ERA18MA099

NTSB accident investigation · American Eurocopter AS350B2 · New York, NY · March 11, 2018

Accident · FatalClass 1 · MajorFinal report
Date
March 11, 2018, 19:08 local (23:08 UTC)
Place
New York, NY
Injuries
5 fatal, 1 minor
Damage
Substantial damage
Phase of flight
Prior to flight
Aircraft
N350LHAmerican Eurocopter AS350B2
Defining event
Prior to flight: Miscellaneous/other
Weather
Visual (VMC) · Dusk
Status
Completed · report January 21, 2020
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Eastern Region Aviation
Parties
EuroTec Canada Ltd., Liberty Helicopters Inc., Airbus Helicopters, TSBC, Transport Canada, EASA, FAA / AVP-100, SAFRAN Helicopter Engines, NYONair, Dart Aerospace, BEA
Safety recommendations
Yes
FAA report
20180311003509A
Case key
96850

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

Liberty Helicopters Inc.'s use of a NYONair-provided passenger harness/tether system, which caught on and activated the floor-mounted engine fuel shutoff lever and resulted in the in-flight loss of engine power and the subsequent ditching. Contributing to this accident were (1) Liberty's and NYONair's deficient safety management, which did not adequately mitigate foreseeable risks associated with the harness/tether system interfering with the floor-mounted controls and hindering passenger egress; (2) Liberty allowing NYONair to influence the operational control of Liberty's FlyNYON flights; and (3) the Federal Aviation Administration's inadequate oversight of Title 14 Code of Federal Regulations Part 91 revenue passenger-carrying operations. Contributing to the severity of the accident were (1) the rapid capsizing of the helicopter due to partial inflation of the emergency flotation system and (2) Liberty and NYONair's use of the harness/tether system that hindered passenger egress.

Findings · 13

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.

Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Unintentional use/operationAmerican Eurocopter AS350B2: 1 caseAll aircraft: 176 casesProbable cause
Engine (turbine/turboprop)Aircraft › Aircraft power plant · InoperativeAmerican Eurocopter AS350B2: 1 caseAll aircraft: 67 casesProbable cause
Culture: safetyOrganizational issues › Management · OperatorAmerican Eurocopter AS350B2: 1 caseAll aircraft: 11 casesProbable cause
Safety programs: adherence to safety programOrganizational issues › Support/oversight/monitoring · OperatorAmerican Eurocopter AS350B2: 1 caseAll aircraft: 5 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · OperatorAmerican Eurocopter AS350B2: 1 caseAll aircraft: 61 casesProbable cause
Culture: safetyOrganizational issues › Management · Other institution/organizationAmerican Eurocopter AS350B2: 1 caseAll aircraft: 11 casesProbable cause
Safety programs: availability of safety programOrganizational issues › Support/oversight/monitoring · Other institution/organizationAmerican Eurocopter AS350B2: 1 caseAll aircraft: 4 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorAmerican Eurocopter AS350B2: 1 caseAll aircraft: 61 casesProbable cause
Enforcement: regulatory requirementsOrganizational issues › Support/oversight/monitoring · FAA/RegulatorAmerican Eurocopter AS350B2: 1 caseAll aircraft: 5 casesProbable cause
Policy/procedure: adequacy of policy/procOrganizational issues › Management · FAA/RegulatorAmerican Eurocopter AS350B2: 1 caseAll aircraft: 106 casesProbable cause
Equipment/furnishings: passenger compartment equipAircraft › Aircraft systems · Unnecessary use/operationAmerican Eurocopter AS350B2: 1 caseAll aircraft: 24 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 Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-19/04. On March 11, 2018, about 1908 eastern daylight time, an Airbus Helicopters AS350 B2, N350LH, lost engine power during cruise flight, and the pilot performed an autorotative descent and ditching on the East River in New York, New York. The pilot sustained minor injuries, the five passengers drowned, and the helicopter was substantially damaged. The FlyNYON-branded flight was operated by Liberty Helicopters Inc. (Liberty), per a contractual agreement with NYONair; both companies considered the flight to be an aerial photography flight operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. (During this accident investigation, the Federal Aviation Administration determined that Liberty operated the flight as a nonstop commercial air tour under 14 CFR Part 91.) Visual flight rules weather conditions prevailed, and no flight plan was filed for the intended 30-minute local flight, which departed from Helo Kearny Heliport, Kearny, New Jersey, about 1850.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-19/04. On March 11, 2018, about 1908 eastern daylight time, an Airbus Helicopters AS350 B2, N350LH, lost engine power during cruise flight, and the pilot performed an autorotative descent and ditching on the East River in New York, New York. The pilot sustained minor injuries, the five passengers drowned, and the helicopter was substantially damaged. The FlyNYON-branded flight was operated by Liberty Helicopters Inc. (Liberty), per a contractual agreement with NYONair; both companies considered the flight to be an aerial photography flight operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. (During this accident investigation, the Federal Aviation Administration determined that Liberty operated the flight as a nonstop commercial air tour under 14 CFR Part 91.) Visual flight rules weather conditions prevailed, and no flight plan was filed for the intended 30-minute local flight, which departed from Helo Kearny Heliport, Kearny, New Jersey, about 1850.

Aircraft

Registration
N350LH
Reported as
American Eurocopter AS350B2
Category
Helicopter
Serial number
7654
Built
2013
Airframe hours
5,510.2
Engine
Turbomeca Arriel 1D1, 712 horsepower, turbo shaft
Damage
Substantial damage
Flight
Other work use · Part 91
Operator
Liberty Helicopters Inc
Registered owner
Meridian Consulting Corp Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 6, 2018 · 14 hours before
Departed
65NJ · Kearny, NJ
Destination
65NJ · Kearny, NJ
Flight plan
Company VFR
Equipment
Satellite tracking device, Video recording device, ADS-B

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Injuries
Minor
Certificates
Flight instructor, Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
February 21, 2018
Seat
Right
Restraint
4-point
Toxicology
Performed
Flight hours
3,100 total · 1,430 in this make and model · 3,020 as pilot in command · 57 in the last 90 days · 33 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
330° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 21 °F
Altimeter
30.05 inHg
Observed at
LGA, 3 nm away

Docket · 79

The files NTSB released with the investigation on September 25, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 851 KBOperations Group Chairman's Factual ReportItem 2 · .PDF · 2 photos · 1.7 MBOperations Attachment 1 - Interview SummariesItem 3 · .PDF · 1.6 MBOperations Attachment 2 - Liberty Chief Pilot Interview (Transcription)Item 4 · .PDF · 270 KBOperations Attachment 3 - Police Interview TranscriptItem 5 · .PDF · 131 KBOperations Attachment 4 - Pilot Training InformationItem 6 · .PDF · 7.4 MBOperations Attachment 5 - Pilot Duty LogsItem 7 · .PDF · 4.8 MBOperations Attachment 6 - Liberty Helicopters Passenger BriefingItem 8 · .PDF · 306 KBOperations Attachment 7 - Liberty Helicopters Emergency ProceduresItem 9 · .PDF · 659 KBOperations Attachment 8 - Liberty and NYONair Charter Customer AgreementItem 10 · .PDF · 1.0 MBOperations Attachment 9 - Liberty Helicopters LOAItem 11 · .PDF · 10.1 MBOperations Attachment 10 - Weight and Balance InformationItem 12 · .PDF · 737 KBOperations Attachment 11 - Loading SOPsItem 13 · .PDF · 292 KBOperations Attachment 12 - NYONair Part 91 New Pilot Onboarding PresentationItem 14 · .PDF · 164 KBOperations Attachment 13 - FAA Air Tour Operators DocumentItem 15 · .PDF · 155 KBOperations Attachment 14 - FAA Legal InterpretationItem 16 · .PDF · 599 KBOperations Attachment 15 - FAA PhotosItem 17 · .PDF · 5 photos · 893 KBOperations Attachment 16 - NYONAir CX Training ManualItem 18 · .PDF · 236 KBOperations Attachment 17 - Spidertracks InformationItem 19 · .PDF · 1.3 MBOperations Attachment 18 - FAA InFO 18003Item 20 · .PDF · 117 KBOperations Attachment 19 - FAA Order 8900.457Item 21 · .PDF · 236 KBOperations Attachment 20 - FAA 8900.1 ReferenceItem 22 · .PDF · 3.7 MBOperations Attachment 21 - Airbus AS-350 VEMD ChecklistItem 23 · .PDF · 6.5 MBOperations Attachment 22 - NYON Customer Service Pilot TrainingItem 24 · .PDF · 102 KBOperations Attachment 23 - Liberty NYONair Pilot Safety Meeting MinutesItem 25 · .PDF · 1.3 MBOperations Attachment 24 - Liberty Training Manual - ExtractsItem 26 · .PDFOperations Addendum 1 - ARS InvoicesItem 27 · .PDF · 144 KBOperations Addendum 2 - FAA Legal Interpretation EmailItem 28 · .PDF · 229 KBOperations Addendum 3 - New York City Economic Development Corporation EmailItem 29 · .PDF · 2.6 MBOperations Addendum 4 - PMI Email QuestionsItem 30 · .PDF · 183 KBOperations Addendum 5 - Accident Pilot Post-Interivew StatementItem 31 · .PDF · 1.6 MBWeather StudyItem 32 · .PDF · 988 KBAir Traffic Control - N350LH Ground TrackItem 33 · .PDF · 1.1 MBAir Traffic Control - FAA Chronological Summary of Flight and Partial Transcription of Voice RecordingsItem 34 · .PDF · 1.1 MBAir Traffic Control Transcript - NTSB Specialist's Factual ReportItem 35 · .PDF · 195 KBAir Traffic Control - FAA Radar Tabular DataItem 36 · XLSX · 15 KBPerformance Study - Specialist's ReportItem 37 · .PDF · 3.4 MBOnboard Image Recorder (GoPro) - Group Chairman's Factual ReportItem 38 · .PDF · 1.2 MBPersonal Electronic Devices (PED) - Specialist's Factual ReportItem 39 · .PDF · 2 photos · 333 KBOnboard Image, Audio, and Data Recorder (Appareo Vision 1000) - Specialist's Factual ReportItem 40 · .PDF · 267 KBAirworthiness Factual ReportItem 41 · .PDF · 652 KBAirworthiness Factual Report - Attachment 1Item 42 · .PDF · 182 KBFSOL - Snap Wire - Materials Laboratory Factual Report 18-059Item 43 · .PDF · 285 KBVideo StudyItem 44 · .PDF · 362 KBAttachment 1 to Video Study - Video 1Item 45 · MOV · 1.3 MBAttachment 2 to Video Study - Video 2Item 46 · .PDF · 39 KBPowerplant Group Chairman's Factual ReportItem 47 · .PDF · 12.2 MBEmergency Flotation System Factual ReportItem 48 · .PDF · 1.6 MBEmergency Flotation System Factual Report - Attachment 1Item 49 · .PDF · 302 KBEmergency Flotation System Factual Report - Attachment 2Item 50 · .PDF · 163 KBEmergency Flotation System Factual Report - Attachment 3Item 51 · .PDF · 102 KBEmergency Flotation System Factual Report - Attachment 4Item 52 · .PDF · 981 KBEmergency Flotation System Factual Report - Attachment 5Item 53 · .PDF · 268 KBEmergency Flotation System Factual Report - Attachment 6Item 54 · .PDF · 654 KBEmergency Flotation System Factual Report - Attachment 7Item 55 · .PDF · 101 KBEmergency Flotation System Factual Report - Attachment 8Item 56 · .PDF · 141 KBEmergency Flotation System Factual Report - Attachment 9Item 57 · .PDF · 159 KBEmergency Flotation System Factual Report - Attachment 10Item 58 · .PDF · 189 KBEmergency Flotation System Factual Report - Attachment 11Item 59 · .PDF · 142 KBEmergency Flotation System Factual Report - Addendum 1Item 60 · .PDF · 126 KB
All 79 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.