# NTSB ERA09TA440: Eurocopter AS 350B3, N186AE, Jacksonville, FL, August 4, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Final report - Date: August 4, 2009, 16:28 local (20:28 UTC) - Place: Jacksonville, FL - Coordinates: 30.274166, -81.803054 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.2742&lon=-81.8031&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: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report January 7, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 74447 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09TA440 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74447/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74447 - Page: https://openairdocs.org/ntsb/ERA09TA440 ## Probable cause The flight instructor's improper decision to attempt hover flight without hydraulic power and his subsequent loss of control. ## 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: [Eurocopter AS 350 B3, 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=8680954), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Hydraulic power system](https://openairdocs.org/ntsb-findings/01022900): Aircraft › Aircraft systems · Simulated malf/failure; cases with it: [Eurocopter AS 350 B3, 3 cases](https://openairdocs.org/ntsb-findings/01022900/cases.md?model=8680954), [All aircraft, 22 cases](https://openairdocs.org/ntsb-findings/01022900/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Eurocopter AS 350 B3, 14 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=8680954), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Eurocopter AS 350 B3, 4 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=8680954), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-hover: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Eurocopter AS 350 B3, 9 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=8680954), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Eurocopter AS 350 B3, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=8680954), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N186AE), registered now, S/N 3872, built 2004 (OpenAirDocs) - Reported make and model: EUROCOPTER AS 350B3 - Registry model: [Eurocopter AS 350 B3](https://openairdocs.org/model/eurocopter-as-350-b3) (registry code 8680954) (OpenAirDocs) - Registry engine: [Turbomeca ARRIEL-2B](https://openairdocs.org/engine/turbomeca-arriel-2b) (registry code 60037, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 3872 - Airframe hours: 1149 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 42; injuries: minor; 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 - Pilot; age 36; injuries: none; 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 ## 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 20090804016419A](https://openairdocs.org/incident/20090804016419A), Aug 4, 2009: Snias AS350B3, Jacksonville, FL, Substantial damage. (-23) While conducting a training flight for us customs/border patrol, the student was practicing normal approach to a hover and hydraulic-loss emergency… ## Docket (7 files) The files NTSB released with the investigation on October 8, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74447. 1.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 548 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337629&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Flight Crew Statements (item 2, .PDF, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337630&FileExtension=.PDF&FileName=Flight%20Crew%20Statements-Redacted.PDF - FAA Inspector Statement (item 3, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337631&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Redacted.PDF - Witness Statement (item 4, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40332258&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Airport Diagram with Accident Location (Provided by FAA) (item 5, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40332260&FileExtension=.PDF&FileName=Airport%20Diagram%20with%20Accident%20Location%20(Provided%20by%20FAA)-Master.PDF - AS 350B3 Flight Training Suplement (excerpt) (item 6, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40332259&FileExtension=.PDF&FileName=AS%20350B3%20Flight%20Training%20Suplement%20(excerpt)-Master.PDF - Photograph # 1 - Helicopter as it came to rest (Provided by CBP) (item 7, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40332265&FileExtension=.PDF&FileName=Photograph%20%23%201%20-%20Helicopter%20as%20it%20came%20to%20rest%20(Provided%20by%20CBP)-Master.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.