IAD98GA039

NTSB accident investigation · Bell 412 · Quantico, VA · March 12, 1998

Accident · No injuriesFinal report
Date
March 12, 1998, 17:30 local (22:30 UTC)
Place
Quantico, VA
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N82628Bell 412
Weather
Visual (VMC) · Day
Status
Completed · report September 7, 2000
Report
Approved by Office Director
FAA report
19980312045109A
Case key
28257

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the pilot's failure to maintain adequate altitude/clearance above the terrain and the lack of management oversight of aircrews and equipment.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterLanding - flare/touchdown
Weather condition - tailwind
Altitude/clearance - not obtained/maintainedPilot in commandCause
Inadequate surveillance,inadequate procedureCompany/operator mgmtCause

Analysis

The FBI helicopter completed two circuits around a training road course at low altitude in pursuit of an automobile. The supervisor of the road course arranged the scenario with the pilot, and an instructor drove the automobile. A second vehicle that followed the pursuit filmed the flight. During the second lap, the vehicle reversed direction as it performed a sudden stop. The helicopter performed a deceleration and the tail skid, tailrotor, and tailboom struck the ground. A request for copies of procedural, operational, maintenance, and safety related programs and documents revealed that they either did not exist, or they were in draft form and unapproved for use. The flight was neither trained for, nor was it briefed. The pilots received training from the helicopter manufacturer, but no agency mission training or evaluations were noted in the accident helicopter. The FBI convened an Aviation Accident Review Board (AARB). According to the Board, '... [Unit] pilots worked under the 'fly one helicopter, fly all helicopter' assumption. AARB members unanimously agreed that no management oversight of [unit] operations currently exists.'

Factual narrative

History of flight

On March 12, 1998, at 1730 eastern standard time, a Bell 412 helicopter, N82628, operated by the Federal Bureau of Investigation (FBI), was substantially damaged when the tail rotor struck the ground while landing at the FBI Training Academy, Quantico, Virginia. The certificated commercial pilots and one passenger were not injured. Visual meteorological conditions prevailed for the public use flight that originated at the FBI Academy Helipad, at 1715. No flight plan was filed for the flight conducted under 14 CFR Part 91.

The pilot in the right seat was at the flight controls. The purpose of the flight was to complete "...a brief training evolution..." at the Tactical Emergency Vehicle Operations Course (TEVOC). During the event the helicopter was to follow a vehicle around the TEVOC, until the vehicle performed a "J-Turn" stop. The helicopter would then land and de-plane a passenger.

In a written statement, the pilot said:

"The helicopter was being utilized to trail a vehicle around the training track at the academy. The vehicle was being driven by a driving instructor and the entire sequence of events had been briefed. As the vehicle reached the point where a 'J' turn was to be accomplished, the driver signaled, and executed the turn...Due to the fact that the turn was on concrete it was completed in a shorter distance that I expected and I initiated a rapid deceleration to arrest the forward speed and bring the helicopter to a hover...The fact that the initial approach was downwind was discussed and taken into account."

According to an Interview Summary provided by the FBI, the second pilot stated he was in the left seat and believed the mission had been authorized and coordinated. According to the summary:

"[The second pilot] was seated on the left side of the aircraft, and that he again understood [the first pilot] to be the Aircraft Commander. They flew straight to the TEVOC course, [the first pilot] was flying the aircraft. [The second pilot] stated that he still had no concept of what exactly they were going to do, he was aware they were going to follow a car around the track. He advised that he has never followed a car around the TEVOC track in the past, nor is he aware of any training in the past that involved similar activity.

[The second pilot] stated that after arriving at the TEVOC course, they flew approximately 10 to 20 feet above the track while following a TEVOC type car around the track. After completing a full lap, [the first pilot] completed a rapid or abrupt deceleration, during which [the second pilot] felt the tail stinger and possibly the boom contact the ground...[The second pilot] stated the abrupt deceleration performed by [the first pilot] surprised him given they were downwind, on an uphill grade, and they were down low. He stated that he did not know what precipitated [the first pilot's] decision to abruptly decelerate."

The pursuit of the vehicle by the helicopter was captured on videotape. A review of the videotape revealed the helicopter completed approximately two left-hand circuits around the TEVOC in pursuit of the vehicle. The helicopter was flown over the pavement between and below the trees bordering each side of the roadway. The helicopter was observed to bank at angles greater than 30 degrees, with the main rotor tips in close proximity to the ground.

During the second lap, the vehicle reversed direction as it performed the J-Turn stop. The helicopter performed a deceleration, and the tailrotor separated from the helicopter after the tail skid, tailrotor, and tailboom struck the ground. The helicopter then leveled at a hover and began a spin to the right. The helicopter landed in an upright position while still in a right-hand turn.

According to the pilot, he closed the throttles and performed a hovering autorotation when a left pedal input did not stop the spin.

The accident occurred during the hours of daylight approximately 42 degrees, 28 minutes north latitude, and 76 degrees, 8 minutes west longitude.

Personnel information

The pilot held a commercial pilot certificate with ratings for airplane single engine land, multi-engine land, rotorcraft helicopter, and instrument airplane and helicopter. He held a flight instructor certificate with ratings for rotorcraft helicopter and instrument helicopter.

The pilot's most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued on February 9, 1998.

The pilot reported 5,031 hours of total flight experience, of which 3,555 hours were in helicopters. The pilot completed the Bell 412 Pilot Ground and Flight Procedures Training Course July 1, 1996, and reported 70 hours experience in make and model since that time.

The FBI utilized a Bureau Aviation Operations (BAO) computer program to track both aircraft and aviator flight hours. A review of BAO records for the pilot revealed he accumulated 80.1 hours of rotary wing time from March 1997 to September 1997. No instrument time was recorded. No flight time was recorded from October 1997, to March 1998. However, in the NTSB Form 6120.1/2, the FBI listed 19.6 hours of flight experience in the Bell 412 during the 90 days prior to the accident.

The pilot's most recent FBI flight evaluation was completed April 10, 1997 in the UH-1 helicopter. No evaluations in the Bell 412 helicopter were documented.

The second pilot held an airline transport pilot certificate for airplane multi-engine land. He held a commercial pilot certificate for airplane single engine land, rotorcraft helicopter and instrument helicopter. The second pilot held a flight instructor certificate for airplane single engine land, rotorcraft-helicopter, and instrument helicopter.

His most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued on March 11, 1998.

The second pilot reported 8,300 hours of total flight experience. He reported 2,650 hours of rotorcraft experience; 120 hours of which were in make and model.

The second pilot's most recent FBI flight evaluation was in the UH-1 helicopter on March 24, 1997. He was evaluated on day, instrument, and NVG tasks. The second pilot was not evaluated on terrain flight. No evaluations in the Bell 412 helicopter were documented.

A review of the BAO program revealed the second pilot logged 88.5 hours of rotary wing time from March 1997 to September 1997. No instrument flight time was recorded. No flight time was recorded from October 1997, to March 1998. However, in the NTSB Form 6120.1/2, the FBI listed 39 hours of flight experience during the 90 days prior to the accident, 8 hours of which was in the Bell 412.

Damage to aircraft

The wreckage was examined and removed from the scene by the FBI prior to NTSB notification.

Examination of the damage and witness marks on the airframe by Bureau aviation accident investigators revealed that at the time of ground contact, the nose-up pitch attitude of the helicopter had been approximately 30-35 degrees, with an approximate nose-left yaw of 23 degrees. Initial ground scars revealed an approximate magnetic direction of 099 degrees.

Aircraft information

The helicopter was owned by the Textron Financial Corporation and operated by the Federal Bureau of Investigation. The helicopter had accumulated 659.7 hours of total time. The last annual inspection was performed on the helicopter on January 22, 1998, at 640.3 aircraft hours.

According to an Interview Summary provided by the FBI, a mechanic who worked on the helicopter stated he was asked to install a fastrope rig on N82628 in July 1996. He explained to the unit supervisor that he could not install the rig without an FAA Form 337. The mechanic said the unit then hired two mechanics that installed the fastrope rig without the accompanying FAA Form 337.

According to the mechanic, the helicopter sustained a

Aircraft

Registration
N82628
Reported as
Bell 412
Category
Helicopter
Serial number
36106
Airframe hours
659
Engine
P&W PT6, 500 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft · Part 91
Operator
Federal Bureau Investigation
Registered owner
Textron Financial Corporation
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 22, 1998 · 19 hours before
Departed
VA
Destination
HEF · Manassas, VA

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
5,031 total · 70 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 20 knots, gusting 27
Visibility
10 statute miles
Lowest ceiling
None
Temperature
36 °F, dew point 5 °F
Altimeter
30.00 inHg
Observed at
NYG, 8 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.