# NTSB WPR20LA029: Agusta A109, N271HC, Salt Lake City, UT, November 13, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: November 12, 2019, 20:08 local (Nov 13, 2019, 03:08 UTC) - Place: Salt Lake City, UT - Coordinates: 40.170555, -111.644996 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.1706&lon=-111.6450&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Inflight upset](https://openairdocs.org/ntsb-events/271) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Leonardo Company - NTSB case key (mKey): 100590 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20LA029 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100590/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100590 - Page: https://openairdocs.org/ntsb/WPR20LA029 ## Probable cause The flight nurse’s inadvertent application of left anti-torque pedal during cruise flight, which resulted in a rapid yaw and pitch movement that caused the tail rotor blades to contact the tailboom. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Agustawestland A109SP, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=0260114), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Inflight upset](https://openairdocs.org/ntsb-events/271) (defining event); cases with it: [Agustawestland A109SP, 1 case](https://openairdocs.org/ntsb-events/271/sequence.md?model=0260114), [All aircraft, 74 cases](https://openairdocs.org/ntsb-events/271/sequence.md) ## Analysis The crew of the helicopter air ambulance flight departed to pick up a patient in night visual meteorological conditions. While en route to their destination, a flight nurse, who was seated in the left seat and communicating with ground personnel, inadvertently depressed the helicopter’s left anti-torque pedal instead of the foot-activated push-to-talk (PTT) switch to activate the microphone. The helicopter suddenly yawed left about 11°, which the pilot immediately countered and restored straight-and-level flight. The helicopter sustained damage to the tail rotor blades and empennage that was not discovered until several hours later when the accident crew was relieved. The damage to the blades and empennage was consistent with their making contact, and the flight data suggest this occurred during the first leg of the shift flight as the crew did not experience any other events that would have caused the degree of damage observed. Postaccident examination of the tail rotor gearbox and tail rotor blades did not reveal any anomalies. A performance analysis by the helicopter manufacturer showed that the amount of left pedal applied at the time of the pilot’s yaw recovery exceeded the parameters tested during certification. The flight nurse seated in the cockpit at the time of the accident normally sat in the rear cabin and was likely not as familiar with the location of the PTT, especially in nighttime lighting conditions. ## Factual narrative On November 12, 2019, about 2008 mountain standard time, an AgustaWestland AW109SP helicopter, N271HC, was substantially damaged during cruise flight near Spanish Fork, Utah. The pilot and two flight nurses were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 air ambulance flight. According to the pilot, the crew departed their base about 1952 and was bound for a motor vehicle accident about 22 minutes away. About 5 minutes from the destination, the flight nurse, seated in the left front seat, attempted to contact personnel on the ground to coordinate their landing. Rather than step on the push-to-talk (PTT) button located on the cabin floor to activate the radio microphone, he inadvertently stepped on the left anti-torque pedal, which resulted in a rapid yaw to the left. The pilot re-established straight and level flight and landed the helicopter uneventfully. The pilot did not observe any unusual signatures on the exterior of the helicopter during a walkaround inspection after they landed at their destination following the accident; however, he did not inspect the tail rotor blades or tailboom. The rest of the flight was uneventful, and the pilot did not report any anomalies with the tail rotor blades or tailboom during the subsequent flights that took place during his shift. After the accident crew arrived at the company’s home base and went off-duty, the oncoming pilot conducted a walkaround inspection in daylight conditions and discovered damage to the tailboom as he approached the helicopter. The helicopter was immediately taken out of service and ferried to the company’s maintenance facility for repair. The nurse who was seated in the left front seat during the accident flight normally rode in the rear cabin of the helicopter, but the crew decided that he would sit in the cockpit during the accident flight to make room for the patient they intended to pick up. The tail rotor blades, tail rotor gearbox, pitch change slider assembly, and the tail rotor hub assembly were examined by the NTSB materials laboratory and the components exhibited no anomalies. The helicopter was equipped with an Appareo flight data monitoring (FDM) system, which indicated that the yaw was about 11°. An NTSB performance study using data retrieved from the FDM corroborated the pilot’s statement and showed that the helicopter rapidly turned left from a heading of 153° to 142° in 1.25 seconds. When the pilot countered the movement with right tail rotor pedal, the helicopter returned to 151° in 2 seconds. During this time, the helicopter rapidly rolled from level flight to -15° to 15° and pitched up 2° before returning to its original altitude. The helicopter manufacturer provided flight handling qualities data obtained during the certification of the accident helicopter. A dynamic stability test point was performed in level flight at 0.9Vh ± 10° yaw where Vh is the calculated maximum horizontal airspeed based onatmospheric conditions. This test involved a 15% pedal input over 0.5 second, which resulted in a 6º-to-15º per second sideslip deviation. A simulation was performed using the accident helicopter’s parametric data and ambient conditions showed that to match the yaw rate and magnitude, a 40% left pedal input (90% pedal position) was required. This resulted in a 20° per second deviation, which exceeded the parameters tested for during certification. ## Aircraft - Registration: [N271HC](https://openairdocs.org/aircraft/N271HC), registered now, S/N 22250, built 2011 (OpenAirDocs) - Reported make and model: Agusta A109 (SP) - Registry model: [Agustawestland A109SP](https://openairdocs.org/model/agustawestland-a109sp) (registry code 0260114) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PW207C](https://openairdocs.org/engine/pratt-whitney-canada-pw207c) (registry code 52203, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 22250 - Year built: 2011 - Engines: Pratt and Whitney PW207 turbo shaft; Pratt and Whitney PW207 turbo shaft - Damage: Substantial damage - Flight: Other work use, Part 135 - Operator: IHC Health Services Inc - Registered owner: IHC Health Services Inc - Airworthiness certificate: Standard, Normal - Last inspection: October 25, 2019, 3,745 hours before - Departed: UT11, Murray, UT - Destination: Spanish Fork, UT - Flight plan: Company VFR - Equipment: Electronic flight bag or handheld device, Data recorder, Electronic multifunction display, Electronic primary flight display, Satellite tracking device, Video recording device, ADS-B, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: none; airline transport; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: helicopter, airplane; medical: class 1, without waivers/limitations; last flight review August 30, 2019; seat: right; restraint: 4-point; flight hours: 11,173 total, 985 in this make and model, 10,443 as pilot in command, 41 in the last 90 days, 33 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 37 °F, dew point 28 °F - Altimeter: 30.16 inHg - Observed at: KPVU, 5 nm away - METAR: METAR KPVU 130256Z 00000KT 10SM CLR 03/M02 A3016 RMK AO2 SLP229 T00331017 58006= ## 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 20191112021169A](https://openairdocs.org/incident/20191112021169A), Nov 12, 2019: Agustawestland A109SP, Springville, UT, Substantial damage. Flight nurse sitting in left cockpit seat pushed left tail rotor pedal causing the tail rotor blades to hit the tail boom causing substantial damage. ## Docket (14 files) The files NTSB released with the investigation on June 1, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100590. 16.3 MB in all. - Aircraft performance study (item 1, PDF, 5 pages, 873 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11355377&FileExtension=pdf&FileName=WPR20LA029_Performance_Study-Rel.pdf - Materials laboratory factual report (item 2, PDF, 12 pages, 16 photos, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12142064&FileExtension=pdf&FileName=21-025%20-%20Materials%20Lab%20Factual%20Report%20(WPR20LA029)-Rel.pdf - Helicopter specialist report (item 3, PDF, 9 pages, 2 photos, 805 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12270698&FileExtension=pdf&FileName=WPR20LA029%20Helicopter%20Specialist%20Report%20v3(FINAL)-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 4, PDF, 9 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12715673&FileExtension=pdf&FileName=N271HC%20NTSB%206120%20Signed%20Nov%2025,%202019_Redacted-Rel.pdf - Record of conversations (item 5, PDF, 7 pages, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12714895&FileExtension=pdf&FileName=Record%20of%20Conversations-Rel.pdf - Email correspondence with operator (item 6, PDF, 10 pages, 457 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12715024&FileExtension=pdf&FileName=Email%20correspondence%20with%20operator3_Redacted-Rel.pdf - N271HC schedule November 12 - 13 (item 7, PDF, 1 page, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12715284&FileExtension=pdf&FileName=N271HC%20Flights%2012%2013%20Nov%202019%20With%20Crew-Rel.pdf - Excerpt from general operations manual (item 8, PDF, 13 pages, 804 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12714504&FileExtension=pdf&FileName=GOM%20References-Rel.pdf - Adult flight nurse operator training records (item 9, PDF, 7 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12715274&FileExtension=pdf&FileName=Gunty%20Aviation%20Training_Redacted-Rel.pdf - Accident flight operations compliance form (item 10, PDF, 1 page, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12715759&FileExtension=pdf&FileName=Ops%20compliance%20form_Redacted-Rel.pdf - Briefing acronyms (item 11, PDF, 1 page, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12714514&FileExtension=pdf&FileName=PEOPLE%20and%20Crew%20Briefings-Rel.pdf - Statement of party representatives to NTSB investigation (item 12, PDF, 1 page, 741 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12716766&FileExtension=pdf&FileName=Certification%20of%20Party%20Representative_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 13, PDF, 2 pages, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12730011&FileExtension=pdf&FileName=Release%20of%20Wreckage%20N271HC%20IHC%20Health%20Services_Redacted-Rel.pdf - Accident photographs (item 14, PDF, 5 pages, 696 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13925133&FileExtension=pdf&FileName=Accident%20Photographs-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.