QUANTICO, VA, USA
N82628
Bell 412
The FBI helicopter completed two circuits around a training road course at low altitude in pursuit of an automobile. The supervisor of the road course arranged the scenario with the pilot, and an instructor drove the automobile. A second vehicle that followed the pursuit filmed the flight. During the second lap, the vehicle reversed direction as it performed a sudden stop. The helicopter performed a deceleration and the tail skid, tailrotor, and tailboom struck the ground. A request for copies of procedural, operational, maintenance, and safety related programs and documents revealed that they either did not exist, or they were in draft form and unapproved for use. The flight was neither trained for, nor was it briefed. The pilots received training from the helicopter manufacturer, but no agency mission training or evaluations were noted in the accident helicopter. The FBI convened an Aviation Accident Review Board (AARB). According to the Board, '... [Unit] pilots worked under the 'fly one helicopter, fly all helicopter' assumption. AARB members unanimously agreed that no management oversight of [unit] operations currently exists.'
HISTORY OF FLIGHT On March 12, 1998, at 1730 eastern standard time, a Bell 412 helicopter, N82628, operated by the Federal Bureau of Investigation (FBI), was substantially damaged when the tail rotor struck the ground while landing at the FBI Training Academy, Quantico, Virginia. The certificated commercial pilots and one passenger were not injured. Visual meteorological conditions prevailed for the public use flight that originated at the FBI Academy Helipad, at 1715. No flight plan was filed for the flight conducted under 14 CFR Part 91. The pilot in the right seat was at the flight controls. The purpose of the flight was to complete "...a brief training evolution..." at the Tactical Emergency Vehicle Operations Course (TEVOC). During the event the helicopter was to follow a vehicle around the TEVOC, until the vehicle performed a "J-Turn" stop. The helicopter would then land and de-plane a passenger. In a written statement, the pilot said: "The helicopter was being utilized to trail a vehicle around the training track at the academy. The vehicle was being driven by a driving instructor and the entire sequence of events had been briefed. As the vehicle reached the point where a 'J' turn was to be accomplished, the driver signaled, and executed the turn...Due to the fact that the turn was on concrete it was completed in a shorter distance that I expected and I initiated a rapid deceleration to arrest the forward speed and bring the helicopter to a hover...The fact that the initial approach was downwind was discussed and taken into account." According to an Interview Summary provided by the FBI, the second pilot stated he was in the left seat and believed the mission had been authorized and coordinated. According to the summary: "[The second pilot] was seated on the left side of the aircraft, and that he again understood [the first pilot] to be the Aircraft Commander. They flew straight to the TEVOC course, [the first pilot] was flying the aircraft. [The second pilot] stated that he still had no concept of what exactly they were going to do, he was aware they were going to follow a car around the track. He advised that he has never followed a car around the TEVOC track in the past, nor is he aware of any training in the past that involved similar activity. [The second pilot] stated that after arriving at the TEVOC course, they flew approximately 10 to 20 feet above the track while following a TEVOC type car around the track. After completing a full lap, [the first pilot] completed a rapid or abrupt deceleration, during which [the second pilot] felt the tail stinger and possibly the boom contact the ground...[The second pilot] stated the abrupt deceleration performed by [the first pilot] surprised him given they were downwind, on an uphill grade, and they were down low. He stated that he did not know what precipitated [the first pilot's] decision to abruptly decelerate." The pursuit of the vehicle by the helicopter was captured on videotape. A review of the videotape revealed the helicopter completed approximately two left-hand circuits around the TEVOC in pursuit of the vehicle. The helicopter was flown over the pavement between and below the trees bordering each side of the roadway. The helicopter was observed to bank at angles greater than 30 degrees, with the main rotor tips in close proximity to the ground. During the second lap, the vehicle reversed direction as it performed the J-Turn stop. The helicopter performed a deceleration, and the tailrotor separated from the helicopter after the tail skid, tailrotor, and tailboom struck the ground. The helicopter then leveled at a hover and began a spin to the right. The helicopter landed in an upright position while still in a right-hand turn. According to the pilot, he closed the throttles and performed a hovering autorotation when a left pedal input did not stop the spin. The accident occurred during the hours of daylight approximately 42 degrees, 28 minutes north latitude, and 76 degrees, 8 minutes west longitude. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for airplane single engine land, multi-engine land, rotorcraft helicopter, and instrument airplane and helicopter. He held a flight instructor certificate with ratings for rotorcraft helicopter and instrument helicopter. The pilot's most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued on February 9, 1998. The pilot reported 5,031 hours of total flight experience, of which 3,555 hours were in helicopters. The pilot completed the Bell 412 Pilot Ground and Flight Procedures Training Course July 1, 1996, and reported 70 hours experience in make and model since that time. The FBI utilized a Bureau Aviation Operations (BAO) computer program to track both aircraft and aviator flight hours. A review of BAO records for the pilot revealed he accumulated 80.1 hours of rotary wing time from March 1997 to September 1997. No instrument time was recorded. No flight time was recorded from October 1997, to March 1998. However, in the NTSB Form 6120.1/2, the FBI listed 19.6 hours of flight experience in the Bell 412 during the 90 days prior to the accident. The pilot's most recent FBI flight evaluation was completed April 10, 1997 in the UH-1 helicopter. No evaluations in the Bell 412 helicopter were documented. The second pilot held an airline transport pilot certificate for airplane multi-engine land. He held a commercial pilot certificate for airplane single engine land, rotorcraft helicopter and instrument helicopter. The second pilot held a flight instructor certificate for airplane single engine land, rotorcraft-helicopter, and instrument helicopter. His most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued on March 11, 1998. The second pilot reported 8,300 hours of total flight experience. He reported 2,650 hours of rotorcraft experience; 120 hours of which were in make and model. The second pilot's most recent FBI flight evaluation was in the UH-1 helicopter on March 24, 1997. He was evaluated on day, instrument, and NVG tasks. The second pilot was not evaluated on terrain flight. No evaluations in the Bell 412 helicopter were documented. A review of the BAO program revealed the second pilot logged 88.5 hours of rotary wing time from March 1997 to September 1997. No instrument flight time was recorded. No flight time was recorded from October 1997, to March 1998. However, in the NTSB Form 6120.1/2, the FBI listed 39 hours of flight experience during the 90 days prior to the accident, 8 hours of which was in the Bell 412. DAMAGE TO AIRCRAFT The wreckage was examined and removed from the scene by the FBI prior to NTSB notification. Examination of the damage and witness marks on the airframe by Bureau aviation accident investigators revealed that at the time of ground contact, the nose-up pitch attitude of the helicopter had been approximately 30-35 degrees, with an approximate nose-left yaw of 23 degrees. Initial ground scars revealed an approximate magnetic direction of 099 degrees. AIRCRAFT INFORMATION The helicopter was owned by the Textron Financial Corporation and operated by the Federal Bureau of Investigation. The helicopter had accumulated 659.7 hours of total time. The last annual inspection was performed on the helicopter on January 22, 1998, at 640.3 aircraft hours. According to an Interview Summary provided by the FBI, a mechanic who worked on the helicopter stated he was asked to install a fastrope rig on N82628 in July 1996. He explained to the unit supervisor that he could not install the rig without an FAA Form 337. The mechanic said the unit then hired two mechanics that installed the fastrope rig without the accompanying FAA Form 337. According to the mechanic, the helicopter sustained a tailskid strike in September 1997, which was not noted in the logbook by the pilot. The mechanic made a logbook entry that reflected a bent tailskid and an elongated tailskid block. Based on his visual inspection of the damage, the mechanic recommended that several inspections be performed, including a tailboom alignment check. Instead, a special agent contacted Bell Helicopter by telephone and the mechanic completed a landing gear deflection check. The helicopter was then returned to service and the logbook entry was not signed off. The mechanic also stated that he contacted Bell Helicopter to ask about the over flight of mandatory maintenance inspections. He said that the helicopter would be on missions when mandatory inspection intervals would elapse and that inspections were "missed". According to the mechanic, "Bell Helicopter advised that it was unacceptable to over fly any inspection time." In September 1997, the helicopter experienced an over torque and was taken by truck to a maintenance facility. An over-torque inspection, annual inspection, and tailboom alignment check were completed on January 22, 1998. The maintenance records did not reflect the tailboom alignment check; however, during an interview with the FBI, the supervisor of the maintenance facility reported the work was completed. In the NTSB Form 6120.1/2, the FBI stated the helicopter was flown 19.4 hours between January 22, 1998 and March 12, 1998. However, according to the BAO computer program, no flight hours were recorded for the helicopter between March 12, 1997 and March 12, 1998. METEOROLOGICAL INFORMATION Weather reported at the Quantico Marine Corps Airfield, 8 miles west of the TEVOC, was: scattered clouds at 5,500 feet. The temperature was 35 degrees and the dewpoint was 5 degrees. The winds were reported from 280 degrees at 20 knots gusting to 27 knots. MEDICAL AND PATHOLOGICAL INFORMATION Dr. John H. Hagman, Director of the Casualty Care Research Center, Bethesda, Maryland, performed toxicological testing. ADDITIONAL INFORMATION On March 20, 1998, the NTSB made a request for copies of various programs and documents in person at the unit offices. A search of the premises by several FBI agents failed to produce any of the requested items. On March 25, 1998, a written request for the same items was forwarded to the FBI. They included: 1. Helicopter Unit Standing Operating Procedures. 2. Helicopter Unit Standardization and Aircrew Training Program. 3. Helicopter Unit Aviation Safety Program. 4. Helicopter Unit Risk Assessment/Risk Management Program. 5. Helicopter Unit Aviation Life Support Equipment Program. 6. Helicopter Unit Pre-Accident Plan (Accident Notification Procedures). 7. Accident aircrew's training records, and computer records of flight hours. 8. Maintenance records and flight hours for N82628, from July 1997, to March 12, 1998. 9. Organizational Chart for the Helicopter Unit, to include key positions within the unit, such as: Safety Officer, Training Officer, and Maintenance Officer. 10. Organizational Chart of the managerial levels above the Helicopter Unit. 11. Helicopter Unit's Night Vision Goggle Standardization and Aircrew Training Program 12. FBI reports generated during the investigation regarding the operation and supervision of the Helicopter Unit. The FBI responded in writing to the request on May 26, 1998. According to the FBI's Aviation Accident Review Board (AARB), with only two exceptions, the material provided to the NTSB "...was in draft/unfinished form, did not reflect approval by anyone, showed no evidence of having been serialized/filed, or displayed no record of dissemination. The documents provided ...had not been approved to become [unit] policies as of [4/16/98]." The Helicopter unit had been in existence for 3 years prior to the accident and operated with no Standing Operating Procedures (SOP). There were no formal briefing procedures, briefing sheets, or methods to establish if briefings occurred. There was no flight plan or any record of the accident flight. According to the review board: "[The pilot] had not filed a flight plan or otherwise prepared a record of the flight, including approving authority; the identity of Pilot-in-Command (PIC), identification of origins and destinations; and the identification of any passengers. In his role as acting supervisor, he approved the flight with a passenger. The TEVOC SSA asked for direct assistance from the [helicopter unit] without approval from his supervisors." The pilot stated that Night Vision Goggles (NVGs) were on board for possible use during the evening hours on the day of the accident. A representative of Bell Helicopter stated the cockpit lighting and instrumentation in the model 412 was not compatible for flight with NVGs. Examination of flight records for both pilots revealed flight evaluations conducted under NVGs were performed in the UH-1 only. No documentation of training or evaluations in the 412 using NVGs was provided. The review board noted that the helicopter unit's supervisor was reassigned November 20, 1997, and from that point the unit members acted as supervisor on a rotating basis. They noted that "documentation of training stopped or diminished following 11/97." The review board also stated:"...no training protocol, performance standards, [or] method for tracking pilot proficiency and currency in those profiles could be identified in any documentation furnished to the investigators. Likewise, no internal system was in place in lieu of the BAO to track pilot flight hours. One member emphasized the fact that no SOPs existed for tactical aircraft training, although most agencies usually follow United States Army protocol. An AARB member noted that [unit] pilots worked under the 'fly one helicopter, fly all helicopter' assumption. AARB members unanimously agreed that no management oversight of [unit] operations currently exists. Management is left to pilots including a monthly rotating supervisor. A concern was voiced that the [helicopter unit] is currently managed by a non-aviation entity with inadequate expertise." In a written response to the AARB, the helicopter unit stated that the Bureau did not require SOP's, but that several were in draft form at the time of the accident. As a result of the investigation, the Federal Bureau of Investigation approved and published programs and flight training manuals proposed by the helicopter unit in November 1998. The aircrew training manuals were for 2 separate airframe and mission types. The program manuals were for larger, generic helicopter units and a smaller, mission specific unit.
the pilot's failure to maintain adequate altitude/clearance above the terrain and the lack of management oversight of aircrews and equipment.
Source: NTSB Aviation Accident Database
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