GENOA, NV, USA
N58352
HUGHES 369D
THE FAA OPERATIONS INSPECTOR WAS OBTAINING FLIGHT TIME FOR RECURRENCY WHILE ADMINISTERING A PROFICIENCY CHECK TO THE PILOT/OPERATOR (PLT). BEFORE FLIGHT, THE INSPECTOR GAVE AN ORAL EXAM TO THE PLT. WHILE PREPARING FOR FLIGHT, THE PLT TOLD THE INSPECTOR THAT THE THROTTLE ON THE RIGHT COLLECTIVE WAS INOPERATIVE (DISCONNECTED), BUT THE INSPECTOR DID NOT ASSIMILATE THIS INFORMATION. ALSO, DURING THE PREFLIGHT INSPECTION, THE INSPECTOR (IN THE LEFT SEAT) DID NOT CHECK THROTTLE CONTINUITY TO THE RIGHT COLLECTIVE CONTROL. DURING THE FIRST PART OF THE FLIGHT, THE INSPECTOR FLEW THE HELICOPTER MOST OF THE TIME. HE THEN PROCEEDED TO HAVE THE PLT PERFORM SPECIFIC MANEUVERS TO SATISFY THE REQUIREMENTS OF A PROFICIENCY CHECK. WHILE RETURNING TO THE AIRPORT, THE INSPECTOR REDUCED HIS THROTTLE TO FLIGHT IDLE TO SIMULATE AN ENGINE FAILURE; HE THEN TRANSFERRED THE CONTROLS TO THE PLT & TOLD HIM TO PERFORM AN AUTOROTATION. THE PLT DID NOT REALIZE THAT THE INSPECTOR HAD REDUCED POWER TO FLIGHT IDLE WITH THE OPERABLE (LEFT) THROTTLE UNTIL HE RAISED THE RIGHT COLLECTIVE IN AN ATTEMPT TO FLY OUT OF THE AUTOROTATION NEAR THE GROUND. SUBSEQUENTLY, THE HELICOPTER SUSTAINED A HARD LANDING. AN INVESTIGATION DISCLOSED THAT THE PILOT/OPERATOR HAD THE RIGHT COLLECTIVE THROTTLE LINKAGE DISCONNECTED ABOUT 2 YEARS BEFORE THE FLIGHT.
History of the Flight On September 22, 1994, at 1145 hours Pacific daylight time, a Hughes (McDonnell Douglas) 369D helicopter, N58352, collided with the terrain at Genoa, Nevada. The pilots were conducting a local area visual flight rules pilot recurrency check and a Title 14 CFR 135.293 pilot proficiency flight check. The helicopter, operated by Skydance Helicopters, Inc., El Cajon, California, sustained substantial damage. The certificated commercial pilot (first pilot) and the certificated airline transport pilot, a Federal Aviation Administration (FAA) operations inspector, sustained minor injuries. Visual meteorological conditions prevailed. The flight originated at Douglas County Airport, Minden, Nevada, at 1000 hours. National Transportation Safety Board investigators interviewed the FAA inspector (herein called the examining inspector) at the Reno Flight Standards District Office on September 26, 1994. In addition, the examining inspector provided the Safety Board with a written statement. Safety Board investigators also conducted two other telephone interviews on September 22 and September 23, 1994, respectively. The examining inspector said that the accident flight was a dual purpose flight. Initially he was going to become recurrent in the accident helicopter make and model; he had not flown one in over a year. Secondly, he was going to provide the pilot with a Title 14 CFR Part 135.293 pilot proficiency check as required by the regulations. The examining inspector arrived at the operator's facility at 0900 hours. The pilot/operator (the pilot) then provided the examining inspector with some changes in the helicopter operations and ground checks. The inspector continued the preflight inspection and also asked the pilot some questions to satisfy the oral portion of the pilot's pilot proficiency check. During the preflight inspection, the inspector did not check the right seat flight controls, including the throttle continuity. (The flight manual does not specifically require this action.) The inspector and operator discussed in depth the starting procedure while the examining inspector was in the left front seat; the seat normally used by the flying pilot. The examining inspector helped the pilot in removing the helicopter from the hangar. The inspector sat in the left seat when the helicopter was on the ramp. The pilot operator stood to the left of the inspector during the start. The inspector thought that the pilot was doing fire guard duties. After the inspector initiated the engine start, the pilot returned to the helicopter and occupied the right front seat. The examining inspector did a hovering maneuver and made some pedal turns to assure that the helicopter was operating normally before he departed on the accident flight. The flight departed the airport and flew to a lower mountain range east of the airport. He also did several maneuvers including a power off autorotation to a power on recovery. While in this area, the examining inspector asked the pilot to do some maneuvers to satisfy the pilot's required items under the 14 CFR 135.293; the inspector reasoned that by having the pilot do these maneuvers, the flight would not have to return to the area. The maneuvers included a pinnacle approach, a confined area approach, and a slope landing. The pilot satisfactorily executed these maneuvers. The examining inspector reassumed the controls and flew to a higher mountainous area about 4 miles west of the airport and about 1 mile east of the accident site. Upon arrival over the mountainous area, the inspector did several maneuvers including those he asked the pilot to do. During this time, the pilot also demonstrated a few slope landing techniques. Afterwards, the examining inspector flew toward the airport. After passing over the mountainous area, the examining inspector reduced the power and asked the pilot to do a power off autorotation to a designated landing area. The pilot entered the autorotation and began to fly toward the designated landing area. The examining inspector said the pilot's technique during the autorotation flight pattern was "textbook"; the pilot's airspeed control and glide path were perfect. During the final approach, about 300 feet above the ground, the examining inspector said he saw the N2 (the turbine power indicator) and the main rotor rpm needles come together. When the helicopter approached the landing area, the examining inspector did not feel any heavy collective movement; he did feel some cyclic movement. The helicopter then sustained a hard landing. On touchdown, the helicopter began to violently "rock back and forth." The main rotor blades severed the tailboom assembly and the engine continued to run. When the helicopter was rocking back and forth, the examining inspector attempted to reach for the fuel control shut off valve located on the lower section of the instrument panel, but was unable to do so. He shut off the engine by placing the left collective throttle to the cut-off position. Before exiting the helicopter, the examining inspector reported that he observed the right collective on the floor and either one or two of the pedals lying on the front of the helicopter. After both pilots exited the helicopter, the inspector saw the pilot place the collective and one or two of the pedals on the right front seat. Safety Board investigators interviewed the pilot/operator on September 26, 1994, at his maintenance facility, Douglas County Airport. The pilot said that his son prearranged the accident flight. He concurred the scheduled flight was a dual purpose flight as stated by the examining inspector. He said that the examining inspector arrived at his facility at 0930 hours. He then observed the examining inspector preflight the helicopter. During the preflight inspection, he informed the examining inspector of certain changes in the helicopter. He told Safety Board investigators that he considered the initial flight was a dual instructional flight to help the examining inspector in becoming current in the helicopter make and model. The pilot also confirmed the examining inspector's statement that he explained the start procedure in depth. He said after he and the examining inspector moved the helicopter out of the hangar he stood by the examining inspector while he started the engine. He said this was the only time he told the examining inspector that the right seat throttle was inoperative; he did not go into a detailed explanation. He stood at the door next to the examining inspector during the start so he could shut off the engine in case of a hot start. The pilot concurred with the examining inspector's statement regarding the route of the flight. He said, however, that the examining inspector did all of the flying except during the accident rotation. He concurred that the examining inspector told him to do a simulated emergency landing (autorotation) to a designated area. The pilot said that he always does autorotations with full power and that he normally "flys out at the bottom of the autorotation." He said that he was not aware that the examining inspector had retarded the throttle to idle before he began the autorotation. Both he and the examining inspector were talking via the "hot mike" during the maneuver. When the helicopter was between 8 and 10 feet above the ground, he applied up collective. During the collective application, the pilot realized that engine power was not available and then knew a hard landing was imminent. He said that after the accident, his foot was jammed between the antitorque pedals. He removed the pedals to release his foot, but he did not recall removing the collective. He said he could have, but did not have a clear recollection of doing so. The pilot also said that the examining inspector emphasized that he was the pilot-in-command (PIC), but that if a real emergency existed the pilot would assume control of the helicopter. The examining inspector said that whoever was flying the helicopter was the PIC. He did say that if a real emergency occurred he would have transferred control to the pilot because of his, the examining inspector's, lack of familiarity of the helicopter. Crew Information First Pilot (Pilot/Operator) The pilot held a commercial pilot certificate with a rotorcraft - helicopter rating. He also held a second- class medical certificate with a "Must have available glasses for near vision" endorsement. The pilot provided the Safety Board with the flight hours reflected on page 3 from memory. He did not have his flight hours logbook in his possession. The pilot said that he had accrued more than 15,000 flight hours of which more than 6,000 hours were flown in the accident helicopter make and model. The pilot satisfactorily completed the last Title 14 CFR 135.293 pilot proficiency check flight administered by an FAA inspector on August 1, 1993. The proficiency flight check was flown in the accident helicopter make and model. Second Pilot (FAA Examining Inspector) The examining inspector holds an airline transport pilot certificate with airplane single-engine land, multiengine land, rotorcraft - helicopter, instrument - airplane and helicopter, and DC-9, B-727, CE-650, BH-204, and DH-206 type ratings. He also holds a flight instructor certificate with airplane single-engine, airplane multiengine, rotorcraft - helicopter, and instrument - airplane and helicopter ratings. The flight hours reflected on Supplement E of this report were provided by the pilot in the Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2. Safety Board investigators did not review the inspector's flight hours logbook. The inspector also showed that he had satisfactorily completed a biennial flight review (BFR) on July 14, 1994; the BFR was flown in a DC-9-80. The examining inspector accrued a total time of 5,300 flight hours of which 1,100 flight hours were flown in a helicopter. The inspector had accrued 10 flight hours in the accident helicopter make and model. The inspector told Safety Board investigators that he had not flown the accident helicopter make and model within the year preceding the accident. Within 90 days preceding the accident, excluding the accident flight, the inspector had not flown any helicopter. Aircraft Information Safety Board investigators examined the accident helicopter's maintenance logbooks. The examination revealed that Skydance Helicopter's maintenance personnel conducted most of the maintenance. The company's mechanic completed the last 100/200-hour inspection on September 9, 1994; the helicopter accrued 9,415.7 hours at the time of the inspection. At the time of the accident, the helicopter accrued 9,436.5 flight hours - 20.8 hours since the inspection. The maintenance records examination also revealed that the removal of the right collective throttle linkage (gas producer torque tube) was not shown. The mechanic told Safety Board investigators that he was employed by the company for 6 months. During that time, he had not removed or replaced the right collective or its throttle linkage. He was, however, aware that the right collective throttle linkage had been removed. He was not aware of any manufacturer or FAA documents that approved the installation of the right collective with its throttle linkage removed. The manufacturer's representative reported that the removal of the throttle linkage is not an approved procedure. The manufacturer's representative provided excerpts from the manufacturer's MDHS Maintenance Manual, which included page 4, section 05-20-10, the 100-hour inspection requirements. The page states, in part: Pilot's and copilot's throttle rigging checks at FULL, GROUND IDLE and CUTOFF positions. The pilot/operator told Safety Board investigators that he ordered his mechanic to remove the right throttle linkage within 2 years preceding the accident. He said that during another proficiency flight test, an FAA inspector (not the inspector involved in this accident) occupying the right seat had inadvertently turned off the engine during a simulated emergency landing. The helicopter sustained substantial damage during the resulting autorotation. The accident helicopter's flight manual approved checklist does not address checking the correlation of the collective throttle linkage movement between the left and right throttle if the right collective is installed. It does address full travel movement of the "Cyclic, collective, and pedal controls." Safety Board investigators computed the helicopter's weight and balance at takeoff and at the accident. The calculated data showed the helicopter was within the manufacturer's specifications. The data also shows that the in-ground-effect (IGE) and the out-of-ground-effect (OGE) gross weights were less than the maximum limits. Wreckage and Impact Information The Safety Board allowed the operator to remove the wreckage to his maintenance facility at Douglas County Airport. Another FAA inspector from the Reno Flight Standards District Office conducted the on-scene investigation before it was removed. The inspector reported that the elevation of the crash site is 4,440 feet mean sea level. He said the area surrounding the crash site is level terrain. The helicopter came to rest right-side-up on a heading of 138 degrees (magnetic), and there were no skid marks. The inspector found all of the helicopter's external components and flight controls near the main impact area. The inspector found one main rotor blade about 12 feet east/southeast from the cockpit/cabin area. This blade exhibited extensive twisting and impact damage. The remaining blades remained connected to the main rotor assembly; two of the blades showed minor leading edge score marks and the third blade exhibited substantial impact damage. The tailboom assembly and drive shaft separated about 3 feet aft of its attach point. The fractured area exhibited a main rotor blade impact signature. The inspector found the tailboom lying next to the separated area; the tail rotor and gear box assembly were lying 75 feet forward of the cabin/cockpit area. The outboard tips of the tail rotor blades separated; one tip end was found about 75 feet southwest of the main wreckage. Safety Board investigators examined the wreckage at the operator's maintenance facility on September 26, 1994. The operator removed the main rotor blades during the recovery operation. The investigators established continuity of the flight controls to their respective operational mechanisms. Continuity of the left throttle linkage to the fuel control was established and its rigging was found within the manufacturer's specifications. As previously stated, the operator removed the right throttle linkage (gas producer control tube). Safety Board investigators found the landing skids intact. There was no evidence of any structural damage at the skid attach points. Medical and Pathological Information Both occupants received minor injuries. Paramedics transported the pilot/operator to a trauma center in Reno, Nevada, and was released later that day; the FAA examining inspector was treated and released from a local hospital. Toxicology examinations of the occupants were not performed nor were they requested. Additional Information The Safety Board did not retain custody of the wreckage or any of its components.
THE PILOT/OPERATOR'S OPERATION OF THE HELICOPTER WITH A DISCONNECTED THROTTLE ON THE RIGHT COLLECTIVE; THE FAA INSPECTOR'S INADEQUATE PREFLIGHT/PRETAKEOFF CHECKS OF THE FLIGHT CONTROL/THROTTLE SYSTEMS; AND THE PILOT/OPERATOR'S FAILURE TO ADEQUATELY INFORM THE INSPECTOR OF THE DISCONNECTED RIGHT THROTTLE, WHICH RESULTED IN AN INADEQUATE POWER RECOVERY FROM AN INSPECTOR INITIATED AUTOROTATION.
Source: NTSB Aviation Accident Database
Aviation Accidents App
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