# NTSB GAA17CA562: Eurocopter AS 350, N515ET, Fullerton, CA, September 27, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: September 27, 2017, 10:00 local (17:00 UTC) - Place: Fullerton, CA - Coordinates: 33.871944, -117.979721 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.8719&lon=-117.9797&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report June 14, 2018 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 96108 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA17CA562 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96108/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96108 - Page: https://openairdocs.org/ntsb/GAA17CA562 ## Probable cause The pilot under evaluation’s failure to maintain adequate airspeed during a simulated hydraulic failure, which resulted in a loss of helicopter control. Contributing to the accident was the check pilot’s delayed remedial action. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Eurocopter AS 350 B2, 13 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=8680950), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Eurocopter AS 350 B2, 2 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=8680950), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Eurocopter AS 350 B2, 4 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=8680950), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Eurocopter AS 350 B2, 2 cases](https://openairdocs.org/ntsb-events/600/sequence.md?model=8680950), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md) - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Eurocopter AS 350 B2, 11 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=8680950), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Eurocopter AS 350 B2, 16 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=8680950), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The check pilot reported that he was administering an annual standardization check ride in the public helicopter. The last maneuver evaluated was a hydraulic failure that would terminate by accomplishing a simulated run-on landing. The maneuver was initiated when the evaluated pilot established an out-of-ground-effect (OGE) hover on the downwind leg of the pattern. The check pilot engaged the hydraulic test button on the center console to "simulate a hydraulic failure." The evaluated pilot lowered the nose and established forward airspeed to maintain controllability. He maintained stabilized forward flight on the downwind leg, and the check pilot disengaged the hydraulic test button. The check pilot moved the hydraulic cutoff switch to the "off" position, and the hydraulic system was disengaged. The evaluated pilot remained on the controls and established a shallow approach until about 3 ft above the runway. Over the runway, the evaluated pilot allowed the helicopter's airspeed to decrease, and the check pilot stated, "Keep the speed up." The evaluated pilot responded by lowering the nose; however, an uncontrollable rapid left yaw ensued. The check pilot took control of the helicopter and attempted to keep the helicopter over the runway, but the nose pitched down, and the main rotor blades struck the ground. The check pilot decreased the fuel control, and the helicopter settled upright on the runway. The helicopter sustained substantial damage to the windscreen above the cabin, the tailboom, and tail rotor drive system. The METAR at the accident airport reported that, at the time of the accident, the wind from 250° at 3 knots, the skies were clear, and the temperature was 72°F. According to the Operator's Flight Manual: In case of loss of hydraulic pressure, the recommended safety speed range is from 40 to 60 kt. CAUTION: DO NOT ATTEMPT TO CARRY OUT HOVER FLIGHT OR ANY LOW SPEED MANEUVER WITHOUT HYDRAULIC PRESSURE ASSISTANCE. THE INTENSITY AND DIRECTION OF THE CONTROL FEEDBACK FORCES WILL CHANGE RAPIDLY. THIS WILL RESULT IN EXCESSIVE PILOT WORKLOAD, POOR AIRCRAFT CONTROL, AND POSSIBLE LOSS OF CONTROL. Postaccident examination revealed no mechanical malfunctions or anomalies that would have precluded normal operation. ## Factual narrative The check pilot reported that he was administering an annual standardization check ride in the public use helicopter. The last maneuver evaluated was a hydraulic failure that would terminate by accomplishing a simulated run-on landing. The maneuver was initiated when the check/evaluated pilot established an out of ground effect (OGE) hover on the downwind leg of the pattern. The check-pilot engaged the hydraulic test button on the center console to "simulate a hydraulic failure." The evaluated pilot lowered the nose and established forward airspeed to maintain aircraft controllability. He maintained stabilized forward flight on the downwind leg, and the check-pilot disengage the hydraulic test button. The check pilot moved the hydraulic cut off switch to the off position, and the hydraulic system was disengaged. The evaluated pilot remained on the controls and established a shallow approach until about 3ft above the runway. Over the runway, the evaluated pilot allowed the helicopter's airspeed to decrease, and the check-pilot stated, "Keep the speed up." The evaluated pilot responded by lowering the nose, however, an uncontrollable rapid left yaw ensued. The check-pilot took control of the helicopter and attempted to keep the helicopter over the runway, but the nose pitched down, and the main rotor blades struck the ground. The check pilot decreased the fuel control and the helicopter settled upright on the runway. The helicopter sustained substantial damage to the windscreen above the cabin, the tailboom and tail rotor drive system. The METAR at the accident airport during the time of the accident reported that the wind from 250° at 3kts, the skies were clear, and the temperature was 72°F. According to the Operator's Flight Manual: In case of loss of hydraulic pressure, the recommended safety speed range is from 40 to 60 kt. CAUTION: DO NOT ATTEMPT TO CARRY OUT HOVER FLIGHT OR ANY LOW SPEED MANEUVER WITHOUT HYDRAULIC PRESSURE ASSISTANCE. THE INTENSITY AND DIRECTION OF THE CONTROL FEEDBACK FORCES WILL CHANGE RAPIDLY. THIS WILL RESULT IN EXCESSIVE PILOT WORKLOAD, POOR AIRCRAFT CONTROL, AND POSSIBLE LOSS OF CONTROL. There were no mechanical malfunctions or anomalies that were identified as a result of this investigation. ## Aircraft - Registration: [N515ET](https://openairdocs.org/deregistered/N515ET-2019-01-11), registration cancelled 2019-01-11, S/N 3425, built 2001 (OpenAirDocs) - Reported make and model: EUROCOPTER AS 350 (B2) - Registry model: [Eurocopter AS 350 B2](https://openairdocs.org/model/eurocopter-as-350-b2) (registry code 8680950) (OpenAirDocs) - Registry engine: [Turbomeca ARRIEL-1D1](https://openairdocs.org/engine/turbomeca-arriel-1d1) (registry code 60053, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 3425 - Year built: 2001 - Airframe hours: 4636 - Engines: Turbomeca Arriel 1D1 9783 horsepower turbo shaft - Damage: Substantial damage - Flight: Instructional, Public use - Operator: Chaparral Air Group - Registered owner: Chaparral Air Group - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 11, 2017 - Departed: LGB, LONG BEACH, CA - Destination: FUL, Fullerton, CA - Airport: FUL, Fullerton Muni, runway 24, 3,121 × 75 ft, asphalt - Equipment: Electronic multifunction display, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Check pilot; age 56; injuries: minor; flight instructor, commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 1, with waivers/limitations; last flight review December 5, 2016; seat: left; flight hours: 8,259 total, 918 in this make and model, 6,705 as pilot in command, 128 in the last 90 days, 27 in the last 30 days, 5 in the last 24 hours - Pilot; age 51; injuries: minor; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane, helicopter; medical: class 1, with waivers/limitations; last flight review June 15, 2017; seat: right; flight hours: 3,915 total, 158 in this make and model, 3,663 as pilot in command, 55 in the last 90 days, 31 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 3 knots - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 63 °F - Altimeter: 29.88 inHg - Observed at: KFUL ## 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 20170927024719A](https://openairdocs.org/incident/20170927024719A), Sep 27, 2017: Eurocopter AS 350 B2, Fullerton, CA, Substantial damage. This was a public use operation as determined by the NTSB. During an annual check ride for a drug enforcement administration pilot at Fullerton airport in… ## Docket (3 files) The files NTSB released with the investigation on April 25, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96108. 4.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462433&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - McFall II - Statement (item 2, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462434&FileExtension=.PDF&FileName=McFall%20II%20-%20Statement-Master.PDF - Photos (Courtesy of Operator) (item 3, .PDF, 2 photos, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462435&FileExtension=.PDF&FileName=Photos%20(Courtesy%20of%20Operator)-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.