WPR19LA205

NTSB accident investigation · Md Helicopter 369 · Eugene, OR · July 28, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
July 27, 2019, 22:15 local (Jul 28, 2019, 05:15 UTC)
Place
Eugene, OR
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N438RCMd Helicopter 369
Defining event
Approach: Loss of tail rotor effectiveness
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20190727016099A
Case key
99965

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 left seat pilot’s failure to account for environmental conditions conducive to a loss of tail rotor effectiveness, which resulted in a loss of tail rotor effectiveness and subsequent loss of control.

Findings · 2

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.

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 pilots reported that they were approaching the airport ramp area for landing from the east with a wind of 10 knots from the north. About 25 to 30 feet above the ramp at an airspeed of about 25 knots, the left seat pilot reduced left pedal pressure to turn the helicopter toward the right into the wind, then subsequently increased left pedal pressure to stop the turn; however, the helicopter continued right and began to spin. The pilot lowered the collective, and the right seat pilot took the flight controls in an attempt to slow the spin. The helicopter impacted the ground hard, spreading the landing skids and resulting in the tail rotor contacting the ramp. Postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. The helicopter’s altitude above the ramp, its low forward speed, and the right turn were conducive to the onset of a loss of tail rotor effectiveness (LTE). Given the lack of mechanical anomalies, it is likely that the loss of control was due to LTE.

Factual narrative

On July 27, 2019, about 2215 Pacific daylight time, a McDonnell Douglas 369E helicopter, N438RC, was substantially damaged when it was involved in an accident near Eugene, Oregon. The two commercial pilots were seriously injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. The pilots reported that they were approaching the airport ramp area for landing from the east with a wind of 10 knots from the north. About 25 to 30 feet above the ramp at an airspeed of about 25 knots, the left seat pilot reduced left pedal pressure to turn the helicopter toward the right into the wind, then subsequently increased left pedal pressure to stop the turn; however, the helicopter continued right and began to spin. The pilot lowered the collective, and the right seat pilot took the flight controls in an attempt to slow the spin. The helicopter impacted the ground hard, spreading the landing skids and resulting in tail rotor contact with the ramp. Postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. The helicopter was mostly intact. Control continuity was established throughout the helicopter with no anomalies noted. Examination of the powertrain revealed a fracture of the main driveshaft flexible joint, and a fracture of the tail rotor driveshaft. All fracture features displayed signatures consistent with overstress. Federal Aviation Administration Advisory Circular (AC) 90-95, Unanticipated Right Yaw in Helicopters, states, "Loss of tail rotor effectiveness (LTE) is a critical, low-speed aerodynamic flight characteristic which can result in an uncommanded rapid yaw rate which does not subside of its own accord and, if not corrected, can result in the loss of aircraft control." In addition, the AC lists the conditions under which LTE may occur: "Any maneuver which requires the pilot to operate in a high-power, low airspeed environment with a left crosswind or tailwind…" and "There is greater susceptibility for LTE in right turns. This is especially true during flight at low airspeed since the pilot may not be able to stop the rotation."

Aircraft

Registration
N438RC
Reported as
Md Helicopter 369 (E)
Category
Helicopter
Serial number
0245E
Built
1987
Airframe hours
9,497
Engine
Rolls Royce 250-C20B, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Other work use · Part 91
Operator
Lane County Sheriffs Office
Registered owner
Lane County Sheriffs Office
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 12, 2019 · 38 hours before
Departed
EUG · Eugene, OR
Destination
EUG · Eugene, OR
Airport
EUG · Mahlon Sweet Field Airport
Equipment
Unknown

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
Pilot
Age
49
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
April 26, 2019
Seat
Left
Restraint
3-point
Flight hours
505 total · 14 in this make and model · 398 as pilot in command · 14 in the last 90 days · 7 in the last 30 days
Role
Co-pilot
Age
74
Injuries
Serious
Certificates
Flight instructor, Airline transport, Commercial, Remote
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Unknown
Seat
Right
Restraint
3-point
Flight hours
999,999 total · 9,999 in this make and model

Weather

Conditions
Visual (VMC) · Night
Wind
350° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 54 °F
Altimeter
30.17 inHg
Observed at
EUG

Docket · 8

The files NTSB released with the investigation on April 19, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.1 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.