SAN JOSE, CA, USA
N4995G
SIKORSKY S-58
THE PILOT WAS CONDUCTING AN EXTERNAL LOAD OPERATION ABOUT 1-1/2 MILES FROM THE DEPARTURE AIRPORT. AFTER FINISHING A LIFT, THE HELICOPTER WAS HOVERING AT ABOUT 100 FEET OVER A 13-STORY BUILDING. WITNESSES HEARD THE ENGINES SPOOL DOWN AND SAW THE ROTOR BLADES SLOWING. THE HELICOPTER DESCENDED ONTO A TWO-LEVEL PENTHOUSE ON THE BUILDING ROOF AND ROLLED ONTO ITS RIGHT SIDE. A PARKING LOT ADJACENT TO THE BUILDING HAD BEEN SELECTED BY THE COMPANY AS A LANDING AREA IN AN FAA-APPROVED LIFT PLAN, BUT OBSTRUCTIONS PREVENTED ITS USE. THE HELICOPTER, COMPRISED PRIMARILY OF MAGNESIUM, WAS CONSUMED BY A POSTCRASH FIRE. FUEL CONSUMPTION WAS ABOUT 11 POUNDS PER MINUTE. THE PILOT BEGAN THE FLIGHT WITH ABOUT 266 POUNDS OF FUEL; DURING THE 17 MINUTE FLIGHT, THE ENGINE WOULD HAVE CONSUMED ABOUT 190 POUNDS OF FUEL. UNUSABLE FUEL FOR THE HELICOPTER WAS 64 POUNDS. OPERATIONS AT MINIMAL FUEL REQUIRED FUEL TANK CROSSFEEDING.
History of the Flight On January 28, 1994, about 0737 hours Pacific standard time, a Sikorsky S58-JT, N4995G, crashed on a high-rise building during an external load operation at San Jose, California. The helicopter was being operated as a visual flight rules (VFR) local flight under Title 14 CFR Part 133 when the accident occurred. The helicopter, registered to and operated by Air One Helicopters Inc., San Jose, California, was destroyed by impact and postimpact fire. The certificated airline transport pilot, the sole occupant, received fatal injuries. Visual meteorological conditions prevailed. The flight originated at the San Jose International Airport about 0722 hours. The operator reported that the helicopter was being utilized to remove a large cooling tower fan from the top of a 13-floor building located in the business district of the city. The pilot contacted the ground controller at the San Jose Air Traffic Control Tower (ATCT) at 0720:18 hours and requested permission to taxi for takeoff. At 0722:05 hours, the aircraft was cleared for departure by the local controller and at 0724:08 hours, the pilot reported as "on station". The building is located about 1 1/2 miles southeast of the airport. A three-man ground crew from the helicopter operator and an air conditioning company were assigned to the operation. A helicopter company employee, a member of the ground crew, reported that the helicopter was originally going to land in the west parking lot of the building to attach a 100-foot Kevlar lifting cable to the belly of the aircraft; however, the landing area was restricted by numerous light poles. The crew member attached the cable to the helicopter while it was at a hover over the top of the building. The crew disassembled a portion of the cooling tower and the helicopter successfully removed a large fan to the ground level parking lot. The helicopter then deposited a 1,800-pound steam cleaning machine on the roof, adjacent to the tower. The crew on the building unhooked the machine from the lifting cable and was preparing to unhook the cable from the helicopter. As the helicopter was at a 100-foot hover above the building, the crew heard the engine sounds decrease and observed the main rotor blades begin to slow. The helicopter then descended vertically onto the top of a two-level central core penthouse building that housed elevator, boiler, and air-conditioning machinery. After contacting the penthouse roof, the helicopter began to roll onto its right side. The main rotor blades contacted the building parapet wall and separated near the inboard ends of the blades. A postcrash fire erupted and the crew attempted to fight the fire with hand extinguishers. The crew indicated that during the impact the vertical tail section of the fuselage separated. After the helicopter came to rest, the main rotor blade roots still attached to the mast were still turning and they could hear the engines still spooling down and then stop completely. The crew was not injured and no persons on the ground level were injured. At 0737:12 hours, a pilot reported the fire on the roof of the building to the San Jose ATCT. A Federal Aviation Administration (FAA) operations inspector, San Jose Flight Standards District Office (FSDO), was observing the lifting operation from the ground-level west parking lot to monitor the flight's compliance with a 14 CFR Part 133 external load plan. He reported that the helicopter was facing toward the west while hovering above the roof and heard the sound of the engine(s) spooling down. The helicopter nose pitched down about 5 degrees and descended vertically without any fuselage yaw. The main rotor blades began slowing down and the helicopter descended out of view. Portions of the main rotor blades fell away from the roof top into the parking lot. The inspector observed smoke and fire about 5 seconds after the crash. Numerous ground witnesses also reported hearing the engine sounds decrease and the main rotor blades slowing down. The initial fire started as a small flame near the cabin area that quickly spread, engulfing the helicopter. The witnesses reported seeing extremely bright sparks emanating from the fire. The accident occurred during the hours of daylight at attitude 37 degrees, 20.91 minutes north and longitude 121 degrees 54.08 minutes west. Other Damage The building received impact and fire damage to the penthouse building and exterior of the roof area. In addition, several upper floors of the building received water damage. Crew Information The pilot held an airline transport pilot certificate with a rotorcraft helicopter rating, and type ratings in Bell 206 and Sikorsky S58 aircraft. He held commercial pilot privileges with a single-engine land rating. In addition, the pilot held a flight instructor certificate with a rotorcraft helicopter rating. He also held a mechanics certificate with airframe and powerplant ratings. The most recent second-class medical certificate was issued to the pilot on August 19, 1993, and contained no limitations. No personal flight records were located for the pilot and the aeronautical experience listed on page 6 of this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City. In addition, information was obtained from a review of records maintained by the operator. According to the information entered on the pilot's application for medical certificate dated August 19, 1994, his total aeronautical experience consisted of 7,000 hours. The operator reported that the pilot had accrued 6,200 hours in helicopters and 1,500 hours in the accident aircraft make and model. In the preceding 90 and 30 days prior to the accident, the report lists a total of 43 and 19 hours, respectively, flown. The operator provided an undated letter from the San Jose FSDO indicating that the pilot was qualified as serve as pilot-in-command in external load operations. The chief pilot reported that the pilot received annual recurrent training, including a check ride, for 14 CFR Part 135 operations. The company does not conduct (nor is one required under Part 133) ground or flight training in external load operations. Since external loads are constantly being conducted, the accident pilot was routinely observed by ground personnel including the chief pilot. The ground crew indicated that no mission briefing was conducted prior to the accident flight. Aircraft Information The accident aircraft is equipped with twin Pratt and Whitney PT-6T engines that provide independent power to a combining gearbox. The gearbox drives a single output shaft connected to an angle gearbox, which provides power input to the main rotor transmission. The aircraft is certified as a single-engine helicopter. The recording hour meter in the aircraft was destroyed. Prior to departure on the accident flight, the aircraft maintenance log sheet indicated that the helicopter had accumulated a total time in service of 8,523.8 flight hours. The helicopter was utilized almost exclusively for external load operations and was maintained according to the manufacturers' inspection program. Examination of the maintenance records revealed that the most recent Phase III inspection was accomplished on August 8, 1993, 47.4 hours before the accident. The left engine had accrued a total time in service of 6,456 hours of operation. The maintenance records note that a major overhaul was accomplished on February 5, 1980, 2,927.5 hours of operation before the accident. The right engine had accrued a total time in service of 5,661.7 hours of operation. The engine was overhauled on September 10, 1984, 2,206.7 hours before the accident. The combining gearbox had accrued a total time in service of 5,747.6 hours of operation. The gearbox was overhauled on November 21, 1983, 2,778.1 hours before the accident. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the aircraft prior to departure. The aircraft fuel system consists of a forward and aft tank. The forward tank is partitioned into six cells. The aft tank consists of two interconnected tanks partitioned into three cells each. The left engine is supplied by the forward tank and the right engine from the aft. Each engine has an engine-driven fuel pump and an electrical boost pump. The fuel supply to each engine is controlled by an electrical shut-off valve. Both engines may receive fuel from either the forward or aft fuel tank by opening an electrically operated cross-feed valve. The aircraft is equipped with low fuel pressure and low fuel quantity caution annunciator lights, one for each engine. A low fuel quantity annunciator activates when 120 pounds, plus or minus 30 pounds, remain in their respective tank. The unusable fuel in the forward tank is 3.5 gallons and 6.0 gallons in the aft tank (a total of 63.7 pounds). The operator reported that on January 26, 1993, the accident aircraft returned from an external load flight. Upon landing, the chief pilot who conducted the flight reported that the fuel gauges indicated 200 pounds of total fuel with 100 pounds each in the forward and aft tanks. No fuel was added following the flight. On January 27, 1993, the pilot of the accident aircraft flew .2 hours on an external load flight. There was no indication on the company fuel log that any fuel was added before or after that flight. On January 28, 1993, the pilot added 30 gallons (201 pounds) of fuel before the accident flight. According to the operator, the helicopter normally operates with a basic fuel load of 200 pounds in each tank. The aircraft has an average fuel burn of 100 gallons (670 pounds) per hour. National Transportation Safety Board investigators calculated the fuel on board at the time of the accident. Using an average weight of 6.7 pounds per gallon, and a fuel burn of 670 pounds per hour, the aircraft would consume 11.2 pounds per minute. The historical events and calculations indicate: 01/26/94 - aircraft landed with 200 pounds of fuel. 01/27/94 - pilot flew .2 hours, consuming 134.4 pounds of fuel. Fuel remaining would be 65.6 pounds. 01/28/94 - pilot added 201 pounds of fuel for a total of 266.6 pounds. An estimated 17 minutes of flight would consume 190.4 pounds of fuel for a total fuel remaining of 76.2 pounds. The main rotor blades are constructed of 23, 11 1/2-inch by 10 1/2-inch-deep metal segments (pockets). These pockets are bonded to the blade spar and form the trailing edge of the blade. Meteorological Information The closest official weather observation station is San Jose, California, which is located about 1 1/2-nautical miles northwest of the accident site. At 0745 hours, a surface observation was reporting in part: Sky condition and ceiling, clear; visibility, 35 miles; temperature, 37 degrees F; dew point, 32 degrees F; wind, calm; altimeter, 30.09 inHg. Communications Review of the air-ground radio communications tapes maintained by the FAA at the San Jose ATCT facility revealed that the aircraft successively and successfully communicated with the positions of ground and local control. No unusual communications were noted between the ATCT facility and the accident aircraft during the review of the tapes. A transcript of the air-to-ground communications between the aircraft and the ATCT facility is included in this report. The company crew working on the building was in radio communication with the pilot during the external load operation. A crew member reported that just prior to the engine sounds decreasing, he heard the pilot state on the company radio, "Oh, (expletive deleted)". Wreckage and Impact Information Safety Board investigators examined the helicopter wreckage at the accident site beginning on January 28, 1994, on the building roof at 675 N. 1st Street. The building roof area has three raised penthouse buildings that house various machinery. A vertical cement parapet about 14 feet high surrounds the entire building roof area along the building's outer edges. The central core penthouse is 34 feet long by 32 feet wide and has a two- level flat roof. The lower level is 15 feet wide and 14 feet high and houses a boiler and an air conditioning chiller. The upper level is 17 feet wide and 19 feet high and houses the elevator shaft and machinery. Several antennas were installed around the upper roof edge and were braced by wire strands. A large air conditioning cooling tower is located between the center and east penthouse. A sheet metal vent assembly on the upper roof area was crushed in a downward and westward direction. The vent housing displayed numerous parallel yellow/green paint transfer marks on the upper surface of the vent. The penthouse upper level roof exhibited about an 18 inch oval- shaped depression located at the northwest corner of the upper level. The vertical cement edge of the upper roof was broken and scuffed adjacent to the roof depression. The helicopter's left main landing gear, strut, and landing light assembly separated from the fuselage and was located below the center penthouse roof, between the center and west penthouse. The helicopter rolled to the right and impacted the lower roof of the penthouse building, coming to rest on its right side. Scuff marks, black paint marks, and areas of broken concrete were noted on the south face of the building's north parapet wall. Portions of the blades were located on the roof, on the ground to the east of the building, and in the parking lot to the west of the building. The external Kevlar cable was found draped from the air conditioning unit over the top of the center penthouse building and down to the wreckage. The main rotor transmission assembly with the rotor mast, blade roots, and supports, separated from the fuselage and was located upside down on the building roof next to the north edge of the center penthouse. The transmission assembly received fire damage as did the penthouse north wall and main building roof. The lower penthouse roof, onto which the fuselage came to rest, was fire damaged. The helicopter's fuselage, from just aft of the engines to just forward of the tail wheel, was consumed by fire. The vertical tail of the fuselage with the tail rotor assembly attached, separated from the fuselage. It was positioned vertically along the north edge of the center penthouse wall with the tail rotor blades resting on the main building roof. The tail wheel was hooked on the top edge of the penthouse roof. The tail rotor blades remained attached to the gearbox and were not damaged. Drive shaft continuity from the point of separation forward of the intermediate gearbox to the tail rotor blades was established. Due to the impact and postimpact fire damage, Safety Board investigators were unable to operate the flight controls by their respective control mechanisms. The collective assembly was found separated from the wreckage, lying over the north wall of the center penthouse. Examination of the left and right collective levers and dual throttle grips revealed that the throttle stop pins were positioned in the full open position. The collective mounted switches normally housed at the forward end of the collective levers were destroyed by fire on the pilot's collective (right side). The postcrash fire incinerated the cabin and cockpit area. Safety Board investigators, however, recovered several extremely damaged instruments. The position of the instrument needles were compared to those of a sister aircraft. The main rotor transmission oil pressure gauge indicated 150 PSI. One needle of the dual hydraulic pressure gauge indicated about 500 PSI and a second needle indicated about 3,000 PSI. The dual needles on the engine torque gauge both indicated about zero. One fuel pressure gauge was recovered and the needle indicated about 15 PSI. The main rotor yellow blade separated about 2 1/2 feet outboard from the root. It fragmented into two additional segments. A black, tar-like material was present on the leading edge at the tip and also on the leading edge at the mi
THE PILOT'S INADEQUATE PREFLIGHT PLANNING/PREPARATION AND SUBSEQUENT FUEL STARVATION, DUE TO AN INADEQUATE SUPPLY OF FUEL. A FACTOR RELATED TO THE ACCIDENT WAS: THE PROXIMITY OF HIGH OBSTRUCTIONS.
Source: NTSB Aviation Accident Database
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