MIA03FA120

NTSB accident investigation · Aerospatiale AS355F1 · Madison, FL · June 11, 2003

Accident · Minor injuriesField investigationFinal report
Date
June 11, 2003, 13:29 local (17:29 UTC)
Place
Madison, FL
Injuries
3 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N217ESAerospatiale AS355F1
Weather
Visual (VMC) · Day
Status
Completed · report September 13, 2005
Report
Approved by Office Director
Parties
FAA FSDO
FAA report
20030611015409A
Case key
57296

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 in command's diverted attention and loss of control while attempting to takeoff, which resulted in the main rotor blades being dragged, and the helicopter rolling over.

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.

Dragged wing,rotor,pod,float or tail/skidTakeoff
Diverted attentionPilot in command
Lift-off - initiatedPilot in command
Aircraft control - not maintainedPilot in commandCause
Roll overTakeoff

Analysis

The pilot stated that after the patient had been loaded on the helicopter, and the other crewmembers had secured themselves inside, he picked the helicopter up into a 3-foot hover, glanced at the gauges, and then looked up again and the helicopter rolled hard to the right with the blades impacting the ground. He said the main rotor blades struck the ground the helicopter rotated 90 degrees to the left, and came to rest on its right side. A flight crew member in the back of the helicopter said that after they had all been secured for takeoff, she looked out through the right window and advised "all clear." She further stated that the helicopter then lifted off, and immediately started falling, with the rotor blades impacting the ground, which caused it to fall. A witness stated that he observed the helicopter lift off the ground, perform a quarter turn to the left, facing north, and hover for a few seconds, before starting to roll to the right side, which immediately caused the main rotors to strike the ground, and the helicopter crashed on its right side. Examination of the helicopter and its systems did not reveal the existence of any preaccident anomalies.

Factual narrative

History of flight

On June 11, 2003, about 1329 eastern daylight time, an Aerospatiale AS-355F1 helicopter, N217ES, registered to Banc One Leasing Corp., and operated by CJ Systems Aviation Group, for Doctor's Memorial Hospital, Perry Florida, as a Title 14 CFR Part 135 aeromedical flight, crashed while attempting to take off from an open sports field in Madison, Florida. Visual meteorological conditions prevailed, and a company visual flight rules flight plan was filed. The commercial-rated pilot was not injured, and the two flightcrew members and one passenger received minor injuries. The helicopter incurred substantial damage. The flight was originating at the time of the accident.

The pilot stated to the NTSB that he landed the helicopter on the ball field to pick up a patient. The helicopter was oriented about 090 degrees magnetic, into the wind. He said he idled the helicopter engines with the main rotors turning for about 10 minutes while waiting for the patient to arrive. After the patient had been loaded on the helicopter, and the other crewmembers had secured themselves inside, he picked the helicopter up into a 3-foot hover, glanced at the gauges, and then looked up again and the helicopter rolled hard to the right with the blades impacting the ground. He said when the main rotor blades struck the ground the helicopter rotated 90 degrees to the left, and came to rest on its right side. After it came to a stop, the pilot said he tried to pull the fuel controls to the off position, and turn off the engines, but was unable. He said he then activated the fuel shutoff, interrupting the fuel supply to the engines, and then turned off the overhead switches and the battery power.

According to a flightcrew member in the back of the helicopter, after they had all been secured for takeoff, she looked out through the right window and advised "all clear." She further stated that the helicopter lifted off, and immediately started falling, with the rotor blades impacting the ground, which caused it to fall.

A witness stated that he observed the helicopter lift off the ground, perform a quarter turn to the left, facing north. He further stated that at this time the helicopter's skids were about 3 or 4 feet off the ground. He said the helicopter then hovered for a few seconds, before starting to roll to the right side, which immediately caused the main rotors to strike the ground, and the helicopter crashed on its right side.

When the helicopter came to rest on its right side a fire ensued. An official with the Madison Fire Department stated that the fire department had equipment and personnel standing by as part of their standard operating procedure for "off helipad" aeromedical operations within city limits, and the firefighters quickly responded and applied water which immediately extinguished the fire. They then extricated all occupants of the helicopter.

Personnel information

According to information obtained from the Director of Operations for the operator, CJ Systems Aviation Group, the pilot of the accident helicopter had been hired on April 1, 2003, two months prior to the accident, and had undergone initial training. At the time of the accident, he reported having accumulated about 2,500 hours total flight experience, of which 42 hours were in the same make and model helicopter as the accident helicopter, and 42 hours had been flown in the last 90 days. On the day of the accident the pilot had flown the accident helicopter for 0.3 hour from Perry, Florida, to the location where the accident occurred.

Records obtained from the FAA showed that the pilot held a commercial pilot certificate, with multiengine land, rotorcraft helicopter, and instrument helicopter ratings. He also held an FAA second class medical certificate, issued on March 18, 2003, with no stated limitations.

Aircraft information

N217ES, is a 1981 Aerospatiale AS355F1, serial number 5059. The helicopter was powered by two 420 horsepower, Allison-Rolls-Royce 250-C20F turbo-shaft engines. According to information obtained from the operator, the helicopter was maintained in accordance with the manufacturer's inspection program as well as a Part 135 Operator's Approved Aircraft Inspection Program (AAIP). The last inspection performed on the helicopter was a 100-hour/AAIP inspection, and it was completed on June 3, 2003. At the time of the accident, the helicopter had accumulated a total of 6,321.8 hours, about 7.0 hours since its last inspection.

Meteorological information

Daylight visual meteorological conditions prevailed at the time of the accident. The Tallahassee Airport, Tallahassee, Florida, 1253, surface weather observation, was scattered clouds at 5,500 feet, a broken cloud layer at 13,000 feet, visibility 10 statute miles, wind from 190 degrees at 5 knots, and the altimeter setting was 30.02 inHg. Tallahassee, Florida, is located about 50 miles west of the accident site.

Wreckage and impact information

Examination of the crash site showed the helicopter was located in geographic position 30 degrees, 28.3 minutes North latitude, 083 degrees 25.2 minutes West longitude, at Lanier Field, Madison, Florida. The helicopter was lying on its right side, and was oriented about due north, with loose accident-related debris being present, consisting mainly of main rotor blade foam and after body skin. All three composite main rotor blades had shattered, and there were multiple ground scars in the vicinity, consistent with the main rotor's impact. The main rotor head and swash plate mechanism had been damaged. There was buckling the left side aft fuselage, but no damage to the undersurface of the helicopter. Both forward windshields had been shattered, and the window above the pilot's position had also been cracked. The skids had not been damaged, and the aft inside section of the right trailing extension of the skid had incurred a gouge and streaking/paint related discoloration. There was fire damage to the aft section of the engines in the area of the tailpipe, and the grass had been burned. Burn marks were consistent with the fire occurring at the point where the engine was on contact with the ground.

One blade exhibiting a wrinkle and there was a single gouge in the grass consistent with the tail rotor having impacted the ground. Limited rotational damage was noted, and preimpact continuity of the tail rotor assembly was verified. The tail rotor drive shaft had been severed and had about a 12-inch section of the drive shaft removed. The section of the tail rotor drive shaft which had been severed had been located above and was about equal to the width of the horizontal stabilizer, and exhibited signatures consistent with it having been stricken by the main rotor blades. The stinger's lower surface had scratches on the lower surface, but was otherwise not damaged. The right horizontal stabilizer had been bent downward at about the midpoint of the stabilizer as the helicopter laid on its side, and the top of the left horizontal stabilizer also exhibited surface gouges and scars.

All arms of the star were sheared approximately 1 inch from the "thick part". The lower panels were removed and control continuity was verified. The pitch change links were intact but bent at the rod ends. The scissors drive adapter (swashplate drive) had dislodged. The stove pipe (swashplate guide) rivets were sheared at the attachment to the main rotor shaft assembly upper case. The lower swashplate scissors were intact. All servos/P/C links/scissors were disconnected and examined. The swashplate rotated freely and with no binding or roughness. No contamination was found to be present in the lubrication grease. The swashplate bearing and PC links were disconnected and examined, and no anomalies were noted. The hydraulic filter assembly were accessed for hydraulic systems No. 1 and 2 and slight amounts of sludge were observed.

The underside of the

Aircraft

Registration
N217ES
Reported as
Aerospatiale AS355F1
Category
Helicopter
Serial number
5059
Airframe hours
6,321.5
Engines
Allison 250-C20F, 420 horsepower, turbo shaftAllison 250-C20F, 420 horsepower, turbo shaft
Damage
Substantial damage
Fire
On-Ground
Flight
Part 135
Operator
C J Systems Aviation Group
Registered owner
Banc One Leasing Corporation
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · June 3, 2003 · 7 hours before
Departed
Madison, FL
Destination
Perry, FL
Flight plan
Company VFR

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
48
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
April 1, 2003
Seat
Right
Flight hours
2,500 total · 42 in this make and model · 1,800 as pilot in command · 42 in the last 90 days · 34 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 5 knots
Visibility
10 statute miles
Lowest ceiling
13,000 ft broken
Temperature
90 °F, dew point 70 °F
Altimeter
30.02 inHg
Observed at
TLH, 50 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.