# NTSB FTW03LA038: Agusta A109E, N142CF, Fort Worth, TX, November 8, 2002 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 8, 2002, 10:35 local (16:35 UTC) - Place: Fort Worth, TX - Coordinates: 32.736946, -97.33889 - Nearby events: https://openairdocs.org/map.md?lat=32.7369&lon=-97.3389&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report July 23, 2003 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 56040 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW03LA038 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56040/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56040 - Page: https://openairdocs.org/ntsb/FTW03LA038 ## Probable cause The pilot's attempted running takeoff with the power controls in the improper position. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - running takeoff - attempted, pilot in command - throttle/power control - improper, pilot in command (cause) - On ground/water collision with object, takeoff - object - pole ## Analysis After landing on the helipad, the pilot reduced the throttles to flight idle. The pilot was then going to demonstrate to the flight crew how the helicopter could taxi and perform a running takeoff. The pilot initiated the takeoff roll, added collective, and realized the engines were not at 100 percent power. Subsequently, the helicopter became airborne, departed the heliport and came to rest on the roof of a lower level parking garage. In an interview, the pilot reported that "he attempted a rolling take-off...with an incorrect power setting (selection switch) which resulted in an emergency landing on the roof of an adjacent automobile parking garage due to insufficient engine power to maintain flight." The pilot had accumulated approximately 6,500 total helicopter flight hours, with 3,100 flight hours as a flight instructor in helicopters, and 25 total hours in the same make and model as the accident helicopter. ## Factual narrative On November 8, 2002, at 1035 central standard time, an Agusta A109E twin-engine helicopter, N142CF, sustained substantial damage following a loss of control while attempting to takeoff from the Harris Hospital Heliport, near Fort Worth, Texas. The commercial pilot, flight paramedic, and flight nurse were not injured. The helicopter was registered to North Central Texas Services, Inc., Grand Prairie, Texas, doing business as (d.b.a.) Care Flite. Visual meteorological conditions prevailed, and a company flight plan was filed for the 14 Code of Federal Regulations Part 91 positioning flight. The flight was originating from the heliport at the time of the accident and was destined for the Grand Prairie Municipal Airport, Grand Prairie. The pilot reported that after attending a public relations event with the helicopter, the pilot was instructed by Care Flite maintenance to return to Harris Hospital, prior to proceeding to Grand Prairie for maintenance. At 1033, the helicopter landed at Harris Hospital. The pilot stated that after landing, he observed construction workers near the helipad, completed some required paperwork, and "I must have gone to flight idle with the engines." The pilot stated that the paramedic had not previously flown in an Agusta 109, so he was going to demonstrate how the helicopter could taxi and perform a running takeoff. The pilot initiated the takeoff roll, added collective, and realized the engines were not at 100 percent power. Subsequently, the helicopter became airborne, departed the heliport and came to rest on the roof of a lower level parking garage. During the accident sequence, the main rotor blades contacted a light standard, the tail rotor gearbox separated from the airframe, and the tailboom sustained structural damage. According to the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2), the pilot had accumulated approximately 6,500 total helicopter flight hours, with 3,100 flight hours as a flight instructor in helicopters, and 25 total hours in the same make and model as the accident helicopter. On November 8, 2002, in an interview with a FAA Aviation Safety Inspector, the pilot reported that "he attempted a rolling take-off from the Harris Methodist Hospital heliport with an incorrect power setting (selection switch) which resulted in an emergency landing on the roof of an adjacent automobile parking garage due to insufficient engine power to maintain flight." ## Aircraft - Registration: [N142CF](https://openairdocs.org/deregistered/N142CF-2007-07-28), registration cancelled 2007-07-28, S/N 11141, built 2002 (OpenAirDocs) - Reported make and model: Agusta A109E - Registry model: [Agusta A109E](https://openairdocs.org/model/agusta-a109e) (registry code 0260101) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PW206C](https://openairdocs.org/engine/pratt-whitney-canada-pw206c) (registry code 52160, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 11141 - Airframe hours: 200.9 - Engines: Pratt & Whitney Canada PW206C 640 horsepower turbo shaft - Damage: Substantial damage - Flight: Positioning, Part 91 - Registered owner: North Central Texas Services, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, October 30, 2002, 9.8 hours before - Departed: TE30, Fort Worth, TX - Destination: GPM, Grand Prairie, TX - Flight plan: Company VFR - Airport: TE30, Harris Hospital ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 2, valid medical--w/ waivers/lim; last flight review August 31, 2002; seat: right; flight hours: 8,500 total, 25 in this make and model, 8,400 as pilot in command, 50 in the last 90 days, 10 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 18 knots, gusting 25 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F ## 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 20021108032649A](https://openairdocs.org/incident/20021108032649A), Nov 8, 2002: Agusta A109E, Fortworth, TX, Substantial damage. (-23) The pilot-in-command stated that he attempted a rolling take-off from harris hospital helipad without 100 percent power available, which caused the… ## Other investigations on N142CF (1) 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. - [NTSB DFW06LA057](https://openairdocs.org/ntsb/DFW06LA057), Jan 19, 2006: Agusta A109E (N142CF), Fort Worth, TX, substantial damage. Probable cause: The pilot's inadvertent encounter with ground resonance which resulted in the destruction of the helicopter. ## Docket (3 files) The files NTSB released with the investigation on May 22, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56040. 650 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 476 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381669&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Inspector Statements (item 2, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381670&FileExtension=.PDF&FileName=FAA%20Inspector%20Statements-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 3, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381672&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.