# NTSB ERA13LA057: Hughes 369D, N369AW, Corning, NY, November 15, 2012

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Limited investigation · Final report
- Date: November 15, 2012, 12:11 local (17:11 UTC)
- Place: Corning, NY
- Coordinates: 42.147499, -77.041946
- Nearby events: https://openairdocs.org/map.md?lat=42.1475&lon=-77.0419&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report April 23, 2014
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Boeing Helicopters, Haverfield Aviation, FAA/FSDO, MD Helicopters
- NTSB case key (mKey): 85595
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA057
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85595/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85595
- Page: https://openairdocs.org/ntsb/ERA13LA057

## Probable cause

The pilot’s failure to maintain adequate altitude while conducting a power line aerial observation flight, which resulted in an in-flight collision with wires. Contributing to the accident was the pilot’s lack of total experience in the type of operation.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Hughes Helicopters HUGHES 369D, 10 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=4470706), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Hughes Helicopters HUGHES 369D, 11 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=4470706), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Experience/qualifications: total experience](https://openairdocs.org/ntsb-findings/02031015): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Hughes Helicopters HUGHES 369D, 1 case](https://openairdocs.org/ntsb-findings/02031015/cases.md?model=4470706), [All aircraft, 126 cases](https://openairdocs.org/ntsb-findings/02031015/cases.md)
- [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Not specified; cases with it: [Hughes Helicopters HUGHES 369D, 11 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=4470706), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Hughes Helicopters HUGHES 369D, 10 cases](https://openairdocs.org/ntsb-events/220/sequence.md?model=4470706), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md)
- [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Hughes Helicopters HUGHES 369D, 26 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=4470706), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Hughes Helicopters HUGHES 369D, 26 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=4470706), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The helicopter was flying west down a hill over power lines that the pilot was inspecting when it struck the top of the power lines that were perpendicular to its flightpath. The tail rotor assembly separated, and the helicopter impacted the ground and came to rest inverted. Postaccident examination of the helicopter did not reveal any preimpact mechanical malfunctions that would have precluded normal operation; however, most of the wreckage sustained extensive thermal- and impact-related damage. The pilot was hired about 3 weeks before the accident. He had no prior power line patrol experience, but he had completed a wire strike avoidance training module about 2 weeks before the accident. The accident occurred during the pilot's second work day of flying power line observation flights. After the accident, the operator instituted a policy requiring that all newly hired pilots obtain 100 flight hours of power line patrol-related flight experience with company crewmembers before being assigned an operation that would require flying with noncompany observers.

## Factual narrative

GPS Data The Garmin GPSMAP 496 was successfully downloaded by the NTSB Vehicle Recorders Laboratory. According to the recorded data, the helicopter departed ELM to the northwest at 1147:56, and then proceeded on a southwesterly heading for about 4 miles. The helicopter flew south over interstate 86, then turned back north and proceeded northeasterly, before proceeding about 1.5 nautical miles northwesterly, and then returning southeasterly along the same route. By about 12:07:10, the helicopter was proceeding westerly, north of interstate 86. From 1210:11 until about 1210:44, the helicopter flew northeasterly along the top of a ridgeline. About 1210:44, the helicopter proceeded southwesterly, crossing interstate 86 about 1211:12 at a GPS recorded altitude of 1,237 feet, and a ground speed of 36 knots. At 1211:27, the helicopter was in the vicinity of the wires that were struck at the accident site, and was flying at GPS recorded altitude of 1,014 feet, a ground speed of 43 knots, and a heading of 240 degrees. The last two recorded points were both at a GPS recorded altitude of 1,010 feet, at 1211:34 and 1211:57. The point recorded at 1211:34, was at a heading of 245 degrees and a ground speed of 11 knots. The last point was recorded on a heading of 33 degrees and a ground speed of 1 knot. The four-place helicopter, serial number 470117D, was manufactured in 1977, and was primarily constructed of aluminum alloy. The main rotor was a fully articulated five-bladed system, with anti-torque provided by a two-bladed semi-rigid type tail rotor. It was powered by an Allison M250-C20B, serial number CAE-836392, turboshaft engine, with a takeoff power rating of 420-shaft horsepower. The helicopter was equipped in a standard left side single pilot configuration. It was also equipped with a wire strike cutting system on the top and bottom portions of the fuselage. The operator reported that the helicopter's most recent 100-hour inspection was performed on October 19, 2012. At that time, the helicopter had been operated for 21,918 total hours. The helicopter had been operated for about 75 hours since the inspection. The engine was manufactured on May 5, 1989, and had been operated for about 12,500 hours since new. On November 15, 2012, at 1211 eastern standard time, a Hughes 369D, N369AW, operated by Haverfield Aviation Inc., was substantially damaged following a collision with power lines and terrain in Corning, New York. The commercial pilot and the observer were fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed for the flight that departed the Elmira-Corning Regional Airport (ELM), Horseheads, New York, about 1145. The aerial observation flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The observer was a utility company employee. According to the operator, the helicopter was temporarily based at the Tri-Cities Airport (CZG) in Endicott, New York, and was being utilized toinspect the power lines after a recent storm. The helicopter conducted an uneventful flight earlier in the day and was subsequently refueled at ELM, before continuing survey operations. Witnesses observed the helicopter flying west, down a hill over power lines which extended east to west. One witness stated that the helicopter appeared below the highest tower, shortly before it struck the top of power lines that extended to the south, perpendicular to the helicopter's flight path. The witness further stated that he did not hear any changes in the rhythm of the rotor blades prior to the impact. The tail rotor assembly separated, the helicopter impacted the ground and came to rest inverted. A postcrash fire consumed a majority of the main wreckage. On site examination of the helicopter was performed by a Federal Aviation Administration (FAA) inspector, who noted power lines wrapped around the main rotor assembly. In addition, the power company reported two power lines "tripped out" at 1211. A handheld Garmin GPSMAP 496 global positioning system receiver was recovered from the accident site and forwarded to the NTSB Vehicle Recorders Laboratory, Washington, DC for data download. An autopsy was performed on the pilot by the Office of the Medical Examiner, Monroe County, New York. The autopsy report revealed the cause of death as "multiple blunt force injuries." Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma was negative for tested substances. The reported weather at ELM, which was located about 8 miles east of the accident site, at an elevation 955 feet mean sea level, at 1153, was: clear skies; visibility 10 statute miles; wind calm; temperature 3 degrees Celsius (C); dew point -2 degrees C; altimeter 30.37 inches of mercury. The pilot, age 24, held a commercial pilot certificate, with ratings for rotorcraft and instrument helicopter. He also held a rotorcraft flight instructor certificate. His most recent FAA second-class medical certificate was issued on March 27, 2012. At that time, he reported a total flight experience of 1,350 hours, which included 30 hours during the previous 6 months. His most recent flight review was conducted on November 8, 2012, in the same make and model as the accident helicopter. According to company records, the pilot was hired by Haverfield Aviation on October 22, 2012. He had no prior power line patrol experience and completed a "Helicopter Accident Reduction – Wire Strike Avoidance" training module on October 28, 2012. At the time of the accident, the pilot had accumulated about 1,635 hours of total flight experience, which included about 10 hours in the same make and model as the accident helicopter, of which 5.2 hours were accumulated during the 24 hours that preceded the accident. The accident occurred during the pilot's second work day of flying power line aerial observation flights. According to a company representative, afterthe accident, Haverfield Aviation instituted a policy requiring that all new hire pilots obtain 100 flight hours of power line patrol related flight experience with company crewmembers prior to being assigned an operation that would require flying with non-company observers. Examination of the helicopter after recovery did not reveal any preimpact malfunctions that would have precluded normal operation; however, the wreckage, with the exception of the tail boom and tail rotor assembly sustained extensive thermal and impact related damage. Evidence of wire contact marks were observed on the main rotor blades, tail rotor blades, tail empennage, and the landing gear skid assembly. The helicopter's wire strike system showed no evidence of wire contact. All observed main rotor blades contained bent and/or broken spars, wrinkled and punctured skin, and varying degrees of trailing edge separation. The white, blue, and yellow blades were separated from the hub at their respective pitch change housings. The green blade was fractured outboard of Blade Station 105 and the outboard section was not recovered. The red blade was fractured just outboard of the root fitting doubler. A majority of the blue blade was not recovered; although a 12 inch section of trailing edge was located from the vicinity of Blades Station 45. Continuity of the drivetrain system could not be established due to impact and fire damage. The main transmission was intact. The output drive gear, transmission input pinion assembly and the tail rotor output pinion assembly rotated freely when manipulated by hand. The upper transmission magnetic chip detector plug was absent of metallic debris. The lower transmission magnetic chip detector plug was not located. The tail rotor driveshaft separated into four main sections, which corresponded with the position and length of fractures observed on the tail boom. The tail boom damage was consistent with main rotor blade contact. The tail rotor gearbox, rotor blades, and pitch control assemblies sustained minor damage and could be manipulated normally. The engine was entangled in airframe structure and wiring. Extraction of the engine revealed extensive postcrash fire damage. Neither the N1 nor the N2 drive trains could be manually rotated. The accessory gearbox, including both chip detectors was consumed by fire. The compressor remained in its normal position. The first stage axial blades exhibited nicking of multiple leading edge surfaces with deflection of several leading edge surfaces bent opposite the direction of blade rotation. The No. 1 turbine wheel was ashen coated, but otherwise normal in appearance. The fuel pump displayed evidence of thermal exposure with melting of the body and fuel pump bowl, which exposed the fuel filter. Both the power turbine governor and fuel control units were destroyed by fire damage.

## Aircraft

- Registration: [N369AW](https://openairdocs.org/deregistered/N369AW-2014-03-10), registration cancelled 2014-03-10, S/N 470117D, built 1977 (OpenAirDocs)
- Reported make and model: HUGHES 369D
- Registry model: [Hughes Helicopters HUGHES 369D](https://openairdocs.org/model/hughes-helicopters-hughes-369d) (registry code 4470706) (OpenAirDocs)
- Registry engine: [Allison 250-C20B](https://openairdocs.org/engine/allison-250-c20b) (registry code 03081, turbo-shaft) (OpenAirDocs)
- Category: Helicopter
- Serial number: 470117D
- Year built: 1977
- Airframe hours: 21918
- Engines: Allison M250-C20B 420 horsepower turbo shaft
- Damage: Substantial damage
- Fire: On-Ground
- Flight: Aerial observation, Part 91
- Operator: Haverfield International Inc., doing business as Haverfield Aviation, Inc.
- Registered owner: Haverfield International Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, October 19, 2012, 73 hours before
- Departed: ELM, Horseheads, NY
- Destination: ELM, Horseheads, NY
- Airport: ELM, Elmira/Corning Rgnl
- Equipment: Handheld GPS

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 24; injuries: fatal; flight instructor, commercial; instrument ratings: helicopter; medical: class 2, without waivers/limitations; seat: left; toxicology performed; flight hours: 1,633 total, 10 in this make and model, 10 in the last 30 days, 5 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 37 °F, dew point 28 °F
- Altimeter: 30.37 inHg
- Observed at: ELM, 8 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 20121115024399A](https://openairdocs.org/incident/20121115024399A), Nov 15, 2012: Hughes 369D, Corning, NY, Destroyed, 2 fatal. On 11-15-12, at 12:11 eastern standard time, two people were killed when a helicopter crashed near the chemung river close to kent phillips elementary school…

## Docket (25 files)

The files NTSB released with the investigation on March 4, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85595. 36.8 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407010&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Witness Statements (item 2, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407573&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF
- ELM Weather Observations (item 3, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407576&FileExtension=.PDF&FileName=ELM%20Weather%20Observations-Master.PDF
- GPS 17 - Specialist's Factual Report (Garmin GPSMAP 496) (item 4, .PDF, 877 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389749&FileExtension=.PDF&FileName=GPS%2017%20-%20Specialist%27s%20Factual%20Report%20(Garmin%20GPSMAP%20496)-Master.PDF
- GPS 17 - Attachment 1 - Tabular Data (CSV) (Garmin GPSMAP 496) (item 5, .CSV, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389750&FileExtension=.csv&FileName=GPS%2017%20-%20Attachment%201%20-%20Tabular%20Data%20(CSV)%20(Garmin%20GPSMAP%20496)-Master.csv
- Maintenance Record (excerpts) (item 6, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407568&FileExtension=.PDF&FileName=Maintenance%20Record%20(excerpts)-Redacted.PDF
- Pilot Experience and Training Records (excerpts) (item 7, .PDF, 409 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407572&FileExtension=.PDF&FileName=Pilot%20Experience%20and%20Training%20Records%20(excerpts)-Redacted.PDF
- NTSB Party Guidance and Certification Form (item 8, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407011&FileExtension=.PDF&FileName=NTSB%20Party%20Guidance%20and%20Certification%20Form-Redacted.PDF
- Retention / Release of Wreckage Form (item 9, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407015&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form-Redacted.PDF
- FAA Forensic Toxicology Fatal Accident Report - Passenger (item 10, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407574&FileExtension=.PDF&FileName=FAA%20Forensic%20Toxicology%20Fatal%20Accident%20Report%20-%20Passenger-Master.PDF
- FAA Forensic Toxicology Fatal Accident Report - Pilot (item 11, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419911&FileExtension=.PDF&FileName=FAA%20Forensic%20Toxicology%20Fatal%20Accident%20Report%20-%20Pilot-Master.PDF
- Haverfield Aviation Post-Accident Actions (item 12, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409108&FileExtension=.PDF&FileName=Haverfield%20Aviation%20Post-Accident%20Actions-Redacted.PDF
- Photograph # 1 – Aerial View of accident site (provided by FAA) (item 13, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407046&FileExtension=.PDF&FileName=Photograph%20%23%201%20%E2%80%93%20Aerial%20View%20of%20accident%20site%20(provided%20by%20FAA)-Master.PDF
- Photograph # 2 – View of helicopter as it came to rest (provided by FAA) (item 14, .PDF, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407047&FileExtension=.PDF&FileName=Photograph%20%23%202%20%E2%80%93%20View%20of%20helicopter%20as%20it%20came%20to%20rest%20(provided%20by%20FAA)-Master.PDF
- Photograph # 3 – Overview of wreckage prior to examination at recovery facility (item 15, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407048&FileExtension=.PDF&FileName=Photograph%20%23%203%20%E2%80%93%20Overview%20of%20wreckage%20prior%20to%20examination%20at%20recovery%20facility%20-Master.PDF
- Photograph # 4 – Close-up view of main wreckage prior to examination at recovery facility (item 16, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407049&FileExtension=.PDF&FileName=Photograph%20%23%204%20%E2%80%93%20Close-up%20view%20of%20main%20wreckage%20prior%20to%20examination%20at%20recovery%20facility%20-Master.PDF
- Photograph # 5 – View of wreckage during examination at recovery facility (item 17, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407053&FileExtension=.PDF&FileName=Photograph%20%23%205%20%E2%80%93%20View%20of%20wreckage%20during%20examination%20at%20recovery%20facility%20-Master.PDF
- Photograph # 6 – View of tailboom and tail rotor assembly during examination at recovery facility (item 18, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407052&FileExtension=.PDF&FileName=Photograph%20%23%206%20%E2%80%93%20View%20of%20tailboom%20and%20tail%20rotor%20assembly%20during%20examination%20at%20recovery%20facility%20-Master.PDF
- Photograph # 7 – View of main rotor blades during examination at recovery facility (item 19, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407054&FileExtension=.PDF&FileName=Photograph%20%23%207%20%E2%80%93%20View%20of%20main%20rotor%20blades%20during%20examination%20at%20recovery%20facility%20-Master.PDF
- Photograph # 8 – Close-up view of skid assembly (item 20, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407055&FileExtension=.PDF&FileName=Photograph%20%23%208%20%E2%80%93%20Close-up%20view%20of%20skid%20assembly%20-Master.PDF
- Photograph # 9 – View of wire strike damage observed on skid strut (item 21, .PDF, 911 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407056&FileExtension=.PDF&FileName=Photograph%20%23%209%20%E2%80%93%20View%20of%20wire%20strike%20damage%20observed%20on%20skid%20strut-Master.PDF
- Photograph # 10 – View of wire strike damage observed on forward skid (item 22, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407057&FileExtension=.PDF&FileName=Photograph%20%23%2010%20%E2%80%93%20View%20of%20wire%20strike%20damage%20observed%20on%20forward%20skid-Master.PDF
- Photograph # 11 – View of engine after removal from fuselage (item 23, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407058&FileExtension=.PDF&FileName=Photograph%20%23%2011%20%E2%80%93%20View%20of%20engine%20after%20removal%20from%20fuselage-Master.PDF
- Photograph # 12 – View of engine compressor during disasembly (item 24, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407059&FileExtension=.PDF&FileName=Photograph%20%23%2012%20%E2%80%93%20View%20of%20engine%20compressor%20during%20disasembly-Master.PDF
- Helicopter Accident/Incident Supplmental Checklist (item 25, .PDF, 265 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407592&FileExtension=.PDF&FileName=Helicopter%20Accident%2FIncident%20Supplmental%20Checklist-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.

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