearing a flight helmet during the accident flight, nor was he required to do so. The NTSB investigator-in-charge proposed to the manufacturer's air safety department about producing and distributing educational guidance encouraging pilots to wear a flight helmet and the manufacturer agreed. MD Helicopters Operational Safety Notice OSN2019-002 Aviation Life Support Equipment – Flight Helmets was created and released to the public in April 2019. The pilot's private heliport is located about 350 ft south of the Upper Straits Lake in a residential area. According to the U.S. Department of Agriculture (USDA) Wildlife Services, Canada Geese build nests on the ground near water and consume grass and aquatic plants. The USDA additionally states that, "Canada geese can collide with aircraft causing fatal results."

Aircraft

Registration
N1601Y
Reported as
MD Helicopters MD-369 (E)
Category
Helicopter
Serial number
0216E
Built
1987
Airframe hours
2,942
Engine
Rolls-Royce 250-C20B, 492 horsepower, turbo shaft
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 17, 2018
Departed
7MI1 · Orchard Lake, MI
Destination
7MI1 · Orchard Lake, MI
Airport
7MI1 · McPhail Heliport
Equipment
Handheld GPS

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
87
Injuries
Serious
Certificate
Private
Medical
Class 3, With waivers/limitations
Last flight review
October 1, 2017
Seat
Left
Restraint
4-point
Flight hours
3,600 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 5 knots
Visibility
10 statute miles
Temperature
86 °F, dew point 70 °F
Altimeter
30.19 inHg
Observed at
KPTK, 6 nm away

Docket · 6

The files NTSB released with the investigation on June 18, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.4 MB in all.

Other investigations on N1601Y · 1

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