WPR12LA029

NTSB accident investigation · Bell 47D1 · San Diego, CA · November 8, 2011

Accident · No injuriesLimited investigationFinal report
Date
November 8, 2011, 14:25 local (22:25 UTC)
Place
San Diego, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N4251ABell 47D1
Defining event
Autorotation: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report August 29, 2012
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Adminstration FSDO
FAA report
20111108026759A
Case key
82270

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 flight instructor's inadequate supervision of the student pilot during a simulated autorotation and the pilots’ failure to use carburetor heat while operating at reduced engine power while in carburetor icing conditions, which resulted in a loss of engine power.

Findings · 5

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.

Action: delayed actionPersonnel issues › Action/decision · Instructor/check pilotBell 47D1: 1 caseAll aircraft: 894 casesProbable cause
Ice/rain protection system: intake anti-ice, deiceAircraft › Aircraft systems · Not used/operatedBell 47D1: 1 caseAll aircraft: 108 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBell 47D1: 2 casesAll aircraft: 1,391 casesProbable cause
Experience/qualifications: total experiencePersonnel issues › Experience/knowledge · Instructor/check pilotBell 47D1: 1 caseAll aircraft: 126 cases
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionBell 47D1: 1 caseAll aircraft: 435 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

During an instructional flight, a practice autorotation was initiated with the intention of performing a power recovery. The student maintained directional control while the certified flight instructor (CFI) adjusted the rotor rpm. The student initiated the power recovery, but the engine did not respond. The student then relinquished control of the helicopter to the CFI, who attempted to cushion the landing, but the helicopter landed hard. The helicopter's engine was equipped with a float-type carburetor, and the weather conditions provided for the possibility of serious carburetor icing at glide power. The accumulation of carburetor ice likely resulted in the loss of engine power. Neither the CFI nor student applied carburetor heat during the autorotation, nor they did not monitor the carburetor temperature gauge during the maneuver. During the postaccident examination of the engine, no mechanical failures or malfunctions were revealed which would have precluded normal operation. The CFI's flight experience in piston-powered helicopters was limited to the 6 hours of training he had provided in the accident helicopter, with his prior rotorcraft experience occurring exclusively in turbine-powered helicopters. This was also the first time he had performed an autorotation in the accident helicopter.

Factual narrative

On November 8, 2011, about 1425 Pacific standard time, a Bell 47D1 helicopter, N4251A, sustained substantial damage during a hard landing at Brown Field Municipal Airport, San Diego, California. The helicopter was being operated as a visual flight rules (VFR) instructional flight under the provisions of 14 Code of Federal Regulations (CFR) Part 91, when the accident occurred. The certified flight instructor (CFI) and the private pilot student/owner were not injured. The flight originated from Brown Field Municipal Airport, about 1355. Visual meteorological conditions prevailed, and no flight plan had been filed. The CFI reported that they had just performed a set of uneventful maneuvers in the traffic pattern, and decided to execute a practice autorotation from 1,000 feet above ground level (agl) to a power recovery at 200 feet agl. During the descent, the student maintained directional control, while the CFI adjusted the rotor rpm. The student then began to reapply engine power at 250 feet agl, however, the engine did not respond. He then relinquished the helicopter controls to the CFI, and the helicopter landed hard. The helicopter sustained substantial damage to the lower fuselage during the landing, and the main rotor blades struck and severed the tailboom. The helicopter was powered by a Franklin, six-cylinder, normally aspirated engine, and equipped with a float-type carburetor. The engine was examined by an inspector from the Federal Aviation Administration (FAA), and an Airframe and Powerplant Mechanic. The accessory case had become cracked during the impact sequence, and as such, the engine could not be operated. The fuel tank and carburetor bowl both contained fuel. A post impact examination did not reveal any anomalies with the engine that would have precluded normal operation. The carburetor icing probability chart from Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor Icing Prevention, indicated a probability of serious icing at glide power at the temperature and dew point reported at the time of the accident. The CFI reported that he monitored the carburetor temperature gauge throughout the flight, and that its indicated temperature did not warrant the use of carburetor heat at any point leading up to the practice autorotation. Neither he nor the student applied carburetor heat during the autorotation, nor did they monitor the temperature during the maneuver. The CFI reported 510 flight hours providing flight training in rotorcraft. His total experience in the Bell 47 series was 6 hours, all of which was performed in the accident helicopter, with the owner present. CFI’s prior helicopter experience occurred exclusively in turbine-powered helicopters, and this was the first time he had performed an autorotation in a Bell 47.

Aircraft

Registration
N4251A
Reported as
Bell 47D1
Category
Helicopter
Serial number
110
Airframe hours
4,727
Engine
Franklin 6V4 SERIES, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 3, 2011 · 10 hours before
Departed
SDM · San Diego, CA
Destination
SDM · San Diego, CA
Airport
SDM · Brown Field, runway 26L, 3,180 × 75 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
47
Injuries
None
Certificates
Military, Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
September 23, 2011
Seat
Right
Flight hours
5,650 total · 6 in this make and model · 4,200 as pilot in command · 17 in the last 90 days · 14 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Age
36
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
November 14, 2010
Seat
Left
Flight hours
700 total · 6 in this make and model · 610 as pilot in command · 6 in the last 90 days · 6 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 37 °F
Altimeter
30.14 inHg
Observed at
SDM

Docket · 7

The files NTSB released with the investigation on July 4, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.8 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 N4251A · 1

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