# NTSB GAA18CA571: Eurocopter AS350, N894NA, Ruidoso, NM, September 29, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 29, 2018, 15:10 local (21:10 UTC) - Place: Ruidoso, NM - Coordinates: 33.396667, -105.785835 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.3967&lon=-105.7858&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report March 20, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 98387 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA571 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98387/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98387 - Page: https://openairdocs.org/ntsb/GAA18CA571 ## Probable cause The pilot's failure to maintain the proper descent rate during landing. Contributing to the accident were the pilot’s failure to conduct preflight performance calculations, which resulted in his operating the helicopter in high-density altitude conditions, and his lack of experience in high-altitude, mountainous flying. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent rate](https://openairdocs.org/ntsb-findings/01062037): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Eurocopter AS 350 B2, 2 cases](https://openairdocs.org/ntsb-findings/01062037/cases.md?model=8680950), [All aircraft, 242 cases](https://openairdocs.org/ntsb-findings/01062037/cases.md) - [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) - [Planning/preparation: performance calculations](https://openairdocs.org/ntsb-findings/02061010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Eurocopter AS 350 B2, 1 case](https://openairdocs.org/ntsb-findings/02061010/cases.md?model=8680950), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md) - [Experience/qualifications: total experience](https://openairdocs.org/ntsb-findings/02031015): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Eurocopter AS 350 B2, 1 case](https://openairdocs.org/ntsb-findings/02031015/cases.md?model=8680950), [All aircraft, 126 cases](https://openairdocs.org/ntsb-findings/02031015/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Eurocopter AS 350 B2, 2 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=8680950), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Training: cRM/MRM training](https://openairdocs.org/ntsb-findings/04031025): Organizational issues › Support/oversight/monitoring · Operator; cases with it: [Eurocopter AS 350 B2, 1 case](https://openairdocs.org/ntsb-findings/04031025/cases.md?model=8680950), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/04031025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Eurocopter AS 350 B2, 4 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=8680950), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092) (defining event); cases with it: [Eurocopter AS 350 B2, 6 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=8680950), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) - [Landing-flare/touchdown: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Eurocopter AS 350 B2, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=8680950), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Landing-flare/touchdown: 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 helicopter pilot was conducting an emergency medical services flight. He reported that, while en route to a ski resort to pick up a patient, he decided to conduct an eastbound reconnaissance over the landing site to scan for obstacles. He saw two cables in front and below the helicopter 's flightpath and initiated a go-around. He added power to clear the cables, and once the tail cleared the cables, he lowered the collective due to a slight drop in the main rotor speed. As he continued the go-around, he initiated a 180º left turn to attempt an approach to the landing site. During the westward approach and while the helicopter was about 20 ft above ground level, he raised the collective to reduce the descent rate, and the main rotor speed subsequently decayed. He felt that, due to the "faster than normal" descent rate, he would not be able to cushion the landing. Before touchdown, a medical crewmember spotted an elevated steel barrier cable below the helicopter, and the pilot made a 90º left turn to avoid a tail rotor strike. The helicopter subsequently touched down hard, bounced, rotated about 180º counterclockwise over the barrier cable, slid down an embankment, and came to rest upright. The helicopter sustained substantial damage to the fuselage and vertical stabilizer. The director of operations reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation. The pilot reported that, during his preflight preparation, he did not calculate the hover-in-ground-effect value, the hover out-of-ground-effect value, or the density altitude for the designated landing site. He added that the accident flight was his second flight in a high-altitude, mountainous environment and that most of his flight hours were accumulated at sea level. He was not aware that the ski resort provided an approach, landing, and takeoff procedure. He added that he should have completed the go-around and circled back around to land. A Federal Aviation Administration inspector reported that, at the time of the accident, the density altitude for the landing site at 9,793 ft was over 12,000 ft. ## Factual narrative The helicopter pilot reported that while enroute to the ski resort to pick up a patient, he decided to conduct an eastbound reconnaissance over the landing site and, after he saw the ground personnel, while scanning for obstacles, he spotted two cables in front and below the aircraft's flight path and initiated a go-around. He added power to clear the cables, and once the tail cleared the cables, he lowered the collective due to a slight droop in the main rotor speed. As he continued with the go-around, he initiated a 180º left turn to attempt an approach into the landing site. During the westward approach, about 20 feet above the ground, the main rotor speed decayed when he raised the collective to reduce his descent rate. He felt that due to his "faster than normal" decent rate, he would not be able to cushion the landing. Prior to touchdown, a medical crew member spotted an elevated steel barrier cable below and the pilot applied another 90º turn to the left to avoid a tail rotor strike. The helicopter touched down hard, bounced, rotated about 180º counterclockwise over the barrier cable, slid down an embankment, and came to rest upright. The helicopter sustained substantial damage to the fuselage and vertical stabilizer. The Director of Operations reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation. The pilot further reported that during his preflight preparation, he did not calculate the hover in ground effect value (HIGE), the hover out of ground effect value (HOGE), or the density altitude for the designated landing site. He added that the accident flight was his second flight in a high altitude, mountainous environment and that most of his flight hours were accumulated at sea level in Texas. He was also not aware that there was an approach, landing and takeoff procedure provided by the ski resort. The director of operations added that the company was not aware that there were dedicated procedures for helicopter medical evacuation. The crew members added that the crew resource management skills and procedures were lacking, prior to and during the accident. They reported that there was no destination or helicopter performance briefing included with the helicopter preflight. The pilot added that he should have completed the go-around and circled back around to land. The Federal Aviation Administration inspector reported, during the time of the accident, the density altitude for the landing site at 9,793 ft was over 12,000 ft. The automated weather observation station located on an airport about 14 NM away, reported that, about the time of the accident, the wind was from 220° at 9 knots, gusting 17 knots. The pilot reported the wind was variable, about 5 knots. The helicopter was landing to the west. ## Aircraft - Registration: [N894NA](https://openairdocs.org/deregistered/N894NA-2021-03-11), registration cancelled 2021-03-11, S/N 2904, built 1996 (OpenAirDocs) - Reported make and model: EUROCOPTER AS350 (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: 2904 - Year built: 1996 - Airframe hours: 8199.4 - Engines: Turbomeca Arriel 1D1 turbo shaft - Damage: Substantial damage - Flight: Part 135 - Operator: Trans Aero Limited, doing business as Trans Aero MedEvac - Registered owner: Roberts Aircraft Co - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, April 9, 2018 - Departed: ATS, Artesia, NM - Destination: El Paso, TX - Flight plan: Unknown - Equipment: Electronic flight bag or handheld device, Video recording device, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: minor; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 2, with waivers/limitations; last flight review April 12, 2018; seat: right; restraint: 4-point; flight hours: 16,818 total, 3,526 in this make and model, 16,818 as pilot in command, 56 in the last 90 days, 26 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 9 knots, gusting 17 - Temperature: 77 °F, dew point 41 °F - Altimeter: 30.27 inHg - Observed at: KSRR, 14 nm away ## 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 20180929016489A](https://openairdocs.org/incident/20180929016489A), Sep 29, 2018: Eurocopter AS 350 B2, Ruidoso, NM, Substantial damage. On September 30, 2018 an astar 350 B2 helicopter (N894NA) registered to roberts aircraft company departed artesia, NM for Ruidoso, NM to pick-up a patient.… ## Docket (9 files) The files NTSB released with the investigation on December 10, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98387. 4.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478867&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photos (item 2, .PDF, 586 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478868&FileExtension=.PDF&FileName=Accident%20Photos-Master.PDF - Record of Conversation - Pilot (item 3, .PDF, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478869&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Record of Conversation-FAA (item 4, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478870&FileExtension=.PDF&FileName=Record%20of%20Conversation-FAA-Master.PDF - Record of Conversation - Medical Crew 1 (item 5, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478871&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Medical%20Crew%201-Master.PDF - Record of Comversation- Medical Crew 2 (item 6, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478872&FileExtension=.PDF&FileName=Record%20of%20Comversation-%20Medical%20Crew%202-Master.PDF - Lifeflight Checklist (item 7, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478873&FileExtension=.PDF&FileName=Lifeflight%20Checklist%20-Master.PDF - Witness Statements (item 8, .PDF, 715 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478874&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Performance Chart (item 9, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478875&FileExtension=.PDF&FileName=Performance%20Chart-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.