WPR09LA144

NTSB accident investigation · MD Helicopter 369D · Trona, CA · March 7, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
March 7, 2009, 10:00 local (18:00 UTC)
Place
Trona, CA
Injuries
3 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N501EFMD Helicopter 369D
Defining event
Approach-VFR pattern final: Loss of tail rotor effectiveness
Weather
Visual (VMC) · Day
Status
Completed · report April 22, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Boeing Helicopters, Federal Aviation Administration FSDO, Rolls-Royce
FAA report
20090307003959A
Case key
73448

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 control while landing in a high density altitude environment due to a loss of tail rotor effectiveness.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Temp/humidity/pressure: high density altitudeEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 278 cases
Performance/control parameters: prop/rotor parametersAircraft › Aircraft oper/perf/capability · Capability exceededHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 182 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 3,958 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The helicopter pilot was flying passengers and equipment to a landing zone on a peak with an elevation of 9,993 feet. He made one high pass around the summit and assessed the wind as light and variable. He made a right circling approach and slowed from 60 knots to 40 knots. The airspeed suddenly decreased to 20 knots and the helicopter yawed 90 degrees to the right. He temporarily stabilized the situation, but then the helicopter went into a violent and uncontrollable right spin. It spun down vertically until it collided with terrain, rolled onto its right side, and slid about 75 yards before coming to a stop facing uphill. One of the passengers held a rotorcraft/helicopter pilot certificate. He indicated that on the first landing attempt the pilot appeared to be running out of left pedal. The second attempt was at a different angle to the landing zone, but once again the pilot seemed to run out of left pedal and the helicopter began to spin. The pilot could not recover during the attempt and the helicopter made three turns before colliding with the terrain. The Rotorcraft Flying Handbook refers to unanticipated yaw that does not subside on its own as a loss of tail rotor effectiveness. It notes that, if not corrected, this can lead to a loss of control. It may occur in all single-rotor helicopters at airspeeds less than 30 knots. A common cause is insufficient tail rotor thrust for a given power setting at higher altitudes, where tail rotor thrust and efficiency are reduced. Another potential cause is encountering a quartering tailwind from certain directions.

Factual narrative

The Rotorcraft Flying Handbook describes unanticipated yaw as an uncommanded yaw rate that does not subside on its own. It notes that, if not corrected, this can lead to a loss of control of the helicopter. This is referred to as a loss of tail rotor effectiveness. It indicates that this condition is not related to equipment or maintenance, and may occur in all single-rotor helicopters at airspeeds less than 30 knots. The tail rotor does not provide adequate thrust to maintain directional control. Common causes are certain wind directions during hover, or insufficient tail rotor thrust for a given power setting at higher altitudes, where tail rotor thrust and efficiency are reduced. On March 7, 2009, about 1000 Pacific standard time, a MD Helicopter 369D, N501EF, collided with terrain near Trona, California. Airwest Helicopters, Inc., was operating the helicopter under the provisions of 14 Code of Federal Regulations (CFR) Part 135. The airline transport pilot and two passengers sustained minor injuries; the helicopter sustained substantial damage to the airframe. The cross-country, on-demand, air taxi flight departed the Wildrose National Park's heliport near Inyokern, California, about 0945. The purpose of the flight was to transport maintenance personnel to a radio tower. Visual meteorological conditions (VFR) prevailed, and a company VFR flight plan had been filed. The pilot departed Redlands, California, and stopped to refuel at Inyokern. He departed Inyokern, and landed at the heliport to load equipment. He then flew 6 miles east to a radio facility on top of Rogers Peak, elevation 9,993 feet. He noted that the peak was at the intersection of two ridge lines; one ran north/south, and the other ran east/west. The north-to-east quadrant consisted of very steep terrain; the other quadrants formed a large ice bowl with grades varying from 15 to 30 degrees. The pilot made one high reconnoiter right-hand turn around the summit. He assessed the wind as light and variable. He continued the circling approach from north to south, east of the ridge line and about 100 feet higher. He slowed from 60 knots to 40 knots so that he could assess his available power during the landing. The pilot felt that the helicopter was performing adequately with the torque level in the top of the green operating range on the torque gage. The airspeed suddenly decreased to 20 knots, and the helicopter yawed 90 degrees to the right. He held the new heading, lowered the nose to gain airspeed, and held the same torque input as he attempted to go over the ridge in order to abort the landing. The situation appeared stable until the helicopter went into a violent and uncontrollable right spin. The pilot indicated that he felt no response to his control inputs. He did not want to land in the ice bowl, and proceeded over the east/west ridge. He was unable to get forward airspeed and stop the spin. The helicopter spun down vertically, and he pulled all remaining pitch to cushionthe impact. The helicopter was on a southwesterly heading, and the main rotor blades made first contact followed by the skids. It rolled onto its right side, and slid about 75 yards before coming to a stop facing uphill. The right front passenger exited through where the bubble had been, and helped the rear passenger out. The pilot turned off the battery and fuel. He exited with the fire extinguisher, and put out a fire in the tailpipe. One of the passengers held a rotorcraft/helicopter pilot certificate. He indicated that on the first landing attempt, the pilot appeared to be running out of left pedal. The second attempt was at a different angle to the landing zone, but once again the pilot seemed to run out of pedal, and the helicopter began to spin. The pilot couldn't recover this time, and it made three turns before colliding with the terrain. Post accident examination of the wreckage revealed no anomalies with the engine that would have precluded normal operation. Examination of the airframe revealed a fracture of a component of the tail rotor control rod. Metallurgical examination determined that the fracture was a result of ductile overload during impact. No anomalies were discovered that would have precluded normal operation.

Aircraft

Registration
N501EF
Reported as
MD Helicopter 369D
Category
Helicopter
Serial number
270091D
Airframe hours
6,897
Engine
Rolls Royce 250 C20, 420 horsepower, turbo shaft
Damage
Substantial damage
Fire
On-Ground
Flight
Part 135
Operator
Airwest Helicopters, Inc.
Registered owner
Airwest Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 11, 2008
Departed
Inyokern, CA
Destination
Rogers Peak, CA
Flight plan
Company VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
Minor
Certificates
Private, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 26, 2008
Seat
Right
Flight hours
7,868 total · 1,300 in this make and model · 6,881 as pilot in command · 7 in the last 90 days · 6 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 21 °F
Altimeter
30.11 inHg
Observed at
KIND, 205 nm away

Docket · 6

The files NTSB released with the investigation on February 11, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.7 MB in all.

FAA reports on this event · 1

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