LAX99GA216

NTSB accident investigation · Hughes OH-6A · Tucson, AZ · June 15, 1999

Accident · Serious injuriesFinal report
Date
June 15, 1999, 13:35 local (20:35 UTC)
Place
Tucson, AZ
Injuries
1 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N6187CHughes OH-6A
Weather
Visual (VMC) · Day
Status
Completed · report May 16, 2001
Report
Approved by Office Director
FAA report
19990615007109A
Case key
46586

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

Fuel exhaustion resulting from pilot's failure to perform adequate fuel consumption calculations. The unreliable and inoperative fuel level indicating system components and the operator's operation of the aircraft with known deficiencies were factors in the accident.

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.

Loss of engine power(total) - nonmechanicalApproach
Fluid,fuel - exhaustionCause
Fuel consumption calculations - not performedPilot in commandCause
Fuel system,low fuel warning light - inoperativeFactor
Engine instruments,fuel quantity gage - inoperativeFactor
Operation with known deficiencies in equipment - performedCompany/operator managementFactor
Forced landingDescent - emergency
Terrain condition - none suitable
Loss of control - in flightEmergency descent/landing
Terrain condition - high obstruction(s)
Proper glidepath - not possiblePilot in commandFactor
Rotor rpm - not maintainedPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The pilot was on short final approach to land when he reported an engine failure. He attempted to stretch his glide to avoid buildings and cars on the ground; however, the helicopter struck railroad tracks next to the field boundary. Damage to the main rotor blades was consistent with a low rotor rpm at impact. The pilot did not recall how much time had elapsed since his last refueling. Examination of the navigation and fuel endurance log from the helicopter cockpit (required by the operator) showed the pilot had not completed the fuel endurance calculations at the time of last fueling. The helicopter was equipped with a main fuel system and an auxiliary fuel system. A deferred maintenance item, 'main fuel gauge unreliable in forward flight,' was still open. The same discrepancy had also been entered previously and it, too, had not been cleared. The auxiliary fuel gauge was entered as inoperative on the deferred maintenance log with 'parts on order' but had not been cleared at the time of the accident. The pilot last recalled reading approximately 78 pounds on the main fuel gauge. He did not recall seeing the 20-minute light illuminate before the accident. A check of the low fuel warning system found that float arm contact in the fuel cell occurred at 34 pounds, which approximates 20 minutes of usable fuel; no discrepancies were found in the operation of the system. No evidence of a fuel spill was found around or under the wreckage. The crashworthy main fuel cell was uncompromised and about 12 ounces of trapped fuel was found. No fuel was found in the auxiliary fuel tank. The light bulbs for the 'Engine Out, Fuel Low, and Master Caution' were removed for examination. One 'Master Caution' bulb showed a small amount of filament stretching, consistent with hot stretching from a light to moderate impact force. The filaments of both 'Fuel Low' bulbs were intact and unstretched, consistent with bulbs not being illuminated during a light to moderate impact. The filaments from both 'Engine Out' bulbs showed a small amount of stretching, again consistent with hot stretching from light to moderate impact. There were no other discrepancies found with the engine or engine-related systems.

Factual narrative

History of flight

On June 15, 1999, at 1335 hours mountain standard time, a Hughes OH-6A, N6187C, crashed during the landing approach at Tucson, Arizona. The aircraft was destroyed and the commercial pilot, the sole occupant, received serious injuries. The U.S. Border Patrol was operating the aircraft as a public-use flight when the accident occurred. The flight originated from the Sells Airport, Sells, Arizona, at an undetermined time on the morning of the accident. Visual meteorological conditions prevailed at the time and no flight plan was filed.

The Federal Aviation Administration local controller at the Tucson International Airport Air Traffic Control Tower (ATCT) had cleared the helicopter for landing on runway 3 and had instructed the pilot to hold short of runway 11L when the pilot reported an engine failure. Based on witness accounts and impact ground scars, the estimated magnetic heading at the time the emergency occurred was between 70 and 80 degrees with the helicopter descending through about 200 to 300 feet agl. Witnesses described the forward airspeed as beginning to slow below 80 knots with an estimated descent angle of between 30 and 40 degrees and a greater than normal rate of descent.

According to witness observations, the pilot attempted to stretch his glide to avoid several buildings and cars; however, the helicopter struck a railroad track that runs along the west side of the airport perimeter. A witness stated that she saw the tail boom of the helicopter rebound into the air following contact with the tracks and then the helicopter spun counterclockwise about 170 degrees before finally coming to rest.

Personnel information

The pilot was a full-time employee of the United States Department of Justice, uniformed Border Patrol division. He held the position as a helicopter pilot since 1987. He was permanently based in Santee, California, and had been detailed to the Tucson office for about a month prior to the accident. His last flight check, a biennial flight review, conducted by the U.S. Border Patrol, was given on December 4, 1998, with no discrepancies noted.

The pilot holds a commercial pilot certificate with ratings for helicopter and airplane single engine land and instrument that was issued on September 10, 1982.

His second-class medical certificate issued on June 16, 1998, stated that he "shall have available glasses for near vision." He was wearing them at the time of the accident.

Aircraft information

Refueling slips indicated that the pilot had landed and refueled twice at Sells since his initial takeoff from Tucson earlier that morning. The pilot recalled only flying "about 6 hours" the day of the accident. He also recalled taking off "about 0730" that morning.

Review of the flight planning and fuel consumption logs in the helicopter revealed that he did not compute an estimated fuel endurance log after his last refueling.

Hughes Aircraft manufactured the helicopter, serial number (S/N) 68-17154, in 1968 as an OH-6A for use in aerial observation and scouting by the U.S. Army. The U.S. Border Patrol obtained the helicopter from military surplus for use in aerial observation as well. Since the date of manufacture it has accumulated a total of 7,177.1 flight hours.

After obtaining the helicopter, the Border Patrol maintained the helicopter on a continuous airworthiness maintenance program, having completed a 300-hour inspection on April 26, 1999, a 25-hour inspection on May 11, 1999, a 100-hour inspection on May 22, 1999, and a 50-hour inspection on June 7, 1999.

The Allison 250-C20B engine, S/N CAE836918, had last been removed, repaired, and tested, and then reinstalled on August 27, 1998, at a total time of 713.5 hours. The removal and repair was due to an N2 lockup with metal found in the engine oil. At the time of the accident, the engine had accumulated a total of 1,338.3 hours.

Review of the maintenance records disclosed that two of the life limited components, the fuel control, S/N 333703, and power turbine governor, S/N 3423R, did not list total times on the engine assembly record.

A deferred maintenance item, "main fuel gauge unreliable in forward flight," was entered on January 7, 1999, and was still open. The same discrepancy had also been entered previously on September 18, 1998, and it had not been cleared. The auxiliary fuel gauge was entered as inoperative on October 11, 1996. This discrepancy showed an entry for "parts on order" but had not been cleared at the time of the accident. According to the pilot's statement, he last recalled reading approximately 78 pounds on the main fuel gauge immediately prior to the engine failure.

The helicopter was equipped with a 50-gallon auxiliary fuel system.

The fueling log for the first flight of the day, June 15, 1999, showed that 58 gallons of JP-8 had been dispensed with 418 gallons remaining. Subsequent fueling slips indicated that an additional 50 gallons and 88 gallons were added later during the same day. The accumulated flight times at the time the refueling events occurred were not available.

The helicopter was not equipped with an auto relight system.

Communications

The pilot contacted the Tucson ATCT operator on tower frequency 118.3 kHz after being handed off by Tucson approach control at 1330:23. The helicopter was issued a discrete transponder beacon code of 0424, and the pilot had radioed approach control that he had information Charlie on his initial call. All prior radio communications were described as routine with no sense of urgency reported.

At 1330:47 the pilot radioed "Tucson Tower, helicopter 6187C coming up on Black Mountain, 3,000, landing Border Patrol." At 2035:33, the operator instructed the pilot to "Okay, you can [air] taxi up to hold short of 11L. I have F-16's turning short final, landing runway 11L." The tower transcript revealed that, 7 seconds later, at 1335:40, the pilot radioed, "Emergency, I just had an engine failure." There were no subsequent radio transmissions from the pilot.

Wreckage and impact information

Safety Board investigators found that the helicopter had impacted on the Southern Pacific railroad tracks that parallel the airport perimeter fence west of the airport property, east of the 7500 block of South Nogales Highway, and just a few feet north of the extended centerline for runway 03. The coordinates were 32 degree 06.983 minutes north and 110 degrees 57.588 minutes west.

Scratches found at the initial point of contact on the railroad tracks were oriented on a magnetic bearing of 075 degrees. The final bearing of the helicopter at rest was about 265 degrees and was about 20 feet further east of the first evidence of ground contact. All portions of the helicopter were found in the immediate area of the wreckage with the exception of the main cabin doors, which had been removed prior to flight.

The majority of the fuselage damage, including the keel beam, was represented by vertical crushing and lateral cracking. The skids were separated from the cross tubes. Both skids and cross tubes were crushed and bent, being partially separated from the helicopter. The structure beneath the pilot's seat was crushed downward about 5 inches. The pilot's seat frame exhibited multiple fractures.

The fuel system incorporates the military's crashworthy design featuring breakaway, self-sealing fuel fittings. Several fuel lines had separated; however, there was no evidence of a fuel spill nor was there any odor of jet fuel detectable. The main fuel cell was torn out of the center section of the lower fuselage; however, the fuel cell remained uncompromised. The non-crashworthy auxiliary fuel tank exhibited a tear but there was no evidence of fuel either inside or outside the tank.

When the forward and main fuel cells were opened, trapped fuel was found. The fuel was drained from both cells and col

Aircraft

Registration
N6187C
Reported as
Hughes OH-6A
Category
Helicopter
Serial number
68-17154
Airframe hours
7,176
Engine
Allison 250-C20B, 420 horsepower, turbo shaft
Damage
Destroyed
Flight
Public aircraft · Part 91
Registered owner
U.S. Department Of Justice
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · June 7, 1999 · 26 hours before
Departed
E78 · Sells, AZ
Destination
TUC
Airport
TUS · Tucson International, runway 3, 7,000 × 150 ft, asphalt

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
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
5,500 total · 1,500 in this make and model · 4,724 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
97 °F, dew point 46 °F
Altimeter
29.00 inHg
Observed at
TUC

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.