# NTSB ERA09LA173: Hughes 369F, N5205C, Moyock, NC, February 24, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: February 24, 2009, 13:36 local (18:36 UTC) - Place: Moyock, NC - Coordinates: 36.455554, -76.20639 - Nearby events: https://openairdocs.org/map.md?lat=36.4556&lon=-76.2064&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-hover: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 minor - Status: Completed, report January 7, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 73388 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA173 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73388/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73388 - Page: https://openairdocs.org/ntsb/ERA09LA173 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Object/animal/substance](https://openairdocs.org/ntsb-findings/03022000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [All aircraft, 224 cases](https://openairdocs.org/ntsb-findings/03022000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-hover: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md) - [Maneuvering-hover: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Maneuvering-hover: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## 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 (not matched to a registry record) - Reported make and model: HUGHES 369F - Category: Helicopter - Serial number: 0015F - Airframe hours: 2870 - Engines: 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 As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 53; injuries: fatal; 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 - Student pilot; age 31; injuries: minor; 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 ## 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 20090224004189A](https://openairdocs.org/incident/20090224004189A), Feb 24, 2009: Hughes 369F, Moyock, NC, Destroyed, 1 fatal. (-23) On February 24, 2009 at approximately 1330 local N5205C a Hughes 369F rotorcraft operated by [privacy data omitted] was conducting part 91 flight… ## Docket (12 files) The files NTSB released with the investigation on September 30, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73388. 4.3 MB in all. - Toxicological Report (item 1, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336076&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337280&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Other Pertinent Forms and Reports; NTSB Helicopter Supplement (item 3, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336082&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20NTSB%20Helicopter%20Supplement-Master.PDF - Other Pertinent Forms and Reports; PAW Safety Improvements (item 4, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336085&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20PAW%20Safety%20Improvements-Master.PDF - Toxicological Report; Coroner Tox Report (item 5, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336089&FileExtension=.PDF&FileName=Toxicological%20Report;%20Coroner%20Tox%20Report-Master.PDF - Witness Statements (item 6, .PDF, 778 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336090&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - FAA Digital Photo 1; Conex Simulator (item 7, .PDF, 793 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336093&FileExtension=.PDF&FileName=FAA%20Digital%20Photo%201;%20Conex%20Simulator-Master.PDF - FAA Digital Photo 2; Damaged upper Railing (item 8, .PDF, 713 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336094&FileExtension=.PDF&FileName=FAA%20Digital%20Photo%202;%20Damaged%20upper%20Railing-Master.PDF - FAA Digital Photo 3; Helicopter during recovery (item 9, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336096&FileExtension=.PDF&FileName=FAA%20Digital%20Photo%203;%20Helicopter%20during%20recovery-Master.PDF - FAA Digital Photo 4; Helicopter Inverted on Stairway (item 10, .PDF, 994 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336098&FileExtension=.PDF&FileName=FAA%20Digital%20Photo%204;%20Helicopter%20Inverted%20on%20Stairway-Master.PDF - Other Pertinent Forms and Reports; Aircaft Flight Log (item 11, .PDF, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336132&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20Aircaft%20Flight%20Log-Redacted.PDF - Passenger Statement; Student Pilot (item 12, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336133&FileExtension=.PDF&FileName=Passenger%20Statement;%20Student%20Pilot-Redacted.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.