WPR11LA469

NTSB accident investigation · Bell 47D1 · Ahwahnee, CA · September 27, 2011

Accident · Serious injuriesLimited investigationFinal report
Date
September 27, 2011, 10:30 local (17:30 UTC)
Place
Ahwahnee, CA
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N9158RBell 47D1
Defining event
Landing: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report June 28, 2012
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20110927022599A
Case key
81906

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s failure to maintain adequate main rotor rpm during the landing approach, which resulted in a loss of control.

Findings · 3

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.

Performance/control parameters: prop/rotor parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedBell 47D1: 1 caseAll aircraft: 182 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBell 47D1: 3 casesAll aircraft: 9,295 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomeBell 47D1: 1 caseAll aircraft: 933 cases

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 pilot and mechanic were on a local area flight to warm the oil before changing the oil lines. As they returned, the pilot slowed the helicopter and initiated a gradual descent to the landing site. The main rotor rpm decreased. As they continued the descent, the clearance from the trees surrounding the landing area was minimal. The pilot attempted to avoid the trees as he tried to regain main rotor rpm. The helicopter impacted a tree and descended nose down into the terrain. According to the mechanic and pilot, they encountered no mechanical anomalies during the flight.

Factual narrative

On September 27, 2011, at 1030 Pacific daylight time, a Bell 47D1, N9158R, collided with trees while descending near Ahwahnee, California. The helicopter was being operated under the provisions of Title 14 Code of Federal Regulations Part 91. The helicopter was substantially damaged. The private pilot sustained serious injuries, and the passenger sustained minor injuries. Visual meteorological conditions prevailed and no flight plan was filed. The pilot departed about 1020 for the local area flight. The Federal Aviation Administration (FAA) accident coordinator responded to the accident site. The helicopter had impacted terrain in a nose down attitude and the tail and tail rotor systems were resting upright against a tree. The pilot submitted a written statement on May 14, 2012. He reported that he was conducting a run on landing and the rotor revolutions per minute (RPM) decreased. He turned away from the trees hoping to recover the RPM. The helicopter then settled into a tree. He said that there were no mechanical malfunctions or failures. In an interview with the NTSB investigator, the passenger said that he had been maintaining the helicopter for about 5 years. The owner had reported what he surmised to be a problem with the number one bearing being loose on the tail rotor drive shaft. Additionally, they had previously installed an oil filter and they were going to change the oil lines. The pilot and mechanic completed the pre-flight inspection and review and noted no problems with the tail rotor drive shaft. They decided to take the helicopter on a short flight to warm the oil. The mechanic had flown with the pilot previously and had no concerns about his operation of the helicopter. They departed from the private landing pad which was located at the pilot's residence. They flew for about 15 minutes with no problems noted. They returned to the area of the landing pad which was surrounded by trees and terrain. The helicopter gradually descended and the mechanic told the pilot that he did not think they were going to maintain clearance from a large tree to the west of their position. About 10 yards from the tree, they were below treetop level and the power [rotor RPM] continued to decrease while the helicopter descended. The pilot attempted to pull out of the landing to avoid the tree and turned the helicopter to the right while increasing collective. The helicopter then collided with the tree. The mechanic had flown in and out of the area with the pilot multiple times. He felt on this occasion, due to the confined area there were no options to recover the helicopter prior to impact with the tree. The mechanic indicated that no mechanical malfunctions occurred. A witness was working as a fire lookout in Miami Mountain Fire Lookout Tower, which was located about 1 mile from the accident site. She heard the helicopter and saw a cloud of dust appear. The helicopter ascended out of the dust cloud and flew approximately 500 feet above ground leveldown a valley. The helicopter then turned and appeared to be returning to the landing pad. The landing pad was surrounded by trees and houses. As the helicopter approached the landing pad, it made a gradual descent while almost coming to a stop. She then saw the tail move from left to right, and the helicopter quickly descended and impacted a tree. The wind was calm at the time. There was no postimpact fire. She immediately called emergency response personnel.

Aircraft

Registration
N9158R
Reported as
Bell 47D1
Category
Helicopter
Serial number
455
Airframe hours
4,831
Engine
Franklin 6V4-178-B32, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Lee Haley
Registered owner
Lee Haley
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 14, 2011
Departed
Ahwahnee, CA
Destination
Ahwahnee, CA

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
71
Injuries
Serious
Certificate
Private
Medical
Class 3, Without waivers/limitations
Seat
Left

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 52 °F
Altimeter
30.04 inHg
Observed at
KMAE, 33 nm away

Docket · 5

The files NTSB released with the investigation on May 22, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.9 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.

Other investigations on N9158R · 1

Matched to the same aircraft by N-number and date.