# NTSB SEA06FA015: Agusta A109E, N950AL, Olympia, WA, October 29, 2005 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: October 28, 2005, 23:24 local (Oct 29, 2005, 06:24 UTC) - Place: Olympia, WA - Coordinates: 47.051944, -122.847221 - Nearby events: https://openairdocs.org/map.md?lat=47.0519&lon=-122.8472&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor, 3 uninjured - Status: Completed, report January 31, 2007 - Report: Approved by Office Director - Parties: CJ Systems Aviation Group, Honeywell, Pratt & Whitney Canada, Agusta aerospace corporation, Federal Aviation Administration - NTSB case key (mKey): 62742 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA06FA015 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62742/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=62742 - Page: https://openairdocs.org/ntsb/SEA06FA015 ## Probable cause The pilot's improper positioning of the number 2 Power Flight Control switch and his inability to obtain the proper climb rate to clear a concrete wall barrier. Contributing factors included the checklist not being followed and the limit override switch not being activated. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, takeoff - throttle/power control - improper, pilot in command (cause) - checklist - not followed, pilot in command (contributing factor) - proper climb rate - not possible, pilot in command (cause) - powerplant controls - not selected, pilot in command (contributing factor) - object - wall/barricade - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground - On ground/water encounter with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis In preparation for departure from the hospital's second story roof helipad, the pilot stated that once both engines were running he put both engine control switches to FLIGHT and verified that there were no caution lights. The aircraft's DO/VERIFY checklist was then verified after all pre-takeoff items had been completed. He then set the rotor rpm switch to the 102% position, pulled enough collective to bring the helicopter to a hover, and then verified 102% rpm before pulling collective for takeoff power and adding forward cyclic to start the climb-out. As the aircraft started its forward motion the pilot heard "ROTOR LOW" in his headset as the helicopter began to settle. The aircraft's tail rotor subsequently impacted the helipad's concrete barrier, resulting in the helicopter descending over a dirt filled courtyard, which was bordered on the east by a building approximately 40 feet away. The aircraft subsequently impacted the building, coming to rest on its right side after spinning around 180 degrees. There was no post-crash fire. The pilot then shut down both engines and aided in the evacuation of the helicopter's occupants. A post-accident examination conducted by an FAA inspector shortly after the accident revealed that both engine control switches were in the OFF position. Testing of various components and both engines failed to reveal any anomalies which would have precluded normal operation of the helicopter. Data from the Enhanced Ground Proximity Warning System (EGPWS) revealed that the number 1 engine was producing normal and abnormally high torque values during the takeoff sequence, while a zero torque value but proper Ng values were observed from data on the number 2 engine during takeoff; this is consistent with the number 2 engine control switch remaining in the IDLE position. The pilot's total time in all helicopters was 7,923 hours, with 15 hours in make and model. The pilot reported that during both his transition ground school training and flight training courses on the type accident helicopter, he had questioned the instructors about previous accidents involving the position of the engine control switches during the start sequence. A comparison of the Agusta Rotorcraft Flight Manual and the Agusta General Familiarization Training Manual revealed they provided inconsistent instructions about when to move the engine control switches from the IDLE to the FLIGHT position. The pilot also revealed that the operation of the limit override switch was never demonstrated during his training and remembered that it was in an awkward position. The limit override switch was not activated during the takeoff sequence, as the pilot was unsuccessful in locating it. ## Factual narrative HISTORY OF FLIGHT On October 28, 2005, at 2324 Pacific daylight time, a twin-engine Agusta A109E helicopter, N950AL, sustained substantial damage after impacting an object and subsequently terrain during takeoff at the Providence St. Peter Hospital, Olympia, Washington. The helicopter was operated by CJ Systems Aviation Group of West Mifflin, Pennsylvania, under contract to Airlift Northwest of Seattle, Washington. The airline transport pilot, one flight nurse, and the patient were not injured. A second flight nurse sustained minor injuries. Visual meteorological conditions prevailed for the air ambulance flight, which was being operated in accordance with 14 CFR Part 135, and a company flight plan was filed. The flight was originating at the time of the accident, with its destination being the Harborview Medical Center, Seattle, Washington. In telephone conversations with the NTSB investigator-in-charge (IIC), and according to the Pilot/Operator Aircraft Accident/Incident Report (NTSB form 6120.1), the pilot reported that following his preflight activities, and after both engines were online (started) and the avionics were on, "...I turned both engine controls to flight and verified that there were no caution lights, except the parking brake. I set the rotor rpm switch to 102% position and looked for the little yellow band at the top of the rotor rpm indicator. I said 'coming up' and pulled enough collective to bring the aircraft to a hover for just a second while I verified 102% RPM and caution lights out, then started pulling collective for takeoff power and added forward cyclic to start [the] climb-out. Just as I reached the point of no return I heard 'ROTOR LOW' in the headset and the aircraft began to settle. I started to look back inside at the instruments, but realized that the aircraft was settling fast and focused my attention back outside because there was a building in front of me. I reached for the Limit Override button with my thumb but could not find it. Then it was too late. I realized the aircraft was going to impact the building in front of me and there was nothing I could do to prevent it." The pilot stated that the next thing he remembered was the aircraft facing 180 degrees from the takeoff track and rolling over on its right side. The pilot reported that about 5 or 6 seconds after the aircraft had come to a stop he managed to reach the engine control knobs and shut down the engines. The pilot stated that after he confirmed that both flight nurses and the patient were all right, he shut off the electrical power and exited the helicopter. The pilot further stated that the wreckage was contained in a garden space between the main hospital building and an adjoining building. The pilot reported that the space was not more than 40 feet wide and the aircraft had impacted the side of the adjoining building and fallen to the ground beside it facing southwest. There was no post-crash fire. The pilot also reported that prior to the takeoff he had completed the company's' DO/VERIFY checklist procedure. In a statement submitted to the IIC dated November 28, 2005, one of the two flight nurses on board the helicopter, who was seated in the forward aft facing seat, reported that as she and the other flight nurse were preparing the patient for the flight, the pilot was starting the helicopter's engines. "The helicopter sounded like it usually does during this process. [The pilot] asked if we were ready to depart and each of us responded in the affirmative. As we lifted from the helipad there was a distinct and dramatic reduction in the noise we usually hear, and we immediately seemed to lose our lift. We had moved forward on the helipad and I could see we were partially over the small wall that goes around the perimeter of the helipad. At this point it was clear that we were going to crash. I could see that we were not only losing lift, but we were actually losing what little altitude we had. There was violent shaking and violent noise for several seconds, and then we impacted the ground." The nurse reported that after the helicopter came to rest she assessed that the other nurse and the patient were okay, and that the pilot was talking and shutting the aircraft down. In a statement submitted to the IIC, dated April 21, 2006, the second flight nurse, who was seated in the aft forward facing seat, stated that she was able to see the monitors and gauges in the front of the aircraft; she noted no anomalies. The nurse reported that the helicopter lifted off approximately 5 to 10 feet and prepared to move forward in a nose down attitude. The nurse stated, "At that point I heard a noise that sounded like powering down. I also heard the verbal warning stating 'rotor low, rotor low', as we began to fall. The aircraft's underside made contact with the side of the helipad structure as we were falling and the aircraft rotated prior to hitting the ground. After the impact we waited until the rotors had stopped turning. I have no recollection of the events that transpired until I was inside the emergency room." The aircraft was recovered and transported to a secured storage facility for further examination by representatives of the NTSB, Federal Aviation Administration, Pratt and Whitney Canada, CJ Systems Aviation Group, Airlift Northwest, and Agusta Aerospace. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate for helicopters, a BV-234 type rating, and commercial privileges for airplane single-engine land, airplane multiengine land, and instrument airplane. The pilot reported a total flight time in all aircraft of 8,014 hours and 6,911 hours total time as pilot-in-command. The pilot also reported 7,923 hours total time in all helicopters, 6,897 hours as pilot-in-command of helicopters, 15 hours total time in make and model, and 1625 hours in the Agusta A109AII helicopter. The pilot reported that he had flown 71 hours in the preceding 90 days, 20 hours in the last 30 days, and 1 hour in the last 24 hours. The pilot was issued a first class medical certificate on August 3, 2005, with a limitation for corrective lenses. According to records supplied by CJ Systems, the pilot was hired by the company on April 17, 2000. The pilot successfully completed an Airman Competency/Proficiency Check on the Agusta A109AII aircraft on April 26, 2000. The pilot subsequently completed Agusta A109E differences training on July 7, 2005, followed by successfully completing the Agusta A109E Initial Flight Course on August 16, 2005, which consisted of 3.5 hours of flight training and an evaluation of maneuvers. AIRCRAFT INFORMATION The red and white helicopter, a 2004-model Agusta A109E aircraft, serial number 11628, was powered by two Pratt & Whitney Canada engines (serial numbers PCE BC 0500 and PCE BC 0501), each rated at 735 horsepower. The aircraft was equipped with a Full Authority Digital Engine Control (FADEC) system. According to the manufacturer the FADEC system ensures accurate control of the engine output speed and fast response changes in power demand. The helicopter was also equipped with a new ergonomic cockpit design, multifunctional liquid crystal display, a four-bladed fully articulated main rotor system, and a retractable landing gear. According to the manufacturer, the helicopter's FADEC system incorporates all control units and accessories for complete automatic and manual control of the engine. It is comprised of three main components, the Fuel Management Module (FMM), the Electronic Engine Control unit (EEC) and the Permanent Magnet Alternator (PMA). The FMM is an electro-mechanical unit driven by the accessory gear box, which governs the fuel flow through the entire operational envelope of the engine. It can operate in the automatic mode (fuel flow controlled by the EEC) or in the manual mode mechanical back-up, (fuel flow controlled by ## Aircraft - Registration: [N950AL](https://openairdocs.org/deregistered/N950AL-2008-09-05), registration cancelled 2008-09-05, S/N 11628, built 2004 (OpenAirDocs) - Reported make and model: Agusta A109E - Registry model: [Agusta A109E](https://openairdocs.org/model/agusta-a109e) (registry code 0260101) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PW206C](https://openairdocs.org/engine/pratt-whitney-canada-pw206c) (registry code 52160, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 11628 - Airframe hours: 189.6 - Engines: Pratt & Whitney Canada PW 206C 735 horsepower turbo shaft; Pratt & Whitney Canada PW 206C 735 horsepower turbo shaft - Damage: Substantial damage - Flight: Part 135 - Registered owner: Airlift Northwest - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, October 1, 2005, 3.2 hours before - Departed: Olympia, WA - Destination: Seattle, WA - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: helicopter, airplane; medical: class 1, without waivers/limitations; last flight review April 1, 2005; seat: right; toxicology performed; flight hours: 8,014 total, 15 in this make and model, 6,912 as pilot in command, 71 in the last 90 days, 20 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 240° at 4 knots - Visibility: 9 statute miles - Lowest ceiling: 794 ft broken - Temperature: 48 °F, dew point 46 °F - Altimeter: 30.02 inHg - Observed at: OLM, 6 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 20051028025869A](https://openairdocs.org/incident/20051028025869A), Oct 28, 2005: Agusta A109E, Olympia, WA, Destroyed. (-23) Shortly after take off from st. peters hospital Olympia, WA heliport augusta 109E, N950AL lost power and hit the wall near the heliport and spiraled down… ## Docket (32 files) The files NTSB released with the investigation on November 7, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=62742. 9.2 MB in all. - Materials Laboratory Factual Report 06-085, Examination of Flex Couplings (Attachment 5) (item 1, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268108&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2006-085,%20Examination%20of%20Flex%20Couplings%20(Attachment%205)-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 340 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268459&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 3, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268462&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - Statement Submitted by Flight Nurses (item 4, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268463&FileExtension=.PDF&FileName=Statement%20Submitted%20by%20Flight%20Nurses-Redacted.PDF - Statement of CJ Systems Representative (item 5, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268466&FileExtension=.PDF&FileName=Statement%20of%20CJ%20Systems%20Representative-Redacted.PDF - Statement of Agusta Representative (item 6, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268539&FileExtension=.PDF&FileName=Statement%20of%20Agusta%20Representative-Redacted.PDF - Wreckage Diagram (item 7, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268540&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Weather Report (item 8, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268541&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Attachment I - Honeywell Inspection and Download Report (item 9, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268542&FileExtension=.PDF&FileName=Attachment%20I%20-%20Honeywell%20Inspection%20and%20Download%20Report-Master.PDF - Attachment 2 - Agusta Aerospace Corporation Report (item 10, .PDF, 603 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268543&FileExtension=.PDF&FileName=Attachment%202%20-%20Agusta%20Aerospace%20Corporation%20Report-Redacted.PDF - Attachment 3 - Ametek Aerospace Report (item 11, .PDF, 623 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268548&FileExtension=.PDF&FileName=Attachment%203%20-%20Ametek%20Aerospace%20Report-Redacted.PDF - Attachment 4 - Hamilton Sundstrand Report (item 12, .PDF, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268549&FileExtension=.PDF&FileName=Attachment%204%20-%20Hamilton%20Sundstrand%20Report-Master.PDF - Toxicological Report (item 13, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268550&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268551&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 15, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268552&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Image 1. View of hospital’s second-story helipad looking south. (item 16, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268553&FileExtension=.PDF&FileName=Image%201.%20%20View%20of%20hospital%C3%A2%E2%82%AC%E2%84%A2s%20second-story%20helipad%20looking%20south.-Master.PDF - Image 2. View of helipad looking northeast in the direction of takeoff. (item 17, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268554&FileExtension=.PDF&FileName=Image%202.%20%20View%20of%20helipad%20looking%20northeast%20in%20the%20direction%20of%20takeoff.-Master.PDF - Image 3. Ground level view looking southwest toward helicopter’s departure path. (item 18, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268555&FileExtension=.PDF&FileName=Image%203.%20%20Ground%20level%20view%20looking%20southwest%20toward%20helicopter%C3%A2%E2%82%AC%E2%84%A2s%20departure%20path.-Master.PDF - Image 4. View from helipad looking northeast toward concrete barrier with tail rotor impact signatures. (item 19, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268556&FileExtension=.PDF&FileName=Image%204.%20%20View%20from%20helipad%20looking%20northeast%20toward%20concrete%20barrier%20with%20tail%20rotor%20impact%20signatures.-Master.PDF - Image 5. View from helipad area looking at impact damage to powerplant building’s west side. (item 20, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268557&FileExtension=.PDF&FileName=Image%205.%20%20View%20from%20helipad%20area%20looking%20at%20impact%20damage%20to%20powerplant%20building%C3%A2%E2%82%AC%E2%84%A2s%20west%20side.-Master.PDF - Image 6. View looking east into debris field observed from second story near tail rotor impact area. (item 21, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268558&FileExtension=.PDF&FileName=Image%206.%20%20View%20looking%20east%20into%20debris%20field%20observed%20from%20second%20story%20near%20tail%20rotor%20impact%20area.-Master.PDF - Image 7. Second-story view looking northeast from the area where the helicopter’s tail rotor stuck the helipad’s concrete barrier. (item 22, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268559&FileExtension=.PDF&FileName=Image%207.%20%20Second-story%20view%20looking%20northeast%20from%20the%20area%20where%20the%20helicopter%C3%A2%E2%82%AC%E2%84%A2s%20tail%20rotor%20stuck%20the%20helipad%C3%A2%E2%82%AC%E2%84%A2s%20concrete%20barrier.-Master.PDF - Image 8. Ground-level view of helicopter at rest looking northeast. (item 23, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268560&FileExtension=.PDF&FileName=Image%208.%20%20Ground-level%20view%20of%20helicopter%20at%20rest%20looking%20northeast.-Master.PDF - Image 9. Ground–level view of helicopter at rest looking north. (item 24, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268561&FileExtension=.PDF&FileName=Image%209.%20%20Ground%C3%A2%E2%82%AC%E2%80%9Clevel%20view%20of%20helicopter%20at%20rest%20looking%20north.-Master.PDF - Image 10. Ground-level view of helicopter at rest looking east with damage to powerplant (background right). (item 25, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268562&FileExtension=.PDF&FileName=Image%2010.%20%20Ground-level%20view%20of%20helicopter%20at%20rest%20looking%20east%20with%20damage%20to%20powerplant%20(background%20right).-Master.PDF - Image 11. Ground-level view of helicopter at rest looking south. (item 26, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268563&FileExtension=.PDF&FileName=Image%2011.%20%20Ground-level%20view%20of%20helicopter%20at%20rest%20looking%20south.-Master.PDF - Image 12. Ground-level view of helicopter at rest looking southwest. (item 27, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268564&FileExtension=.PDF&FileName=Image%2012.%20%20Ground-level%20view%20of%20helicopter%20at%20rest%20looking%20southwest.-Master.PDF - Image 13. Ground-level view looking southwest at main wreckage and tail rotor assembly. (item 28, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268565&FileExtension=.PDF&FileName=Image%2013.%20%20Ground-level%20view%20looking%20southwest%20at%20main%20wreckage%20and%20tail%20rotor%20assembly.-Master.PDF - Image 14. Ground-level view looking south at helicopter’s empennage and tail section with tail rotor assembly. (item 29, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268566&FileExtension=.PDF&FileName=Image%2014.%20%20Ground-level%20view%20looking%20south%20at%20helicopter%C3%A2%E2%82%AC%E2%84%A2s%20empennage%20and%20tail%20section%20with%20tail%20rotor%20assembly.-Master.PDF - Image 15. View of center console with power management switches in the OFF position. (item 30, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268567&FileExtension=.PDF&FileName=Image%2015.%20%20View%20of%20center%20console%20with%20power%20management%20switches%20in%20the%20OFF%20position.-Master.PDF - Image 16. View of the P8615 connector with red band visible. (item 31, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268568&FileExtension=.PDF&FileName=Image%2016.%20%20View%20of%20the%20P8615%20connector%20with%20red%20band%20visible.-Master.PDF - Image 17. Electronic Display Unit #1 (OEI page - example). (item 32, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268569&FileExtension=.PDF&FileName=Image%2017.%20%20Electronic%20Display%20Unit%20%231%20%20%20%20(OEI%20page%20-%20example).-Master.PDF 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.