MIA02TA082

NTSB accident investigation · Aerospatiale SA319B Alouette III · Altoona, FL · April 9, 2002

Accident · Serious injuriesFinal report
Date
April 9, 2002, 11:21 local (15:21 UTC)
Place
Altoona, FL
Injuries
1 serious, 1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N2UHAerospatiale SA319B Alouette III
Weather
Visual (VMC) · Day
Status
Completed · report April 28, 2004
Report
Approved by Office Director
Parties
American Eurocopter Corporation, U.S. Forest Service, FAA Flight Standards District Office
FAA report
20020409009159A
Case key
54497

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 intentional operation of the helicopter with known deficiencies in equipment (inoperative normal brakes), and the pilot's improper use of the cyclic flight controls after the helicopter started rolling following touchdown.

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.

Miscellaneous/otherLanding - flare/touchdown
Operation with known deficiencies in equipment - initiatedPilot in commandCause
Landing gear,normal brake system - inoperative
Cyclic - improper use ofPilot in commandCause

Analysis

The accident pilot noted that the day before the accident date, the normal brakes were inoperative. Maintenance was notified of the brake discrepancy, and he was advised by maintenance personnel that the brakes would be inspected that evening during the planned 25-hour inspection. The next morning (day of the accident), he became aware the brakes had not been repaired and he believed he was informed while in dispatch of a search and rescue mission; the site was located approximately 40 miles from the helibase. He expressed concern to the chief pilot about operation of the helicopter with inoperative brakes, but the chief pilot felt it was alright for the flight to proceed. Since the assigned mission was for search and rescue, the chief pilot suggested and he concurred, "that due to possible lives at stake, I could accept the mission." The flight departed, proceeded to the search area with negative results, then elected to return to the helibase. After arrival at the helibase, he performed a hover power check. After completion of the hover power check, he maneuvered the helicopter over the landing pad. The chief pilot was standing by with chocks to chock the wheels upon landing as was previously arranged due to the inoperative brakes. He made a normal touchdown and as the nose gear lowered, he expected the chief pilot to chock the wheels. As the helicopter settled, it rolled forward towards the hangar, and he attempted to control the forward movement by positioning of the flight controls, aware of the cyclic limitations during ground operations. He could not arrest the forward movement and was concerned about contacting the hangar; the chocks were not in place. The next thing he recalled was feeling the helicopter vibrating, followed by the cyclic making extreme movements in the cockpit. The pilot also stated that the helicopter encountered what he felt were normal vibrations, and was not positive the helicopter encountered complete ground resonance. He attempted to lift to a hover to correct the situation but was not sure if the helicopter even became airborne. The passenger stated that after landing, he noticed out of the corner of his eye the helicopter appeared to be rolling forward. He later recalled the pilot stating that the helicopter was lifting. He noticed a vibration, and noted that the nose lifted to what he thought was a normal angle. The vibration turned into violent shaking which was throwing him around in his seat. The helicopter moved to over grass and started moving down a little faster. He noticed that parts from the helicopter started separating either when the helicopter quit moving towards the ground or the nose landing gear was fully compressed. An object hit his left arm and thigh coming to rest on the floor near his feet. He noted the pilot trying to secure the engine, smelled jet fuel, and evacuated the wreckage. The chief reported that the pilot made a normal approach which ended with a power check at a low hover. The pilot then maneuvered the helicopter over the helipad to land and after touching down, the helicopter began to roll forward slightly. He stated that the pilot attempted to pick up to a hover and when only the main landing gears were on the ground but fully extended, the helicopter began to shake. He reported hearing a loud sound or crash and the pilot and passenger exited the helicopter. He secured the engine with the emergency fuel shutoff lever. He further stated that with respect to the brakes, he and the director of maintenance (DOM) were both aware that the brakes were inoperative the day before, and on the day of the accident before the accident flight, he was made aware the brakes were not repaired. He called the DOM who advised the brakes would be fixed on the accident date, and he (chief pilot) considered the inoperative brakes to be a minor deficiency; the helicopter was not taken out of service. He further reported that due to the search and rescue mission, the urgency and considerations changed, and that he believed the inoperative brake situation needed to be addressed promptly but was not an airworthy issue when compared for example with a fixed wing airplane. Review of the "Aircraft Contract Daily Diary" sheet for the day before the accident revealed, "...Hydraulic brakes not working-mechanic notified." According to a FAA airworthiness inspector, maintenance personnel from the owner of the helicopter performed maintenance on the wheel brakes of the helicopter the day before the accident but did not have a proper fitting to bleed the brakes. Maintenance personnel were scheduled to bleed the brakes on the day of the accident but did not. No maintenance record entry was made in the permanent maintenance records indicating the brakes were inoperative. The helicopter did not have an FAA approved minimum equipment list (MEL).

Factual narrative

On April 9, 2002, about 1121 eastern daylight time, an Aerospatiale SA319B III, N2UH, registered to Brainerd Helicopters, Inc., operated by U.S. Forest Service, was substantially damaged while landing at the Ocala National Forest Fire Center helibase, Altoona, Florida. Visual meteorological conditions prevailed at the time and the public use flight was receiving U.S. Forest Service flight following. The commercial-rated pilot was not injured, while a U.S. Forest Service employee acting as an observer sustained serious injuries. The flight originated about 0939, from the Ocala National Forest Fire Center helibase.

The pilot stated that the day before the accident date, the helicopter was in the hangar and the brakes would not set when he attempted to set them. He notified maintenance of the brake discrepancy, and was advised by maintenance personnel that the brakes would be inspected that evening during the planned 25-hour inspection. He planned to return the next morning at 0830, for a planned bug flight mission scheduled for 0900. The next morning (day of the accident), he became aware the brakes had not been repaired and he believed he was informed while in dispatch of a search and rescue mission; the site was located approximately 40 miles from the helibase. He expressed concern to the chief pilot about operation of the helicopter with inoperative brakes, but the chief pilot felt it was alright for the flight to proceed. Since the assigned mission was for search and rescue, the chief pilot suggested and he concurred, "that due to possible lives at stake, I could accept the mission." The flight departed and proceeded to the coordinates that were provided where he met with law enforcement. He then departed from the landing site and flew about 1 hour, then landed in an open area. He briefed the law enforcement individual then elected to return to the helibase. While en route to the helibase, rising smoke was spotted at a location approximately 15 miles southeast of the search area. He elected to perform an "aerial recon" of the smoke and determined it was from an intentional burn that was under control.

The pilot further stated the flight proceeded to return to the helibase and after arrival, he performed a hover power check. After completion of the hover power check, he maneuvered the helicopter over the landing pad. The chief pilot was standing by with chocks to chock the wheels upon landing as was previously arranged due to the inoperative brakes. He made a normal touchdown and as the nose gear lowered, he expected the chief pilot to chock the wheels. As the helicopter settled, it rolled forward towards the hangar, and he attempted to control the forward movement by positioning of the flight controls, aware of the cyclic limitations during ground operations. He could not arrest the forward movement and was concerned about contacting the hangar; the chocks were not in place. The next thing he recalled was feeling the helicopter vibrating, followed by the cyclic making extreme movements in the cockpit. The pilot also stated that the helicopter encountered what he felt were normal vibrations, and was not positive the helicopter encountered complete ground resonance. He attempted to lift to a hover to correct the situation but was not sure if the helicopter even became airborne.

The passenger stated that he made an entry in a daily diary the day before the accident date describing the brake discrepancy. On the accident flight after landing, he noticed out of the corner of his eye the helicopter appeared to be rolling forward. He later recalled the pilot stating that the helicopter was lifting. He noticed a vibration, and noted that the nose lifted to what he thought was a normal angle. The vibration turned into shaking which increased quickly to the point that it was violent and throwing him around in his seat. The helicopter moved to over grass and started moving down a little faster. He noticed that parts from the helicopter started separating either when the helicopter quit moving towards the ground or the nose landing gear was fully compressed. An object hit his left arm and thigh coming to rest on the floor near his feet. He noted the pilot trying to secure the engine, smelled jet fuel, and evacuated the wreckage.

The chief pilot of the owner of the helicopter was waiting at the helipad with chocks in hand to chock the helicopter after landing. He reported that the pilot made a normal approach which ended with a power check at a low hover. The pilot then maneuvered the helicopter over the helipad to land and after touching down, the helicopter began to roll forward slightly. He stated that the pilot attempted to pick up to a hover and when only the main landing gears were on the ground but fully extended, the helicopter began to shake. He reported hearing a loud sound or crash and the pilot and passenger exited the helicopter. He secured the engine with the emergency fuel shutoff lever. He further stated that with respect to the brakes, he and the director of maintenance (DOM) were both aware that the brakes were inoperative the day before, and on the day of the accident before the accident flight, he was made aware the brakes were not repaired. He called the DOM who advised the brakes would be fixed on the accident date, and he (chief pilot) considered the inoperative brakes to be a minor deficiency; the helicopter was not taken out of service. He further reported that due to the search and rescue mission, the urgency and considerations changed, and that he believed the inoperative brake situation needed to be addressed promptly but was not an airworthy issue when compared for example with a fixed wing airplane.

Review of the "Aircraft Contract Daily Diary" sheet for the day before the accident revealed, "...Hydraulic brakes not working-mechanic notified."

According to a FAA airworthiness inspector, maintenance personnel from the owner of the helicopter performed maintenance on the wheel brakes of the helicopter the day before the accident but did not have a proper fitting to bleed the brakes. Maintenance personnel were scheduled to bleed the brakes on the day of the accident but did not. No maintenance record entry was made in the permanent maintenance records indicating the brakes were inoperative. The helicopter did not have an FAA approved minimum equipment list (MEL).

Aircraft

Registration
N2UH
Reported as
Aerospatiale SA319B Alouette III
Category
Helicopter
Serial number
2050
Airframe hours
3,275
Engine
Turbomeca Astazou XIVF, 870 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft · Public use
Operator
U.S. Forest Service
Registered owner
Brainerd Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 14, 2002 · 57 hours before
Departed
Altoona, FL
Flight plan
Company VFR
Airport
Ocala Nat'l Forrest Fire Ctr

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
60
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
September 24, 2001
Seat
Right
Flight hours
5,000 total · 750 in this make and model · 1,900 as pilot in command · 45 in the last 90 days · 27 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 7 knots, gusting 16
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 59 °F
Altimeter
30.27 inHg
Observed at
KOCF, 32 nm away

Docket · 15

The files NTSB released with the investigation on March 8, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 MB in all.

FAA reports on this event · 1

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