# NTSB WPR19LA205: Md Helicopter 369, N438RC, Eugene, OR, July 28, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: July 27, 2019, 22:15 local (Jul 28, 2019, 05:15 UTC) - Place: Eugene, OR - Coordinates: 44.121387, -123.207221 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.1214&lon=-123.2072&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of tail rotor effectiveness](https://openairdocs.org/ntsb-events/242) - Highest injury: Serious injuries - Injuries: 2 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): 99965 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA205 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99965/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99965 - Page: https://openairdocs.org/ntsb/WPR19LA205 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: prop/rotor parameters](https://openairdocs.org/ntsb-findings/01062052): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 1 case](https://openairdocs.org/ntsb-findings/01062052/cases.md?model=3027369), [All aircraft, 182 cases](https://openairdocs.org/ntsb-findings/01062052/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 6 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=3027369), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Loss of tail rotor effectiveness](https://openairdocs.org/ntsb-events/242) (defining event); cases with it: [Mcdonnell Douglas Helicopter 369E, 2 cases](https://openairdocs.org/ntsb-events/242/sequence.md?model=3027369), [All aircraft, 100 cases](https://openairdocs.org/ntsb-events/242/sequence.md) - [Approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Mcdonnell Douglas Helicopter 369E, 9 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=3027369), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Mcdonnell Douglas Helicopter 369E, 8 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=3027369), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## 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](https://openairdocs.org/deregistered/N438RC-2023-10-07), registration cancelled 2023-10-07, S/N 0245E (OpenAirDocs) - Reported make and model: Md Helicopter 369 (E) - Registry model: [Mcdonnell Douglas Helicopter 369E](https://openairdocs.org/model/mcdonnell-douglas-helicopter-369e) (registry code 3027369) (OpenAirDocs) - Category: Helicopter - Serial number: 0245E - Year built: 1987 - Airframe hours: 9497 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: serious; 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 - Co-pilot; age 74; injuries: serious; 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 ## 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 20190727016099A](https://openairdocs.org/incident/20190727016099A), Jul 27, 2019: Mcdonnell Douglas Helicopter 369E, Eugene, OR, Substantial damage. 07/27/2019 Helicopter was inbound to the north run-up area. As the helicopter approached 50 foot AGL it rapidly climbed to 200 feet and then began to spin and… ## Docket (8 files) The files NTSB released with the investigation on April 19, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99965. 19.1 MB in all. - Record of email - NTSB materials laboratory (item 1, PDF, 3 pages, 752 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9198446&FileExtension=pdf&FileName=ROE%20mat%20lab-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 10 pages, 7.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9186376&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Google earth maps (item 3, PDF, 4 pages, 465 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9201553&FileExtension=pdf&FileName=Google%20Earth%20Maps-Rel.pdf - Airframe examination observations (item 4, PDF, 11 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9187748&FileExtension=pdf&FileName=airframe%20examination%20notes-Rel.pdf - FAA advisory circular #90-95 for unanticipated right yaw in helicopters (item 5, PDF, 10 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9199119&FileExtension=pdf&FileName=FAA%20Adisory%20circular-Rel.pdf - Statement of party representatives to NTSB investigation (item 6, PDF, 1 page, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9204668&FileExtension=pdf&FileName=Party%20Form%20-%20MDHI_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9203783&FileExtension=pdf&FileName=Wreckage%20release%20signed_Redacted-Rel.pdf - On scene photos - courtesy of the lane county sheriffa��s office (item 8, PDF, 2 pages, 375 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9188064&FileExtension=pdf&FileName=on%20scene%20photos%20from%20leo-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.