# NTSB CEN18LA365: MD Helicopters MD-369, N1601Y, Orchard Lake, MI, September 3, 2018 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 3, 2018, 15:00 local (19:00 UTC) - Place: Orchard Lake, MI - Coordinates: 42.572223, -83.394996 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.5722&lon=-83.3950&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report September 14, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: MD Helicopters, Boeing, FAA East Michigan FSDO - NTSB case key (mKey): 98215 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA365 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98215/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98215 - Page: https://openairdocs.org/ntsb/CEN18LA365 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 6 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=3027369), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 2 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=3027369), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 3 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=3027369), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 2 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=3027369), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Object/animal/substance: animal(s)/bird(s)](https://openairdocs.org/ntsb-findings/03022045): Environmental issues › Physical environment · Response/compensation (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 1 case](https://openairdocs.org/ntsb-findings/03022045/cases.md?model=3027369), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/03022045/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Mcdonnell Douglas Helicopter 369E, 2 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=3027369), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Mcdonnell Douglas Helicopter 369E, 3 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=3027369), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## 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](https://openairdocs.org/deregistered/N1601Y-2023-08-08), registration cancelled 2023-08-08, S/N 0216E (OpenAirDocs) - Reported make and model: MD HELICOPTERS MD-369 (E) - Registry model: [Mcdonnell Douglas Helicopter 369E](https://openairdocs.org/model/mcdonnell-douglas-helicopter-369e) (registry code 3027369) (OpenAirDocs) - Registry engine: [Allison 250-C20 series](https://openairdocs.org/engine/allison-250-c20-series) (registry code 03020, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: 0216E - Year built: 1987 - Airframe hours: 2942 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 87; injuries: serious; 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 ## Other investigations on N1601Y (1) 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. - [NTSB LAX87LA157](https://openairdocs.org/ntsb/LAX87LA157), Mar 19, 1987: McDonnell Douglas 369E (N1601Y), Phoenix, AZ, substantial damage ## Docket (6 files) The files NTSB released with the investigation on June 18, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98215. 8.4 MB in all. - Accident Photographs (item 1, .PDF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484553&FileExtension=.PDF&FileName=Accident%20Photographs%20-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484554&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Record of Conversation (item 3, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484555&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation%20-Master.PDF - NTSB Party Member Forms (item 4, .PDF, 428 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484556&FileExtension=.PDF&FileName=NTSB%20Party%20Member%20Forms%20-Master.PDF - MD Helicopters Operational Safety Notice OSN2019-002 (item 5, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484557&FileExtension=.PDF&FileName=MD%20Helicopters%20Operational%20Safety%20Notice%20OSN2019-002-Master.PDF - USDA Living With Wildlife Canada Geese (item 6, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484558&FileExtension=.PDF&FileName=USDA%20Living%20With%20Wildlife%20Canada%20Geese%20-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.