GAA16LA182

NTSB accident investigation · Hughes 369 · Weatherford, TX · April 8, 2016

Accident · Serious injuriesLimited investigationFinal report
Date
April 8, 2016, 09:30 local (14:30 UTC)
Place
Weatherford, TX
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N298SDHughes 369
Defining event
Takeoff: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report January 18, 2017
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA North Texas FSDO
FAA report
20160408008779A
Case key
92985

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

The pilot/mechanic's inadequate postmaintenance and preflight inspections, which resulted in his failure to remove the antitorque pedal lock and a subsequent loss of control during hover operations.

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.

Inspection: preflight inspectionPersonnel issues › Task performance · PilotHughes 369A: 3 casesAll aircraft: 551 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelHughes 369A: 1 caseAll aircraft: 57 casesProbable cause
Rotorcraft flight control: tail rotor control systemAircraft › Aircraft propeller/rotor · Inadequate inspectionHughes 369A: 2 casesAll aircraft: 13 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomeHughes 369A: 2 casesAll aircraft: 933 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

The pilot/mechanic stated that, while performing maintenance on the helicopter, he locked the left side antitorque (tail rotor) pedals to keep them out of the way; however, he forgot to unlock them after completing the maintenance. The pilot then conducted a post-maintenance hover check, and, upon increasing collective, the helicopter entered a spin, traveled about 40 feet, and collided with a building and trees. The pilot stated that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation, and that the accident was the result of his failure to remove the antitorque pedal lock before flight.

Factual narrative

On April 8, 2016, about 0930 central daylight time, a MD Helicopters (formerly Hughes) 369A helicopter, N298SD, collided with a building and trees during takeoff at the Staggs Heliport (TE93), Weatherford, Texas. The commercial pilot/airframe and power plant mechanic sustained serious injuries, and the helicopter sustained substantial damage. The helicopter was registered to, and operated by the pilot as a day, visual flight rules (VFR) flight under the provisions of 14 Code of Federal Regulations Part 91 as a maintenance check flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight originated from the Staggs Heliport (TE93), about 0930. The pilot/mechanic submitted a written statement to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on April 30, and stated that during a battery installation on the helicopter, he "locked" the left side anti-torque (tail rotor) pedals in the cockpit to keep them out of the way during the battery installation and forgot to "unlock" them. While conducting a powered maintenance check after an engine installation on the ground, he stated that he was checking the governor and had his seat restraint system on in the right seat for when he "goes to the top end." He stated that he "pulled collective to check at a hover" and the helicopter departed the ground, spun several times, traveled about 40 feet, and collided with a building and trees. The pilot/mechanic sustained serious injuries from the accident sequence. The pilot/mechanic further stated that this was a maintenance error. The helicopter sustained substantial damage to the main rotor system, the fuselage, the tailboom, and the tail rotor system. The pilot/mechanic verified that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. AIRCRAFT INFORMATION The accident helicopter was originally manufactured as an OH-6A for the US Army. After the completion of service with the US Army, the helicopter was issued a standard airworthiness certificate by the Federal Aviation Administration (FAA). WRECKAGE AND IMPACT INFORMATION The photographs of the wreckage supplied by the FAA aviation safety inspector (ASI) showed that the helicopter came to rest with its left side against a small group of trees in close proximity to a residential building and both of the skids had collapsed. Three of the four main rotor blades exhibited several bends at various locations through the length of the blades due to impacting the trees and building while one main rotor blade separated at the blade root. The bottom of the fuselage exhibited crushing consistent with a downward impact with terrain and the tailboom was bent at about the midpoint between the tail rotor and the fuselage. The tailboom was also crushed inward on the left side, just forward of the tail rotor system. The lower vertical fin displayed impact damage on the lower left side.Inside the cockpit, the anti-torque pedals on the right side were observed with the left anti-torque pedal positioned in place with an adjustment pin installed at the top of the pedal arm and the right anti-torque pedal was also positioned in place but did not have an adjustment pin installed at the top of the pedal arm. On the left side of the cockpit, the left anti-torque pedal was displaced from the pedal arm and lying against the center console with the adjustment pin missing and the right anti-torque pedal was positioned in place with an adjustment pin installed at the top of the pedal arm. The center section of the right side cockpit windshield was punctured during the accident sequence. On the right side of the cockpit, the FAA ASI reported that underneath the floor board was various mechanic tools. He further reported that it appears that this foreign object debris did not contribute to the accident. ADDITIONAL INFORMATION Preflight Checklist Excerpts from the US Army Operators Manual Helicopter Observation OH-6A TM 55-1520-214-10 (1976) for the preflight checklist are available in the public docket for this accident. Anti-Torque Control System Excerpts from the US Army Operators Manual Helicopter Observation OH-6A TM 55-1520-214-10 (1976) for the anti-torque control system are available in the public docket for this accident. MD Helicopters Service Letter SL369H-124R3 MD Helicopters has published Service Letter SL369H-124R3 (2004). This document describes the maintenance and operation requirements of surplus 369A (OH-6A) series helicopters and states in part: Failure to comply with established FAA regulations, airworthiness directives, mandatory retirement, overhaul life limits, and proper inspection and maintenance procedures may lead to loss of control of the helicopter and subsequent injury, death and/or property damage.

Aircraft

Registration
N298SD
Reported as
Hughes 369 (A)
Category
Helicopter
Serial number
280332
Built
1968
Airframe hours
4,195
Engine
Rolls-Royce 250-C10B, 250 horsepower, turbo shaft
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 14, 2016
Departed
TE93 · Weatherford, TX
Destination
TE93 · Weatherford, TX
Airport
TE93 · Staggs
Equipment
None

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
67
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 2, With waivers/limitations
Last flight review
May 18, 2014
Seat
Right
Restraint
3-point
Flight hours
649 total · 11 in this make and model · 601 as pilot in command · 11 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
80° at 12 knots
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
66 °F, dew point 25 °F
Altimeter
30.20 inHg
Observed at
KNFW, 15 nm away

Docket · 7

The files NTSB released with the investigation on November 2, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.5 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.

Other investigations on N298SD · 1

Matched to the same aircraft by N-number and date.