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Cases › CEN15FA003 · Part 135 fatal

BELL HELICOPTER TEXTRON 206L 1AIR EVAC EMS INC

Wichita Falls, TX, USA · 2014-10-04·N335AE

3
fatal
1
serious
Fatal
highest injury
Destroyed
damage

What happened

NTSB summary, verbatim

The pilot reported that he was making an approach to a hospital helipad into light wind at night when he chose to go around because he felt that the approach was too high and fast. The pilot lowered the helicopter's nose, added power, and raised the collective, and the helicopter then entered a rapid, "violent" right spin. A review of the last 43 seconds of the helicopter's flight track data revealed that, as the helicopter approached the helipad, it descended from 202 to 152 ft and decelerated from a ground speed of about 9 to 5 knots before it turned right. The pilot attempted to recover from the uncommanded spin by applying left antitorque pedal and cyclic, but he was unable to recover, and the helicopter then spun several times before impacting power lines/terrain. Postaccident examination of the helicopter and the engine revealed no mechanical anomalies that would have caused the helicopter's uncommanded right spin. The helicopter was under its maximum allowable gross weight at the time of the accident, and the wind was less than 4 knots. Federal Aviation Administration guidance states that the loss of tail rotor effectiveness could result in an uncommanded rapid yaw, which, if not corrected, could result in the loss of aircraft control. The guidance further indicates that, at airspeeds below translational lift, the tail rotor is required to produce nearly 100 percent of the directional control and that, if the required amount of tail rotor thrust is not available, the aircraft will yaw right. Therefore, it is likely that that the pilot did not adequately account for the helicopter's low airspeed when he applied power to go around, which resulted in a sudden, uncommanded right yaw due to a loss of tail rotor effectiveness.

Photographs

4the aircraft, and what the investigators found
Wreckage and site documentation · 4 photographs from the docket

Photographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.

Probable cause

the Board's determination
The pilot’s failure to maintain yaw control when he applied power to execute a go-around at a low airspeed in dark, night conditions, which resulted in a rapid, uncommanded right yaw due to a loss of tail rotor effectiveness.

Occurrence sequence

3 stepsNTSB coding · CICTT taxonomy
  1. 1 · Approach-VFR go-around
    Loss of tail rotor effectiveness
  2. 2 · Approach-VFR go-around
    Loss of control in flight
    defining event
  3. 3 · Uncontrolled descent
    Collision with terr/obj (non-CFIT)

Findings

3 causal · 1 contributing
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Aircraft control — Pilot
  • CAUSE
    Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Yaw control — Not attained/maintained
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Light condition › Dark — Effect on personnel
  • FACTOR
    Aircraft › Aircraft systems › Fuel system › Fuel storage — Design

Safety recommendations

1 issuedwhat changed because of this accident
  • A-15-012Closed - Acceptable Alternate ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require, for all newly manufactured rotorcraft regardless of the design’s original certification date, that the fuel systems meet the crashworthiness requirements of 14 Code of Federal Regulations 27.952 or 29.952, “Fuel System Crash Resistance.”

NTSB analysis

from the final report

The pilot reported that he was making an approach to a hospital helipad into light wind at night when he chose to go around because he felt that the approach was too high and fast. The pilot lowered the helicopter's nose, added power, and raised the collective, and the helicopter then entered a rapid, "violent" right spin. A review of the last 43 seconds of the helicopter's flight track data revealed that, as the helicopter approached the helipad, it descended from 202 to 152 ft and decelerated from a ground speed of about 9 to 5 knots before it turned right. The pilot attempted to recover from the uncommanded spin by applying left antitorque pedal and cyclic, but he was unable to recover, and the helicopter then spun several times before impacting power lines/terrain. Postaccident examination of the helicopter and the engine revealed no mechanical anomalies that would have caused the helicopter's uncommanded right spin. The helicopter was under its maximum allowable gross weight at the time of the accident, and the wind was less than 4 knots. Federal Aviation Administration guidance states that the loss of tail rotor effectiveness could result in an uncommanded rapid yaw, which, if not corrected, could result in the loss of aircraft control. The guidance further indicates that, at airspeeds below translational lift, the tail rotor is required to produce nearly 100 percent of the directional control and that, if the required amount of tail rotor thrust is not available, the aircraft will yaw right. Therefore, it is likely that that the pilot did not adequately account for the helicopter's low airspeed when he applied power to go around, which resulted in a sudden, uncommanded right yaw due to a loss of tail rotor effectiveness.