# NTSB NYC08LA028: Bell 407, N555BH, Morristown, TN, November 9, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 9, 2007, 16:10 local (22:10 UTC) - Place: Morristown, TN - Coordinates: 36.179164, -83.375274 - Nearby events: https://openairdocs.org/map.md?lat=36.1792&lon=-83.3753&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 30, 2008 - Report: Approved by Office Director - Parties: FAA/FSDO - NTSB case key (mKey): 67058 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08LA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67058/pdf - Page: https://openairdocs.org/ntsb/NYC08LA028 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Propeller/rotor contact to person, standing - idling rotors - clearance - not maintained, pilot in command (cause) - procedures/directives - not complied with, pilot in command (contributing factor) - 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 (not matched to a registry record) - Reported make and model: Bell 407 - Category: Helicopter - Serial number: 53201 - Airframe hours: 1956 - Engines: 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. - Pilot; age 64; injuries: fatal; 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 (OpenAirDocs). - [Accident 20071109827549A](https://openairdocs.org/incident/20071109827549A), Nov 9, 2007: Bell 407, Morristown, TN, No damage, 1 fatal. (-23) On November 9, 2007 in Morristown Tennessee (mor) a Bell helicopter BHT-407 with a registration number 555BH was being operated by registered owner logan… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.