ERA17LA305

NTSB accident investigation · MD Helicopter 369 · Lawrenceville, GA · September 1, 2017

Accident · Serious injuriesLimited investigationFinal report
Date
September 1, 2017, 10:58 local (14:58 UTC)
Place
Lawrenceville, GA
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N5189KMD Helicopter 369
Defining event
Landing: Loss of tail rotor effectiveness
Weather
Visual (VMC) · Day
Status
Completed · report November 15, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20170901011329A
Case key
95936

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

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Probable cause

The pilot's inadequate compensation for wind conditions during the approach to landing, which resulted in a loss of helicopter control due to a loss of tail rotor effectiveness.

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotAll aircraft: 9,295 casesProbable cause
Wind: tailwindEnvironmental issues › Conditions/weather/phenomena · Response/compensationAll aircraft: 594 casesProbable cause
Performance/control parameters: powerplant parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedAll aircraft: 81 casesProbable cause
Wind: tailwindEnvironmental issues › Conditions/weather/phenomena · Effect on operationAll aircraft: 594 cases

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

During the approach to line up with a helipad, the commercial pilot noted that the helipad was not set up for landing into the wind, so he discontinued the approach and decided to land on a nearby wash rack, into the wind. As he turned right, the helicopter encountered a wind gust, or the wind was blocked by a nearby outbuilding, which can cause a turbulent effect. The helicopter suddenly and violently yawed right and pitched up. He attempted to correct the condition with pedal and cyclic inputs; however, a right spin ensued, and the helicopter spun to the ground and then came to rest on its right side. The pilot reported that there were no preimpact mechanical malfunctions or anomalies with the helicopter that would have precluded normal operation. It is likely that the pilot did not adequately compensate for wind conditions, and when he added power to compensate, the helicopter yawed right and pitched up. The pilot was unable to stop the yaw and lost helicopter control due to a loss of tail rotor effectiveness.

Factual narrative

On September 1, 2017, at 1058 eastern daylight time, a MD Helicopters 369FF, N5189K, was substantially damaged while maneuvering to land at Gwinnett County Airport (LZU), Lawrenceville, Georgia. The commercial pilot and a pilot-rated crewmember were seriously injured. The helicopter was operated by the Gwinnett County Police Department as a local, public-use flight. Day, visual meteorological conditions prevailed at the time, and no flight plan was filed. The flight originated at LZU about 1000. The pilot reported the following that the preflight inspection of the helicopter and en route portions of the flight were uneventful. After about 1 hour on station performing law enforcement duties, the pilot returned to LZU to get ahead of deteriorating weather conditions. The flight was cleared to land on taxiway whiskey, then perform a side-step maneuver to the police helipad. The pilot recalled winds from 220° at 10 knots. He performed a normal approach to a 10-foot hover to taxiway whiskey. As he made a left turn to line up with the helipad, he noted that the cart on the helipad was not set up for a landing into the wind. He elected to discontinue the approach and make a right turn to land on a wash rack, into the wind. As the pilot was about to initiate the turn to the wash rack, the pilot noted a "strong wind gust" followed by a "sudden, uncommanded, violent, right yaw" and "what seemed to be an uncommanded climb." He applied cyclic and pedal inputs; however, the helicopter continued in a right spin for at least two full rotations until it impacted the ground. The pilot and crewmember were met by first responders and transported to a local hospital for treatment of their injuries. The pilot later reported that a small, county-owned outbuilding near the police pad can mask or block the wind, creating a turbulent effect. He stated that the perceived wind gust could also have been the tail rotor becoming "unmasked" from behind the outbuilding. The pilot further reported there were no preimpact mechanical malfunctions or anomalies that would have precluded normal operation of the helicopter. An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. He reported that the helicopter came to rest on its right side in the grass, adjacent to a taxiway. There was no fire. Structural damage to the fuselage, tail rotor, and main rotor were confirmed. The main rotor blades were severed during the impact and were scattered up to 220 feet from the main wreckage. His examination of the wreckage did not reveal evidence of a mechanical malfunction or anomaly.

Aircraft

Registration
N5189K
Reported as
MD Helicopter 369 (FF)
Category
Helicopter
Serial number
0603FF
Built
1984
Airframe hours
8,032
Engine
Allison 250-C30, 425 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft - local · Public use
Operator
Gwinnett County Police Department
Registered owner
County Of Gwinnett Georgia
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 25, 2017
Departed
LZU · Lawrenceville, GA
Destination
LZU · Lawrenceville, GA
Airport
LZU · Gwinnett
Equipment
Unknown

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
38
Injuries
Serious
Certificates
Military, Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
June 9, 2017
Seat
Left
Restraint
4-point
Flight hours
942 total · 44 in this make and model · 942 as pilot in command · 20 in the last 30 days · 1 in the last 24 hours
Role
Other flight crew
Age
46
Injuries
Serious
Certificate
Commercial
Medical
Class 2, Without waivers/limitations
Seat
Right
Restraint
4-point

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 8 knots
Visibility
7 statute miles
Lowest ceiling
1,500 ft broken
Temperature
77 °F, dew point 70 °F
Altimeter
29.93 inHg
Observed at
LZU

Docket · 6

The files NTSB released with the investigation on October 24, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.8 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.