Aviation Accident Summaries

Aviation Accident Summary ERA09LA139

Monroe, NC, USA

Aircraft #1

N4191A

HUGHES OH-6A

Analysis

During a flight to "simulate a mission" to examine power lines, the helicopter had been paralleling the west side of transmission lines. While resetting the global position system (GPS), the pilot-in-command (PIC) transferred controls to the pilot-rated-passenger. While the PIC was trying to reduce the sensitivity of the GPS warning system, the helicopter made a right turn of almost 260 degrees of heading change, allowing the helicopter to be on a perpendicular ground track and traveling directly toward the power lines. The helicopter collided with the topmost lines in the set, which were the grounding wires for the transmission line. The helicopter was observed by an eyewitness impacting the power line and descending to the ground. Examination of the wreckage revealed no evidence of any mechanical deficiencies. Several witnesses heard the helicopter and reported that it sounded normal prior to impacting the power lines. The main rotor blade was separated from the main wreckage. The pilot-rated-passenger had a history that he had not revealed to the Federal Aviation Administration of kidney stones, severe knee pain, and regular use of prescription pain medication. This pilot had seen an orthopedic surgeon the day before the accident for continuing knee pain, for which he had requested and received additional pain medication "to help him sleep." Toxicological testing was consistent with the recent use of the potentially impairing narcotic medication that had been prescribed the day before the accident. It is possible that the pilot-rated-passenger was impaired or distracted by knee pain, by the use of narcotic medication for that pain, or by fatigue due to insomnia from the knee pain; however, the investigation could not conclusively determine if impairment or distractions contributed to the accident.

Factual Information

HISTORY OF FLIGHT On January 22, 2009, about 1030 eastern standard time, a Hughes OH-6A, N4191A, was substantially damaged when it impacted the ground after making contact with high tension power lines near Monroe, North Carolina. The helicopter departed Monroe Regional Airport (EQY), Monroe, North Carolina about 1000. The certificated flight instructor received serious injuries and the certificated commercial pilot-rated-passenger was killed. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time for the local flight and no flight plan was filed. According to employees at the airport, the two pilots were planning on flying the helicopter from EQY to Columbia, South Carolina. Prior to the accident flight their plans had changed and they decided to remain in the local area and practice viewing power lines from the air, while calibrating the global position system (GPS). The helicopter was seen flying over downtown Monroe about 1010 and according to an eyewitness, everything looked and sounded normal. Another eyewitness, who saw the helicopter approximately 3 miles from the accident site, stated that everything sounded normal and he estimated the helicopters altitude as 100 feet above ground level (agl). One eyewitness reported seeing the helicopter impact the power lines. This eyewitness stated that he was outside of his place of business when an employee drew his attention to the helicopter. He looked up, saw the helicopter impact the power lines, and then blue flashes of light. He then heard a boom, and watched the helicopter impact the ground. Phone interviews with numerous witnesses along the helicopter’s flight path observed the helicopter at various altitudes, but all reported that the helicopter engine sounded normal. One witness, who lived in close proximity to the accident location, did not see the accident; however, he did hear the helicopter approaching. He could not differentiate which direction it was coming from, followed by a "buzzing" sound which he estimated lasted approximately 20 seconds, a "loud bang," and then heard what sounded like the helicopter impacting the ground. One eyewitness heard the helicopter approaching, and when one of his employees stated that it was "flying too low," he turned and observed it impact the power lines, saw blue flashes of light, heard a boom, and then observed the helicopter descending towards the ground. In a phone interview with the accident pilot, he stated that on the morning of the accident flight he and the pilot-rated-passenger had been planning to practice a "sample mission" while trying to acquire a contract to perform power line observations. During the day prior to the accident, the helicopter was fueled and relocated from its normal hangar to a heated hangar that was acquired just for the evening prior to the accident flight. While relocating the helicopter, the accident pilot observed that the GPS unit was "acting up" and had decided to take it home and work on it. Since the GPS antenna was mounted on the helicopter, he was unable to ascertain if it was working until it was reattached to the helicopter antenna. Approximately 0700 during the morning of the accident date, the "sample mission" had been canceled due to adverse weather conditions at their destination. Approximately 0900, the two pilots elected to remain in the local area and "simulate a mission," which would require them to fly between 75 and 100 feet agl. The pilot stated that due to the work on the GPS the evening prior, the GPS had reverted back to its factory default settings and announced obstacles within the helicopters flight path. The accident pilot, seated in the right front seat, was familiar with the GPS unit and transferred control of the helicopter to the pilot-rated-passenger, who was seated in the left front seat. The pilot attempted to reduce the sensitivity of the visual warning system. The GPS unit was located on the left side of the instrument panel and required the pilot to lean forward and to the left, to the extent of the shoulder harness in order to adjust the unit. While performing adjustments on the unit, the pilot’s visibility was restricted due to his head being down to perform the adjustments, and during these adjustments he felt "a violent shaking and a loud noise." Data from the GPS was downloaded at the NTSB Vehicle Recorder Laboratory. Examination of the ground tack of the helicopter, utilizing the last 100 recorded data points, since the GPS time was unable to be validated, revealed that the helicopter was on a southwesterly track paralleling the west side a power line. During the last eight recorded data points, the GPS indicated that the helicopter was in a right turn. The last recorded data point indicated that the helicopter was on a heading of 119 degrees true and the latitude and longitude recording corresponded in the vicinity of the accident location. PERSONNEL INFORMATION Certificated Flight Instructor The certificated flight instructor, age 35, held a commercial and certificated flight instructor certificate, with a rating for rotorcraft-helicopter. He reported 1,100 total hours of flight experience, including 1,000 hours as pilot in command (PIC). He reported 110 total hours of flight experience in the accident helicopter make and model, including 105 hours as PIC. His most recent flight review was completed on October 25, 2008 and his most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on July 3, 2007. Commercial Pilot The commercial pilot-rated-passenger, age 46, held a commercial pilot certificate, with a rating for rotorcraft-helicopter. His most recent FAA second-class medical certificate was issued on May 21, 2008, at which time he reported 250 total hours of flight experience and 50 total hours of flight experience within the preceding 6 months. AIRCRAFT INFORMATION The accident helicopter was manufactured in 1967 for the military, and then on March 18, 1997, it was issued an FAA standard airworthiness certificate. On July 10, 2007, the helicopter was registered to the Charlotte Helicopter Flight Academy, which was owned by one of the accident pilots. The helicopter was equipped with an Allison 250-C10D, turbo-shaft engine. The engine data plate stated that the engine was overhauled during May 1994 and at that time had 3,412 total hours of service. The last entry in the maintenance logbooks were dated June 2, 2007 and at that time the helicopter had 5,623.9 total hours in service. According to the maintenance logbook, the last 100-hour inspection was completed on February 20, 2007 and the helicopter had 5,598.6 total hours time in service. A local mechanic informed the FAA that he had performed a 100/300-hour/Annual inspection on the helicopter and engine on June 26, 2008 and at that time the helicopter had 5,660.7 total hours in service. He subsequently produced the checklist he utilized as well as a copy of the logbook entry that should have been in the logbooks. METEOROLOGICAL INFORMATION The 1053 weather observation at EQY, 4 miles west-northwest of the accident site, reported winds from 240 degrees at 5 knots, clear skies, 10 miles visibility, temperature 2 degrees C, dew point minus 8 degrees C, and an altimeter setting of 30.17 inches of mercury. WRECKAGE AND IMPACT INFORMATION The helicopter was examined by an FAA inspector who responded to the accident site. The helicopter came to rest in an open field and was lying on its left side beneath the overhead high tension power lines. The helicopter’s main rotor was separated from the fuselage and was approximately 75 feet away from the main wreckage. One blade was separated from the hub and was located forward of the main wreckage along a tree line at the edge of the open field. The pitch change links on the swash plate were fractured, separated from their respective attach points and exhibited fractures similar to impact damage. The helicopter rested on its left side, and the cockpit, cabin area and aft fuselage, including the tailboom, were damaged by impact forces. The support post for the right side pilot door exhibited marks and a compression bend reducing the occupant's survivability space. Photos taken of the power lines revealed five intact tension power lines and two grounding wires that were located above the intact lines. The grounding wires were severed at a point approximately mid-span between the adjacent poles. MEDICAL AND PATHOLOGICAL INFORMATION Postmortem examination of the pilot-rated-passenger was conducted by the North Carolina Department of Health and Human Services, Office of the Chief Medical Examiner. The cause of death was listed as "…blunt force traumatic injuries." The FAA's Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot-rated-passenger. The report stated that 0.065 ug/ml Dihydrocodeine was detected in the urine, 0.156 ug/ml Hydrocodone was detected in the urine and 0.016 ug/ml was detected in the blood, and 0.147 ug/ml Hydromorphone was detected in the urine, but not in the blood, and Ibuprofen was detected in the Urine. Medical records maintained on the pilot-rated-passenger by personal health care providers and by a pharmacy documented at least two kidney stones (in April 2006 and June 2007), treatment of high blood pressure since at least March 2007, and treatment for arthritis of the right knee since at least February of 2008. An orthopedic surgeon's note on the day before the accident noted, in part, that this pilot "…does have some grinding that hurts, especially painful up and down stairs. Also, some pain at work. He works as a helicopter pilot. … Inspection of gait reveals a minimal antalgic [painful] gait favoring the right lower extremity. Inspection of his right knee and leg show some moderate quadriceps atrophy. … MRI: … multiple loose bodies within the knee, some moderate arthritic change … some moderate chondromalacia patella. Assessment: Right knee mild osteoarthritis with some patellofemoral chondromalacia. … He is also requesting some more pain medication which was given previously. I spent some time counseling him regarding the long-term use of narcotics for arthritis. He is understanding that we will not be prescribing these long-term; however, he does need to help him sleep after a long night. We have given him a prescription for Vicoprofen [hydrocodone/ibuprofen], a total of 30. He has reassured me that he will not use these long term and that he will definitely not use them before flying a helicopter. …" The pilot-rated-passenger’s most recent Application for Airman Medical Certificate, dated May 21, 2008, indicated "No" in response to "Do You Currently Use Any Medication," and to all items under "Medical History," including specifically "High or low blood pressure" and Kidney stone or blood in urine." "Total Pilot Time" was noted as 250 hours "To date" and 50 hours in the "Past 6 months." Height was noted as 75 inches and weight as 235 pounds. All items under "Report of Examination" were noted as "Normal," including "Upper and lower extremities (Strength and range of motion)." ADDITIONAL INFORMATION During a phone interview with a local flight instructor who had instructed both accident pilots, he reported that both were "excellent students." He further remembered that the surviving accident pilot was "extremely cautious with the limits" of the helicopter. He further stated that the pilot-rated-passenger "only wanted to fly" and that on several occasions they flew in a Robinson helicopter and he "always wanted stick time." He further stated that knowing both pilots and the pilot-rated-passenger’s willingness to always want to fly and the pilot's willingness to allow others to fly, he felt that "there was no way [pilot] would not have let [pilot-rated-passenger] fly."

Probable Cause and Findings

The pilot-rated-passenger’s failure to maintain clearance from a known wire hazard during low-level maneuvering. Contributing to the accident was the pilot-in-command’s inadequate monitoring of the flight.

 

Source: NTSB Aviation Accident Database

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