ERA09LA173

NTSB accident investigation · Hughes 369F · Moyock, NC · February 24, 2009

Accident · FatalLimited investigationFinal report
Date
February 24, 2009, 13:36 local (18:36 UTC)
Place
Moyock, NC
Injuries
1 fatal, 1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N5205CHughes 369F
Defining event
Maneuvering-hover: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report January 7, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20090224004189A
Case key
73388

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 flight instructor's failure to verify that the helicopter's skid was clear of an obstruction while demonstrating a one-skid and toe-in landing maneuver. Contributing to the accident was the flight instructor's decision to practice this maneuver at an unauthorized landing site.

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.

Info processing/decision: decision making/judgmentPersonnel issues › Action/decision · Instructor/check pilotAll aircraft: 3,098 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotAll aircraft: 792 casesProbable cause
Performance/control parameters: lateral/bank controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleAll aircraft: 390 casesProbable cause
Object/animal/substanceEnvironmental issues › Physical environment · Contributed to outcomeAll aircraft: 224 cases

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 purpose of the accident flight was to provide familiarization training in the MD-530 to an experienced and qualified helicopter pilot, recently hired by the company, before that new pilot’s deployment to Iraq. The certificated flight instructor (CFI) chose to demonstrate one-skid and toe-in landings/confined area landing technique on a ship simulator. The maneuver was beyond basic familiarization procedures and the site chosen by the flight instructor was not approved for familiarization training. The student pilot stated that the CFI did a circling pattern around the simulators to make sure that they were clear. Then he started an approach to the top rail. When they got close to touching down the student leaned forward and looked at the toe of the skid and saw it was under the top rail. He was reaching for the press to talk button to tell the CFI when the helicopter flipped over the railing and into a stairwell.

Factual narrative

On February 24, 2009, about 1336 eastern standard time, a Hughes 369F helicopter, N5205C, registered to EP Aviation LLC, and operated by Presidential Airways Incorporated, crashed into a ship board landing simulator (Conex), while practicing skid toe landings, at the Blackwater Airstrip (NC61), Moyock, North Carolina. The airline transport pilot, certified flight instructor (CFI) was killed and the commercial-rated student pilot received minor injuries. The helicopter sustained substantial damage. The flight was operated as an instructional flight under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and no flight plan was filed. Visual meteorological conditions prevailed (VMC) at the time of the accident. The flight departed from Elizabeth City CG Air Station/Regional Airport (ECG), Elizabeth City, North Carolina, about 1230 the same day. According to the student, they departed ECG after lunch for the afternoon portion of training. They arrived at the hangar at NC61 and the ground crew at Presidential Airways repositioned the "Little Bird" docking cart. The pilots practiced the toe landings and then single skid landings to both sides. The CFI demonstrated one landing to each side and then the student performed three to four landings on each side. At the completion of these practice landings they repositioned to the conexes to practice the same toe landings. At the completion of those practice landings, they proceeded to the ship board landing simulators, which were constructed of conexes. The student pilot stated that the CFI did a circling pattern around the simulators to make sure they were clear. Then he started an approach to the top rail. When they got close to touching down, the student leaned forward and looked at the toe of the skid and saw it was under the top rail. He was reaching for the press to talk button to tell the CFI when the helicopter flipped over the railing and into a stairwell. When the helicopter settled, the engine was still running. The student went to shut it off and found the throttle was at idle, and he rolled it the rest of the way to the off position. The student pilot released his restraint and tried to get the CFI to respond, but he did not. He pulled the CFI from the helicopter and got him to the ground where paramedics were waiting. Witnesses in the local area who observed the helicopter landing on the conex stated that they believed that the helicopter got one or both skids stuck on the railings of the conex and then flipped over. According to Presidential Airways, the purpose of the accident flight was to provide familiarization training in the MD-530 to an experienced and qualified helicopter pilot, recently hired by the company, before that new pilot’s deployment to Iraq. All mission-specific training for the pilot was to be conducted in Iraq with more experienced pilots. Therefore, the company evaluated the accident flight as “low risk,” as only basic procedures were to be practiced. Forundetermined reasons, the flight instructor chose to demonstrate one-skid and toe-in landings/confined area landing technique on a ship simulator. The maneuver was beyond basic familiarization procedures, and the site chosen by the flight instructor was not approved for the training. The CFI, age 53, held an FAA airline transport pilot certificate, with airplane single engine land, multi-engine land, rotorcraft helicopter, instrument ratings in rotorcraft and airplanes, and flight instructor ratings for rotorcraft and instrument rotorcraft. The CFI held a second-class medical certificate issued on September 29, 2008, with a restriction that he must wear corrective lenses. According to the helicopters operator, the CFI had accumulated 9,000 hours as pilot in command in all aircraft and 1,300 hours as a CFI in helicopters. Examination of the helicopter by the Federal Aviation Administration (FAA) found it inverted in the stairwell of the second level of the conex. The top rail of the upper conex was broken and hanging down from its original location. Railings on the second level were observed impact damaged and bowed downward in the middle. The helicopter was recovered and transported to a Presidential Airways hangar for further examination. The FAA inspector found the main rotor blades broken and partially separated. The tail boom sustained substantial damage and the tail rotor blades were partially separated. According to the FAA inspector, no preimpact failures or malfunctions of the airframe or engine were identified that would have prevented normal operation. An autopsy was performed on the pilot on February 26, 2009, by the Brody School of Medicine at East Carolina University, Greenville, North Carolina. The autopsy findings included, "Blunt and crush force injuries of head due to helicopter crash." Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report indicated that there was not carbon monoxide or cyanide in the blood, and no ethanol detected in Vitreous and no drugs detected in blood. As a result of this accident Presidential Airways, made several safety improvements in their training operations; to include closure of the training site used by the accident crew, creation of a local risk mitigation form to be completed before each training flight, instituted a local area/training mission release process approved only by the Director of Operations or appropriate Chief Pilot, and has validated that all training programs adhere to the FAA practical Test Standards.

Aircraft

Registration
N5205C
Reported as
Hughes 369F
Category
Helicopter
Serial number
0015F
Airframe hours
2,870
Engine
Allison 250-C30, 650 horsepower, turbo shaft
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Presidential Airways Inc.
Registered owner
EP Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 20, 2008 · 36 hours before
Departed
NC61 · Moyock, NC
Destination
NC61 · Moyock, NC
Airport
NC61 · Blackwater Airstrip

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
53
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
April 30, 2008
Seat
Left
Toxicology
Performed
Flight hours
9,000 total · 9,000 as pilot in command · 4 in the last 24 hours
Role
Student pilot
Age
31
Injuries
Minor
Certificates
Commercial, Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
2,811 total · 2,327 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 55 °F
Altimeter
30.40 inHg
Observed at
ECG, 12 nm away

Docket · 12

The files NTSB released with the investigation on September 30, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.3 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.