Friday, January 26, 2018

Horizon / Alaska Airlines, de Havilland Dash 8-400, N412QX: Incident occurred December 29, 2017 at Pullman–Moscow Regional Airport (KPUW), Whitman County, Washington -and- Accident occurred November 19, 2017 at Sacramento International Airport (KSMF), California

‘It’s a cover-up from the Federal Aviation Administration at the highest level’: Cockpit voice recording can’t be used in investigation, source says

The mystery at Pullman–Moscow Regional Airport (KPUW): Plane mistakenly lands on taxiway, but was key evidence inspected?



A top Federal Aviation Administration official has forbidden inspectors who are trying to determine why a Horizon Air commercial jet mistakenly landed on a Pullman, Washington, airport taxiway from reviewing “critical” evidence: recorded cockpit conversations between that flight’s pilots, a federal official familiar with the investigation said

The directive came straight from John Duncan, FAA’s head of flight standards who is in charge of the agency’s flight inspectors across the country, said the source, who requested anonymity because of the sensitive nature of the probe. Despite the cockpit voice recorder being quarantined by Horizon Air, inspectors investigating the incident have been prevented from listening to the audio of the pilot discussions.

“It’s a cover-up from the FAA at the highest level,” the source said. “We don’t want this to happen again because next time they could hit someone and people will die.”

FAA spokesman Ian Gregor declined to comment Friday: “The FAA does not comment on pending investigations.”

The wayward flight is the latest high-profile airport mishap involving botched landings, including three at San Francisco International Airport — one of which could have resulted in one of the country’s biggest air disasters. Experts have said cockpit voice recorders are critical to determining what caused flight crew confusion. In the end, the Dec. 29 incident at Pullman-Moscow Regional Airport ended with the Horizon jet, along with its 38 passengers and four crew members, landing safely with no injuries.

U.S. Rep. Mark DeSaulnier, D-Concord, has been lobbying for improvements to how aviation and airline officials collect and save the cockpit recordings, which are often lost if not immediately pulled because the audio will overwrite itself. After the three alarming SFO incidents and others across the country, DeSaulnier wrote the FAA and pushed for a public hearing on the issue.

“Oh man,” DeSaulnier said by phone Friday. “What are they hiding? Why aren’t they being more forthcoming?”

The congressman said his office was in the process of crafting a letter to the FAA asking for details about the Pullman incident.

On December 29, Horizon Air Flight 2184 landed on the small airport’s taxiway during a driving rain storm that had shorted out the runway lights. Alaska Airlines, which operates Horizon, said the 17-year veteran pilot misidentified Taxiway Alpha as Runway 6 and landed. The airline also said the pilots have been temporarily suspended from flying during the investigation.

Because the Horizon plane actually landed on the taxiway, federal regulations require the airline to immediately report the incident to the National Transportation Safety Board and to preserve the critical data, including the cockpit voice recorder. The airline followed the rules, but the NTSB declined to investigate the incident.

It’s not always required that cockpit voice recordings be retrieved, and if they are not, they will be overwritten. That is what happened in the SFO near misses. In one case, an Air Canada plane narrowly averted landing on a taxiway crowded with four fully loaded jets awaiting takeoff. But because it didn’t land on the taxiway, the airline was not required to retain the recording and the plane took off hours later.

The FAA has initiated a probe in the Horizon Air incident, but that effort has now been diminished, according to the source.

“If I were doing it and I didn’t have all the information, I couldn’t close the investigation. It is that crucial … The CVR will tell you everything,” the source said of the cockpit recordings. “(The FAA) flat out told them you can’t listen to that tape. To me, that’s very troubling.”

Interviewing pilots is helpful, experts have said, but the raw conversations leading up to the aviation error are pivotal.

“It helps us figure things out in case someone lies to us,” the source said.

Federal regulations require the recorder to be held for at least 60 days by the airline, but the federal official said the concern is that once that period ends, the data could be lost forever.

“Then we’ll never know what happened.”

Story and comments ➤ https://www.mercurynews.com



PULLMAN, WASH. —  Last month, a Horizon Air plane mistakenly landed on a taxiway at a small airport in Washington. It was serious enough that the flight crew was suspended, but federal aviation officials have kept most of the details under wraps.

The major gaffe had a happy ending — the plane landed safely on the empty taxiway and no one was injured. But some aviation experts say the Pullman mistake coupled with several other high profile near-misses involving botched landings, including three at San Francisco International Airport, provide a good reason why cockpit voice recordings should be preserved and reviewed after dangerous aviation incidents, wreck or no.

Congressman Mark DeSaulnier, D-Concord, is someone who also wants to make sure critical evidence is kept. When aviation and airline officials failed to collect evidence from the three SFO incidents and others across the country, DeSaulnier pushed the Federal Aviation Administration to find a way to capture more of the recordings and for a public hearing on the issue.

“We need to get to the bottom of these,” DeSaulnier said. “We need to understand what the standards are, if they are followed and do they need to be strengthened.”

And that’s why the Pullman incident is so strange.

Because the Horizon plane actually landed on the taxiway, federal regulations require the airline, which is operated by Alaska Airlines, to immediately report the incident to the National Transportation Safety Board and to preserve the critical data, including the cockpit voice recorder.

The airline and federal officials confirm that this was done. However, the NTSB declined to investigate the incident. The FAA has initiated a probe but refuses to say whether its investigation will include reviewing the audio. It hinted it will not.

FAA spokesman Allen Kenitzer repeatedly told this news agency his agency could not comment on an ongoing investigation and his only comment about the cockpit recordings was: “The FAA does not have the regulatory authority to remove cockpit voice recorders.”



Taxiway landing

On Dec. 29, a heavy rain and melting snow created a flash flood that caused an electrical failure of the Pullman-Moscow Regional Airport’s runway lights, leaving only the blue taxiway lights working as Horizon Air Flight 2184 approached.

At about 6:20 p.m., the flight crew, about three miles from the airport, positioned the aircraft for landing and attempted to activate the remote-controlled runway lights, according to an Alaska Airlines statement. The crew had not been alerted about the inoperable lights — the airport director said the facility did not know about the outage yet — and the 17-year veteran pilot misidentified Taxiway Alpha as Runway 6 and landed. No other aircraft were on the taxiway at the time.

“The pilots have been temporarily removed from flight status while the landing is being investigated internally and in partnership with investigating authorities,” Alaska Airlines said.

Aviation experts say taxiway lights are clearly blue and instruments would have guided the flight crew to the airport’s darkened runway, which should have caused the pilot to abort the landing. The Pullman airport, which has one landing strip and one taxiway, has no tower, but air crews can communicate with each other via radio.

“It is a big mistake,” said Michael Barr, former director of the USC Aviations Safety Program. “Especially at night because runway lights are much different than taxiway lights.”

The runway is 100 feet wide, but the taxiway a narrow 60 feet, said airport manager Tony Bean.

“I don’t think visibility was a problem (that night),” Bean said. “It was a very, very, very strange occurrence.”

Normally, after a major incident, the FAA, even when it is investigating, will provide the public with basic preliminary information. However, all the flight specifics from Pullman came from the airline and airport manager. And there was confusion three weeks after the incident between the NTSB and FAA.

“For more information, you’ll want to contact the NTSB. They are leading this investigation,” Kenitzer said on Jan. 18.

The same day, NTSB spokesman Eric Weiss said: “We are not conducting a separate Investigation on this event. As such, we did not gather any recorder data.”

The next day, Weiss said: “We are looking into several wrong runway/airport/taxiway landings and have documented that this event occurred. However, we will not be conducting a separate investigation given our current resources.”

He did later confirm that Horizon properly notified them and the airline “indicated that the recorders had been quarantined.”

The FAA refuses to say if they are reviewing the audio. Nearly a month after the taxiway landing, no one will say what happened to the cockpit voice recordings after they were removed by the airline, or if they have been reviewed.
Barr said that audio is critical evidence to find exactly why the pilots veered from the runway.

“It’s very important,” the aviation safety expert said, “if they’d like to know what happened.”

Story and comments ➤ https://www.mercurynews.com

Federal Aviation Administration / Flight Standards District Office; Sacramento, California

Flight QXE2119:  Aircraft sustained a birdstrike to the nose of the fuselage. No injuries. Damage substantial. Landed without incident.

http://registry.faa.gov/N412QX

Date: 20-NOV-17
Time: 03:33:00Z
Regis#: QXE2119
Aircraft Make: BOMBARDIER
Aircraft Model: DH8D
Event Type: ACCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: SUBSTANTIAL
Activity: COMMERCIAL
Flight Phase: EN ROUTE (ENR)
Aircraft Operator: HORIZON AIR
Flight Number: QXE2119
City: SACRAMENTO
State: CALIFORNIA

Firm to build jet-powered drones in Oklahoma City, bring 350 jobs


A California-based jet-powered drone manufacturer is moving at least 350 employees and part of its engineering, design and manufacturing operations to Oklahoma City, company and state leaders said Friday.

Kratos Defense & Security Solutions Inc. develops and manufactures jet drones used for military missile tests and other applications. The new Oklahoma City facility will be home to much of the company's design and manufacturing of a new version of offensive jet drones intended to be used in combat along with manned aircraft.

"We can fly our aircraft as a wingman for an F-22," Steve Fendley, president of Kratos' unmanned systems division said in a news conference on Friday. "The manned pilot can fly to a proximity and deploy the unmanned aircraft farther without having to threaten himself."

Kratos has four engineers and 25 support employees at a temporary Oklahoma City location. The company is looking for a permanent facility near Tinker Air Force Base where it will house its expanded research and production offices. The new location also will be home to some of the company's manufacturing operations.

Fendley said he expects the company to be in the new facility by the end of the year and to have 350 to 500 Oklahoma City employees within five years.


Gov. Mary Fallin leads a press conference at the state Capitol on January 26, 2018.


"We're close to reaching our production capacity in California," Fendley said. "Our intention here is to install our tactical performance capability, both the development and production of those systems. For those tactical aircraft systems, their home will be here. We will develop and produce them here in Oklahoma."

Aviation and aerospace is Oklahoma's second largest industry behind the energy sector, but Kratos represents a portion of the industry new to the state.

"These are cutting-edge components of technology and aviation coming to Oklahoma City," said Roy Williams, president of the Greater Oklahoma City Chamber. "It represents the future of the industry. Much of what we have in Oklahoma City is maintenance and overhaul, which is taking care of everything that is old. This is the next wave of growth in the sector. We think this is a home run."

Kratos also represents the revival of aerospace manufacturing in the state, said Vince Howie, aerospace and defense director at the Oklahoma Department of Commerce.

"This is the beginning of a long and fruitful relationship," he said. "We've brought aircraft manufacturing back to Oklahoma."

Kratos executives chose Oklahoma City after meeting with Rep. Steve Russell, R-Oklahoma City, Gov. Mary Fallin and other state and local leaders, Fendley said.

"All of the pieces in Oklahoma fit what we were looking for," he said. "We wanted a state that is supportive of the business we're in, supportive of the military, supportive of advancements of our capability testing, have a close proximity to military bases and have the potential for a flight test facility."

Fendley said his company is negotiating with the Federal Aviation Administration for the ability to run flight tests at the Oklahoma Air & Space Port in Burns Flat, which is home to the third-longest civilian airport runway in North America.

"We hope to eventually do ground testing and possibly eventually flight testing there," Fendley said. "If we can do that, Oklahoma is really our center focus for all the development work we do."

Kratos has conducted most of its tests on military bases in California, where it must work around military schedules.

"The opportunity to take advantage of a facility like (Burns Flat) with the proximity we have with the size and capacity and ceiling all the way to space, is incredible," Fendley said.

Besides the proximity to Burns Flat and Tinker Air Force Base, Fendley said the company also was drawn by the state's engineering and Quality Jobs tax credits.

Oklahoma has a checkered history of providing tax credits to aerospace companies based at or interested in Burns Flat. Rocketplane, for example, took in $18 million in state subsidies before filing for bankruptcy in 2010.

Gov. Fallin pointed out, however, that Krotos is an established company that operates in 20 states and five countries and has more than 3,000 employees and close to $1 billion in contracts.

"This is not a startup company," she said.

Earlier this month, Kratos announced a $23 million unmanned aerial drone system production award from an unnamed customer, and a $93 million contract to supply target drones to the Army. This most recent contract makes Kratos the sole supplier of jet-powered, sub-scale target drones to all branches of the U.S. military.

Aerospace firms produced about $4.9 billion in goods and services in the Oklahoma City metro, according to a 2016 study by the Greater Oklahoma City Chamber.

Tinker Air Force Base is a major driver for the local aerospace industry, which includes firms such Boeing Aerospace, Pratt & Whitney, Lockheed Martin Aircraft, Northrop Grumman, General Electric Aviation and AAR Aircraft Services.

While Kratos is a strong benefit to the Oklahoma economy on its own, it also will help state and economic leaders attract additional businesses to the state, Fallin said.

"When you get a company like Kratos to locate in Oklahoma, they have suppliers that will look at the possibility of coming to Oklahoma because they want to do business with a major supplier of unmanned aerospace and the latest technology," Fallin said. "It's great for Tinker and all of our other military installations to be able to partner with a company like this."

Story, photo gallery and video ➤ http://newsok.com

Bellanca 17-30A Super Viking, N39894: Accident occurred March 01, 2017 near Carson Airport (KCXP), Carson City, Nevada


The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office: Reno, Nevada
Continental Motors; Mobile, Alabama

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf 

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

http://registry.faa.gov/N39894


Location: Carson City, NV

Accident Number: WPR17LA072
Date & Time: 03/01/2017, 1250 PST
Registration: N39894
Aircraft: BELLANCA 17-30A
Aircraft Damage: Substantial
Defining Event: Fuel related
Injuries: 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The airline transport pilot was conducting the airplane's first flight after about 1 1/2 years of inactivity and the completion of an annual inspection. A witness reported that the airplane took off normally, but the retractable landing gear remained extended. As the airplane neared the end of the runway, about 300 ft above ground level, the engine sounded as though it "decreased to idle." The airplane entered a right, 180o turn and descended rapidly before impacting the ground.

During a postaccident test run, the engine operated normally at both idle and full power settings and during abrupt changes between idle and full power. However, it operated inconsistently at 2,100 rpm for about 30 seconds before stabilizing at that power setting. During this time, the fuel pump pressure fluctuated. Following the test run, the fuel manifold valve was disassembled, revealing rust on the screen, lower housing, and plunger, consistent with exposure to water. The diaphragm was removed and a small amount of fuel was found on the "dry" side of the valve; the vent extending from this section was examined and clear of debris. Examination of the airframe and engine maintenance logs revealed that the airplane flew a total of 73 hours and underwent 3 annual inspections in the previous 8 years. It is likely that water accumulated in the fuel system sometime during the airplane's prolonged periods of disuse, resulting in corrosion of the fuel manifold valve's internal components. Because the corrosion was internal, it would not have been detected without disassembly of the fuel manifold, which is not part of the annual inspection procedure. It is likely that this corrosion caused the manifold valve plunger to temporarily stick, which restricted fuel flow to the engine and resulted in the anomalous operation during the postaccident test run as well as the loss of power on the accident flight. Following the loss of engine power, the pilot initiated a turn back to the runway, during which the airplane exceeded its critical angle of attack and experienced an aerodynamic stall.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

A total loss of engine power due to internal corrosion of the fuel manifold valve. Also causal was the pilot's decision to return to the runway following the loss of engine power shortly after takeoff, and his exceedance of the airplane's critical angle of attack during the turn, which resulted in an aerodynamic stall. 

Findings

Aircraft

Fuel distribution - Fatigue/wear/corrosion (Cause)
Fuel distribution - Malfunction (Cause)

Personnel issues
Aircraft control - Pilot (Cause)


Factual Information 


On March 1, 2017, about 1250 Pacific standard time, a Bellanca 17-30A, N39894, experienced a loss of engine power shortly after takeoff from the Carson Airport (CXP), Carson City, Nevada. The pilot, sole occupant, was seriously injured, and the airplane sustained substantial damage to both wings. The airplane was registered to and operated by the pilot as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident no flight plan was filed for the local flight.

At the time of this report, the pilot was unable to provide a statement or complete the NTSB Pilot/Operator Aircraft Accident/Incident Report Form 6120.1.

A witness reported that he observed the airplane takeoff normally, with the exception that the landing gear remained in the down position. At the end of the runway, when the airplane was no higher than 300 feet, it sounded as if the engine decreased to idle. The airplane made a right 180o turn and descended rapidly before impacting the ground.

Postaccident examination of the airframe revealed continuous control continuity throughout the airframe. In addition, control continuity was established from the cabin to the throttle, mixture, and propeller controls. The fuel lines were intact from the engine to the firewall, and from the wing tanks to the fuselage; the remaining lines were inaccessible due to airframe damage. Air was blown from the engine driven fuel pump inlet line aft through the fuel selector and air/fuel exited the left wing fuel tank outlet line. With no obvious anomalies with the airframe or engine, the engine was shipped to Continental Motors to be run in a test cell.

The engine was installed into a test cell. It started normally and ran for a while at 1,200 RPM with no anomalies noted. The power was increased to 2,100 rpm and the engine operated inconsistently; the fuel pump pressure was fluctuating, and after about 30 seconds the engine stabilized. After stabilization, a magneto check was completed and no abnormalities were noted. The engine power was increased to 2,400 RPM momentarily before full power was applied; the engine continued to operate normally. The engine power was abruptly changed between idle and full power several times with no anomalies noted. Unable to recreate the inconsistent running engine, it was shut down normally and removed from the test cell.

The fuel components were removed from the engine. The fuel manifold valve was disassembled and rust indicative of corrosion was present on the screen and lower housing of the unit. The plunger was removed and it also exhibited rust. The diaphragm was removed and a small amount of fuel was found on the "dry" side of the valve; the vent extending from this section was examined and clear of debris.

The most recent entries from the airplane's airframe and engine maintenance logbooks were three annual inspections that occurred over a span of about 8 years. The tach time difference between these inspections was a total of 73 hours, for an average of 9 hours a year. The wife of the pilot reported that they purchased the airplane in 2002, and it has been parked in a hangar for a majority of their ownership. About 1.5 years leading up to the accident, the airplane had been undergoing an annual inspection and new paint, which was completed on February 24, 2017. When the maintenance was completed, the pilot ran the airplane's engine on the ground for about 45 minutes with no anomalies noted; the accident flight was the first flight post maintenance.

According to a Continental Motors representative the fuel manifold valve is generally not disassembled by a mechanic in the field, and there are rarely issues with this engine component. If fuel issues are suspected, the troubleshooting section of the Continental Motors Standard Practices Manual (M-0) directs the mechanic to an isolated fix. If the problem is isolated to the fuel manifold, it is to be removed and either sent to an appropriate overhaul facility, or replaced by a new or rebuild from Continental Motors. 

History of Flight

Initial climb

Fuel related (Defining event)
Loss of engine power (total)
Off-field or emergency landing

Landing
Aerodynamic stall/spin
Collision with terr/obj (non-CFIT) 

Pilot Information

Certificate: Airline Transport; Flight Engineer
Age: 61, Male
Airplane Rating(s): Multi-engine Land; Multi-engine Sea; Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): Glider
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 10/28/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 22000 hours (Total, all aircraft) 



Aircraft and Owner/Operator Information

Aircraft Manufacturer: BELLANCA
Registration: N39894
Model/Series: 17-30A
Aircraft Category: Airplane
Year of Manufacture: 1973
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 73-30544
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 02/24/2017, Annual
Certified Max Gross Wt.: 
Time Since Last Inspection: 1 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3394 Hours as of last inspection
Engine Manufacturer: CONT MOTOR
ELT: Not installed
Engine Model/Series: IO 520 SERIES
Registered Owner: On file
Rated Power: 285 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: CXP, 4705 ft msl
Observation Time: 1255 PST
Distance from Accident Site: 0 Nautical Miles
Direction from Accident Site:
Lowest Cloud Condition: Clear
Temperature/Dew Point: 7°C / -9°C
Lowest Ceiling: None
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 4 knots, 100°
Visibility (RVR):
Altimeter Setting: 30.41 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Carson City, NV (CXP)
Type of Flight Plan Filed: None
Destination: Carson City, NV (CXP)
Type of Clearance: None
Departure Time: 1250 PST
Type of Airspace:

Airport Information


Airport: Carson Airport (CXP)
Runway Surface Type: Asphalt
Airport Elevation: 4705 ft
Runway Surface Condition: Dry
Runway Used: 9
IFR Approach: None
Runway Length/Width: 6100 ft / 75 ft
VFR Approach/Landing: Forced Landing 

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious
Latitude, Longitude: 39.192222, -119.732778 (est)



NTSB Identification: WPR17LA072
14 CFR Part 91: General Aviation
Accident occurred Wednesday, March 01, 2017 in Carson City, NV
Aircraft: BELLANCA 17-30A, registration: N39894
Injuries: 1 Serious.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On March 1, 2017, about 1250 Pacific standard time, a Bellanca 17-30A, N39894, experienced a loss of engine power shortly after takeoff from the Carson Airport (CXP), Carson City, Nevada. The pilot, sole occupant, was seriously injured, and the airplane sustained substantial damage to both wings. The airplane was registered to, and operated by, the pilot as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident and it is unknown if a flight plan was filed. The flight was destined for an unknown location.

A witness reported that they observed the airplane takeoff normally, with the exception that the landing gear remained in the down position. At the end of the runway, when the airplane was no higher than 300 feet, it sounded as if the engine decreased to idle. The airplane made a right 180 degree turn and descended rapidly before impacting the ground. 

The airplane has been recovered to a secure location for further examination.

Eurocopter AS 350 B3, N413LP, Helicorp Inc: Accident occurred February 21, 2017 at Fernando Luis Ribas Dominicci Airport (TJIG), San Juan, Puerto Rico

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; San Juan, Puerto Rico

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf 


Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf 

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


HeliCorp Inc: http://registry.faa.gov/N413LP


Location: San Juan, PR
Accident Number: ERA17LA126
Date & Time: 02/21/2017, 1015 AST
Registration: N413LP
Aircraft: EUROCOPTER AS 350
Aircraft Damage: Substantial
Defining Event: Fire/smoke (non-impact)
Injuries: 2 None
Flight Conducted Under:  Part 91: General Aviation - Instructional

Analysis 

The pilot/owner of the turbine helicopter was practicing autorotations with a flight instructor. After completing several autorotations uneventfully, the instructor asked if he could perform one, and the pilot agreed. Near the flare at the end of the maneuver, the pilot heard the engine overrev, followed by an Nr (rotor speed) aural warning, followed by a fire warning light illumination on the instrument panel. After landing, the pilot exited the helicopter with a fire extinguisher and attempted to extinguish an engine fire.

Review of data downloaded from a vehicle-engine multifunction display and digital engine control unit revealed that the first failure recorded during the flight indicated that the gas generator rotation speed (N1) reached an out-of-limit value. At that time, the fuel regulation was in mixed mode, as the collective twist grip throttle control was out of the "flight" detent and the pilot was manually controlling the throttle. A second failure was recorded 2 seconds later, which indicated that the free turbine rotation speed (N2) reached an out-of-limit value. The failure was triggered by the maximum recorded value of 545 rpm, which equated to a turbine speed (Nr) of 140%.

The engine's freewheeling turbine was designed to separate turbine blades at 150% Nr in order to prevent the turbine disc separating at 170% Nr. It is likely that the flight instructor excessively opened the fuel metering unit via the twist grip throttle manual control, which resulted in an engine overspeed, turbine blade separation, and subsequent engine fire. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The flight instructor's incorrect manipulations of the twist grip throttle control during a practice autorotation, which resulted in an engine overspeed and subsequent fire.

Findings

Aircraft
Fuel controlling system - Incorrect use/operation (Cause)

Personnel issues
Incorrect action performance - Instructor/check pilot (Cause)

Factual Information

On February 21, 2017, about 1015 Atlantic standard time, an Airbus Helicopters (Eurocopter) AS 350 B3, N413LP, operated by the commercial pilot, was substantially damaged during a practice autorotation at Fernando Luis Ribas Dominicci Airport (TJIG), San Juan, Puerto Rico. The flight instructor and commercial pilot were not injured. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the flight that originated from TJIG about 0900.

According to the flight instructor's written statement, he was the pilot-in-command for the flight and the commercial pilot/owner of the helicopter was practicing autorotations. During recovery from the last 180° autorotation, the flight instructor noticed that the engine rpm continued to increase and exceeded limitations, followed by a vibration in the helicopter. He then immediately landed on a grass area near a runway. After the landing, a mechanic told him that the helicopter's engine was on fire. The flight instructor completed the engine fire procedure and exited the helicopter.

According to the commercial pilot's written statement, he had completed several training maneuvers and autorotations uneventfully. The flight instructor then asked if he could perform an autorotation and the commercial pilot agreed. During the flare at the end of the autorotation, the commercial pilot heard the engine overrev, followed by an Nr (rotor speed) aural warning, followed by a fire warning light illumination on the instrument panel. After landing, the commercial pilot exited the helicopter with a fire extinguisher and attempted to extinguish an engine fire.

Review of airport security video revealed that the helicopter was descending to a grass area adjacent to the runway. About 30 feet above ground level, smoke began emitting from the helicopter and it climbed out of the video frame. It then descended back into the video frame and landed on the grass while smoke continued to emit from the helicopter.

Examination of the helicopter by a Federal Aviation Administration inspector revealed that the fire resulted in damage to the engine deck support structure and a portion of the tail rotor drive shaft. A vehicle and engine multifunction display (VEMD), digital engine control unit (DECU), hydromechanical unit (HMU), and assembly valve were retained for examination and data download at the manufacturers' facilities under the supervision of the Bureau d'Enquetes et d'Analyses (BEA) in France. Examination and testing of the HMU and assembly valve did not reveal any anomalies that would have precluded normal engine operation.

Review of data downloaded from the VEMD and DECU revealed that during the accident flight, the first failure recorded by both computers was an NG/N1 failure, respectively. The failure was recorded at 1 hour, 13 minutes, 18 seconds (1:13:18) into the 1-hour, 14-minute flight by the VEMD and 1:13:27 by the DECU. The recorded failure indicated that the gas generator rotation speed (N1) reached an out of limit value. At that time, the fuel regulation was in mixed mode as the collective twist grip throttle control was out of the "flight" detent and the pilot was manually controlling the throttle. A second failure was recorded 2 seconds later, which indicated that the free turbine rotation speed (N2) reached an out of limit value. The failure was triggered by the maximum recorded value of 545 rpm, which equated to an Nr of 140%.

According to a representative from the engine manufacturer, the engine's freewheeling turbine was designed for its turbine blades to separate at 150% turbine speed. The design was to prevent the turbine disc from separating at a turbine speed of 170%. During his examination of the engine, the representative observed evidence consistent with the turbine blades separating, resulting in an engine fire. 

History of Flight

Autorotation
Miscellaneous/other
Fire/smoke (non-impact) (Defining event)

Pilot Information

Certificate: Airline Transport; Commercial
Age: 37, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: 3-point
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 02/07/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 09/20/2016
Flight Time: 6250 hours (Total, all aircraft), 950 hours (Total, this make and model), 5500 hours (Pilot In Command, all aircraft), 280 hours (Last 90 days, all aircraft), 40 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft) 

Pilot Information

Certificate: Commercial
Age: 74, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 03/03/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 01/01/2016
Flight Time:  8467 hours (Total, all aircraft), 5200 hours (Total, this make and model), 8467 hours (Pilot In Command, all aircraft), 31 hours (Last 90 days, all aircraft), 12 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: EUROCOPTER
Registration: N413LP
Model/Series: AS 350 B3
Aircraft Category: Helicopter
Year of Manufacture: 1999
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 3228
Landing Gear Type: High Skid
Seats: 6
Date/Type of Last Inspection: 06/09/2016, 100 Hour
Certified Max Gross Wt.: 4961 lbs
Time Since Last Inspection: 59 Hours
Engines: 1 Turbo Shaft
Airframe Total Time:  1846 Hours at time of accident
Engine Manufacturer: Turbomeca
ELT: C126 installed, not activated
Engine Model/Series: Arriel 2B
Registered Owner: HELICORP INC
Rated Power: 871 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: TJIG, 10 ft msl
Observation Time: 1001 AST
Distance from Accident Site: 0 Nautical Miles
Direction from Accident Site: 0°
Lowest Cloud Condition: Scattered / 3000 ft agl
Temperature/Dew Point: 23°C / 19°C
Lowest Ceiling: Broken / 5500 ft agl
Visibility:  8 Miles
Wind Speed/Gusts, Direction: 6 knots/ 12 knots, 330°
Visibility (RVR):
Altimeter Setting: 29.95 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Juan, PR (TJIG)
Type of Flight Plan Filed: None
Destination: San Juan, PR (TJIG)
Type of Clearance: None
Departure Time: 0900 AST
Type of Airspace: 

Airport Information

Airport: Fernando Luis Ribas Dominicci (TJIG)
Runway Surface Type: Grass/turf
Airport Elevation: 10 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Simulated Forced Landing 

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: In-Flight
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude:  18.456667, -66.098333 (est)

NTSB Identification: ERA17LA126
14 CFR Part 91: General Aviation
Accident occurred Tuesday, February 21, 2017 in San Juan, PR
Aircraft: EUROCOPTER AS 350, registration: N413LP
Injuries: 2 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On February 21, 2017, about 1015 Atlantic Standard Time, an Airbus Helicopters (Eurocopter) AS 350 B3, N413LP, operated by the commercial pilot, was substantially damaged during a practice autorotation at Fernando Luis Ribas Dominicci Airport (TJIG), San Juan, Puerto Rico. The flight instructor and commercial pilot were not injured. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the flight that originated from TJIG about 0830.

According to the flight instructor's written statement, he was the pilot-in-command for the flight and the commercial pilot was practicing autorotations. During recovery from the last 180° autorotation, the flight instructor noticed that the engine rpm continued to increase and exceeded limitations, followed by a vibration in the helicopter. He then immediately landed on a grass area near a runway. After the landing, a mechanic told him that the helicopter's engine was on fire. The flight instructor completed the engine fire procedure and exited the helicopter.

According to the commercial pilot's written statement, he had completed several training maneuvers and autorotations uneventfully. The flight instructor then asked if he could perform another autorotation and the commercial pilot agreed. During the flare at the end of the autorotation, the commercial pilot heard the engine overrev, followed by an Nr aural warning, followed by a fire warning light illumination on the instrument panel. After landing, the commercial pilot exited the helicopter with a fire extinguisher and attempted to extinguish an engine fire.


Examination of the helicopter by a Federal Aviation Administration inspector revealed that the fire resulted in damage to the engine deck support structure and a portion of the tail rotor drive shaft. A vehicle engine multi display (VEMD), digital engine control unit (DECU), hydromechanical unit (HMU), and adjusted valve were retained for examination.

Eurocopter MBB-BK 117 C-2, N140SF: Accident occurred October 12, 2017 at Ingersoll Airport (KCTK), Canton, Fulton County, Illinois

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Springfield, Illinois

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N140SF

Location: Canton, IL
Accident Number: GAA18CA012
Date & Time: 10/12/2017, 2335 CDT
Registration: N140SF
Aircraft: EUROCOPTER DEUTSCHLAND GMBH MBB BK 117
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional 

The helicopter flight instructor reported that he was training a new company pilot at night, and they were using night vision goggles. He added that, while in a hover, he attempted to demonstrate the use of the controllable search light to the pilot in the right seat.

The flight instructor added that, "to adjust the light, I took the [left] cyclic in my left hand which would normally be holding the left collective and attempted to reach the control switch for the light and grabbed the throttles of the right collective with my right hand. My right hand would normally be on the left cyclic." He further added that, he then inadvertently pushed down on the collective and the helicopter began to settle on the runway. He reported in response "my reflex was to pull up with my left hand (which would normally be on the collective)," and when he did so the helicopter moved rearward. Subsequently, he "pushed the cyclic forward to correct" the rearward movement, but in doing so, the helicopter touched down hard and the main rotor impacted the upper wire strike protection unit.

The main rotor sustained substantial damage.

The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.

Flight Instructor Information

Certificate: Airline Transport; Flight Instructor
Age: 54, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 01/26/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 07/11/2017
Flight Time: (Estimated) 6933 hours (Total, all aircraft), 1130 hours (Total, this make and model), 5845 hours (Pilot In Command, all aircraft), 53 hours (Last 90 days, all aircraft), 18 hours (Last 30 days, all aircraft) 

Pilot Information

Certificate: Commercial
Age: 29, Male
Airplane Rating(s): None
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: Unknown
Instrument Rating(s): Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 05/30/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 12/15/2016
Flight Time:  (Estimated) 3888 hours (Total, all aircraft), 11 hours (Total, this make and model), 3650 hours (Pilot In Command, all aircraft), 56 hours (Last 90 days, all aircraft), 9 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: EUROCOPTER DEUTSCHLAND GMBH
Registration: N140SF
Model/Series: MBB BK 117 C-2
Aircraft Category: Helicopter
Year of Manufacture: 2010
Amateur Built: No
Airworthiness Certificate: Transport
Serial Number: 9389
Landing Gear Type: Skid
Seats: 5
Date/Type of Last Inspection: 10/02/2017, AAIP
Certified Max Gross Wt.: 7887 lbs
Time Since Last Inspection:
Engines: 2 Turbo Shaft
Airframe Total Time: 3156.9 Hours at time of accident
Engine Manufacturer: TURBOMECA/ SAFRAN
ELT: C126 installed, not activated
Engine Model/Series: ARRIEL 1E2
Registered Owner: BB&T EQUIPMENT FINANCE CORP.
Rated Power: 760 hp
Operator: OSF AVIATION LLC.
Operating Certificate(s) Held: On-demand Air Taxi (135)
Operator Does Business As:
Operator Designator Code: O84A 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: KCTK, 683 ft msl
Observation Time: 0454 UTC
Distance from Accident Site: 0 Nautical Miles
Direction from Accident Site: 0°
Lowest Cloud Condition: Partial Obscuration
Temperature/Dew Point: 14°C / 11°C
Lowest Ceiling: Overcast / 2000 ft agl
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 11 knots, 180°
Visibility (RVR):
Altimeter Setting: 30.11 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: PEORIA, IL (PIA)
Type of Flight Plan Filed: Company VFR
Destination: Canton, IL (CTK)
Type of Clearance: Traffic Advisory; VFR; VFR Flight Following
Departure Time: 2255 CST
Type of Airspace: Class G 

Airport Information

Airport: INGERSOLL (CTK)
Runway Surface Type: Asphalt
Airport Elevation: 683 ft
Runway Surface Condition: Dry
Runway Used: 36
IFR Approach: None
Runway Length/Width: 3899 ft / 75 ft
VFR Approach/Landing: Full Stop

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 40.563611, -90.074167 (est)