# NTSB SEA08TA188: Hughes 369D, N622PB, Bonners Ferry, ID, August 18, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Final report - Date: August 18, 2008, 16:30 local (23:30 UTC) - Place: Bonners Ferry, ID - Coordinates: 48.858333, -116.508331 - Nearby events: https://openairdocs.org/map.md?lat=48.8583&lon=-116.5083&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report September 30, 2009 - Report: Approved by Office Director - Parties: Federal Aviation Administration, USFS - NTSB case key (mKey): 68777 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA08TA188 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68777/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68777 - Page: https://openairdocs.org/ntsb/SEA08TA188 ## Probable cause The pilot's inadequate preflight planning for the takeoff and the helicopter loading that exceeded the lift performance capability of the helicopter. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Wind: variable wind](https://openairdocs.org/ntsb-findings/03034025): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Hughes Helicopters HUGHES 369D, 1 case](https://openairdocs.org/ntsb-findings/03034025/cases.md?model=4470706), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/03034025/cases.md) - [Planning/preparation: weight/balance calculations](https://openairdocs.org/ntsb-findings/02061015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Hughes Helicopters HUGHES 369D, 1 case](https://openairdocs.org/ntsb-findings/02061015/cases.md?model=4470706), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Hughes Helicopters HUGHES 369D, 3 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=4470706), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Alertness/Fatigue: fatigue due to work schedule](https://openairdocs.org/ntsb-findings/02013520): Personnel issues › Physical · Pilot; cases with it: [Hughes Helicopters HUGHES 369D, 1 case](https://openairdocs.org/ntsb-findings/02013520/cases.md?model=4470706), [All aircraft, 25 cases](https://openairdocs.org/ntsb-findings/02013520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Hughes Helicopters HUGHES 369D, 3 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=4470706), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Hughes Helicopters HUGHES 369D, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=4470706), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) - [Emergency descent: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Hughes Helicopters HUGHES 369D, 3 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=4470706), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Hughes Helicopters HUGHES 369D, 9 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=4470706), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The pilot was assigned to pick up three firefighters and their gear from a mountain site and he completed load calculations prior to the flight. The pilot had planned for hover in ground effect performance, although the terrain in the area was sloped and contained vegetation and rocks. As he flew into the area, the pilot assessed the winds and noted that they were coming from the south from 5 to 7 knots. He landed into the wind, picked up the passengers, and stabilized the helicopter in a 3 to 4-foot hover to verify the power. He departed into the wind and began a slow steady climb to clear trees. The helicopter then began to descend toward the trees. The pilot applied additional power but could not stop the descent. He then force-landed the helicopter on downed trees and stumps. During the accident sequence, the tail rotor drive shaft sheared. After exiting the helicopter, the pilot noted that the winds had shifted. The passengers said the winds had been shifting prior to the pilot's arrival. There were no mechanical malfunctions reported with the helicopter. Review of the pilot’s duty time showed that he had worked in excess of the contract requirements, and may have been fatigued. Post accident review of the loaded weight of the helicopter revealed that it exceeded the load limits for the operation. ## Factual narrative On August 18, 2008, at 1630 Pacific daylight time, a Hughes 369D, N622PB, collided with terrain near Bonners Ferry, Idaho. The United States Forest Service (USFS) was operating the helicopter as a public use flight. The helicopter sustained substantial damage; the commercial pilot and three passengers were not injured. Visual meteorological conditions prevailed and a visual flight rules (VFR) company flight plan and flight following were in effect. The pilot departed from Bonners Ferry Ranger Station about 1600. According to a written statement submitted by the pilot, he departed from the Bonners Ferry Ranger Station to remove three firefighters and their gear from a mountain. He flew to the landing site and assessed the landing zone and winds, which were blowing out of the south from 5 to 7 knots. He landed the helicopter into the wind. The passengers and equipment were loaded and the pilot stabilized the helicopter at a 3 to 4-foot hover to check the power. The pilot departed into the wind and began a slow steady climb to clear trees that were 100 feet away, and about 10 to 15 feet higher than the takeoff point due to the down sloping terrain. At 30 feet above ground level and 40 feet from takeoff point, the helicopter started to descend toward the trees. The pilot applied additional power, but could not stop the descent. The pilot stopped forward movement in order to prevent impacting trees, applied right pedal, and rotated the helicopter about 270 degrees to land on the sloping terrain. The helicopter landed on downed trees and stumps. The pilot reduced the collective on landing and rolled the throttle off. The helicopter then slipped off of a log and nosed up 20 to 30 degrees, and the tail rotor impacted a log. After exiting the helicopter, the pilot noted that the winds were now blowing from the north. The passengers indicated that the winds had been shifting but they did not advise the pilot of this condition. The pilot did not report any mechanical malfunctions with the helicopter. A later interview with the pilot indicated that he had planned for hover in ground effect performance. Post accident examination revealed that the tail rotor drive shaft was sheared. Under the USFS contract, the pilots are required to have 2 full days off every 14 days. If travel during the off time is work related and exceeds 30 minutes, it is considered duty time. From August 1 until the time of the accident, the pilot worked 17 days and 182 hours. Review of the load calculation showed that on the form, figures for a helicopter equipped with a Rolls Royce 250C20R were noted, rather than figures for the accident helicopter’s engine which was a Rolls Royce 250C20B. Actual payload for the previous day’s flight was recorded as 745 pounds. Review of the load calculation for the accident flight showed a gross weight at 2,940 pounds for the hover in ground effect, and a payload of 739 pounds. The hover out of ground effect was 2,840 pounds, with a payload of 639pounds. Following the accident, the United States Forest Service investigator calculated the hover in ground effect weight at 2,820 pounds, and a payload of 619, and the hover out of ground effect as 2,660 pounds with a payload of 459 pounds. Using the actual weather conditions reported from the site, the hover in ground effect weight was 2,920 pounds with a payload of 719 pounds, and the hover out of ground effect was 2,720 pounds with a payload of 519 pounds. The accident flight was the pilot’s first time operating out of the Fisher Peak landing site, which was located on a slope with vegetation and rocks. The site was established in 1994, and used in 2000, 2003, and from 2005-2007. There were no wind indicators at the landing site, which was required by the USFS. In preparation for the flight, the passengers wore hard hats instead of flight helmets. According to the Interagency Helicopter Operations Guide (IHOG), firefighters may use a hardhat with a chinstrap only when being transported as a passenger during fire operations from an established, managed helispot/helibase to another established, managed helispot/helibase. ## Aircraft - Registration: [N622PB](https://openairdocs.org/aircraft/N622PB), registered now, S/N 880318D, built 1978 (OpenAirDocs) - Reported make and model: HUGHES 369D - Registry model: [Hughes Helicopters HUGHES 369D](https://openairdocs.org/model/hughes-helicopters-hughes-369d) (registry code 4470706) (OpenAirDocs) - Registry engine: [Allison 250 SER 400HP](https://openairdocs.org/engine/allison-250-ser-400hp) (registry code 03013, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 880318D - Airframe hours: 12699 - Engines: Allison 250-C20B 420 horsepower turbo shaft - Damage: Substantial damage - Flight: Public aircraft - federal, Public use - Operator: United States Forest Service - Registered owner: Panhandle Helicopter, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, August 15, 2008, 8 hours before - Departed: Bonners Ferry, ID - Destination: Bonners Ferry, ID - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: none; commercial; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review April 30, 2008; seat: left; flight hours: 7,771 total, 1,240 in this make and model, 7,239 as pilot in command, 177 in the last 90 days, 66 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 5 knots, gusting 14 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 95 °F, dew point 39 °F - Altimeter: 30.00 inHg - Observed at: SZT ## Docket (12 files) The files NTSB released with the investigation on July 2, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68777. 11.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315624&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - POH Sections 5 and 8 (item 2, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314282&FileExtension=.PDF&FileName=POH%20Sections%205%20and%208-Master.PDF - Load Calculations (item 3, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314701&FileExtension=.PDF&FileName=Load%20Calculations-Redacted.PDF - USFS Pilot Interview Notes (item 4, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314702&FileExtension=.PDF&FileName=USFS%20Pilot%20Interview%20Notes-Master.PDF - Pilot's Duty Time (item 5, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314866&FileExtension=.PDF&FileName=Pilot%27s%20Duty%20Time-Master.PDF - IHOG Chapter 8 (item 6, .PDF, 460 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314852&FileExtension=.PDF&FileName=IHOG%20Chapter%208-Master.PDF - IHOG Chapter 9 (item 7, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314853&FileExtension=.PDF&FileName=IHOG%20Chapter%209-Master.PDF - Photo 1. Accident Site (Provided by USFS) (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314275&FileExtension=.PDF&FileName=Photo%201.%20Accident%20Site%20(Provided%20by%20USFS)-Master.PDF - Photo 2. Landing Area (Provided by USFS) (item 9, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314276&FileExtension=.PDF&FileName=Photo%202.%20Landing%20Area%20(Provided%20by%20USFS)-Master.PDF - Photo 3. Driveshaft End (Provided by Owner) (item 10, .PDF, 751 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314277&FileExtension=.PDF&FileName=Photo%203.%20Driveshaft%20End%20(Provided%20by%20Owner)-Master.PDF - Photo 4. Driveshaft Coupling (Provided by Owner) (item 11, .PDF, 439 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314278&FileExtension=.PDF&FileName=Photo%204.%20Driveshaft%20Coupling%20(Provided%20by%20Owner)-Master.PDF - Photo 5. Original Landing Zone (Provided by USFS) (item 12, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314843&FileExtension=.PDF&FileName=Photo%205.%20Original%20Landing%20Zone%20(Provided%20by%20USFS)-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.