# NTSB ERA16CA060: Eurocopter Deutschland EC 135, N639ME, Monongahela, PA, November 6, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: November 6, 2015, 06:00 local (11:00 UTC) - Place: Monongahela, PA - Coordinates: 40.18222, -79.910003 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.1822&lon=-79.9100&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report January 15, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA-Allegheny FSDO - NTSB case key (mKey): 92401 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16CA060 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92401/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92401 - Page: https://openairdocs.org/ntsb/ERA16CA060 ## Probable cause The inadequate securing of the wheeled fire extinguisher's cover which resulted in it being blown off of the fire extinguisher and ingested into the helicopter's fenestron during takeoff, resulting in a loss of directional control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Object/animal/substance: debris/dirt/foreign object](https://openairdocs.org/ntsb-findings/03022055): Environmental issues › Physical environment · Effect on equipment (probable cause); cases with it: [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/03022055/cases.md) - [Tail rotor: tail rotor blade](https://openairdocs.org/ntsb-findings/01046410): Aircraft › Aircraft propeller/rotor · Damaged/degraded (probable cause); cases with it: [All aircraft, 31 cases](https://openairdocs.org/ntsb-findings/01046410/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: 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) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis After liftoff during a helicopter emergency medical service (HEMS) flight with a patient on board, the pilot of the HEMS helicopter brought it in to a 1 to 2 foot hover and was preparing to make a right pedal turn into the wind, when a cover from a wheeled fire extinguisher, was blown airborne by the main rotor wash and ingested into the tail rotor (fenestron) of the helicopter. The helicopter lost tail rotor authority and began to spin clockwise. The pilot lowered the collective and the helicopter rotated approximately 150 degrees, then impacted the ground and continued to rotate another 20 to 30 degrees, for a total of 170 to180 degree turn, and came to rest. Examination of the helicopter by a Federal Aviation Administration inspector revealed damage to the landing gear skid tubes, fenestron composite housing, and the forward cross tube gimbal which had pushed up into a composite non-structural area of the fuselage. It was discovered, that the wheeled fire extinguisher that the cover had blown off of, had been inspected for serviceability just four days prior to the accident. ## Factual narrative After liftoff during a helicopter emergency medical service (HEMS) flight with a patient on board, the pilot of the HEMS helicopter brought it in to a 1 to 2 foot hover and was preparing to make a right pedal turn into the wind, when a cover from a wheeled fire extinguisher, was blown airborne by the main rotor wash and ingested into the tail rotor (fenestron) of the helicopter. The helicopter lost tail rotor authority and began to spin clockwise. The pilot lowered the collective and the helicopter rotated approximately 150 degrees, then impacted the ground and continued to rotate another 20 to 30 degrees, for a total of 170 to180 degree turn, and came to rest. Examination of the helicopter by a Federal Aviation Administration inspector revealed damage to the landing gear skid tubes, fenestron composite housing, and the forward cross tube gimbal which had pushed up into a composite non-structural area of the fuselage. It was discovered, that the wheeled fire extinguisher that the cover had blown off of, had been inspected for serviceability just four days prior to the accident. ## Aircraft - Registration: N639ME (not matched to a registry record) - Reported make and model: EUROCOPTER DEUTSCHLAND GMBH EC 135 (T2) - Category: Helicopter - Serial number: 0563 - Year built: 2007 - Airframe hours: 5110.2 - Engines: TURBOMECA ARRIUS 2B2 634 horsepower turbo shaft; Turbomeca Arrius 2B2 634 horsepower turbo shaft - Damage: Substantial damage - Flight: Part 135 - Operator: Center For Emergency Medicine Of Western - Registered owner: Center For Emergency Medicine Of Western - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, November 4, 2015 - Departed: 5PA5, Monongahela, PA - Destination: 78PA, NEWTOWN SQUARE, PA - Flight plan: Company VFR - Airport: 5PA5, Monongahela Valley Hospital - Equipment: Satellite tracking device, Auto-pilot, Electronic multifunction display, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: none; commercial; instrument ratings: helicopter; medical: class 1, with waivers/limitations; last flight review May 28, 2015; seat: right; restraint: 4-point; flight hours: 4,413 total, 1,198 in this make and model, 2,663 as pilot in command, 82 in the last 90 days, 14 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Dawn - Wind: 180° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 12,000 ft broken - Temperature: 66 °F, dew point 52 °F - Altimeter: 29.95 inHg - Observed at: KAGC, 10 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 20151106022539A](https://openairdocs.org/incident/20151106022539A), Nov 6, 2015: Eurocopter Deutschland Gmbh EC 135 T2+, Monongahela, PA, Minor damage. During take-off from monongehela valley Hospital (5PA5) helipad with two medical crewmembers and a patient onboard, the helicopter rotor wash blew a vinyl… ## Docket (4 files) The files NTSB released with the investigation on January 8, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92401. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 661 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435442&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector's Statement (item 2, .PDF, 606 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435443&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Structures (item 3, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435444&FileExtension=.PDF&FileName=Structures-Master.PDF - Photo Array (item 4, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435445&FileExtension=.PDF&FileName=Photo%20Array-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.