# NTSB CEN20CA395: Bell 407, N489DM, Fort Worth, TX, September 15, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Data collection · Final report - Date: September 15, 2020, 16:53 local (21:53 UTC) - Place: Fort Worth, TX - Coordinates: 32.5942, -97.1917 - Nearby events: https://openairdocs.org/map.md?lat=32.5942&lon=-97.1917&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 101980 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20CA395 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101980/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101980 - Page: https://openairdocs.org/ntsb/CEN20CA395 ## Probable cause The flight instructor’s delay in rolling the throttle to the fly position during a practice autorotation maneuver that resulted in a hard landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Personnel issues](https://openairdocs.org/ntsb-findings/02060000): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/02060000/cases.md?model=1182206), [All aircraft, 137 cases](https://openairdocs.org/ntsb-findings/02060000/cases.md) - [Performance/control parameters: prop/rotor parameters](https://openairdocs.org/ntsb-findings/01062052): Aircraft › Aircraft oper/perf/capability · Related operating info (probable cause); cases with it: [Bell 407, 3 cases](https://openairdocs.org/ntsb-findings/01062052/cases.md?model=1182206), [All aircraft, 182 cases](https://openairdocs.org/ntsb-findings/01062052/cases.md) - [Performance/control parameters: descent rate](https://openairdocs.org/ntsb-findings/01062037): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Bell 407, 2 cases](https://openairdocs.org/ntsb-findings/01062037/cases.md?model=1182206), [All aircraft, 242 cases](https://openairdocs.org/ntsb-findings/01062037/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092) (defining event); cases with it: [Bell 407, 13 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=1182206), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis During a routine training flight, the helicopter was in the traffic pattern practicing power recovery auto-rotations, with the pilot under training at the flight controls. During the 5th practice auto-rotation, the flight instructor reduced the throttle, and the helicopter began a normal descent. During the deceleration flare, about 75 ft above ground level, the flight instructor heard the low rotor RPM audio tone. Using a positive transfer of control, the flight instructor quickly took the flight controls. He increased the throttle to what he believed to be the “FLY” position. The helicopter settled onto a taxiway. The main rotor blades severed the vertical fins on the horizontal stabilizer, and the tail rotor driveshaft was severed. The operator reported that the pilot did not rapidly roll the throttle to the “FLY” position during the deceleration/flare, and the helicopter contacted the ground at less than 100% rotor RPM. The operator stated that there were no mechanical anomalies with the helicopter that would have precluded normal operations. ## Aircraft - Registration: [N489DM](https://openairdocs.org/aircraft/N489DM), registered now, S/N 53619, built 2004 (OpenAirDocs) - Reported make and model: Bell 407 (No Series) - Registry model: [Bell 407](https://openairdocs.org/model/bell-407) (registry code 1182206) (OpenAirDocs) - Registry engine: [Rolls-Royce 250-C47B](https://openairdocs.org/engine/rolls-royce-250-c47b) (registry code 54585, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 53619 - Year built: 2004 - Airframe hours: 4775 - Engines: Rolls-Royc 250-C47B 650 horsepower turbo shaft - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Dea - Registered owner: Dea - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 1, 2020, 36 hours before - Departed: AFW, Fort Worth, TX - Flight plan: Company VFR - Airport: AFW, Fort Worth - Equipment: ADS-B, Data recorder, Electronic flight bag or handheld device, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 57; injuries: none; airline transport, flight instructor, commercial; airplane ratings: multi-engine sea, single-engine land; instrument ratings: helicopter; medical: class 1, with waivers/limitations; last flight review July 28, 2020; seat: left; restraint: 4-point; flight hours: 10,300 total, 912 in this make and model, 9,290 as pilot in command, 145 in the last 90 days, 85 in the last 30 days, 1 in the last 24 hours - Pilot; age 41; injuries: none; commercial; airplane ratings: single-engine sea; instrument ratings: airplane, helicopter; medical: class 2, without waivers/limitations; last flight review May 14, 2020; seat: right; restraint: 4-point; flight hours: 1,017 total, 135 in this make and model, 878 as pilot in command, 129 in the last 90 days, 37 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 61 °F - Altimeter: 29.94 inHg - Observed at: AFW, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20200915021479A](https://openairdocs.org/incident/20200915021479A), Sep 15, 2020: Bell 407, Fort Worth, TX, Substantial damage. On 09/15/2020 at 1720 CDT a Bell 407 helicopter suffered a hard landing on taxiway papa at alliance airport in Fort Worth, TX during autorotation training. The… ## Docket (2 files) The files NTSB released with the investigation on August 12, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101980. 6.6 MB in all. - NTSB form 6120 pilot operator report CEN20CA395 (item 1, PDF, 9 pages, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11759502&FileExtension=pdf&FileName=NTSB%20Form%206120%20Pilot%20Operator%20Report%20CEN20CA395_Redacted-Rel.pdf - Photo array CEN20CA395 (item 2, PDF, 3 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12214261&FileExtension=pdf&FileName=Photo%20Array%20CEN20CA395_Redacted-Rel.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.