Childress, TX, USA
N28MP
HUGHES 369
The helicopter was in a hover about 120-150 feet above the ground while a utility worker performing a long-line operation worked on a transmission tower. After the loss of power, the helicopter spun and descended during which the worker was pulled off the tower by the attached long line. The pilot performed an autorotation that resulted in a hard landing. The pilot sustained serious injuries and the worker sustained fatal injuries. Postaccident examination of the helicopter revealed no usable fuel on board, and fuel quantities between the fuel tank and engine were consistent with fuel exhaustion. The examination revealed that the electrical wire to the start pump was not secured, which allowed for the possibility of it interfering with the fuel quantity transmitter float mechanism, thus providing erroneous cockpit fuel quantity indications to the pilot. The examination also revealed that the low fuel quantity annunciator was inoperative due to separation of the fuel quantity transmitter's low-level fuel whisker. Recent maintenance of the helicopter's fuel system by the operator's maintenance personnel included the replacement of the start pump and testing of the low-level fuel light by electrically grounding the top of the fuel quantity transmitter using safety wire. A vacuum check of the fuel system was not performed after the fuel system had been opened. The method for testing the low-level fuel light and the lack of a vacuum check were not in accordance with the maintenance manual and the helicopter manufacturer's service bulletin relating to the start pump installation. Postaccident examination of the helicopter also revealed a nonstandard installation of an engine mounted fuel filter petcock drain valve. No written company procedures and/or fueling records were available that required pilots to track fuel loading and time-based fuel consumption in order to determine time remaining for flights and their termination. The pilot stated that he would have the helicopter refueled when the fuel gauge indicated about 100 lbs. However, had the operator and/or pilot calculated the flight time remaining based on known fuel quantities that were independent of fuel gauge indications, then any fuel gauge inaccuracies would be have become apparent.
HISTORY OF FLIGHTOn November 27, 2012, about 1558 central standard time, a MD Helicopters, Inc. MD 500D (Hughes 369D), N28MP, experienced a loss of engine power during long-line power line construction. The helicopter subsequently impacted terrain during a forced landing near the transmission tower where the work was being performed. The helicopter received substantial damage. The commercial pilot sustained serious injuries, and the long-line worker was fatally injured. The helicopter was registered to and operated by Brim Equipment Leasing Inc. (D.B.A. Brim Aviation) under the provisions of 14 Code of Federal Regulations Part 133 as an external-load operation flight. Visual meteorological conditions prevailed for the flight that originated near the accident site, which was about two miles northeast of Childress, Texas. The long-line operation consisted of a 50 foot long-line with a web seat attached to and suspended underneath the helicopter. The long-line worker was performing work on the power line while attached to the helicopter hovering overhead. The pilot said that they had planned to hang travelers on a section of east/west power line towers on the day of the accident. He said that on the day of the accident, a 15-gallon fuel load was "working best." His rule for refueling was that he obtained fuel when the fuel gauge indication was close to 100 pounds, which he said would almost allow a ½-hour of flight time. A company mechanic said that the first operation of the day was to unclip the lines. A full load of fuel was loaded onto the helicopter with only the main tank fueled. He said that he remembered filling the helicopter with fuel two times and each time 15 gallons of fuel was loaded, which was the amount specified by the pilot. The mechanic did not know how much fuel was added prior to the accident. The mechanic said that the helicopter was gone for about an hour since its last refueling prior to the accident. The fuel added was not recorded in a log. About 1400, the pilot departed on a flight to repair a section of fiber optic line that fell down before work continued on the towers. He then flew back and landed at the landing zone where the helicopter was re-rigged for crew operations and refueled. He lifted off with the long-line worker, and they worked on several towers. A traveler was hung on the tower near the accident site, and the helicopter was positioned in a stable hover about 120-150 feet above the ground. The helicopter experienced a pronounced sharp left yaw, which the pilot thought was from a wind gust. The pilot said that it was "milliseconds" between the left yaw and the engine "winding down." The pilot did not hear any unusual noises or vibrations before the loss of engine power and the only annunciation he had time to see was the engine-out annunciation. He did not see any other red/yellow annunciators illuminate. The pilot applied right pedal input. The helicopter started to settle, and he then heard the engine out horn and saw the engine out light illuminate. The pilot's first thought was to get away from the tower because the helicopter would have hit the lower arm of the tower. As the helicopter moved away from the tower, he looked at the horizon and estimated that the helicopter was about 50 feet above the ground when he "bottomed out the collective." The helicopter settled faster and onto the ground in a right-side-low attitude. A long-line worker on the ground said that he was about 200-300 feet away from the helicopter when he "heard all the sound go away" and "it just shut down," while the helicopter was on the north side of the tower. The helicopter then spun clockwise 180 degrees when it lost power. He said the helicopter "seemed" to spin and turn "pretty fast" and did not recall how fast it spun. He said that the long-line worker was hanging on the traveler when he was pulled off the traveler by the long-line. The long-line worker that was on the ground and witnessed the accident stated there was no easy way for a long-line worker to release from a harness and it would take several seconds to do so. The pilot stated there was no company policy or procedure for the release of the long-line. The pilot said that he could not "specifically say" that he was trained to release the long-line. If a long-line worker wanted to get off of the long-line, he had to be "jettisoned." The pilot said that for the long-line worker to jettison themselves, they would have to use a knife to cut the long-line. PERSONNEL INFORMATIONThe pilot held a commercial pilot certificate with a rotorcraft-helicopter rating. He reported a total aircraft flight time of 2,700 hours, of which 800 hours were in the MD 500D (Hughes 369D) helicopters. Since 1990, he was a helicopter pilot in law enforcement and search and rescue operations. Since 2009, he was a helicopter pilot in Part 91, 133, and 135 operations. Until September 2012, he was employed as a full-time pilot flying Eurocopter helicopters for power line and freight flights, after which he was employed on a part-time basis. On September 16, 2012, he was hired by Brim Aviation as a helicopter pilot. On September 17 and September 18, 2012, he received pilot training at Brim Aviation that was comprised of ground and flight training. Company Pilot Training and Qualification Record showed that the pilot's ground training consisted of ground testing, and the flight training consisted of two flights. The record did not indicate total flight, ground, and testing hours received by the pilot nor flight maneuvers he performed and the results of those maneuvers. The record had only two entries by the company president, who was also the company's director of operations, which stated the pilot passed knowledge and skill requirements outlined in Part 133 and 137. There were no entries to identify who provided and the pilot's flight instruction. During the pilot's post-accident interview, he identified the company instructor/check airman as the person who provided his flight training and testing. The pilot did not have a Federal Aviation Administration (FAA) record of any previous incidents, accidents, or enforcement actions. The pilot had been off work for several weeks prior to beginning work on November 26, 2012. The pilot said that he left his home in Chico, California, on November 24, 2012, to travel to Texas to begin work on November 26, 2012. On November 26, 2012, he slept all night and woke up once to go to the bathroom and woke up again at 0730 to start his work day. He worked until 0830-0900, returned to the hangar at 1000 after further flying was cancelled due to wind conditions, and went to bed about 2230. On the day of the accident, he left the crew quarters located in Childress, Texas, about 0700 and drove about 20-30 minutes to the hangar where the helicopter was kept near Wellington, Texas. Part 133 did not have any crew member duty time/rest requirements. The pilot said that his work duration was dependent on a combination of daylight, time, and number of towers. In the southern areas of the country, work duration was driven by daylight. Post-accident examination of the helicopter revealed one bottle of 5-hour ENERGY drink in the glove box between the front seats of the helicopter. The pilot said that he did not take any prescription or over-the-counter medications before the accident flight. He said that he does not consume any alcoholic beverages while on work trips and did not consume 5-hour ENERGY drinks. The pilot stated that he did not have any safety concerns pertaining to Brim Aviation. AIRCRAFT INFORMATIONThe aircraft was a MD Helicopters, Inc. MD 500D (Hughes 369D), serial number 970191D, helicopter certified under Civil Air Regulations (CAR) Part 6. The helicopter was purchased by and registered to Brim Equipment Leasing Inc. in 2005 and was used in long-line and law enforcement operations. The helicopter was powered by a Rolls Royce, 250-C20B, serial number CAE-836143, engine. The helicopter was equipped with an ARS-Air Rescue Systems (ARS) belly band, part number: "ARS-3RR 10a", date of manufacture: "22389-312A-10 of 10", date-in-service: "6-3-12". The last maintenance inspection on the helicopter was a 100-hour inspection dated November 17, 2012, at an aircraft total time of 15,301.6 hours and a Hobbs time of 5,901.4 hours. The helicopter flew about 4 or 5 times since that inspection, which was performed in a hangar at Brim Aviation's Wellington, Texas, facility. According to the MD 500D Rotorcraft Flight Manual, section 2-11, Fuel System Limitations, Table 2-1, lists the usable fuel for standard non self-sealing fuel tanks as 1.9 gallons. Section 3-13, Fuel System Malfunctions, states that "FUEL LEVEL LOW" indicator would be "ON" when approximately 35 lbs of fuel (22.5 lbs usable) remain in the fuel tank. Investigators examined the helicopter for the presence of a maintenance discrepancy log. The only log found aboard the helicopter that contained a section for discrepancies, titled "PILOTS REMARKS OR DISCREPENCIES," was contained in a "Brim Aviation Engineering Log Book Report." The Brim Aviation Engineering Log Book Report began with its first entry on page 2401, dated November 11, 2011, and ended with its last entry on page 2446, which was not dated. Page 2445 was dated November 16, 2012. Only two pages within The Brim Aviation Engineering Log Book Report contained airworthiness entries within the discrepancies section, which were on pages 2409, undated, and 2410, dated February 18, 2012. The discrepancy entry on page 2409 was: "Throttle friction sticky" and "Pilot's door exterior handle non operational." The discrepancy entry on page 2410 was: "Pilot's exterior door handle – inop," "Gov. control linkage – Bolt spins – Retighten & Re cotter," "Reinstall Skid Mirror," Reinstall Steps." There were no entries within the "POWER CHECKS" section for any of the pages from 2401 to 2445. The pilot stated that engine trend monitoring was not performed. The PILOTS REMARKS OR DISCREPENCIES sections of the remaining pages within this log contained flight/customer information. According to page 2440 of the log, an entry dated October 17, 2012, at a Hobbs time of 5,817.3 hours, and aircraft total time of 15,217.5 hours, within the "MECHANICS: CORRECTIVE ACTION & LIST ALL MAINTENANCE PERFORMED," states in part: "Replaced airframe anti ice filer with new part." "Drained and wiped clean fuel cell bladders, removed, cleaned, and reinstalled fuel boost pump." "All work done IAW csp-hmi-2 and Rolls Royce engine" The MD Helicopters, Inc. Maintenance Manual, CSP-HMI-2, B. Start Pump Installation, page 410, revision 19, states in part: "CAUTION" "Ensure start pump wire lead is wrapped around or tie-wrapped to the fuel supply hose so that there is no possibility of its interfering with fuel quantity transmitter float mechanism. Ensure electrical connections will not be strained by G-induced hose movements." The operator's mechanic who performed the maintenance listed on page 2440, stated in an interview that he held an airframe and power plant certificate issued in March 2009 and did not hold an inspection authorization rating. He was employed by the company for about two years and has been the primary mechanic since July or August 2012. He said that his position at the company is that of a field mechanic and he works on four other company aircraft. He spends half of his time in the hanger and the other half in the field. He performs maintenance, fueling, ground operations, and the rigging of equipment. He said his maintenance training was "on-the-job." The mechanic stated that maintenance to the fuel system was performed after a pilot, who he said was probably a pilot other than the accident pilot, reported a "shudder." He said that he did not know if the report was made on October 4, 2012, and whether there was a written record of that report. He said that when he worked on the fuel system, he drained fuel from the fuel tank under both access covers on the floor of the cabin. The pilot helped him replace the start pump and flush the fuel system. He said that he reinstalled the sump drain and boost pump. The fuel tank was partially filled with a "few gallons" of fuel and the boost pump was operated and fuel flow was noted. He said that they removed the fuel quantity transmitter. He said that the pilot only removed the floor access covers to the fuel tank and held a 5-gallon bucket when they drained the fuel. The mechanic said that he was looking at the helicopter maintenance manual while he was performing the maintenance on the fuel system. The mechanic said that he did not perform vacuum checks of the fuel system and did not know how to perform those checks without reading the maintenance manual. He did not perform a vacuum check after working on the fuel system. When asked how he checked the low fuel annunciator light, the mechanic said that he grounded the fuel quantity transmitter by contacting the top of the transmitter with a safety wire. The MD Helicopters, Inc. Maintenance Manual, CSP-HMI-2, Fuel System Inspection/Check, page 501, revision 44, states in part, that testing of the FUEL LEVEL LOW WARNING LIGHT is performed by be refueling the helicopter with 35 lbs. of fuel remaining for commercial operations and 75 lbs. of fuel remaining for noncommercial machines. With the helicopter battery switch in the EXT PWR position and external power connected, the FUEL LEVEL LOW WARNING LIGHT must be off for these fuel remaining quantities. The MD Helicopters, Inc. Maintenance Manual, CSP-HMI-2, Fuel System Inspection/Check, page 601, revision 19, states in part: "WARNING" "Air entering the airframe fuel supply lines may cause a power reduction or flameout. Fuel system vacuum and fuel air bleed procedures must be performed after opening fuel the supply system for any reason, prior to releasing the helicopter for flight." The mechanic stated that he did not have any safety concerns pertaining to Brim Aviation. According to FAA Order 8900.1, volume 6, chapter 5, paragraph 6-1378, (B), (1), (a), a current copy of the operator's operating certificate and current authorizations must be onboard each rotorcraft during Part 133 operations. The "Brim Aviation Rotorcraft-Load Combination Flight Manual" (RLCFM) and "Operations Specifications" that were onboard the accident helicopter at the time the accident were not current and had been amended. The 12-page RLCFM and 17-page Operations Specifications onboard the accident helicopter were approved by the FAA's Portland Flight Standards District Office (FSDO). According to the onboard Operations Specifications, section A001. Issuance and Applicability, only showed approval for the operator to conduct class A, B, and C external load operations. Section A003. Aircraft Authorization listed the accident helicopter with only applicable load classes A, B, and C. FAA records showed that the operator was approved for class D operations. The operator was requested and provided a current copy of their operations specifications following the accident, which listed under section A001, class D external load operations. Section A003 applicable load classes was blank for all of the listed aircraft. The only airworthiness requirements cited in the onboard and current operations specifications were in section A447, Emergency Airworthiness Directive (EAD) Notification, which stated that the owner or operator of aircraft identified in the certificate holder or operator's aircraft listing is primarily responsible for maintaining the aircraft in an airworthy condition as required under Parts 91.403a and 39. This section also section designated the certificate holder's EAD notification representative. There were no requirements within the operations specifications for compliance with service bulletins (SBs). A SB relating to start pump wire routing was issued by MD Helicopters on September 15, 1987, that was to be accomplished within 25 hours of helicopter operation or at the next removal of the fuel start pump or fuel quantity sender unit, whichever occurred first and at each subsequent removal of the start pump from the fuel cell. The SB
The improper maintenance of the helicopter fuel system that resulted in erroneous fuel gauge indications and the pilot’s inadequate fuel management, both of which resulted in fuel exhaustion during a long-line hover. Also causal was the lack of company procedures to ensure adequate maintenance and fuel planning.
Source: NTSB Aviation Accident Database
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