IAD98GA110

NTSB accident investigation · Hughes OH-6A · Newark, TX · September 25, 1998

Accident · FatalFinal report
Date
September 25, 1998, 11:15 local (16:15 UTC)
Place
Newark, TX
Injuries
1 fatal, 1 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N234ZMHughes OH-6A
Weather
Visual (VMC) · Day
Status
Completed · report November 22, 2000
Report
Approved by Office Director
Case key
45302

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

Failure of the Instructor Pilot to control the helicopter's rate of descent during a demonstrated autorotation. Contributing to the accident were the Operator's lack of: a. Instructor Pilot standardization procedures, and b. Specific or adequate flight demonstration procedures and techniques for both instructor and transition pilots.

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.

Abrupt maneuverApproach - vfr pattern - downwind
Hard landingDescent
Gear collapsedLanding - flare/touchdown
FireLanding

Analysis

The flightcrew and helicopter were properly certified and maintained in according with federal regulations. Weather was not a factor. At the time of the accident, the flight was not communicating with any tower or air traffic facility. Communications could have aided in initiating rescue and fire-fighting operations if a check-in schedule with KAFW tower or other facility or agency had been established. Facilities affected the accident, because there were no extinguishers or other fire-fighting equipment at the accident site, which was a usual autorotative training area. There was pilot-stated evidence that there may have been a power-related or other control problem with the accident helicopter, becoming apparent at a most critical time, that is, during power-on recover from a demonstrated autorotation. Specific evidence came from the interview and statement of a DEA Special Agent/Pilot, who on September 14, 1998, took the TP on a demonstration flight in the accident helicopter, prior to the TP beginning the OH-6A transition syllabus. The Special Agent/Pilot's written statement to the accident investigation, stated in part, 'The aircraft was flared, forward momentum was checked, and the aircraft was leveled as it started to descend toward the ground. At this time, collective was applied in order to recover to a three foot hover. I was surprised at the engine's reaction. I perceived a delay followed by an engine surge which created a significant yaw to the right.' Also, following his initial statement, when asked about the availability of power during recovery from the practice autorotations, the TP emphatically stated, 'Make sure you check that engine.' The engine was disassembled for an engineering examination and report under Safety Board IIC-oversight at Rolls Royce Allison, Indianapolis. In a similar manner, the main gearbox, transmission drive shaft, and overriding clutch were disassembled and subjected to engineering examinations and a report at the Boeing facility, Mesa, Arizona. The components examined at the two facilities were not severely fire-damaged. The engine, upon disassembly, evidenced that it was capable of producing power at the time of impact. The examinations of the main gearbox/overriding clutch systems showed no evidence of pre-impact damage and evidenced the ability to turn normally prior to impact. However, because of extensive fire damage or destruction to the fuel cells and related fuel lines, that system was not capable of being subjected to similar engineering examinations. Following a request at the beginning of the interview that he initially describe the event in his own words, and a few questions would then follow, the TP described a series of events that began after he made the comment regarding a '50 foot area,' in which the IP quickly took control of the helicopter, entered a climbing turn, leveled out, and then initiated an abrupt, steep angle of bank, and steep approach to a final in which the TP, 'hoped there would be enough at the end.' The impact site showed tail rotor blade strikes, first, evidencing a high nose attitude at impact. A high nose attitude at impact may indicate that, if the helicopter were responding to control inputs, the pilot was still attempting to arrest momentum. The IP was involved in an incident on November 3, 1995, in which the DEA Aviation Section Incident Form states, he 'took control of the A/C and said that he would demonstrate a zero airspeed autorotation.' That description is similar to the IP taking control of the accident helicopter following the TP's statement. The 1995 incident report continues, the IP 'then entered the maneuver and began explaining a proper procedure. At approx. 70' AGL [he] began to flare the A/C at which point [he] stated, 'I forgot to roll the throttle in.'' The autorotative recovery continued as an overtorque. 'As the A/C began to level at approx. [? feet] I noticed the torque gauge indicate past 120 [percent] at which point the maneuver was terminated [in] a hover.' The 1995 incident report leaves questions unanswered, but '120 percent' [an overtorque] raises a question whether an overtorque was necessary to recover, and 'terminate in a hover.' The IP was the only OH-6A instructor pilot for the DEA at KAFW. However, an interview with the training officer evidenced a lack of scheduled standardization meetings or procedures involving unit IPs, regardless of models, or involving the accident IP and the other OH-6A pilots in command that were based at KAFW. Scheduled standardization meetings should have been even more useful than normally expected, in that the flight operations manual was essentially copied from the U.S. Army manual, and, as the DEA training officer confirmed, under specific instructor pilot and transition pilot performance criteria, there was no more precise writing than that which was found in the OH-6 Pilot Transition lesson plan, which stated, 'Introduce Autorotations.'

Factual narrative

History of flight

At 1115 central daylight time (CDT), September 25, 1998, a Drug Enforcement Administration (DEA) OH-6A, registration N234ZM, manufactured by Hughes Helicopter as serial no. 59-1178, crashed about 1 mile east of Copeland Airport (airport identifier 4TA, airport elevation 688 feet mean sea level - msl), Newark, Texas. [1, reference footnotes following Narrative] The helicopter impacted on a southwesterly course onto slightly-rising ranchland about 3/4 mile from the headquarters of Kenneth Copeland Ministries. [2] The land in the area of the crash site was owned by the Texas National Guard and was used by the DEA for helicopter flight training. [3] There were two persons on board the helicopter: an instructor pilot (IP) who was an employee of Raytheon Corporation, and a transition pilot (TP). The TP was a DEA special agent/pilot on a syllabus flight as part of transition training from reciprocating engine-powered helicopters to the turbine-powered OH-6A. The DEA-owned public-use aircraft was being flown on a VFR flight plan, as an instructional flight conducted under the Code of Federal Regulations, 14 CFR Part 91. The IP sustained fatal injuries. [4] The TP escaped from the wreckage, having sustained severe burns. [5] The helicopter was destroyed. [6]

The flight departed the DEA operations facility at Alliance Airport (identifier KAFW), Texas, at 1028 CDT [7] for the practice area, about 9 miles west of KAFW . The TP received a commercial pilot "add-on" helicopter rating, September 19, 1998, following an FAA check flight in a Schweizer 300CB. [8] Prior to beginning the OH-6A transition syllabus with the IP, the TP flew two OH-6A familiarization flights with another DEA OH-6A aircraft commander. [9] The accident flight was the 5th flight in syllabus transitional training for the TP that started September 21, 1998, all with the accident IP, who was the designated DEA instructor for the OH-6A. [10]

Interviewed in hospital intensive care, the TP stated that upon arrival in the training area he flew a series of normal approaches and practice autorotations to recovery with power. [11] After the TP completed recovery from a practice autorotation, the IP complemented him on his performance. The TP acknowledged the instructor's complement, but stated that he may have to autorotate to a "50-foot area in Dallas." The TP then took control of the helicopter and said "watch this," [12] the IP initiated a turning climb to the left and about 300 feet above ground level (agl) initiated an "abrupt" maneuver, a near-90 degree left angle of bank and a "fast and steep angle of descent." The TP stated that he hoped "there would be enough at the end." [13]

The TP stated that the helicopter hit hard and the left skid broke. He "saw Larry" (the IP in the left seat) below him on the ground. The TP was able to unstrap and exit his seat and the helicopter, which was in flames. His clothing was burning, he rolled on the ground, tried to put out the flames, and two men came to him to assist and cut his clothing from him. He tried to sit and told them to "get Larry, get Larry." He asked for water.

A third man arrived, who had been driving in his pickup truck and had observed the helicopter flying level, then turn left and descend to impact. [14] He stated that when he ran to the burning helicopter, he saw the remaining pilot motionless and apparently fatally-injured. Because of the intensity of the fire, the men were not able to extract the IP. The third man to arrive then called Copeland Airport, notified them of the crash and fire, and requested that they immediately bring foam-producing fire extinguishers to the site.

Based on a 47-minute flight duration, it is estimated that the aircraft consumed approximately 18 gallons of jet fuel, at 22 gallons per hour approximate consumption. At this rate of consumption, approximately forty-four gallons of fuel is estimated to have remained in the tank at the time of impact.

The accident occurred in daylight, in visual meteorological conditions, at 33 degrees, 00 minutes north latitude, and 97 degrees, 29 minutes west longitude.

Injuries to persons

The IP sustained fatal injuries. The TP sustained major injuries, as severe burns.

Damage to aircraft

The aircraft was destroyed by impact and post-crash fire.

Personnel information

The flightcrew was comprised of a contractor-provided (Raytheon) Instructor Pilot and a DEA Special Agent transition pilot. The IP held FAA ratings as an airline transport pilot (ATP), certified flight instructor (CFI), and certified flight instructor - instrument (CFI-I) in helicopters; and commercial pilot (COMM) single engine land (SEL), instrument (INST) and CFI in airplanes. He had a total of approximately 14,500 flight hours. Less than 200 of the total flight hours were in fixed-wing aircraft, the remainder in helicopters. The TP accumulated 1,003 total flight hours, 77.6 of which were in helicopters, the remainder in fixed wing. The TP held FAA ratings as COMM multi-engine land (MEL), and INST in airplanes and COMM in helicopters. Upon completion of an FAA examination, including a check flight in a Schweizer 300CB, the TP received a commercial pilot rating - helicopter, September 19, 1998.

The instructor (ip)

The IP, age 51, had worked 6 years as a contractor-provided instructor at the DEA's Aviation Operations Center. The operations center was previously located at Addison Airport north of Dallas, then moved to Alliance Airport, north of Fort Worth, February 1994. The IP first soloed in 1965, and flew as a U.S. Army helicopter pilot in Vietnam in 1968. He subsequently held flight positions for operators in the United States and at foreign bases, including offshore oil rig, jungle "helerig" and South American and Caribbean drug eradication operations. His last Class I medical certificate was dated January 14, 1998, and included the limitations "Pilot must wear corrective lenses for near vision. NIDDM - No Meds - Hemoglobin A1C was 6.8."

FAA records showed no enforcement actions regarding the IP. There was one Accident/Incident Report, which referred to a Controlled Collision with the Ground, resulting from a main drive shaft boot failure, in a Bell 205 helicopter, occurring June 28, 1978. Also, DEA operational records showed two previous flight incidents. In the first incident, two uncommanded engine shutdowns occurred during two demonstrated hovering autorotations on the same day, in the accident helicopter, N234ZM. The report noted that both engine shutdowns occurred as the IP, seated in the left seat, rolled the throttle to idle. A possible cause was listed as "Mechanical problem." The left seat position did not have a flight-idle release. Responding maintenance actions recorded collective and engine linkage inspections and repairs. A second incident, occurred November 3, 1995. [15] Under Describe Event/Situation, the DEA Aviation Section Incident Form states, the IP "took control of the A/C and stated that he would demonstrate [a] zero airspeed auto-rotation. [He] then entered the maneuver and began explaining a proper procedure. At approx. 70' AGL [he] began to flare the A/C at which point [he] stated, "I forgot to roll the throttle in." As the A/C began to level at approx. [? feet] I noticed the torque gauge indicate past 120 [percent] at which point the maneuver was terminated [in] a hover."

Transition pilot (tp)

The TP, age 34, had served as a DEA Special Agent approximately 6 years. Previously, he had served for 2 years as a Dallas Police Officer, and for 2 1/2 years as an Officer in the U.S. Navy. During his Naval service, he received Naval Flight Instruction, including Aircraft Carrier Qualification. DEA records did show a designation as a Naval Aviator. FAA records showed no Accidents, Incidents, or Enforcement actions. His most recent medical certificate was Clas

Aircraft

Registration
N234ZM
Reported as
Hughes OH-6A
Category
Helicopter
Serial number
591178
Airframe hours
4,783
Engine
Allison 250C20/T63A72, 420 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Public aircraft · Part 91
Registered owner
Drug Enforcement Admin
Airworthiness certificate
Special, Special flight (Special)
Last inspection
Annual · June 16, 1998 · 17 hours before
Departed
KAFW · Alliance Airprt, TX
Flight plan
VFR
Airport
KAFW · Alliance Airport

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
51
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
14,500 total · 784 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 10 knots
Visibility
5 statute miles
Lowest ceiling
None
Temperature
90 °F
Altimeter
29.00 inHg
Observed at
KAF, 9 nm away