ERA09TA440

NTSB accident investigation · Eurocopter AS 350B3 · Jacksonville, FL · August 4, 2009

Accident · Minor injuriesFinal report
Date
August 4, 2009, 16:28 local (20:28 UTC)
Place
Jacksonville, FL
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N186AEEurocopter AS 350B3
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
20090804016419A
Case key
74447

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor's improper decision to attempt hover flight without hydraulic power and his subsequent loss of control.

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 pilotEurocopter AS 350 B3: 6 casesAll aircraft: 3,098 casesProbable cause
Hydraulic power systemAircraft › Aircraft systems · Simulated malf/failureEurocopter AS 350 B3: 3 casesAll aircraft: 22 cases
Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotEurocopter AS 350 B3: 14 casesAll aircraft: 9,295 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedEurocopter AS 350 B3: 4 casesAll aircraft: 1,269 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 certified flight instructor and a commercial pilot receiving instruction were practicing maneuvers in the helicopter with the hydraulic system turned off, to simulate a hydraulic system failure. The commercial pilot was conducting a practice approach to a runway, with a transition to a hover. As the helicopter approached 5 feet above the ground, the commercial pilot began to lose directional control of the helicopter. The flight instructor assumed control; however, the helicopter entered multiple revolutions, climbs, and descents before it contacted the ground, spun, and rolled over. The fuselage, tail rotor and main rotor drive systems were substantially damaged. Examination of the helicopter did not reveal any preimpact mechanical malfunctions; nor did either pilot report any mechanical abnormalities. According to the helicopter manufacturer's flight manual training supplement, hovering without hydraulic power was not an approved procedure and would result in "excessive pilot workload, poor aircraft control, and possible loss of control."

Factual narrative

On August 4, 2009, about 1628 eastern daylight time, a Eurocopter AS 350B3 helicopter, N186AE, was substantially damaged while maneuvering at Herlong Airport (HEG), Jacksonville, Florida. The certified flight instructor (CFI) sustained minor injuries and the certificated commercial pilot receiving instruction was not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the instructional flight that originated at Jacksonville Naval Air Station (NIP), Jacksonville, Florida. The helicopter was owned by the US Department of Homeland Security and operated by Customs and Border Protection (CBP) as a public use flight. According to a CBP representative and the pilots, the pilots were practicing maneuvers with the hydraulic system turned off, to simulate a hydraulic system failure. The commercial pilot was conducting a practice approach to runway 25, with a transition to a hover. As the helicopter approached 5 feet above the ground, the commercial pilot began to lose directional control, and requested that the flight instructor take control of the helicopter. The flight instructor assumed control; however, the helicopter entered multiple revolutions, climbs, and descents, before it contacted the ground, spun, and rolled over. The helicopter came to rest about 290 feet south of runway 25, on a magnetic heading about 080 degrees. The fuselage, tail rotor and main rotor drive systems were substantially damaged. Examination of the helicopter by a Federal Aviation Administration (FAA) inspector did not reveal any preimpact mechanical malfunctions; nor did either pilot report any mechanical abnormalities. The CFI reported 2,782 hours of total helicopter fight experience, which included 580 hours in the same make and model as the accident helicopter. The commercial pilot reported 1,154 hours of total helicopter flight experience, which included 12 hours in the same make and model as the accident helicopter. Review of the AS 350B3 flight manual training supplement revealed that practice hovering without hydraulic power was not an approved procedure. The manual stated, in part: "Caution: Do not attempt to carry out hover flight or any low speed maneuver without hydraulic pressure assistance. The intensity and direction of the control feedback forces will change rapidly. This will result in excessive pilot workload, poor aircraft control, and possible loss of control." Winds, reported at an airport located about 5 miles southwest of HEG, at 1550, were variable at 6 knots.

Aircraft

Registration
N186AE
Reported as
Eurocopter AS 350B3
Category
Helicopter
Serial number
3872
Airframe hours
1,149
Engine
Turbomeca Arriel 2B/2B1, 847 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft - federal · Public use
Operator
U S Customs and Border Protection
Registered owner
U S Department Of Homeland Security
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 21, 2009 · 52 hours before
Departed
NIP · Jacksonville, FL
Destination
HEG · Jacksonville, FL
Flight plan
Company VFR
Airport
HEG · Herlong, runway 25, 4,000 × 100 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
42
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
July 17, 2009
Seat
Left
Flight hours
3,422 total · 580 in this make and model · 1,264 as pilot in command · 62 in the last 90 days · 30 in the last 30 days · 2 in the last 24 hours
Role
Pilot
Age
36
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
July 11, 2009
Seat
Right
Flight hours
2,620 total · 12 in this make and model · 1,200 as pilot in command · 30 in the last 90 days · 12 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 6 knots
Visibility
10 statute miles
Lowest ceiling
4,500 ft broken
Temperature
91 °F, dew point 75 °F
Altimeter
30.01 inHg
Observed at
VQQ, 5 nm away

Docket · 7

The files NTSB released with the investigation on October 8, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.2 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.