# NTSB WPR13LA137: Hughes 369HS, N471M, Latangai Island, Papua New Guinea, March 2, 2013 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: March 2, 2013, 13:20 local (13:20 UTC) - Place: Latangai Island, Papua New Guinea - Coordinates: -0.511111, 156.538333 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=-0.5111&lon=156.5383&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-hover: Inflight upset](https://openairdocs.org/ntsb-events/271) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report December 15, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA International Field Office - NTSB case key (mKey): 86351 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR13LA137 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/86351/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=86351 - Page: https://openairdocs.org/ntsb/WPR13LA137 ## Probable cause The failure of both the pilot and the fish master of the vessel to adequately monitor their environment, which resulted in a collision. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Hughes 369HS, 3 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=4470728), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Other (probable cause); cases with it: [Hughes 369HS, 3 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=4470728), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-hover: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Hughes 369HS, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=4470728), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Maneuvering-hover: Inflight upset](https://openairdocs.org/ntsb-events/271) (defining event); cases with it: [Hughes 369HS, 1 case](https://openairdocs.org/ntsb-events/271/sequence.md?model=4470728), [All aircraft, 74 cases](https://openairdocs.org/ntsb-events/271/sequence.md) ## Analysis The pilot reported that, as he was flying toward a school of fish, he observed a nearby fishing vessel moving in the same general direction. He flew over the vessel then continued toward a fish aggregating device (FAD), which is a floating object designed and strategically placed to attract fish; it was located about 0.7 mile away from the vessel. As the pilot approached the FAD, he circled twice and then descended the helicopter into a low hover over the FAD. The helicopter was positioned into the wind, and the vessel was approaching the helicopter from behind. With the helicopter still in a low hover, the fish spotter reached out of the helicopter to attach a radio buoy to the FAD. Shortly after, the helicopter was struck from behind by the vessel. The helicopter subsequently plunged into the ocean. The fish master, who was at the controls of the vessel, reported that he observed the helicopter circle twice before it appeared to fly out of the area. He was slowing the vessel when it was about 500 meters (0.3 mile) from the FAD when he observed the helicopter in front of the vessel. The captain of the vessel reported that he was on the vessel's helicopter deck when he noticed the helicopter circle twice and then descend to a hover. He stated that he was unsure what the helicopter was doing until he saw the fish spotter reach for the FAD. At this time, he felt the fish master reverse the vessel; however, it still impacted the helicopter's tail. The Federal Aviation Administration Model Civil Aviation Regulations, Version 2.7, Part 11 states, "Each operator shall conduct operations so as not to endanger persons or property on the surface nor aircraft in flight." The U.S. Department of Homeland Security, United States Coast Guard Navigation Rules state, "every vessel shall at all times maintain a proper look-out by sight and hearing...as to make a full appraisal of the situation and of the risk of collision." Both the pilot and the fish master of the vessel should have been adequately monitoring their environment and their failure to do so resulted in a collision. ## Factual narrative On March 2, 2013, about 1320 Universal coordinated time (UTC), a Hughes 369HS, N471M, impacted the Pacific Ocean after being struck by a commercial fishing vessel in international waters near Latangai Island, Papua New Guinea. The airline transport pilot sustained serious injuries, and the one fish spotter (passenger) sustained fatal injuries. The helicopter's main rotor assembly and tail rotor assembly were substantially damaged. The aircraft was registered to and operated by Jerry's Helicopter Service, Inc. under the provisions of 14 Code of Federal Regulations Part 91. Day, visual meteorological conditions prevailed for the flight and no flight plan had been filed. The flight originated from the helicopter's designated vessel (MV FK 869) at approximately 1220 UTC. The pilot reported that while flying the fish spotter found a fish formation. The pilot was flying towards it when he observed a fishing vessel motoring nearby, and in the general direction of, where the fish were spotted. The pilot circled over the vessel and identified it as the Pacific Ranger before it proceeded to circle over the fish formation. When the fish spotter found the fish aggregating device (FAD), which are floating objects designed and strategically placed to attract fish, the pilot approached the FAD and hovered over it at a low altitude about 0.7 miles away from the Pacific Ranger. During this time, the helicopter was positioned into the wind, with the Pacific Ranger approaching from behind. The fish spotter reached out of the helicopter and attempted to attach a radio buoy to the FAD when the helicopter suddenly shook violently and plunged into the ocean, coming to rest upside down. The fish master of the Pacific Ranger was at the controls at the time of the accident. He reported that prior to seeing the helicopter he observed it on radar when it was about 20 miles away. The helicopter approached the Pacific Ranger and circled around it twice. The fish master reported that it appeared that they did not find the FAD and flew out of the area. When the vessel was about 500 meters from the FAD he was slowing down the vessel when he observed the helicopter in front of them. The captain of the Pacific Ranger reported that he was on the helicopter deck of the Pacific Ranger watching for tuna and FADs when he noticed the helicopter circle twice and descend to a hover about five ship lengths in front of, and facing away from, the Pacific Ranger. He was unsure what the helicopter was doing until he observed the fish spotter climb onto the float of the helicopter and reach for the FAD. At this time, he felt the fish master reverse the Pacific Ranger, however, they still impacted the tail of the helicopter. A GPS, which contained waypoints the pilot created during the flight, was recovered from the helicopter and taken to the manufacturer for analysis. The GPS data indicated that when the helicopter initially flew in front of the Pacific Ranger, the helicopter was about 1.7nautical miles (nm) (about 2 miles) away from the FAD and the Pacific Ranger was about 1.9 nm (2.3 miles) away. The helicopter continued toward the FAD and made one large circle, followed by a smaller circle, before descending to a low hover. The GPS did not indicate time nor did it show the speed of the helicopter or Pacific Ranger. According to The Federal Aviation Administration's Model Civil Aviation Regulations (MCARS), Version 2.7, Part 11 states under Fish Spotting Operating Rules, "Each operator shall conduct operations so as not to endanger persons or property on the surface nor aircraft in flight." According to the U.S. Department of Homeland Security, United States Coast Guard Navigation Rules state "every vessel shall at all times maintain a proper look-out by sight and hearing as well as by all available means appropriate in the prevailing circumstances and conditions so as to make a full appraisal of the situation and of the risk of collision." ## Aircraft - Registration: [N471M](https://openairdocs.org/deregistered/N471M-2020-09-04), registration cancelled 2020-09-04, S/N 1140671S, built 1974 (OpenAirDocs) - Reported make and model: HUGHES 369HS (HS) - Registry model: [Hughes 369HS](https://openairdocs.org/model/hughes-369hs) (registry code 4470728) (OpenAirDocs) - Registry engine: [Allison 250-C20](https://openairdocs.org/engine/allison-250-c20) (registry code 03080, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 1140671S - Year built: 1974 - Airframe hours: 9921 - Engines: Allison 250-C18 317 horsepower turbo shaft - Damage: Substantial damage - Flight: Aerial observation, Part 91 - Operator: Jerrys Helicopter Service Inc - Registered owner: Jerrys Helicopter Service Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, February 27, 2013, 11 hours before - Departed: Latangai Island, POPP - Destination: Latangai Island, POPP - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: serious; airline transport, foreign, flight instructor; instrument ratings: helicopter; medical: class 1, with waivers/limitations; last flight review August 8, 2012; seat: left; restraint: 3-point; flight hours: 7,475 total, 3,518 in this make and model, 6,372 as pilot in command, 165 in the last 90 days, 102 in the last 30 days, 7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 15 knots, gusting 20 - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 82 °F - Altimeter: 29.84 inHg ## 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 20130302003479A](https://openairdocs.org/incident/20130302003479A), Mar 2, 2013: Hughes 369HS, Latangai Island, Substantial damage, 1 fatal. Aircraft was on a fish spotting flight in the south pacific with a crew of one pilot and one passenger (spotter). Fish were spotted in the vicinity of another… ## Docket (11 files) The files NTSB released with the investigation on November 10, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=86351. 5.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 670 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389424&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pacific Ranger Crew Members Statements (item 2, .PDF, 888 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418759&FileExtension=.PDF&FileName=Pacific%20Ranger%20Crew%20Members%20Statements-Redacted.PDF - Helicopter Pilot's Sketch of the Event (item 3, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418760&FileExtension=.PDF&FileName=Helicopter%20Pilot%27s%20Sketch%20of%20the%20Event-Master.PDF - Record of Conversation - Pilot in Command (item 4, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418761&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot%20in%20Command-Master.PDF - Record of Conversation - Jerry's Helicopter Service (item 5, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418762&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Jerry%27s%20Helicopter%20Service-Master.PDF - GPS Examination (item 6, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418763&FileExtension=.PDF&FileName=GPS%20Examination-Redacted.PDF - Google Earth Image - GPS Plots (item 7, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418764&FileExtension=.PDF&FileName=Google%20Earth%20Image%20-%20GPS%20Plots-Master.PDF - FAA Model Civil Aviation Regulation - Part 11 (item 8, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418765&FileExtension=.PDF&FileName=FAA%20Model%20Civil%20Aviation%20Regulation%20-%20Part%2011-Master.PDF - U. S. Department of Homeland Security - United States Coast Guard Navigation Rules (item 9, .PDF, 547 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418766&FileExtension=.PDF&FileName=U.%20S.%20Department%20of%20Homeland%20Security%20-%20United%20States%20Coast%20Guard%20Navigation%20Rules-Master.PDF - Evidence Control Form (item 10, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418767&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Redacted.PDF - Photo 1 - Fishing Vessel Pacific Ranger (Courtesy of Operator) (item 11, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418768&FileExtension=.PDF&FileName=Photo%201%20-%20Fishing%20Vessel%20Pacific%20Ranger%20(Courtesy%20of%20Operator)-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.