# NTSB GAA19CA403: Md Helicopter 369, N500SC, Summersville, SC, June 26, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: June 26, 2019, 16:37 local (20:37 UTC) - Place: Summersville, SC - Coordinates: 33.062221, -80.28083 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.0622&lon=-80.2808&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-hover: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report May 21, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99819 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA403 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99819/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99819 - Page: https://openairdocs.org/ntsb/GAA19CA403 ## Probable cause The copilot’s disabling of the flight controls of an operating helicopter without telling the pilot on the controls, which resulted in a subsequent loss of control and collision with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · Copilot (probable cause); cases with it: [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md) - [Rotorcraft flight control: tail rotor control system](https://openairdocs.org/ntsb-findings/01046720): Aircraft › Aircraft propeller/rotor · Incorrect use/operation (probable cause); cases with it: [All aircraft, 13 cases](https://openairdocs.org/ntsb-findings/01046720/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-hover: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering-hover: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot, seated in the left seat, reported that he taxied and landed the helicopter on a taxiway after completing a mission. After landing, the copilot, seated in the right seat, disembarked with the passenger to request fuel from the fixed-base operator. The copilot returned to the helicopter without boarding and instructed the pilot to reposition the helicopter to the airport's refueling station because the fuel truck was inoperative. Once the copilot was clear of the helicopter, the pilot brought the helicopter to a hover, but the helicopter began to spin clockwise. He then applied left pedal, but the helicopter continued to spin and climbed about 7 ft above ground level. The pilot stated that, after two revolutions, he realized that the right-seat, left antitorque pedal was "chocked" and added that he was not aware that the copilot had "chocked" the pedals. He immediately initiated an autorotation, but the helicopter's tail rotor and main rotor blades struck the ground. The copilot reported that, after exiting the cockpit, while the pilot had positive control of the flight controls, he chocked the pedals on the right side by removing the left antitorque pedal, rotating it 180°, and reinstalling it, which prevented full travel of the left antitorque pedal on both sides of the cockpit. He added that he did not tell the pilot he had chocked the pedals and that he did not know why he chocked the pedals. The helicopter sustained substantial damage to the main and tail rotor systems and tailboom. The pilot reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation. ## Factual narrative The helicopter's pilot, seated in the left seat, reported that he taxied and landed the helicopter on a taxiway after completing a mission with a copilot onboard. After landing, the copilot, seated in the right seat, disembarked with the passenger, to request fuel from the fixed base operation. The copilot returned to the helicopter and without boarding, instructed the pilot to reposition the helicopter to the airport's refueling station because the fuel truck was inoperative. Once the copilot was clear of the helicopter, the pilot brought the helicopter to a hover, but the helicopter began to spin clockwise. He then applied left pedal, but the helicopter continued to spin and climbed about 7 ft above ground level. After two revolutions, the pilot realized that the right seat, left hand anti-torque pedal was "chocked." He immediately initiated an autorotation, but the helicopter's tail rotor and main rotor blades struck the ground. The copilot reported that, after exiting the cockpit, while the pilot had positive control of the flight controls, he "chocked" the pedals on the right side, by removing the left-hand anti-torque pedal, rotated it 180°, and reinstalled it. This action prevents full travel of the left anti-torque pedal on both sides of the cockpit. He did not tell the pilot he had chocked the pedals, and the pilot added that he was not aware that the copilot had "chocked" the pedals. The copilot added that he did not know the reason why he "chocked" the pedals. The helicopter sustained substantial damage to the main rotor system, tail rotor system and tailboom. The pilot reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation. A senior leadership official for the operator reported that "chocking the pedals" is a common, unwritten practice utilized when both pilots exit the helicopter while the engine is running. He added that there was a consensus between both full time and part-time pilots approving the "chocking of pedals", although the action is not approved by the manufacturer. Conversely, the pilot, who is also the unit safety officer, reported that he did not agree with the practice but did not express his concern to management and went along it, adding that the practice and the organizational culture does not reflect a Just Safety Culture. According to a manager, a safety management systems (SMS) manual was created 2 years earlier, but its "Hazard Identification and Analysis" and "Safety Risk Assessment and Mitigation" processes were not utilized to determine the risks associated with "chocking the pedals." The manager added that the SMS program is not properly understood nor utilized by all pilots or management and seen as another program created by upper management to satisfy a requirement. According to the manufacturer, "locking" the pedals while the engine is running, is not an approved procedure (refer to the Operational Safety NoticeOSN2019-004 in the docket). ## Aircraft - Registration: N500SC (not matched to a registry record) - Reported make and model: Md Helicopter 369 (E) - Category: Helicopter - Serial number: 0334E - Year built: 1989 - Airframe hours: 11719.1 - Engines: Rolls Royce RR250-C20B 420 horsepower turbo shaft - Damage: Substantial damage - Fire: On-Ground - Flight: Aerial observation, Part 91 - Operator: South Carolina Law Enforcement Division - Registered owner: South Carolina Law Enforcement Division - Airworthiness certificate: Unknown - Last inspection: 100 hour, June 11, 2019 - Departed: DYB, Summersville, SC - Destination: DYB, Summersville, SC - Airport: DYB, Summerville - Equipment: Satellite tracking device, Electronic multifunction display, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: minor; commercial; medical: class 2, without waivers/limitations; last flight review February 20, 2019; seat: left; restraint: 4-point; flight hours: 836 total, 759 in this make and model, 708 as pilot in command, 51 in the last 90 days, 27 in the last 30 days, 5 in the last 24 hours - Co-pilot; age 63; injuries: none; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; medical: class 2, with waivers/limitations; seat: none; restraint: none ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 68 °F - Altimeter: 30.11 inHg - Observed at: KDYB ## 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 20190626006419A](https://openairdocs.org/incident/20190626006419A), Jun 26, 2019: Mcdonnell Douglas Helicopter 369E, Summerville, SC, Destroyed. After landing the copilot and deputy exited the aircraft and walked to the FBO to get fuel. Copilot was told the fuel truck was inoperative and the aircraft… ## Docket (9 files) The files NTSB released with the investigation on January 3, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99819. 2.8 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=40479546&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photos (item 2, .PDF, 264 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479547&FileExtension=.PDF&FileName=Accident%20Photos-Master.PDF - Pilot's Statement (item 3, .PDF, 420 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479548&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Co-Pilot's Statement (item 4, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479549&FileExtension=.PDF&FileName=Co-Pilot%27s%20Statement-Master.PDF - Follow-up Record of Conversation - Co-Pilot (item 5, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479550&FileExtension=.PDF&FileName=Follow-up%20Record%20of%20Conversation%20-%20Co-Pilot-Master.PDF - Party Submission Form (item 6, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479551&FileExtension=.PDF&FileName=Party%20Submission%20Form-Master.PDF - Record of Conversation - Unit Lt. (item 7, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479552&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Unit%20Lt.-Master.PDF - Record of Conversation - Flight Instructor (item 8, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479553&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Flight%20Instructor-Master.PDF - Manufacturer Operational Notice (item 9, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479554&FileExtension=.PDF&FileName=Manufacturer%20Operational%20Notice-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.