WPR17LA005

NTSB accident investigation · Mcdonnell Douglas Helicopter 369E · Waimea, HI · October 4, 2016

Accident · No injuriesLimited investigationFinal report
Date
October 4, 2016, 09:10 local (19:10 UTC)
Place
Waimea, HI
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N311VTMcdonnell Douglas Helicopter 369E
Defining event
Initial climb: Unknown or undetermined
Weather
Visual (VMC) · Day
Status
Completed · report January 25, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20161004017849A
Case key
94196

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 NTSB’s determination of the probable cause, and any contributing factors.

Impact of the lift cable after it exited the helicopter during liftoff with the main rotor (MR) blades, which resulted in the separation of an MR blade tip and the vertical vibration of the helicopter.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The commercial pilot reported that, after completing an external cargo lift operation, he landed at a remote location to jettison the lift cable and to board the two ground workers for a ferry flight back to their home base. Shortly after liftoff, the pilot felt a moderate aberration in the cyclic flight control, followed by a significant vertical vibration. The pilot subsequently observed that the main rotor (MR) blade track had a substantial blade spread. Subsequently, the pilot conducted a forced emergency landing to a nearby suitable area. A postaccident examination of the helicopter revealed that one MR blade was missing about 9 inches of its blade tip, consistent with impact with an object of substantial mass, possibly a cable; the damage was not consistent with separation of the blade end due to a preexisting condition. Two other MR blades exhibited scuff marks and scratches along their leading edges with areas that had defined parallel scratches, consistent with cable impact. The pilot reported that he released the lift cable before the flight, and it was not recovered. The pilot added that, after he released the cable, the ground crew placed the coiled cable in the rear compartment that had no doors. Examination of the lift cable release mechanism revealed no damage to the component, and additional testing revealed no anomalies that would have precluded normal operation of the lift cable mechanism. There is no evidence that the lift cable remained attached to the hook during the accident flight; therefore, it was likely in the passenger compartment at liftoff as reported by the pilot. Therefore, based on the damage to the MR blades, it is likely that the cable exited the helicopter during liftoff and subsequently impacted the MR, which resulted in the separation of an MR blade tip and the vertical vibration of the helicopter.

Factual narrative

The factual narrative942 words

On October 4, 2016, about 0910 Hawaiian standard time, a McDonnell Douglas Helicopter (MDHI), 369E N311VT, sustained substantial damage to the main rotor during initial climb from a remote location at Kohala Mountains near Waimea, Hawaii. The commercial pilot and 2 passengers were not injured. The helicopter was registered to, and operated by Volcano Helicopters Inc., under the provision of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed for the flight, which operated on a company flight plan. In his initial statement, the pilot reported that the purpose of the flight was to provide multiple external cargo lift deliveries between a construction project site located on the Kohala Mountain and various locations within the project boundary. At 0745, the helicopter took off from Hilo International Airport (ITO), Hilo, Hawaii with only the pilot on board and no cargo. Enroute to the Kohala Mountain project site, the pilot landed at the Hawaii Board of Water Supply's Kamuela reservoir to board two ground workers who manned a ground procedure of the external cargo tasks (connect, disconnect and handling of the cargo), and then flew to the construction site. Two passengers disembarked, after which the helicopter successfully completed an external cargo lift assignment. The helicopter then returned to a cargo platform at the construction site to jettison the 20-foot lift cable and to board the two ground workers and their accompanying baggage for the return ferry flight. The pilot reported that he pressed an electrical "Release" switch located on the cyclic to jettison the lift cable prior to takeoff. After the ground workers loaded their equipment and boarded the helicopter, they conveyed to the pilot via the helicopter's intercom system the completion of the loading, boarding and secure seating The lift-off and departure into forward flight (climb and acceleration of speed) proceeded within instrument parameters specified in the operating manuals, with no indication of malfunction. The helicopter was established in stable departure on the enroute course and heading for the cruise altitude and speed. During the initial climb, about 75 feet above ground level, and speed of about 20-25 knots, the pilot experienced a moderate aberration in the cyclic flight control, followed by a significant vertical vibration, and observed that the main rotor blade track had a substantial blade spread. The pilot performed a forced emergency landing to a nearby suitable area. The Federal Aviation Administration (FAA) Inspector conducted an examination and noted that one main rotor blade was missing about 6 inches of the blade tip, two other blades exhibited small impact serrations on their respective leading edges, and the remaining two blades were not damaged. No organic bird material was observed on the blades, but the inspector reported that it appeared as if "something metallic-like had struck the blades, however that object was notlocated." Other damages appeared to be post-impact, which included a cracked instrument panel at the bottom edge on both sides, left and right side of the fuselage above the engine area, tail rotor blades, vertical stabilizer damage at the upper end, and horizontal stabilizer damage on the right side, to include the vertical winglet. He also stated that the lift cable was not found in the helicopter or at the site. Furthermore, the inspector tested and confirmed no malfunction of the jettison switch used to release the cable. After the helicopter was released to the insurance company, the pilot conducted an examination of the wreckage, and submitted a written addendum to the initial report of his finding. The addendum is appended to the docket. In the addendum, the pilot confirmed that the lift cable and the main rotor blade tip were missing. The pilot again stated that after the completion of the airlift operation, he used the "Eject" switch to jettison the cable, and added that the ground crew of the external load operation coiled and loaded the cable on the floor of the rear cabin of the helicopter for the return ferry flight to base. Due to a necessity to continuously remain on the flight controls during the final loading, the pilot did not personally conduct an exterior preflight check. In addition, the helicopter was configured without the left and right rear cabin doors. The pilot inspected and tested the electric cargo hook system, and found no anomalies or malfunctions. The National Transportation Safety Board structural engineer examined the photos and concluded that one of the main rotor blades suffered extensive damage. The outboard 9 inches was separated, the blade spar was deformed aft, and the trailing edge was buckled along about half its length. Two other main rotor blades were scuffed/scratched in localized areas. The aft fuselage around the tailboom attach point was buckled and fractured. The horizontal stabilizer and vertical stabilizer also sustained impact damage. In the addendum report, the pilot reported that debriefing of procedures of the operation and emergency landing identified three additions to the current Pilot's Standard Operating Procedures. 1. Pre-flight Aircraft Exterior Check: The check of the tail and main rotor blade's leading edge protection tape shall be a requirement of the preflight checklist as an individual and separate listing. 2. Flight in "rear Doors Off" Configuration: All material or item loaded on the floor for a flight in the 'Rear door off' configuration shall be required to be physically secured to a tie-down fixture to prevent movement and loss from the cabin. 3. Unimproved field loading and departure procedures: In operations that require the pilot to continually remain at the flight controls, clearance is an advisory of the ground crew. The pilot shall validate the advisory with routine signal or voice communications reports on individual item, function or procedure.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N311VT
Reported as
Mcdonnell Douglas Helicopter 369E (E)
Category
Helicopter
Serial number
0229E
Built
1987
Airframe hours
17,334
Engine
Rolls Royce 250 C20R/2, 450 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Volcano Helicopters Inc
Registered owner
Volcano Helicopters Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 16, 2016
Departed
ITO · Hilo, HI
Destination
ITO · Hilo, HI
Flight plan
Company VFR
Equipment
Satellite tracking device

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
54
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 27, 2015
Seat
Front
Restraint
4-point
Flight hours
28,500 total · 26,500 in this make and model · 28,400 as pilot in command · 270 in the last 90 days · 100 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 55 °F
Altimeter
30.37 inHg
Observed at
PHMU, 7 nm away

Docket · 5

The files NTSB released with the investigation on November 2, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.5 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.