NYC08LA028

NTSB accident investigation · Bell 407 · Morristown, TN · November 9, 2007

Accident · FatalLimited investigationFinal report
Date
November 9, 2007, 16:10 local (22:10 UTC)
Place
Morristown, TN
Injuries
1 fatal
Damage
No damage
Phase of flight
Standing
Aircraft
N555BHBell 407
Weather
Visual (VMC) · Day
Status
Completed · report April 30, 2008
Report
Approved by Office Director
Parties
FAA/FSDO
FAA report
20071109827549A
Case key
67058

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 clearance from the idling main rotor blade. Contributing to the accident was the pilot's failure to comply with the manufacturer's procedure for securing the helicopter.

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.

Propeller/rotor contact to personStanding - idling rotors
Clearance - not maintainedPilot in commandCause
Procedures/directives - not complied withPilot in commandFactor
Aircraft unattended/engine(s) running

Analysis

After arriving at the destination airport, the pilot taxied the helicopter to the fuel pumps. The pilot then realized that the fuel pumps were for aviation gasoline and not for jet fuel, so he advised the passengers that he would assist them in unloading, and then reposition the helicopter to the other fuel pump. After carrying the passengers' bags and using the restroom at the fixed base operator, the pilot returned to the helicopter. While walking toward the unoccupied helicopter, the pilot was struck by the idling main rotor. The helicopter's rotorcraft flight manual did not describe a procedure for the pilot to exit the helicopter while the engine and rotor continued to operate, but did state that during shutdown the pilot should, "Remain on the flight controls until the rotor has come to a complete stop." Additionally, post-accident examination of the helicopter revealed that the cyclic friction lock was not tightened, which contradicted with the flight manual's shutdown checklist. The substance found during the post-mortem toxicological testing of the pilot would not normally be expected to cause impairment of psychomotor or cognitive functions.

Factual narrative

On November 9, 2007, about 1610 central standard time, the pilot of a parked Bell 407, N555BH, was fatally injured when he was struck by the helicopter's idling main rotor at Moore-Murrell Airport (MOR), Morristown, Tennessee. The helicopter was not damaged. Visual meteorological conditions prevailed, and no flight plan was filed for the 14 Code of Federal Regulations Part 91 local positioning flight.

According to one of the passengers on the previous flight, after they had arrived at Morristown, the pilot taxied the helicopter to the fuel pumps. The pilot later realized that the fuel pumps were for aviation gasoline and not for jet fuel, so he advised the passengers that he would assist them in unloading, and then reposition the helicopter to the other fuel pump. After carrying the passengers' bags and using the restroom at the fixed base operator, the pilot returned to the helicopter. While walking toward the idling, unoccupied helicopter, the pilot was struck by main rotor. The passenger, who was familiar with the operation of the accident helicopter, subsequently approached and shut down the helicopter.

Another witness was inside the terminal, and watched the pilot as he walked toward the helicopter. He initially thought that the pilot saw the turning main rotor blades, but then began to yell "stop, stop, stop." The pilot continued forward, and walked into the path of the main rotor. The witness recalled that the pilot was wearing a baseball cap and glasses, and that he walked briskly toward the helicopter with his head lowered. The witness estimated that the main rotor blades were tilted forward, and that the rotor blade tip path was about 5 1/2 feet off the ground. At the time, he thought to himself, "those rotor blades are sure tilted forward." He also estimated that the winds were "gusting" to about 10 knots.

According to a Federal Aviation Administration (FAA) inspector, post-accident examination of the helicopter revealed that the cyclic friction lock was not tightened. The hydraulic system switch was in the "armed/on" position; however, the passenger stated that he had toggled the switch to that position when he shut down the helicopter. The passenger further stated that the pilot's normal procedure for unloading passengers while the helicopter idled was to turn the hydraulic system off.

A review of the accident helicopter's rotorcraft flight manual revealed that the third item under the engine shutdown checklist was, "Cyclic friction - Increase so that cyclic maintains centered position." After shutting off the fuel valve during the shutdown procedure, the checklist stated, "Pilot - Remain on the flight controls until rotor has come to a complete stop." The manual did not describe a procedure for the pilot to secure and exit the helicopter while the engine and rotor continued to operate.

The pilot held a commercial pilot certificate with multiple ratings including rotorcraft-helicopter and instrument helicopter. His most recent FAA seconding class medical certificate was issued on August 8, 2007. According to the FAA inspector, the pilot had 7,500 total hours of flight experience, with 2,000 hours of flight experience in the accident helicopter make and model. According to the passenger, the pilot had flown with the operator since 1982.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The test revealed the presence of Doxazosin in the pilot's blood and liver.

The weather conditions reported at Morristown, at 1556, included winds from 260 degrees at 8 knots. According to the FAA inspector, these winds equated to a quartering tailwind relative to the helicopter's orientation on the ramp.

Aircraft

Registration
N555BH
Reported as
Bell 407
Category
Helicopter
Serial number
53201
Airframe hours
1,956
Engine
Rolls Royce 250-C47B, 650 horsepower, turbo shaft
Damage
No damage
Flight
Positioning · Part 91
Registered owner
Logan and Kanawha Coal Co LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · October 1, 2007
Departed
MOR · Morristown, TN
Destination
MOR
Airport
MOR · Moore-Murrell Airport

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, With waivers/limitations
Toxicology
Performed
Flight hours
7,500 total · 2,000 in this make and model · 10 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 8 knots
Visibility
10 statute miles
Observed at
MOR

FAA reports on this event · 1

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