CEN19FA020

NTSB accident investigation · Hughes 369 · McDougal, AR · November 2, 2018

Accident · FatalClass 2 · FieldFinal report
Date
November 2, 2018, 13:15 local (18:15 UTC)
Place
McDougal, AR
Injuries
1 fatal, 2 minor
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N5187SHughes 369
Defining event
Maneuvering-low-alt flying: Low altitude operation/event
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Central Region
Parties
Air2, MD Helicopters, Boeing, FAA, Rolls-Royce Engines
FAA report
20181102021389A
Case key
98586

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 the helicopter's clearance from the powerline structure while hovering in gusty wind conditions, which resulted in an inadvertent collision with the structure and an uncontrolled descent into terrain.

Findings · 4

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.

Object/animal/substance: wireEnvironmental issues › Physical environment · Effect on equipmentHughes Helicopters HUGHES 369D: 11 casesAll aircraft: 588 casesProbable cause
Performance/control parameters: heading/courseAircraft › Aircraft oper/perf/capability · Not attained/maintainedHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 82 casesProbable cause
Wind: gustsEnvironmental issues › Conditions/weather/phenomena · Effect on operationHughes Helicopters HUGHES 369D: 2 casesAll aircraft: 1,199 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 and two crewmembers of the helicopter were performing external load operations to decommission power line structures. The crew reported that, during the first flight after their lunch break, the pilot was hovering the helicopter next to the power line structure when they heard a "loud boom" and "metallic crunch" and the crews' short haul lines were released from the helicopter. The helicopter descended and impacted the ground beneath the structure, fatally injuring the pilot, while the two crewmembers sustained minor injuries. A postaccident examination of the helicopter revealed no mechanical anomalies that would have precluded normal operation. The power line structure displayed an indentation consistent with impact with the top of the new steel utility pole. There was also a gouge mark to the side of the upper cap plate of the structure, consistent in shape with the indentation mark to the pole. Therefore, it is likely that the pilot failed to maintain clearance from the power line structure while hovering, resulting in contact with the structure. One lineman stated that before the impact, the pilot did not seem calm and hesitated in responding to the lineman's communications. He said that the helicopter was moving around a lot when he was attaching to the pole, and he could see the helicopter shadow and saw the tail "darting around." Weather data at the time of the accident indicated the winds were 12 knots gusting to 19-25 knots from the southwest with likely unstable air from the surface up to an altitude of 400-500 ft. It is likely the pilot had difficulty maintaining the helicopter's clearance from the utility pole due to the gusty wind conditions. Toxicology testing performed on the pilot revealed diphenhydramine and tramadol in the pilot's blood and urine. Because both drugs undergo postmortem redistribution, the investigation could not determine whether the pilot was impaired by either drug.

Factual narrative

Note: Re-registration of the helicopter from N5187 to N454AR was pending with the Federal Aviation Administration (FAA), however, the tail number had already been repainted to reflect the new registration. Narrative damage to aircraft place holder Narrative additional information place holder Narrative flight recorders place holder Narrative other damage place holder On October 2, 2018 about 1315 central daylight time, a Hughes 369D helicopter, N5187S, was destroyed when it was involved in an accident near McDougal, Arkansas. The pilot was fatally injured, and the two linemen sustained minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 133 external load operation. The helicopter had departed from a grass landing zone after a lunch break with two linemen tethered to the helicopter for short haul operations in connection with utility line work to decommission power line structures. Figure 1: Main Wreckage and Landing Zone Locations One of the linemen stated he was in communication with the pilot via a Bluetooth communication system to coordinate his placement on the utility pole. The pilot was hovering the helicopter next to the power line structure when they heard a "loud boom" and "metallic crunch" and the crews' short haul lines were released from the helicopter. The helicopter descended and impacted the ground beneath the structure. The lineman stated that the pilot typically had a calm demeanor during operations; however, before the pole strike, the pilot was not calm and hesitated in responding to the lineman's communications. The lineman said the helicopter was "getting choppy and moving around a lot" when he was attaching to the utility pole, but he did not look up at the helicopter. He could see the helicopter shadow on the ground and saw the tail "darting around." Figures 3 and 4: Photograph of Impact of Top of Steel Utility Pole and Cap Plate with Impact Mark A postaccident examination of the helicopter revealed no mechanical anomalies that would have precluded normal operation. Narrative communications place holder The area surrounding the accident site was documented using official Meteorological Aerodrome Reports (METARs) and Specials (SPECIs). Figure 5: Sectional chart of accident area with the location of the accident site and the closest surface observation site. Observations from the two closest airports to the accident site, around the accident time, indicated visual flight rules conditions; however, the winds increased in magnitude with gusts to 19 knots out of the southwest. At K4M9, weather at 1315 CDT, automated, wind from 250° at 12 knots. At 1335 CDT, automated weather at K4M9 was wind from 240° at 10 knots with gusts to 17 knots. At KPOF weather at 1253 CDT, automated, wind from 220° at 11 knots. At 1353 CDT, automated weather at KPOF was wind from 220° at 14 knots with gusts to 19 knots. The closest weather surveillance radar located in Memphis, Tennessee, indicated reflectivityvalues between 20 and 34 dBZ moved from west to east above the accident site at the accident time. These reflectivity values corresponded to light to moderate precipitation and occurred at the same time as the wind gusts increased to 17 knots at Corning Municipal Airport at 1335, which was located 10 miles west-southwest of the accident site. There were no lightning flashes around the accident site at the accident time. Based on information from one of the linemen, the accident pilot checked the weather conditions before the flight, but it is unknown which weather products the pilot checked. A search of archived ForeFlight information indicated that the accident pilot did not review or request any weather information from ForeFlight. It is unknown if the accident pilot checked or received additional weather information during the accident flight. Narrative survival aspects place holder Narrative injuries to persons place holder Narrative personal information place holder The State Crime Laboratory, Little Rock, Arkansas, performed an autopsy of the pilot. The cause of death was multiple traumatic injuries and drowning, and the manner of death was accident. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected the sedating antihistamine diphenhydramine at 0.037 micrograms per milliliter (µg/mL) in the pilot's blood; diphenhydramine was also detected in urine. Diphenhydramine (commonly marketed as Benadryl) is available over the counter in products used to treat colds, allergies, and insomnia. The therapeutic range is 0.025 to 0.100 µg/mL. Diphenhydramine undergoes postmortem distribution and central levels may be two to three times higher than peripheral levels. Tramadol (commonly marketed as Ultram) was detected in cavity blood at 0.058 µg/mL; tramadol and its active metabolite O-desmethyltramadol were detected in the pilot's urine. Tramadol is an opioid analgesic used to relieve moderate to severe pain. Tramadol carries the warning that it may impair mental or physical ability required for the performance of hazardous tasks. The therapeutic range for tramadol is 0.05 to 0.50 µg/mL in blood. Tramadol undergoes postmortem redistribution and there is a high degree of inter-individual variation in its distribution in the body. Narrative fire place holder Narrative tests and research place holder The main wreckage came to rest on the north side of wooden and steel utility pole structures in a muddy soybean field. This area of the field was flooded with about 2 ft of water at the time of the accident due to heavy rains prior to the accident. The helicopter impacted the ground on the right side; the damage was consistent with nearly vertical forces. The main wreckage included the fuselage, left skid and rear strut, right rear strut, main rotor drive shaft, and engine. All five main rotor blades, the tail rotor section, tail boom, and right skid were found in the area surrounding the main wreckage. Figure 2: Main Wreckage Beforeimpacting the ground, the helicopter's main rotor blades impacted the top of the steel utility pole. A drone was used to observe the impact damage and showed an inward indentation in the top of the pole, as shown in Figure 3. The tower cap plate was separated and about 3/4 of the plate was submerged in water. There was a gash in the side of the plate, as shown in Figure 4. Gash in the Side of Cap Plate Platelate Impact Damage from Main Rotor Blade

Aircraft

Registration
N5187S
Reported as
Hughes 369 (D)
Category
Helicopter
Serial number
610968D
Built
1982
Airframe hours
14,109.3
Engine
Rolls Royce M250-C20B, 420 horsepower, turbo shaft
Damage
Destroyed
Flight
External load · Part 133
Operator
Air2 LLC
Registered owner
Air2 LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 7, 2018
Departed
McDougal, AR
Destination
McDougal, AR
Equipment
ADS-B

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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Injuries
Fatal
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
June 3, 2018
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
9,999 total · 9,999 in this make and model · 3,272 as pilot in command · 103 in the last 90 days · 38 in the last 30 days · 4 in the last 24 hours
Role
Other flight crew
Injuries
Minor
Restraint
3-point
Role
Other flight crew
Injuries
Minor
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
50 °F, dew point 46 °F
Altimeter
29.20 inHg
Observed at
K4M9, 21 nm away

Docket · 12

The files NTSB released with the investigation on November 17, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.