AMERICAN EUROCOPTER CORP AS350B2LIBERTY HELICOPTERS INC
New York, NY, USA · 2018-03-11·N350LH
What happened
NTSB summary, verbatimThe Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-19/04. On March 11, 2018, about 1908 eastern daylight time, an Airbus Helicopters AS350 B2, N350LH, lost engine power during cruise flight, and the pilot performed an autorotative descent and ditching on the East River in New York, New York. The pilot sustained minor injuries, the five passengers drowned, and the helicopter was substantially damaged. The FlyNYON-branded flight was operated by Liberty Helicopters Inc. (Liberty), per a contractual agreement with NYONair; both companies considered the flight to be an aerial photography flight operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. (During this accident investigation, the Federal Aviation Administration determined that Liberty operated the flight as a nonstop commercial air tour under 14 CFR Part 91.) Visual flight rules weather conditions prevailed, and no flight plan was filed for the intended 30-minute local flight, which departed from Helo Kearny Heliport, Kearny, New Jersey, about 1850.
Photographs
6the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationLiberty Helicopters Inc.'s use of a NYONair-provided passenger harness/tether system, which caught on and activated the floor-mounted engine fuel shutoff lever and resulted in the in-flight loss of engine power and the subsequent ditching. Contributing to this accident were (1) Liberty's and NYONair's deficient safety management, which did not adequately mitigate foreseeable risks associated with the harness/tether system interfering with the floor-mounted controls and hindering passenger egress; (2) Liberty allowing NYONair to influence the operational control of Liberty's FlyNYON flights; and (3) the Federal Aviation Administration's inadequate oversight of Title 14 Code of Federal Regulations Part 91 revenue passenger-carrying operations. Contributing to the severity of the accident were (1) the rapid capsizing of the helicopter due to partial inflation of the emergency flotation system and (2) Liberty and NYONair's use of the harness/tether system that hindered passenger egress.
Occurrence sequence
8 stepsNTSB coding · CICTT taxonomy- 1 · Prior to flightMiscellaneous/otherdefining event
- 2 · ManeuveringFuel starvation
- 3 · ManeuveringLoss of engine power (total)
- 4 · Emergency descentAttempted remediation/recovery
- 5 · Emergency descentOff-field or emergency landing
- 6 · LandingRoll over
- 7 · After landingEvacuation
- 8 · After landingMiscellaneous/other
Findings
13 causal · 0 contributing- CAUSEAircraft › Aircraft systems › Equipment/furnishings › Flight compartment equipment — Design
- CAUSEAircraft › Aircraft systems › Fuel system › Fuel selector/shutoff valve — Unintentional use/operation
- CAUSEAircraft › Aircraft power plant › Engine (turbine/turboprop) — Inoperative
- CAUSEOrganizational issues › Management › Culture › Safety — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Adherence to safety program — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — Operator
- CAUSEOrganizational issues › Management › Culture › Safety — Other institution/organization
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Availability of safety program — Other institution/organization
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Enforcement › Regulatory requirements — FAA/Regulator
- CAUSEOrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — FAA/Regulator
- CAUSEAircraft › Aircraft systems › Landing gear system › Emergency floatation section — Design
- CAUSEAircraft › Aircraft systems › Equipment/furnishings › Passenger compartment equip — Unnecessary use/operation
Safety recommendations
17 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Prohibit all open-door commercial passenger-carrying aircraft flights that use passenger harness systems, unless the harness system allows passengers to rapidly release the harness with minimal difficulty and without having to cut or forcefully remove the harness. (Urgent)
TO THE FEDERAL AVIATION ADMINISTRATION: Modify the supplemental passenger restraint system (SPRS) approval process to (1) require letter of authorization (LOA) applicants to specify a need for and the intended use of an SPRS for each aircraft; (2) require the Federal Aviation Administration to evaluate and review, for each specified aircraft, the need for the SPRS on that aircraft for all intended uses; all SPRS design, manufacture, installation, and operational considerations, including, at a minimum, the potential for passengers to become entangled during emergency egress; the adequacy of passenger emergency egress briefings; and the potential for the SPRS to interfere with aircraft controls; and (3) ensure that each LOA lists the specific aircraft on which the holder is authorized to use an SPRS.
TO THE FEDERAL AVIATION ADMINISTRATION: Until you implement the supplemental passenger restraint system (SPRS) approval process as recommended in Safety Recommendation A-19-24, prohibit the use of SPRS for passenger-carrying doors-off operations.
TO THE FEDERAL AVIATION ADMINISTRATION: Review the activation system designs of Federal Aviation Administration-approved rotorcraft emergency flotation systems for deficiencies that may preclude their proper deployment, such as a lack of a means to identify high pull forces on manual activation handles or inadequate guidance on the intended use of the activation system, and require corrective actions based on the review findings.
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Miscellaneous Guidance 10 in Advisory Circular (AC) 27 and AC 29 to include design objectives for emergency flotation systems that consider human factors design objectives, such as activation handle pull-force characteristics; provisions for clear, unambiguous, and positive feedback to pilots to indicate that the float system was successfully deployed; and inspections to ensure that an installation of a manual activation system does not preclude a pilot’s ability to deploy the floats, as designed, after it has been fielded.
TO THE FEDERAL AVIATION ADMINISTRATION: Require all commercial air tour operators, regardless of their operating rule, to implement a safety management system.
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Title 14 Code of Federal Regulations 1.1, “General Definitions,” to include definitions for the terms “aerial work” and “aerial photography” that specify only business-like, work-related aerial operations, as originally intended.
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Order 8900.1, Flight Standards Information Management System, to include guidance for inspectors who oversee Title 14 Code of Federal Regulations (CFR) Part 91 operations conducted under any of the 14 CFR 119.1(e) exceptions to identify potential hazards and ensure that operators are appropriately managing the associated risks.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop and implement national standards within Title 14 Code of Federal Regulations (CFR) Part 135, or equivalent regulations, for all air tour operations with powered airplanes and rotorcraft to bring them under one set of standards with operations specifications, and eliminate the exception currently contained in 14 CFR 135.1.
TO AIRBUS HELICOPTERS: Modify the floor-mounted fuel shutoff lever in AS350-series helicopters to protect it from inadvertent activation due to external influences.
TO THE FEDERAL AVIATION ADMINISTRATION: After the actions requested in Safety Recommendation A-19-32 are completed, require owners and operators of existing AS350-series helicopters to incorporate the changes.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop guidance on how to identify intoxicated or impaired passengers, and distribute it to operators who carry passengers for hire under Title 14 Code of Federal Regulations Part 91 and Part 135.
TO THE EUROPEAN UNION AVIATION SAFETY AGENCY: After the actions requested in Safety Recommendation A-19-32 are completed, require owners and operators of existing AS350-series helicopters to incorporate the changes.
TO LIBERTY HELICOPTERS, INC: Establish a safety management system.
TO LIBERTY HELICOPTERS, INC.: Train your employees to identify signs of impairment and intoxication in passengers and to deny those passengers boarding, when appropriate.
TO NYONAIR: Establish a safety management system.
TO NYONAIR: Train your employees to identify signs of impairment and intoxication in passengers and to deny those passengers boarding, when appropriate.
NTSB analysis
from the final reportThe Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-19/04. On March 11, 2018, about 1908 eastern daylight time, an Airbus Helicopters AS350 B2, N350LH, lost engine power during cruise flight, and the pilot performed an autorotative descent and ditching on the East River in New York, New York. The pilot sustained minor injuries, the five passengers drowned, and the helicopter was substantially damaged. The FlyNYON-branded flight was operated by Liberty Helicopters Inc. (Liberty), per a contractual agreement with NYONair; both companies considered the flight to be an aerial photography flight operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. (During this accident investigation, the Federal Aviation Administration determined that Liberty operated the flight as a nonstop commercial air tour under 14 CFR Part 91.) Visual flight rules weather conditions prevailed, and no flight plan was filed for the intended 30-minute local flight, which departed from Helo Kearny Heliport, Kearny, New Jersey, about 1850.