Cases › CEN09MA117 › The analyst
SIKORSKY S-76CPHI INC
What the docket says, assembled. No language model is involved, so nothing on this page can be invented — every line traces to a recorder, a report page or the Board's own record.
31
timed facts
8
precedents
40
passages to ask
Ask the docket
passages, not paraphrasesTry
Every answer is a passage of the docket with the page it came from, or the words “not in the docket”. Nothing is summarised or reasoned for you — read the source.
One timeline
31 timed factsthe recorder events from the FDR report, with the transcript's warnings, callouts, the words nearest each event and the final seconds — on one clock, as printed in each report- 12:06:19.3CVR STARTp.7“OF RECORDING”read in context ↗
- 13:53:55.9CVR CAM-?p.7“two in the back three in the middle.”read in context ↗
- 13:53:58 CSTFDRpre-flightp.11MPFR flight data began recording (power-up)
- 13:54:02.9CVR CAM-3p.7“if you can give me that book...somebody else's book. it's not yours huh? CEN09MA117”read in context ↗
- 13:56:18.3CVR HOT-2warningp.11“uh overspeed bleed valve lights?”read in context ↗
- 13:57:01.3CVR HOT-2p.13“T five's lit. blades turning. oil pressure on the rise.”read in context ↗
- 13:57:07-14:01:02 CSTFDRstart/run-upp.11Main rotor speed increased, engine 1 and 2 torque rising within the next minute; autopilots 1 and 2 engaged at 14:00:15; rotor speed reached 107% at 14:01:02see the traces at this moment ↗
- 13:57:14.6CVR HOT-2p.13“T five's stable. forty seven percent.”read in context ↗
- 13:57:24.8CVR HOT-2warningp.13“overspeed warning light?”read in context ↗
- 13:58:00.3CVR HOT-2warningp.14“overspeed warning light?”read in context ↗
- 13:58:25.3CVR HOT-2calloutp.15“alright. start engine checklist complete. before takeoff VFR.”read in context ↗
- 13:59:06.7CVR HOT-1warningp.16“set. now we won't crash.”read in context ↗
- 14:01:23.6CVR HOT-2calloutp.19“takeoff brief?”read in context ↗
- 14:01:36.3CVR RDO-2calloutp.19“Morgan City four eight pappa alpha one reposition for takeoff.”read in context ↗
- 14:03:17.5CVR RDO-2calloutp.20“Morgan City traffic Petroleum four eight pappa on flyway for southwest takeoff Morgan City.”read in context ↗
- 14:03:50.2CVR HOT-2p.20“now we're back at max gross.”read in context ↗
- 14:03:52.6CVR HOT-1p.20“alright.”read in context ↗
- 14:03:54 CSTFDRtakeoff/cruisep.11Torque rose, followed by increasing altitude and airspeed - takeoff; levelled at about 640 ft pressure altitude cruising at 135 ktssee the traces at this moment ↗
- 14:04:54.7CVR HOT-2calloutp.21“after takeoff complete.”read in context ↗
- about 14:09:42 CSTFDRcruisep.11Level at about 820 ft radio altitude and 138 kts, a loud bang recorded on the CVR; within 2 seconds engine 1 and 2 torque and main rotor speed began decreasing and several MPFR parameters went invalid (loss of the #2 DC primary bus)see the traces at this moment ↗
- 14:09:42-14:09:52 CSTFDRdescentp.11Airspeed and altitude decreased steadily; at about 458 ft radio altitude and 129 kts the EGPWS recorded a Mode 2 Terrain alert, followed 2 s later by a Mode 2 Pull Up (both annunciated on the CVR); a Mode 6 Bank Angle alert was logged but superseded aurallysee the traces at this moment ↗
- 14:09:47.6CVR HOT-2p.23“what the hell happened?”read in context ↗
- 14:09:50.0CVR HOT-1final secondsp.23“low rotor.”read in context ↗
- 14:09:51.4CVR HOT-2final secondsp.23“I cannot hear you.”read in context ↗
- 14:09:52.5CVR TAWSfinal secondsp.23“terrain terrain.”read in context ↗
- 14:09:53.8CVR TAWSfinal secondsp.23“pull up. CEN09MA117”read in context ↗
- 14:09:54.6CVR HOTfinal secondsp.24“[sound similar to landing gear warning tone]”read in context ↗
- 14:09:55.2CVR TAWSfinal secondsp.24“pull up.”read in context ↗
- 14:09:57.2CVR TAWSfinal secondsp.24“altitude altitude.”read in context ↗
- 14:09:58 CST (SRN 280,184.2)FDRimpactp.11Last data: radio altitude 70 ft, airspeed 27 kts; MPFR, CVR and EGPWS all stopped simultaneously (impact)see the traces at this moment ↗
- 14:09:58.0CVR HOT-?final secondsp.24“[sound of grunt]”read in context ↗
Flight Data Recorder 10 - Factual Report of Group Chairman · 6 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 25 of 237 lines shown
How the Board coded the sequence
- Enroute-cruise: Birdstrike→
- Enroute-cruise: Loss of engine power (partial)→
- Emergency descent: Loss of control in flight
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- BELL 206 · AIR EVAC EMS INCHydro, OK
- ●Environmental issues › Physical environment › Object/animal/substance
BirdstrikeLoss of control in flight - BELL HELICOPTER TEXTRON CANADA 407 · AIR METHODS CORPStuttgart, AR
- ●Environmental issues › Physical environment › Object/animal/substance
Birdstrike - PILATUS PC-12/45 · GUARDIAN FLIGHT LLCStagecoach, NV
- ●Aircraft › Aircraft systems › Auto flight system
- ●Personnel issues › Psychological › Perception/orientation/illusion
- ●Personnel issues › Task performance › Use of equip/info
Loss of control in flight - BEECH E18S · AIRCAP MANAGEMENT CO INCMiami Gardens, FL
- ●Personnel issues › Task performance › Use of equip/info
Loss of control in flightLoss of engine power (partial) - BOEING 757-222 · UNITED AIRlNES INCDenver, CO
- ●Environmental issues › Physical environment › Object/animal/substance
Birdstrike - AIRBUS HELICOPTERS EC 130 T2 · AIR METHODS CORPChelsea, AL
- ●Personnel issues › Task performance › Use of equip/info
Loss of control in flight - Cessna 208 · Martinaire AviationVictoria, TX
- ●Personnel issues › Psychological › Perception/orientation/illusion
- ●Personnel issues › Task performance › Use of equip/info
Loss of control in flight - AIRBUS HELICOPTERS INC AS350B3E · AIR METHODS CORPFrisco, CO
- ●Organizational issues › Development › Design
- ●Personnel issues › Task performance › Use of equip/info
Loss of control in flight
What the record says
a pattern, not a findingacross the 8 closest cases · 8 carry coded findings · 8 have a probable causeFindings the Board cited in those cases
- 5 of 8Personnel issues › Task performance › Use of equip/infocited here too
- 3 of 8Environmental issues › Physical environment › Object/animal/substancecited here too
- 3 of 8Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- 2 of 8Personnel issues › Psychological › Perception/orientation/illusioncited here too
Occurrences it coded
- 6 of 8Loss of control in flight
- 3 of 8Birdstrike
- 3 of 8Collision with terr/obj (non-CFIT)
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Physical environment › Object/animal/substance
- Psychological › Perception/orientation/illusion
- Task performance › Use of equip/info
Cited here, not seen in the precedents
- Aircraft structures › Windows-windshield system
- Support/oversight/monitoring › Enforcement
Common in the precedents, not cited here
- Aircraft oper/perf/capability › Performance/control parameters
A teaching device, not a verdict: what the record would have looked at, next to what the Board found.
In the Board’s words — the closest cases
- CEN24FA0942024-01-21 · BELL 206 · AIR EVAC EMS INC
The helicopter’s inflight collision with cackling geese, resulting in an inflight breakup.
- CEN18FA0332017-11-20 · BELL HELICOPTER TEXTRON CANADA 407 · AIR METHODS CORP
An in-flight loss of control due to bird strikes.
- WPR23MA1132023-02-25 · PILATUS PC-12/45 · GUARDIAN FLIGHT LLC
The pilot’s loss of control due to spatial disorientation while operating in night instrument meteorological conditions, which resulted in an in-flight breakup. Contributing to the accident was the disengagement of the autopilot for undetermined reasons, as well as the operator’s insufficient flight risk assessment process and lack of organizational oversight.
- ERA11FA2742011-05-02 · BEECH E18S · AIRCAP MANAGEMENT CO INC
The pilot’s improper response to a loss of power in the No. 2 engine and his failure to ensure that the airplane was airworthy. Contributing to the accident was the inadequate engine maintenance by the operator's maintenance personnel.
- ENG11IA0512011-09-26 · BOEING 757-222 · UNITED AIRlNES INC
**This probable cause was modified on 4/5/2012. Please see the public docket for this accident to view the original probable cause.** The initial damage to the fan blades was caused by the ingestion of a Red-Tailed Hawk that caused one or more fan blades to fracture, striking the fan case and causing it to bulge. The initial fan blade fragment release impacted and damaged other passing fan blades generating various sized blades fragments. Some of these blade fragments were propelled forward of the fan case by…
What it recommended after them
- A-17-008TO THE FEDERAL AVIATION ADMINISTRATION: Require that existing Airbus Helicopters dual-hydraulic AS350-series helicopters be equipped with a visual and an aural alert for the loss of hydraulic boost to the pedal controls, which would result… · CEN15MA290Closed - Unacceptable Action
- A-17-009TO AIRBUS HELICOPTERS: For newly manufactured dual-hydraulic AS350-series helicopters, assess and implement changes to the dual hydraulic system that would both ensure pedal control hydraulic assistance and mitigate the possibility of pilot… · CEN15MA290Closed - Acceptable Action
- A-17-010TO AIRBUS HELICOPTERS: For existing dual-hydraulic AS350-series helicopters, assess and implement changes to the dual hydraulic system that would both ensure pedal control hydraulic assistance and mitigate the possibility of pilot error dur… · CEN15MA290Closed - Acceptable Action
- A-17-011TO THE FEDERAL AVIATION ADMINISTRATION AND THE EUROPEAN AVIATION SAFETY AGENCY: After the actions requested in Safety Recommendation A-17-10 are completed, require operators of Airbus Helicopters dual-hydraulic AS350-series helicopters to i… · CEN15MA290Open - Unacceptable Response
- A-17-012TO THE ASSOCIATION OF CRITICAL CARE TRANSPORT: In collaboration with the Association of Air Medical Services and the Air Medical Operators Association, establish a working group to develop and distribute guidelines, for those who purchase,… · CEN15MA290Open - Acceptable Response
- A-17-013TO THE ASSOCIATION OF AIR MEDICAL SERVICES AND AIR MEDICAL OPERATORS ASSOCIATION: Work with the Association of Critical Care Transport to establish a working group to develop and distribute guidelines, for those who purchase, lease, or cont… · CEN15MA290Open - Acceptable Response
This is the pattern in the NTSB’s own record across similar accidents — which findings it cited, what it coded, what it recommended. It is drawn from the record, not written about this case, and it never assigns blame: investigations exist to prevent the next accident (ICAO Annex 13).