# NTSB WPR19LA135: Bell 206, N49643, Oxnard, CA, May 4, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: May 4, 2019, 09:45 local (16:45 UTC) - Place: Oxnard, CA - Coordinates: 34.220275, -119.223892 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.2203&lon=-119.2239&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Inflight upset](https://openairdocs.org/ntsb-events/271) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 99393 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA135 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99393/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99393 - Page: https://openairdocs.org/ntsb/WPR19LA135 ## Probable cause The pilot’s inability to maintain control of the helicopter while maneuvering at a low altitude due to reasons that could not be determined based on available evidence. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bell 206B, 45 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1181511), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Bell 206B, 9 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=1181511), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01060000): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Bell 206B, 1 case](https://openairdocs.org/ntsb-findings/01060000/cases.md?model=1181511), [All aircraft, 63 cases](https://openairdocs.org/ntsb-findings/01060000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Inflight upset](https://openairdocs.org/ntsb-events/271) (defining event); cases with it: [Bell 206B, 3 cases](https://openairdocs.org/ntsb-events/271/sequence.md?model=1181511), [All aircraft, 74 cases](https://openairdocs.org/ntsb-events/271/sequence.md) - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Bell 206B, 57 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1181511), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The operator reported that this was the helicopters third flight of the day. However, this was the first paint material load of the day. As the pilot made his third pass over the greenhouses, he noticed that he was using more left cyclic to maintain level flight. He continued to spray in attempt to correct any load imbalances, however, the helicopter continued to lean further to the right. The pilot maneuvered away from the greenhouses. The helicopter’s right turn continued to increase until it impacted the ground at about a 45o bank. A post impact fire ensued and completely consumed the helicopter. The operator further reported that the helicopter was equipped with 2, 60-gallon mixture tanks mounted on each side of the aircraft. The tanks were connected through a transfer equalizing tube which fed a centrally located electric pump. The pump then sent the wash through the spray booms. The operator mentioned that they believe one of the mixture tanks stopped transferring, which would cause the helicopter to be imbalanced. Due to the destruction of the helicopter during impact and the post impact fire there was not enough evidence to determine if there were any mechanical anomalies with the helicopter or spray system. ## Factual narrative On May 4, 2019, about 0945 Pacific daylight time, a Bell 206B helicopter, N49643, was destroyed when it was involved in an accident near Oxnard, California. The pilot was seriously injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 133 aerial application flight. The operator reported that this was the helicopters third flight of the day. However, this was the first paint material load of the day. As the pilot made his third pass over the greenhouses, he noticed that he was using more left cyclic to maintain level flight. He continued to spray in attempt to correct any load imbalances, however, the helicopter continued to lean further to the right. The pilot maneuvered away from the greenhouses. The helicopter’s right turn continued to increase until it impacted the ground at about a 45-degree bank. A post impact fire ensued and completely consumed the helicopter. The operator further reported that the helicopter was equipped with 2, 60-gallon mixture tanks mounted on each side of the aircraft. The tanks were connected through a transfer equalizing tube which fed a centrally located electric pump. The pump then sent the wash through the spray booms. The operator mentioned that they believe one of the mixture tanks stopped transferring, which would cause the helicopter to be imbalanced. Postaccident examination of the helicopter did not reveal any anomalies with the helicopter, however, it was destroyed, and mostly consumed by impact and fire related damage. ## Aircraft - Registration: [N49643](https://openairdocs.org/deregistered/N49643-2019-09-05), registration cancelled 2019-09-05, S/N 1813, built 1975 (OpenAirDocs) - Reported make and model: Bell 206 (B) - Registry model: [Bell 206B](https://openairdocs.org/model/bell-206b) (registry code 1181511) (OpenAirDocs) - Registry engine: [Allison 250-C20 series](https://openairdocs.org/engine/allison-250-c20-series) (registry code 03020, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: 1813 - Year built: 1975 - Airframe hours: 20629 - Engines: Rolls Royce 250 C-20B 420 horsepower turbo shaft - Damage: Substantial damage - Fire: On-Ground - Flight: Aerial application, Part 137 - Operator: Aspen Ag Helicopters Inc - Registered owner: Aspen Ag Helicopters Inc - Airworthiness certificate: Special, Restricted (Special) - Last inspection: 100 hour, March 21, 2019, 66 hours before - Departed: OXR, Oxnard, CA - Destination: OXR, Oxnard, CA - Flight plan: Company VFR - Airport: OXR, Oxnard Airport - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 41; injuries: serious; flight instructor, commercial; instrument ratings: helicopter; medical: class 2, without waivers/limitations; last flight review February 2, 2018; seat: front; restraint: 4-point; flight hours: 4,910 total, 2,600 in this make and model, 3,910 as pilot in command, 250 in the last 90 days, 80 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 8 statute miles - Lowest ceiling: 1,500 ft overcast - Temperature: 61 °F, dew point 54 °F - Altimeter: 29.94 inHg - Observed at: OXR, 2 nm away ## 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 20190504003939A](https://openairdocs.org/incident/20190504003939A), May 4, 2019: Bell 206B, Oxnard, CA, Destroyed. On may 4, 2019 N49643 s/n 1813, Bell helicopter 206B was equipted with agricultural equiptment (isolair model 3900 agricultural spray system). The tanks were… ## Other investigations on N49643 (1) 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. - [NTSB LAX86LA155](https://openairdocs.org/ntsb/LAX86LA155), Mar 23, 1986: Bell 206B (N49643), Huntington Bch, CA, substantial damage ## Docket (4 files) The files NTSB released with the investigation on March 22, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99393. 10.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12350918&FileExtension=pdf&FileName=6120%20printed%202-Rel.pdf - Record of memorandum - postaccident examination observations (item 2, PDF, 1 page, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11843949&FileExtension=pdf&FileName=ROM%20exam-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 3, PDF, 1 page, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9206073&FileExtension=pdf&FileName=wreckage%20release%20signed_Redacted-Rel.pdf - On scene photos (item 4, PDF, 3 pages, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11844386&FileExtension=pdf&FileName=On%20scene%20photos-Rel.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.