# NTSB NYC95GA060: Eurocopter AS-350-B, N20SP, Cambridge, MA, February 22, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Final report - Date: February 22, 1995, 09:37 local (14:37 UTC) - Place: Cambridge, MA - Location: 42.3760° N, 71.1187° W: Placed by OpenAirDocs: center of Cambridge, MA, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=42.3760&lon=-71.1187&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report December 12, 1995 - Report: Approved by Office Director - Safety recommendations: Yes - NTSB case key (mKey): 38868 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC95GA060 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38868/pdf - Page: https://openairdocs.org/ntsb/NYC95GA060 ## Probable cause 1) THE MASSACHUSETTS STATE POLICE (MSP) MANAGEMENT'S FAILURE TO PROVIDE ADEQUATE OVERSIGHT OF ITS AIR WING; 2) FUEL CONTAMINATION AND OBSTRUCTED FUEL INJECTOR NOZZLES, DUE TO INADEQUATE FUEL STORAGE AND STORAGE REQUIREMENTS BY THE MSP, RESULTING IN A LOSS OF ENGINE POWER; AND 3) THE FAILURE OF THE PILOT TO EXECUTE A PROPER AUTOROTATION, WHICH RESULTED IN A LOSS OF ROTOR RPM AND SUBSEQUENT LOSS OF HELICOPTER CONTROL. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, cruise - airport facilities,fuel storage - inadequate (cause) - facility,inadequate manuals/directives, company/operator management (cause) - fluid,fuel - contamination,water (cause) - fluid,fuel - contamination,other than water (cause) - fuel system,injector - obstructed (cause) - Forced landing, emergency descent/landing - terrain condition - none suitable - Loss of control - in flight, emergency descent/landing - autorotation - improper, pilot in command (cause) - rotor rpm - not maintained, pilot in command (cause) - inadequate training, company/operator management (cause) - insufficient standards/requirements, company/operator mgmt (cause) - In flight collision with object, descent - uncontrolled - object - building(nonresidential) ## Analysis A MASSACHUSETTS STATE POLICE (MSP) HELICOPTER DEPARTED A HELIPORT WITH TWO CREWMEMBERS & TWO PASSENGERS, & CLIMBED TO ABOUT 600' OVER A RIVER. WITNESSES REPORTED SEEING A PUFF OF "SMOKE" (OR VAPOR) FROM THE ENGINE EXHAUST. THE HELICOPTER WAS OBSERVED TO TURN TOWARD THE RIVER BANK & DESCEND AT AN ANGLE BETWEEN 45 & 70 DEGREES. WITNESSES STATED THAT THE MAIN ROTOR BLADES WERE EITHER TURNING SLOWLY OR HAD STOPPED PRIOR TO THE HELICOPTER COLLIDING WITH A BOAT HOUSE ROOF. NO PREIMPACT FAILURE OF THE MAIN ROTOR OR TRANSMISSION WAS FOUND. EXAMINATION OF THE ENGINE REVEALED THAT FIVE OF THE SIX FUEL INJECTION PORTS WERE CLOGGED. SAMPLES FROM THE HELICOPTER FUEL SYSTEM CONTAINED IRON OXIDE & WATER. THE MSP HAD A 6,000 GALLON IN-GROUND FUEL STORAGE TANK THAT HAD NOT BEEN MAINTAINED OR SECURED IN 14 YEARS (EXCEPT FOR A FILTER CHANGE BETWEEN 1984 AND 1986). FUEL SAMPLES FROM THE STORAGE TANK CONTAINED HIGH LEVELS OF RUST & WATER, AS WELL AS DEGRADED THERMAL PROPERTIES. FURTHER INVESTIGATION REVEALED THAT THERE WAS A LACK OF OVERSIGHT IN THE MSP AIR OPERATIONS & NO TRAINING, SAFETY, OR FUEL MANAGEMENT PROGRAM. RECORDS SHOWED THAT IN THE PAST FIVE YEARS, THE MSP PROVIDED THE PILOT WITH ONLY ONE TRAINING SESSION THAT CONSISTED OF A TW0 DAY GROUND SCHOOL & ONE FORMAL TRAINING FLIGHT. ## Factual narrative HISTORY OF FLIGHT On February 22, 1995, about 0937 eastern standard time, a Eurocopter, AS-350-B, helicopter, N20SP, operated by the Massachusetts State Police (MSP), was destroyed when it collided with a boat house during a forced landing near Cambridge, Massachusetts. The two pilots and two passengers were fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the passenger flight conducted under 14 CFR Part 91. The pilots, Troopers James Mattaliano and Paul Perry, worked from 1500 until 2300, on February 21, 1995. The pilots reported to work the morning of February 22, 1995, about 0700. Their mission that morning was to pick-up two AT&T employees at the Nashua Street Heliport, and transport them to the MSP Headquarters in Framingham, Massachusetts. Trooper Mattaliano was the senior pilot; therefore, he was considered the pilot-in-command. The MSP rented hangar space from Wiggins Airways, at the Norwood Memorial Airport (OWD), in Norwood, Massachusetts. The hangar was shared with another helicopter operator. At 0750, the pilot/manager of this operator reported that he observed Trooper Perry enter the hanger, and walk around N20SP. He saw Trooper Perry approach the right side of N20SP where the tail joins the main fuselage, touch the helicopter, and then walk aft and visually inspect the tail rotor area. Trooper Perry then opened the hangar doors and moved N20SP outside, where the two troopers boarded N20SP and started the engine. He estimated that the run-up lasted about 10 minutes, and the helicopter departed to the northeast. According to OWD Air Traffic Control Tower (ATCT) records, N20SP departed OWD, about 0922. Using the call sign of State Police One, N20SP contacted Boston ATCT, at 0924, and requested clearance into the Boston Class B airspace to land at the Nashua Street Heliport. The helicopter was cleared into the airspace and, at 0930, the pilot of N20SP reported landing assured at the heliport. At 0936:16, N20SP contacted Boston ATCT and requested clearance out of the Class B airspace, at 800 feet. The Boston ATCT granted the request, and the pilot of N20SP stated "thanks," at 0936:29. That was the last transmission received from N20SP. Boston ATCT Radar plotted N20SP reaching an altitude of 600 feet mean sea level, at 0937:00, before beginning a decent below radar coverage. Over 20 witness statements were taken from personnel who observed the helicopter after it departed from the Nashua Heliport. The witnesses observed the helicopter flying westbound over the Charles River. A puff of smoke was seen coming from the helicopter in the vicinity of the engine. The helicopter then turned to the right and descended toward the north bank of the river. The witnesses estimated the angle of descent was between 45 and 70 degrees. Most of the witnesses observed smoke trail from the engine exhaust area. Eleven witnesses stated that the main rotor blades were turning slowly, or not at all. The helicopter struck two metal structures extending from the Harvard Sailing Pavilion and came to rest on the roof. The accident occurred during the hours of daylight approximately 42 degrees, 22 minutes north latitude, and 71 degrees, 00 minutes west longitude. PERSONNEL INFORMATION Trooper James Mattaliano held a Commercial Pilot Certificate with a rating for rotorcraft helicopter, and a Private Pilot Certificate with a rating for airplane single engine land. He was not instrument rated. His most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued on April 6, 1994. Trooper Mattaliano's total flight time was estimated at 1,150 hours, of which approximately 900 hours were in this make and model. Trooper Paul Perry held a Private Pilot Certificate with ratings for airplane single engine land, and rotorcraft helicopter. He was not instrument rated. His most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued on January 4, 1995. Trooper Perry's total flight time was estimated to be about 340 hours, of which approximately 180 hours were in this make and model. The Safety Board made several requests for Trooper Mattaliano's and Trooper Perry's pilot logbooks. They were not provided to the Safety Board. Additionally, the Safety Board made requests to the Massachusetts State Police to obtain copies of the remaining Air Wing pilot's log books, to review flight hours and training. The requested information was not provided. WRECKAGE AND IMPACT INFORMATION An NTSB Investigator examined the helicopter wreckage on February 22, 1995, at the accident scene, and on February 23 and 24, 1995, after the wreckage was moved to a facility in Boston, Massachusetts. The examination revealed that all major components of the helicopter were accounted for at the scene. The helicopter main fuselage came to rest on a boat house roof, on an approximate magnetic bearing of 360 degrees. The tail boom was separated from the fuselage and submerged in water next to the boat house. The main fuselage and cabin were destroyed. The pilot's instrument and caption panel were intact. Examination revealed that caption chips for the generator, bleed air valve, and engine oil pressure contained broken or deformed light bulb filaments. The yellow and blue star arms of the main rotor head were fractured on the leading edge. The fractures continued aft and inboard, at a 45 degree angle, and the star arms were bent opposite the direction of rotation. The red star arm was not fractured. The pitch change rods, and the main rotor collective and cyclic servos remained connected. Except for the fore and aft cyclic servo, the servo piston rods moved freely and pumped fluid. The fore and aft servo was damaged from impact with the main transmission. The main transmission support rods were separated, and the transmission was shifted forward. The three main rotor blades (MRB) were attached to their respective star arms of the main rotor head. The three MRBs displayed black marks on the bottom of each blade tip. The roof area under the MRBs was covered with black tar. The yellow and red blades were intact, and displayed chord wise scratches on the lower leading edges. The red blade also displayed chord wise scratches on the lower skin surface. The blue blade was broken about 3 feet from the root, and the tip cap was peeled upward. Trailing edge debonding was observed on the red and blue blades. The tail boom was bent in the vicinity of the number two bearing support. The right side tail boom mount was torn, and the left side was separated along the rivet line. The tail rotor drive shaft was uncoupled at the point of separation from the fuselage. The tail rotor gear box, hub, and blades where intact. These components remained attached to the tail boom and were not damaged. When the tail rotor drive shaft was rotated, the gear box output shaft turned the tail rotor. Flight control continuity was verified from the mixing unit to the servo controls. Rotation of the main rotor mast confirmed drive train continuity from the transmission to the engine, and to the tail rotor drive shaft. The free-wheeling capability of the transmission was also confirmed. Examination of the transmission revealed lubrication through out the transmission, and the gears rotated freely. A bore scope inspection of the upper and lower chip detector areas revealed no internal damaged. The upper and lower chip detectors were absent of debris. The fuel tank was ruptured and destroyed. The airframe fuel filter was intact and a fuel sample was taken from the filter for further examination. The power turbine and the freewheel section of the engine rotated freely ## Aircraft - Registration: [N20SP](https://openairdocs.org/deregistered/N20SP-1997-02-25), registration cancelled 1997-02-25, S/N 1915 (OpenAirDocs) - Reported make and model: EUROCOPTER AS-350-B - Registry model: [Aerospatiale AS350B](https://openairdocs.org/model/aerospatiale-as350b) (registry code 8680800) (OpenAirDocs) - Category: Helicopter - Serial number: 1915 - Airframe hours: 2870 - Engines: TURBOMECA ARRIEL 1B 641 horsepower turbo shaft - Damage: Destroyed - Flight: Public aircraft, Part 91 - Registered owner: Dept Of Public Safety - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, February 13, 1995, 20 hours before - Departed: MA89, BOSTON, MA - Destination: FRAMINGHAM, MA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; commercial, private; airplane ratings: single-engine land; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 1,150 total, 900 in this make and model, 20 in the last 90 days, 13 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 7 knots - Visibility: 12 statute miles - Lowest ceiling: 3,300 ft overcast - Temperature: 88 °F, dew point 70 °F - Altimeter: 30.00 inHg - Observed at: BOS, 5 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 (OpenAirDocs). - [Accident 19950222002239A](https://openairdocs.org/incident/19950222002239A), Feb 22, 1995: Snias AS350B, Cambridge, MA, Destroyed, 4 fatal. State police flight. Climbing over river. Lost power. Rotors stopped. Fuel had rusty water. Injectors clogged. 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.