Sunday, October 28, 2018

Cessna 210-5, registered to and operated by the pilot, N8347Z: Fatal accident occurred October 16, 2017 in Russian Mission, Alaska

Kyle Stevens, 31

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Bethel, Alaska
Continental Motors; Mobile, Alabama

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


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
Location:  Russian Mission, AK
Accident Number: ANC18FA003
Date & Time: 10/16/2017, 1430 AKD
Registration: N8347Z
Aircraft: CESSNA 210
Aircraft Damage: Destroyed
Defining Event: VFR encounter with IMC
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On October 16, 2017, about 1430 Alaska daylight time, a Cessna 210-5 airplane, N8347Z, impacted the Yukon River about 10 miles southwest of Russian Mission, Alaska. The private pilot sustained fatal injuries, and the airplane was destroyed. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed at the accident site. No flight plan had been filed for the visual flight rules (VFR) flight, and no record of the pilot receiving a preflight weather briefing could be found. The flight originated about 1415 from Kako Airport, Kako, Alaska, with a destination of Bethel Airport (PABE), Bethel, Alaska. 

Visual meteorological conditions were reported at the time of departure. According to a pilot of an airplane that departed about 10 minutes ahead of the accident airplane on the same route of flight and also destined for Bethel, widespread areas of low-level fog (between 400 and 600 ft above ground level [agl]) existed along the route. This pilot stated, during a postaccident interview, that he conversed with the accident pilot (after he departed from Kako) about the fog layers. No further radio communications occurred between the pilots. The interviewed pilot indicated that he tried to contact the accident pilot about 15 minutes after their conversation but received no response. After arriving at PABE and loading passengers, the interviewed pilot departed for a return flight to Kako. During that flight, he searched for the accident pilot's airplane but could not locate the airplane. After landing at Kako, the interviewed pilot notified the Federal Aviation Administration (FAA) Flight Service Station about the overdue airplane, and the FAA issued an alert notice (ALNOT) at 1748. On October 17, the accident airplane was located submerged in the Yukon River about 10 miles southwest of Russian Mission. 

The interviewed pilot stated that he flew his airplane at 1,500 ft agl above the fog and with 20-mile visibility. The pilot also stated that, at that altitude, he could see fog laying on the ground, on hills, and over the Yukon River. He did not know the altitude of the accident airplane but indicated that, in the area of the accident site, the fog was thick with no holes visible.

Pilot Information

Certificate: Private
Age: 31, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 02/01/2014
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  35 hours (Total, all aircraft) 

The pilot, age 31, held a private pilot certificate with an airplane single-engine land rating. The pilot did not have an instrument rating. His most recent third-class medical certificate was issued on February 1, 2014, without waivers or limitations. At the time of the pilot's application for his medical certificate, he reported 35 hours of total flight experience. A relative of the pilot estimated that he had accumulated about 160 hours of total flight experience. 

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N8347Z
Model/Series: 210 5
Aircraft Category: Airplane
Year of Manufacture: 1963
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 205-0347
Landing Gear Type: Tricycle
Seats: 
Date/Type of Last Inspection:  09/08/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 5533.7 Hours as of last inspection
Engine Manufacturer: Continental Motors
ELT: Installed, not activated
Engine Model/Series: O-470
Registered Owner: On file
Rated Power: 265 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane was manufactured in 1963 and was equipped with a Continental Motors IO-470 series engine. The airplane's last annual inspection was completed on September 8, 2017. At that time, the airplane had accumulated 5,533.7 total hours, and the tachometer displayed 1,649.2 hours. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: PARS, 51 ft msl
Distance from Accident Site: 9 Nautical Miles
Observation Time: 2213 UTC
Direction from Accident Site: 24°
Lowest Cloud Condition: Scattered / 300 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 3600 ft agl
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual: / Unknown
Wind Direction: 140°
Turbulence Severity Forecast/Actual: / Unknown
Altimeter Setting: 29.68 inches Hg
Temperature/Dew Point: 3°C / 2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: RUSSIAN MISSION, AK (9AK2)
Type of Flight Plan Filed: None
Destination: BETHEL, AK (BET)
Type of Clearance: None
Departure Time: 1415 AKD
Type of Airspace: Class G 

The National Transportation Safety Board (NTSB) performed a detailed weather study for this accident. Russian Mission Airport, located about 9 nautical miles (nm) north-northeast of the accident site, was the closest airport with official weather observations. At 1413 (about 17 minutes before the accident), a METAR reported the following information: wind from 140° at 3 knots; visibility 10 statute miles; scattered clouds at 300 ft agl, scattered clouds at 2,600 ft agl, and broken ceiling at 3,600 ft agl; temperature 37°F; dew point 36°F; and altimeter setting 29.68 inches of mercury. At 1446 (about 16 minutes after the accident), a METAR reported the following information: wind from 170° at 4 knots; visibility 10 statute miles with light rain; scattered clouds at 1,000 ft agl, broken ceiling at 2,300 ft agl, and overcast skies at 3,400 ft; temperature 37°F; dew point 34°F; and altimeter setting 29.68 inches of mercury. In addition, the 1446 METAR reported that the rain began at the airport at 1432.

Marshall Don Hunter Sr. Airport, Marshall, Alaska, the next closest airport with official weather observations, was located 21 nm northwest of the accident site. At 1356 (34 minutes before the accident), a METAR reported wind from 250° at 4 knots, visibility 10 statute miles, broken ceiling at 2,700 ft agl and overcast skies at 3,500 ft agl, temperature 37°F, dew point 35°F, and altimeter setting 29.67 inches of mercury.

Only one pilot report (PIREP) was available for the 3 hours surrounding the accident at an altitude below 18,000 ft and within 200 nm of the accident site. The PIREP was reported over Aniak, Alaska (about 50 nm southeast of the accident site), at 1512. The pilot of a Cessna 208 reported an overcast ceiling at 700 ft with cloud tops at 4,000 ft.

The area forecast issued at 1206, which was valid at the time of the accident, forecasted an AIRMET for instrument conditions, broken to overcast ceiling at 300 ft with cloud tops at 10,000 ft, and visibilities below 1 mile in mist with improving conditions forecast into the afternoon and evening hours.

The closest National Weather Service Weather Surveillance Radar-1988, Doppler (WSR-88D) was near PABE, located 52 miles south-southwest of the accident site. The radar detected reflectivity targets and associated rain showers above the accident site at 1422 and 1432. The area of rain showers was moving from southwest to northeast and had moved over and past the accident site between 1402 and 1442. No lightning strikes were at or near the accident site at the accident time.

The FAA's aviation weather cameras in Russian Mission showed the weather conditions surrounding the time of the accident. Images from the south- and southwest-facing cameras depicted rain shower conditions with the rain showers moving across the area with low ceiling and visibility conditions within the rain showers beyond the visibility reference point. The south-facing camera also indicated a low bank of clouds toward the Yukon River, the accident site, and along the intended flight route.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 61.640000, -161.445556 

The airplane was located about 10 miles southwest of Russian Mission, submerged about 15 ft in the Yukon River. The main wreckage was recovered and moved ashore. A portion of the forward fuselage, the engine, and the wings were located but could not be recovered. The location of these parts items has been confirmed using SONAR equipment and will be examined if they are eventually recovered at a later date.

The horizontal and vertical stabilizers remained attached to the empennage. The vertical stabilizer and left horizontal stabilizer were relatively free of impact damage. About 3 ft of the outboard portion of the right horizontal stabilizer and elevator was displaced about 45° up and was absent any leading-edge nicks or gouges.

The aft fuselage separated from the forward fuselage at the upper production joint near the forward end of the rear windows. The rivets from the upper production joint on the left side were pulled through the joint, which was consistent with the left wing rotating forward during impact. The rivets from the upper production joint on the right side did not pull but were popped out, which was consistent with the right wing rotating aft during impact.

The front left (pilot) seat was located about 5 miles downstream from the main wreckage location. The seat did not show any evidence of compression damage. The front right (copilot) seat was located about 10 miles downstream from the main wreckage location. Compression damage appeared on the bottom of the seat on the right side. More compression was found on the forward right side of the seat than on the rear right side. The left side of the seat showed relatively little crushing damage.

Medical And Pathological Information

The State of Alaska Medical Examiner's Office, Anchorage, Alaska, conducted an autopsy of the pilot. His cause of death was multiple blunt force injuries.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot, which were negative for drugs, ethanol, and carbon monoxide. 

Tests And Research

The airplane was equipped with a J.P. Instruments (JPI) Engine Data Monitor (EDM) model 730, installed under STC SA00432SE and STC SA2586NM. The EDM model 730 is a panel-mounted LCD display that can monitor and record up to 24 parameters related to engine operations, including cylinder head temperature for each cylinder, exhaust gas temperature for each cylinder, fuel flow, fuel pressure, RPM, manifold pressure, and oil pressure and temperature.

The EDM was removed from the accident airplane and sent to the NTSB's Vehicle Recorders Laboratory in Washington, DC, for download. The data began recording at 1418:42 and were recorded in 6-second intervals. At 1420:30 and 1421:30, the engine parameters appeared consistent with the engine run-up. The manifold pressure, rpm, and other engine parameters appeared consistent with the takeoff roll at 1421:40.

For about the next 9.5 minutes, until the data recording ended at 1431:06, all engine parameters appeared nominal. Specifically, the final set of recorded data indicated that the cylinder head temperatures ranged from 290° to 365° F, exhaust gas temperatures ranged from 1,404° to 1,503° F, fuel flow was 13.1 gallons per hour, rpm was 2,415, manifold pressure was 23.4 inches of mercury, oil pressure was 39 psi, and oil temperature was 123° F. The EDM specialist's factual report is in the public docket for this accident.

The attitude indicator was also removed from the airplane and was examined by the NTSB Materials Laboratory in Washington, DC. The indicator's glass face was intact with slight scratching damage. No significant deformation damage was found on the outside of the case. After disassembly, the gimbals were found to move freely. Further disassembly to the gyro revealed wetness and corrosion, but the rotor spun freely on the shaft within its housing. No scoring or deep gouge marks were observed in either the rotor or gyro housing surfaces.

Additional Information

An FAA safety brochure, titled "Spatial Disorientation Visual Illusions," included the following information:

The flight attitude of an airplane is generally determined by the pilot's visual reference to the natural horizon. When the natural horizon is obscured, attitude can sometimes be maintained by visual reference to the surface below. If neither horizon nor surface visual references exist, the airplane's attitude can only be determined by artificial means such as an attitude indicator or other flight instruments. Surface references or the natural horizon may at times become obscured by smoke, fog, smog, haze, dust, ice particles, or other phenomena, although visibility may be above VFR minimums. This is especially true at airports located adjacent to large bodies of water or sparsely populated areas, where few, if any, surface references are available. Lack of horizon or surface reference is common on over-water flights, at night, or in low visibility conditions.

To prevent spatial disorientation, the brochure recommended relying on flight instruments when flying in reduced visibility conditions and not attempting visual flight when there is a possibility of being trapped in deteriorating conditions.

NTSB Identification: ANC18FA003
14 CFR Part 91: General Aviation
Accident occurred Monday, October 16, 2017 in Russian Mission, AK
Aircraft: CESSNA 210, registration: N8347Z
Injuries: 1 Fatal.

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 either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On October 16, 2017, about 1430 Alaska daylight time, a Cessna 210-5 airplane, N8347Z, impacted the waters of the Yukon River, about 10 miles southwest of Russian Mission, Alaska. The private pilot sustained fatal injuries, and the airplane was destroyed. The flight was being operated by the pilot as a 14 Code of Federal Regulations (CFR) Part 91 visual flight rules (VFR) flight. Visual meteorological conditions were reported at the time of departure. No flight plan had been filed and there is no record of the pilot receiving a preflight weather briefing. The flight originated about 1415 from the Kako Airport, Kako, Alaska, and it was destined for Bethel, Alaska. 

According to a pilot that departed about 10 minutes ahead of the accident pilot on the same route of flight and also destined for Bethel, wide-spread areas of low level fog existed along the route. He stated in an interview that after both aircraft departed and were airborne, he conversed with the accident pilot and discussed the fog layers. He flew his route at 1,500ft above ground level (agl), above the fog and in good visibility but he was unsure of the altitude of the accident pilot. He estimated the fog existed between 400ft agl and 600ft agl. When he tried to contact the accident pilot about 15 minutes later, there was no response and no further radio communications were received.

After arriving in Bethel and loading passengers, the interviewed pilot departed for a return flight to Kako. Along the flight, he searched for the second airplane, but was unsuccessful in locating the airplane. After landing at Kako, he notified the FAA Flight Service Station and an alert notice (ALNOT) was issued at 1748. On October 17, the airplane was located about 10 miles southwest of Russian Mission, submerged in the waters of the Yukon River. The main wreckage was recovered and moved to shore. To date, a portion of the forward fuselage, the engine and wings remain submerged. The location of these items has been confirmed using SONAR equipment and will be examined if recovered later. 

The closest official weather observation station is Russian Mission, which is located about 10 miles northeast of the accident site. At 1413, a METAR was reporting, in part, wind 140° at 3 knots; visibility 10 statute miles; clouds and ceiling 200 ft scattered, 2,600 ft scattered, 3,600 ft broken; temperature 37° F; dew point 36° F; altimeter 29.68 inches of Mercury.

Cessna 401B, owned and operated by the pilot, N401HH: Fatal accident occurred October 04, 2017 in Salters, Williamsburg County, South Carolina

Henry Curtis Haddock

Henry Curtis Haddock, a Kingstree, South Carolina, native who turned a love of flying into a lifelong career, died on October 4th, 2017. He was 66. 

Mr. Haddock graduated from Kingstree High School before earning a degree in Aircraft Technology from Florence-Darlington Technical College. As an aircraft mechanic at the Florence airport, Mr. Haddock yearned to get off the ground. At 17, he learned to fly. He earned local notoriety when he built a 1949 Piper Clipper from a “pile of parts” he had purchased.


Alec Taylor of Taylor Helicopters saw potential in the young Mr. Haddock. He offered him his first flying gig, crop dusting with a Cessna “Ag Wagon” in Latta, South Carolina. Several years later Mr. Haddock started his own company, Haddock Flying Service, Inc. The company used Hiller helicopters to spray timber and crops throughout the Southeast.  Mr. Haddock often piloted family and friends to his favorite vacation destination in Eleuthera, Bahamas. On October 4th he flew for the last time.



Wilson "Ken" Kenneth Britton, II

Ken was a 1993 graduate of Clemson University with a BS degree in Wildlife, Fisheries and Biology. He was quarry manager for Argos US in Harleyville, South Carolina. Ken was an avid hunter and loved to be outdoors. Most importantly, he loved his two children, Madeleine and Wilson and spending time with them.


The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Columbia, South Carolina
Textron; Wichita, Kansas
Continental Motors Inc; Mobile, Alabama

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/N401HH




Location: Salters, SC
Accident Number: ERA18FA004
Date & Time: 10/04/2017, 1745 EDT
Registration: N401HH
Aircraft: CESSNA 401
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On October 4, 2017, about 1745 eastern daylight time, a Cessna 401B, N401HH, was destroyed when it impacted terrain while maneuvering near a private airport in Salters, South Carolina. The commercial pilot and passenger were fatally injured. The airplane was owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which departed the airport about 1730.

A witness at the airport reported seeing the airplane take off from the private grass runway. About 10 minutes later, the airplane made a low pass over the runway, then entered a steep climb. The witness stated that the airplane rolled left, the left wing dropped, and the airplane rolled inverted and began descending in a nose-low attitude. The airplane rolled to a level attitude before it disappeared behind trees. The wreckage was located in an open field that was surrounded by trees about 1 mile southwest of the runway.

Another witness, who was about 1/2 mile from the end of the runway, described hearing the airplane make what sounded like a "high speed pass down the runway." He saw the airplane in a wings-level attitude, then it "snapped a barrel roll." He said the airplane rolled wings level over an open field about 100 to 150 yards before the tree line, and he subsequently heard the airplane impact trees.

The first witness recorded a cell phone video of the airplane just before impact; the footage was consistent with his statement. 

Pilot Information

Certificate: Commercial; Private
Age: 66, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 07/27/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  15000 hours (Total, all aircraft) 

The pilot held a commercial pilot certificate with ratings for airplane single- and multi-engine land, instrument airplane, and rotorcraft-helicopter. He also held an airframe and powerplant mechanic certificate. His most recent Federal Aviation Administration second-class airman medical certificate was issued on July 27, 2017, with the limitation, "must have glasses for near vision." At that time, he reported 15,000 total hours of flight experience. The pilot's flight experience at the time of the accident could not be determined. 

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N401HH
Model/Series: 401 B
Aircraft Category: Airplane
Year of Manufacture: 1969
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 401B0004
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 08/15/2017, Annual
Certified Max Gross Wt.: 6301 lbs
Time Since Last Inspection: 9 Hours
Engines: 2 Reciprocating
Airframe Total Time: 5557.1 Hours as of last inspection
Engine Manufacturer: CONT MOTOR
ELT: Installed, not activated
Engine Model/Series: TSIO-520-E9
Registered Owner: HADDOCK FLYING SERVICE INC
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None 

The six-seat, low-wing, retractable-gear airplane was manufactured in 1969. It was powered by two Continental TSIO-520E, 300-horsepower engines, driving McCauley three-bladed, constant-speed, full-feathering propellers.

The airplane's most recent annual inspection was completed on August 5, 2017, at 5557.1 total aircraft hours. The airplane had accrued 9.2 hours since the previous annual inspection on March 25, 2016. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KCKI, 66 ft msl
Distance from Accident Site: 14 Nautical Miles
Observation Time: 1735 EDT
Direction from Accident Site: 22°
Lowest Cloud Condition: Scattered / 4700 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: / None
Wind Direction:  
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.28 inches Hg
Temperature/Dew Point: 26°C / 17°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point:  Salters, SC (PVT)
Type of Flight Plan Filed: None
Destination:  Salters, SC (PVT)
Type of Clearance: None
Departure Time: 1730 EDT
Type of Airspace: Class G 

At 1735, the weather reported at Williamsburg Regional Airport, Kingstree, South Carolina, about 14 miles north of the accident site, included calm wind, 10 statute miles visibility, scattered clouds at 4,700 ft and 6,500 ft, temperature 26°C, dew point 17°C, and an altimeter setting of 30.28 inches of mercury.

Airport Information

Airport: PVT (PVT)
Runway Surface Type: N/A
Airport Elevation: 70 ft
Runway Surface Condition: Vegetation
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  33.496389, -79.957222 (est)

The airplane was examined at the accident site and all major components were accounted for at the scene. The wreckage path began in trees about 50 ft above the ground and was oriented on a magnetic heading about 280°. The main wreckage came to rest inverted on a heading of 230° and was consumed by a postcrash fire.

The outboard portion of the left wing was located at the initial tree strike. Fragments of the airframe were located at a second tree strike about 350 ft from the initial tree strike. The outboard portion of the right wing was located about 320 ft beyond the second tree strike. The main wreckage was about 930 ft from the initial tree strike; the right engine was about 90 ft past the main wreckage.

The flaps and the landing gear were retracted. Flight control cable continuity was confirmed from the all flight control surfaces to the cockpit area. Flight control cable continuity within the cockpit could not be confirmed due to fire damage. All cockpit instrumentation was destroyed by fire.

The left engine was separated from the nacelle and the wing and found inverted by the left wing. All six cylinders remained attached at their bases; the cooling fins sustained impact damage. The engine was manually rotated and thumb compression was obtained on all cylinders. A borescope inspection of the cylinders revealed that the tops of all pistons and all intake and exhaust valves exhibited normal combustion signatures. The propeller separated from the engine at the attachment bolts.

The right engine was separated forward of the main wreckage; it was found inverted and attached to the wing nacelle. All six cylinders remained attached; Nos. 2, 4 and 6 displayed cooling fin impact damage. The engine was manually rotated and thumb compression was obtained on all cylinders. A borescope inspection of the cylinders revealed that the tops of all pistons and all intake and exhaust valves exhibited normal combustion signatures. The propeller was separated from the engine at the propeller flange. 



Medical And Pathological Information

The Medical University of South Carolina, Charleston, South Carolina, conducted an autopsy of the pilot. The cause of death was listed as multiple blunt force injuries.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of samples from the pilot. The testing was positive for ethanol at 0.185 gm/dl in the urine and .0210 gm/dl in cavity blood. N-propanol was also found in cavity blood. In addition, colchicine, 0.122 µg/ml of diphenhydramine, donepezil, acetaminophen, benazepril, naproxen, and rosuvastatin were identified in urine.

Ethanol is the intoxicant commonly found in beer, wine, and liquor. It acts as a central nervous system depressant. After ingestion, at low doses, it impairs judgement, psychomotor functioning, and vigilance; at higher doses it can cause coma and death. The effects of ethanol are generally well understood; it significantly impairs pilot performance, even at very low levels. Federal Aviation Administration regulations prohibit any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more ethanol in the blood. Because ingested alcohol is distributed throughout the body, levels from different postmortem tissues are usually similar after ingestion. N-propanol is a type of alcohol that is produced in body tissues after death.

Colchicine is a prescription medication used to treat and prevent attacks of gout. It is not considered impairing.

Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under the trade names Benadryl and Unisom. Diphenhydramine carries the following FDA warning: "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Compared to other antihistamines, diphenhydramine causes marked sedation; this is the rationale for its use as a sleep aid. Altered mood and impaired cognitive and psychomotor performance may also be observed. In fact, in a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%. The therapeutic range for diphenhydramine is 0.0250 to 0.1120 µg/ml. Diphenhydramine undergoes pos mortem redistribution where, after death, the drug can leach from storage sites back into blood.

Donepezil is a prescription medication often marketed with the name Aricept and used to slow the progression of cognitive decline in Alzheimer's disease. While it is not considered impairing, the underlying disease is.

Hydroxychloroquine is an antimalarial medication that has anti-inflammatory properties that lead to its use in the treatment of rheumatoid arthritis. It is not considered cognitively impairing.

Acetaminophen is an analgesic available over the counter, commonly marketed with the name Tylenol. Benazepril is a blood pressure medication. Naproxen is an anti-inflammatory drug available over the counter and commonly marketed with the names Naprosyn and Aleve. Rosuvastatin is a cholesterol lowering medication commonly marketed with the name Crestor. None of these substances are considered impairing.

According to records obtained from the pilot's most recent primary care physician, he initiated care with the doctor on February 2, 2017. In the review of symptoms with the pilot, the physician noted, "no memory loss." The physician performed a mini-mental status exam and the pilot scored 28/30 points. He recalled only one of three objects after 5 minutes. The physician diagnosed "memory loss," but did not perform other testing. 

Three months later, the pilot returned to the doctor. According to the review of symptoms, the pilot denied episodes of weakness, loss of consciousness, memory impairment, difficulty concentrating, or any other neurologic or psychiatric issues. His neurologic exam was documented as normal; however, he was diagnosed with essential tremor, memory loss, and transient ischemic attack as well as hypertension. The physician added another blood pressure medication and prescribed donepezil for memory loss.



NTSB Identification: ERA18FA004
14 CFR Part 91: General Aviation
Accident occurred Wednesday, October 04, 2017 in Salters, SC
Aircraft: CESSNA 401B, registration: N401HH
Injuries: 2 Fatal.

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 either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On October 4, 2017, about 1745 eastern daylight time, a Cessna 401B, N401HH, was destroyed after it impacted terrain while maneuvering near Salters, South Carolina. The commercial pilot and a passenger were fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

A witness at the airport reported seeing the airplane takeoff. About 10 minutes later, the pilot made a low pass over the grass strip and then began a steep climb. The witness stated the airplane rolled left, the left wing dropped and the airplane was inverted and descending in a nose low attitude. The airplane's wings were level before it disappeared behind trees. The airplane was located in an open field that was surrounded by trees about 1 mile southwest from the departure airport.

The airplane was examined at the accident site and all major components were accounted for at the scene. The wreckage path began in trees about 50 ft above the ground, and was oriented about 280° magnetic. The main wreckage came to rest inverted, facing 230° and was consumed by a postcrash fire.

The outboard portion of the left wing was located at the initial tree strike. Fragments of the airframe were located at a second tree strike, about 350 ft from the initial tree strike. The outboard portion of the right wing was located about 320 ft beyond the second tree strike. The main wreckage was about 930 ft from the initial tree strike, the right engine was about 90 ft past the main wreckage.

The flaps and the landing gear were in the up position. Flight control cable continuity was confirmed from the all flight control surfaces to the cockpit area. Flight control cable continuity within the cockpit could not be confirmed due to fire damage. All cockpit instrumentation was destroyed by fire.

The left engine was separated from the nacelle and the wing, and found inverted by the left wing. All six cylinders remained attached at their bases, the cooling fins sustained impact damage. The engine was manually rotated, thumb compression was obtained on all cylinders. A borescope inspection of the cylinders revealed the tops of all pistons and all intake and exhaust valves exhibited normal combustion signatures. The propeller separated from the engine at the attachment bolts.

The right engine was separated forward of the main wreckage; it was found inverted and attached to the wing nacelle. All six cylinders remained attached; Nos. 2, 4 and 6 had cooling fin impact damage. The engine was manually rotated and thumb compression was obtained on all cylinders. A borescope inspection of the cylinders revealed the tops of all pistons and all intake and exhaust valves exhibited normal combustion signatures. The propeller was separated from the engine at the propeller flange.

The six-seat, low-wing, retractable-gear equipped airplane was manufactured in 1969. It was powered by two Continental TSIO-520E, 300-horsepower engines, driving McCauley three-bladed, constant speed, full feathering propellers.

The pilot held a commercial pilot certificate with an airplane single and multiengine land, and rotorcraft/helicopter ratings. He also held ratings for single and multiengine instrument airplane, and airframe and powerplant mechanic. His most recent Federal Aviation Administration second-class airman medical certificate was issued on July 27, 2017, with the limitation, "must have glasses for near vision." At that time, he reported 15,000 total flight hours.

At 1735, the weather reported at Williamsburg Regional Airport (CKI), Kingstree, South Carolina, about 14 miles north of the accident site, included wind calm, visibility 10 statute miles; scattered clouds at 4,700 ft, scattered clouds at 6,500 ft; temperature 26° C, dew point 17° C, and altimeter 30.28 inches of mercury.

Schweizer 269C-1, owned by Herlihy Helicopters Inc and operated by Helicopter Flight Services, N204HF: Fatal accident occurred September 08, 2017 at Flying W Airport (N14), Medford, Burlington County, New Jersey

James Evan Robinson

Troy Gentry, one half of the country duo Montgomery Gentry, died after the helicopter crashed on September 8th, 2017. He was scheduled to perform at the Flying W Airport (N14) and resort later that evening. 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Philadelphia, Pennsylvania
Sikorsky; Coatesville, Pennsylvania
Lycoming; Williamsport, Pennsylvania

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/N204HF



Location: Medford, NJ
Accident Number: ERA17FA317
Date & Time: 09/08/2017, 1300 EDT
Registration: N204HF
Aircraft: SCHWEIZER 269C
Aircraft Damage: Substantial
Defining Event: Hard landing
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis

The purpose of the flight was to provide an orientation/pleasure flight to the passenger, who was scheduled to perform in a concert on the airport later that evening. Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported that he could "roll" the twist-grip; however, there was no corresponding change in engine power when he did so.

Three helicopter flight instructors, one a Federal Aviation Administration (FAA) inspector, one an FAA designated examiner, and a company flight instructor, joined the conversation on the radio to discuss with the pilot remedial actions and landing options. These options included a shallow, power-on approach to a run-on landing, or a power-off, autorotational descent to landing. The instructors encouraged the pilot to perform the run-on landing, but the pilot reported that a previous run-on landing attempt was unsuccessful. He then announced that he would shut down the engine and perform an autorotation, which he said was a familiar procedure that he had performed numerous times in the past. The instructors stressed to the pilot multiple times that he should delay the engine shutdown and autorotation entry until the helicopter was over the runway surface.

Video footage from a vantage point nearly abeam the approach end of the runway showed the helicopter about 1/4 to 1/2 mile south of the runway as it entered a descent profile consistent with an autorotation. Toward the end of the video, the descent profile steepened and the rate of descent increased before the helicopter descended out of view. Witnesses reported seeing individual rotor blades as the main rotor turned during the latter portion of the descent.

The increased angle and rate of descent and slowing of the rotor blades is consistent with a loss of rotor rpm during the autorotation. Despite multiple suggestions from other helicopter instructors that he initiate the autorotation above the runway, the pilot shut down the engine and entered the autorotation from an altitude about 950 ft above ground level between 1/4 and 1/2 mile from the end of the runway. Upon realizing that the helicopter would not reach the runway, the pilot could have landed straight ahead and touched down prior to the runway or performed a 180° turn to a field directly behind the helicopter; however, he continued the approach to the runway and attempted to extend the helicopter's glide by increasing collective pitch, an action that resulted in a decay of rotor rpm and an uncontrolled descent.

Examination of the wreckage revealed evidence consistent with the two-piece throttle control tie rod assembly having disconnected in flight. The internally threaded rod attached to the bellcrank and an externally threaded rod-end bearing attached to the throttle control arm displayed damage to the three end-threads of each. The damage was consistent with an incorrectly adjusted throttle control tie rod assembly with reduced thread engagement, which led to separation of the rod end bearing from the tie rod and resulted in loss of control of engine rpm via the throttle twist grip control. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's early entry into and failure to maintain rotor rpm during a forced landing autorotation after performing an engine shutdown in flight, which resulted in an uncontrolled descent. Contributing to the accident was the failure of maintenance personnel to properly rig the throttle control tie-rod assembly, which resulted in an in-flight separation of the assembly and rendered control of engine rpm impossible. 

Findings

Aircraft
Main rotor blade system - Incorrect use/operation (Cause)
Descent/approach/glide path - Not attained/maintained (Cause)
Descent rate - Not attained/maintained (Cause)
Power lever - Failure (Factor)

Personnel issues
Aircraft control - Pilot (Cause)
Decision making/judgment - Pilot (Cause)
Scheduled/routine maintenance - Maintenance personnel (Factor)

Factual Information


HISTORY OF FLIGHT

On September 8, 2017, about 1300 eastern daylight time, a Schweizer 269C-1 helicopter, N204HF, was substantially damaged during a collision with terrain while performing a forced landing to runway 01 at Flying W Airport (N14), Medford, New Jersey. The commercial pilot and passenger were fatally injured. The helicopter was owned by Herlihy Helicopters Inc and operated by Helicopter Flight Services under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight.

According to the chief flight instructor for the operator, the purpose of the flight was to provide an orientation/pleasure flight to the passenger, who was scheduled to perform in a concert on the airport later that evening.

Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported that he could "roll" the twist-grip but that there was no corresponding change in engine rpm when he did so.

The company flight instructor and another helicopter flight instructor, who was a designated pilot examiner (DPE), were monitoring the frequency and engaged the pilot in conversation about potential courses of action to accomplish a landing. A Federal Aviation Administration (FAA) inspector, who was also a helicopter instructor and examiner, joined the conversation on the radio.

Options discussed included a shallow approach to a run-on landing or a power-off, autorotational descent to landing. The instructors suggested that the pilot perform the run-on landing; however, the pilot reported that a previous attempt to perform a run-on landing was unsuccessful and announced that he would stop the engine and perform a power-off autorotation. The pilot stated that this was a familiar procedure he had performed numerous times in the past. When asked over the radio by the DPE when he had last performed an autorotation to touchdown, the pilot replied that 4 months had elapsed since his most recent touchdown autorotation. Subsequent attempts to convince the pilot to attempt a run-on landing were unsuccessful.

According to the DPE and the FAA inspector, the pilot was advised "multiple times" to aim to touch down "midfield" and not to initiate the engine shutdown and autorotation until over the runway. According to the DPE, his last reminder to the pilot came when the helicopter was on a 2-mile final approach.

A video forwarded to the NTSB by local police was recorded from a vantage point nearly abeam the approach end of runway 01. The video showed the helicopter about 1/4 mile south of the runway as it entered a descent profile consistent with an autorotation. Toward the end of the video, the descent profile became more vertical, and the rate of descent increased before the helicopter descended out of view. No sound could be heard from the helicopter.

During a postaccident interview with law enforcement, the company flight instructor reported that the helicopter entered the autorotation about 950 ft above ground level (agl) and that the helicopter was quiet during its descent "because the engine was off." During the descent, the rotor rpm decayed to the point where the instructor could see the individual rotor blades. The helicopter descended from view before reaching the runway threshold, and the sounds of impact were heard. Both the instructor and the FAA inspector reported that a high-pitched "whine" could be heard from the helicopter during the latter portion of the descent.

In a written statement, the flight instructor reported, "[the pilot] began the autorotative descent, but it was not long before it became apparent it was not being executed correctly. I began to see individual blades instead of a translucent disc. His vertical speed increased while his horizontal speed became almost non-existent. The nose of the [helicopter] rolled forward. Instead of being able to see the bottom of the [helicopter]… all I could see was the cockpit glass and rotor head."

James Evan Robinson graduated from Middle Georgia State University with a Bachelor of Science degree in Aviation Science and Management. He was a commercial pilot and flight instructor having worked for Helicopter Flight Services in Medford, New Jersey.   

PERSONNEL INFORMATION

The pilot held commercial and flight instructor certificates, each with ratings for rotorcraft-helicopter and instrument helicopter. His most recent FAA second-class medical certificate was issued April 12, 2017.

Excerpts of the pilot's logbook revealed that he had logged 480.9 total hours of flight experience, of which about 300 hours were in the accident helicopter make and model. The last entry logged was for 1.2 hours in the accident helicopter on the day of the accident.

Company training records indicated that the pilot had received the training required by the operator for employment as a flight instructor, and his last airman competency check was completed satisfactorily on April 19, 2017, in the accident helicopter.

AIRCRAFT INFORMATION

The helicopter was a single-engine, two-seat, light utility helicopter constructed primarily of aluminum alloy and powered by an air-cooled, Lycoming HO-360-C1A, 180-horsepower engine. It was equipped with conventional collective and cyclic control sticks and tail rotor control pedals.

The main rotor was a fully articulated, three-bladed design, and the tail rotor was a two-bladed, semi-rigid, anti-torque rotor design. Power was transmitted from the engine to the rotor system through a V-belt drive, which incorporated a free-wheeling (one-way) sprag clutch, a main drive transmission, a tail rotor transmission, and shafts.

According to FAA records, the helicopter was manufactured in 2000, delivered to the owner/operator, and had accrued about 7,899 total aircraft hours. Its most recent 100-hour inspection was completed on August 17, 2017, at 7,884 total aircraft hours.

A review of maintenance records revealed that the helicopter's engine was replaced with factory rebuilt or overhauled engines at the manufacturer's recommended overhaul intervals. Engine changes occurred in 2003, 2006, and most recently, on September 24, 2011.

The records reflected numerous entries regarding carburetor discrepancies. Carburetors were adjusted or removed and replaced with loaner carburetors then reinstalled following repairs. In February 2014, the carburetor was removed, sent out for repair, and reinstalled by the operator.

On August 31, 2016, the operator installed a throttle control cable manufactured by McFarlane Aviation Products, as documented on an FAA Form 337. A cable from the original equipment manufacturer was not available per the operator, and the FAA approved the manufacture and installation, which required the cable's inspection at 25-hour intervals. The inspections were documented; the most recent was completed concurrent with the annual inspection conducted 15 hours before the accident.

The operator was interviewed during a meeting with NTSB investigators and FAA inspectors regarding the maintenance history of the accident helicopter. He was later interviewed by telephone to gain more detail about the disassembly/reassembly and rigging of the throttle during carburetor/engine changes.

According to the operator, when the engine was changed for overhaul, the carburetor traveled with the engine, and the throttle control arm was removed at the carburetor splined shaft. The throttle control bellcrank was removed from the front of the carburetor, and the entire throttle control system remained with the helicopter. The throttle control arm, the throttle tie rod, the throttle control bellcrank, and the throttle cable all remained attached to each other and to the helicopter. He stated that, because of this, there was no need to disconnect or adjust the throttle tie rod that connected the bellcrank and the throttle control arm.

He also stated that, when a new engine was installed, the correct "angle" was measured for the installation of the throttle control arm on the carburetor. Adjustment of idle and mixture set screws was often required, as the carburetors were often set at the factory "for airplanes."

When asked about the most recent installation of the throttle control cable, the operator stated that the cable was a fixed measurement and changing the cable did not change the rigging of the throttle. He said that, when the cable was changed, no throttle rigging adjustments were necessary; the cable was disconnected at the bellcrank upstream of the tie rod and throttle control arm. He repeated that the cable installation was "plug and play" and that no adjustments were necessary to achieve/maintain proper throttle rigging.

The operator was asked specifically about the throttle rigging and the nominal measurement of the tie rod during the throttle rigging procedure following the most recent engine change. He stated, "I don't know if I did. I'm sure I did, because that's part of the procedure, but I'm not 100 percent [sure]."

According to the manufacturer's maintenance manual, actions that required compliance with the throttle rigging procedure included:

1. Installation of a new engine (Section 3-15, page 3-26)
2. Installation of a new throttle control cable (Section 4-19, page 4-19)
3. Installation of a new carburetor (Section 5-55, page 5-21)

METEOROLOGICAL INFORMATION

At 1254, the weather recorded at South Jersey Regional Airport (VAY), 2 miles west of N14, included clear skies and wind from 260° at 13 knots gusting to 18 knots. The temperature was 21°C, and the dew point was 9°C. The altimeter setting was 30.13 inches of mercury.

AIRPORT INFORMATION

N14 was at 49 ft elevation and was equipped with a single runway, oriented 01/19. The operator's hangar was positioned at the south end of the field, approximately abeam the numbers for runway 01. A creek, oriented east/west, crossed about 200 ft south of the approach end of runway 01. The creek bed was lined with small trees and low brush and bisected the area between the runway and an open field immediately south of the airport.

The field was about 1,400 ft long and 300 ft wide at its narrowest point and was oriented in the same general direction as the runway. The surface was mowed grass or "scraped" and flattened soil.

WRECKAGE AND IMPACT INFORMATION

The wreckage was examined at the accident site and all major components of the helicopter were accounted for at the scene. The initial ground scar was about 10 ft before the main wreckage, which was about 220 ft from the threshold of runway 01 and aligned with the runway.

The cockpit was significantly deformed by impact damage, and the tailboom was separated at the fuselage. The engine and main transmission remained mounted in the airframe, and all main rotor blades were secured in their respective grips, which remained attached to the main rotor head and mast. The pitch-change link for the yellow rotor blade was fractured and displayed signatures consistent with overstress. Each of the three blades was bent significantly at its respective blade root. The blades showed little to no damage along their respective spans toward the blade tips, which was consistent with low rotor rpm at ground contact.

Flight control continuity was established from the individual flight controls through breaks to the main rotor head and tail rotor. The pilot's and co-pilot's throttles both moved together when the pilot's throttle was actuated by hand. The movement was limited due to damage on the pilot's collective; during the continuity check, an internal component of the pilot's collective disconnected and continuity between the two throttles was lost.

Continuity of the throttle control cable was confirmed from the collective jackshaft to the throttle bellcrank assembly, to which it remained securely attached. The throttle bellcrank assembly was intact, but separated from its mount, which was fractured. The internally threaded portion of the two-piece throttle control tie rod was securely attached to the throttle bellcrank assembly. The internally threaded portion of the tie rod was filled with an organic material that resembled the roots in the impact crater.

Drivetrain continuity was established to the main and tail rotors. The main gearbox housing was intact and attached to the bottom of the main rotor mast and to the center frame. The main gearbox rotated freely and exhibited continuity from input to the main rotor driveshaft, and the free-wheeling (one-way) sprag clutch operated correctly.

The engine was rotated by hand at the cooling fan, and continuity was confirmed from the powertrain through the valvetrain to the accessory section. Compression was confirmed on all cylinders using the thumb method. The magnetos were removed and actuated with a drill, and spark was produced at all terminal leads. Borescope examination of each cylinder revealed signatures consistent with normal wear, with no anomalies noted.

The carburetor was separated from the engine, displayed impact damage, and was found near the initial ground scar. The externally-threaded portion of the two-piece throttle control tie rod was still attached to the throttle arm. The throttle and mixture arms were actuated by hand and moved smoothly through their respective ranges. The filter screen was removed and was absent of debris. The carburetor contained fuel, which appeared absent of water and debris.

The collective control and jackshaft assembly with the associated throttle cable and bellcrank assemblies, as well as each half of the throttle tie rod, were retained for further examination at the NTSB Materials Laboratory.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of Medical Examiner, County of Burlington, New Jersey, performed an autopsy on the pilot. The cause of death was listed as "multiple injuries."

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The results were negative for the presence of drugs and alcohol.

TESTS AND RESEARCH

The throttle tie rod assembly was received separated at the threaded joint. The components were unbolted from the carburetor throttle arm and the throttle cable before receipt in the materials laboratory. The tie rod assembly consisted of an internally threaded rod attached to the bellcrank and an externally threaded rod-end bearing and jam nut attached to the throttle arm. The tie rod was separated at the threaded joint between the two pieces. The rod end jam nut was found about midway between the threaded end and the rod end bearing eye.

Magnified examinations of the externally threaded rod-end bearing threads revealed mechanical damage to the three end threads. The damage was consistent with thread-to-thread wear.

Visual examination of the internal threads in the rod revealed cellulose material (wood) imbedded into the threads. After brush cleaning, damage was visible to the three end threads. The damage included pock-marks and a reduced thread flank size, consistent with vibratory thread-to-thread wear. These three threads corresponded to the three worn threads on the bearing fitting. Threads further inside the rod were bright, shiny, and undamaged.

Once installed, each end of the throttle tie rod remained fixed and were unable to rotate.

An exemplar Schweizer 269C-1 helicopter was examined in Lancaster, Pennsylvania. The rigging of the throttle control arm and throttle tie rod (4.97 inches +/- .02 inch) was confirmed, and the helicopter was started and idled at a speed about 1,000 rpm. The engine was stopped, the throttle tie rod was disconnected and adjusted to the approximate operating length of the accident tie rod (5.5 inches) and reinstalled. The engine was started and idled at a speed about 1,100 rpm.

According to the Sikorsky maintenance manual for the Schweizer 269C-1 helicopter, after rigging the throttle control system, idle speed was adjusted to its prescribed rpm range (+/-200rpm) by idle/mixture screw adjustments of the carburetor.

The Sikorsky maintenance manual also required a 50-hour inspection of the engine in accordance with the engine manufacturer's publications and a 100-hour inspection of the fuel control linkage. The Sikorsky flight manual required an inspection of the general engine area before each flight.

On November 16, 2017, Sikorsky Aircraft Corporation issued Alert Service Bulletin ASB-C1B-048 for a one-time inspection of the throttle control tie rod assembly to verify the length of throttle control tie rod assembly dimension.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

The owner of Helicopter Flight Services held airline transport, commercial, and flight instructor certificates with multiple ratings for each. He also held a mechanic certificate with ratings for airframe, powerplant, and inspection authorization, and performed much of the maintenance of the accident helicopter, including the most recent throttle cable inspection.

ADDITIONAL INFORMATION

US Army Hughes TH-55A (Hughes/Schweizer 269) Manual (TM 55-1520-233-10) Chapter 9, Emergency Procedures, 9-12, Throttle Failure, stated, "If the throttle becomes inoperative in flight, continue to a landing area that will permit a shallow approach and running landing."

The manufacturer's Pilot's Flight Manual does did not contain an emergency procedure for throttle failure. An informal survey of two other manufacturers of piston-powered helicopters by the FAA inspector assigned to this accident revealed that neither published such a procedure in their flight manuals.

The US Army Training Circular (TC) 3-04.4, "Fundamentals of Flight," specified the following regarding autorotations:

1-123. During powered flight, rotor drag is overcome with engine power. When the engine fails or is deliberately disengaged from the rotor system, some other force must sustain rotor RPM so controlled flight can be continued to the ground. Adjusting the collective pitch to allow a controlled descent generates this force. Airflow during helicopter descent provides energy to overcome blade drag and turn the rotor. When the helicopter descends in this manner, it is in a state of autorotation. In effect, the aviator exchanges altitude at a controlled rate in return for energy to turn the rotor at a RPM [an rpm] that provides aircraft control and a safe landing. Helicopters have potential energy based on their altitude above the ground. As this altitude decreases, potential energy is converted into kinetic energy used in turning the rotor. Aviators use this kinetic energy to slow the rate of descent to a controlled rate and affect a smooth touchdown.

Circle of Action

1-139. The circle of action is a point on the ground that has no apparent movement in the pilot's field of view (FOV) during a steady-state autorotation. The circle of action would be the point of impact if the pilot applied no deceleration, initial pitch, or cushioning pitch during the last 100 feet of autorotation. Depending on the amount of wind present and the rate and amount of deceleration and collective application, the circle of action is usually two or three helicopter lengths short of the touchdown point.

Last 50 to 100 Feet

1-140. It can be assumed autorotation ends at 50 to 100 feet and landing procedures then begin. To execute a power-off landing for rotary-wing aircraft, an aviator exchanges airspeed for lift by decelerating the aircraft during the last 100 feet. When executed correctly, deceleration is applied and timed so rate of descent and forward airspeed are minimized just before touchdown. At about 10 to 15 feet, this energy exchange is essentially complete. Initial pitch application occurs at 10 to 15 feet. This is used to trade some of the rotor energy to slow the rate of descent prior to cushioning. The primary remaining control input is application of collective pitch to cushion touchdown. Because all helicopter types are slightly different, aviator experience in that particular aircraft is the most useful tool for predicting useful energy exchange available at 100 feet and the appropriate amount of deceleration and collective pitch needed to execute the exchange safely and land successfully.

FAA Advisory Circular (AC) 61-140, "Autorotation Training - Predominant Cause of Accidents/Incidents," states:

A review of NTSB reportable accidents and incidents during autorotation training/instruction indicates that the predominant probable cause is failure to maintain main rotor .... rpm (Nr) and airspeed within the Rotorcraft Flight Manual (RFM) or pilot's operating handbook (POH) specified range, resulting in an excessive and unrecoverable rate of descent."

According to the FAA Helicopter Handbook: "If too much collective pitch is applied too early during the final stages of the autorotation, the kinetic energy may be depleted, resulting in little or no cushioning effect available. This could result in a hard landing with corresponding damage to the helicopter."

The US Army Hughes TH-55A Manual (TM 55-1520-233-10) states in Chapter 9, Emergency Procedures, 9-12, Engine Failure – Cruise, "Collective pitch should never be applied to reduce rpm for extending glide distance because of the reduction in rpm available for use during touchdown. 

History of Flight

Maneuvering
Powerplant sys/comp malf/fail

Autorotation

Hard landing (Defining event)

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 30, Male
Airplane Rating(s): None
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s): Helicopter
Second Pilot Present: No
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: Yes
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 04/12/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 04/19/2017
Flight Time: 480 hours (Total, all aircraft), 300 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: SCHWEIZER
Registration: N204HF
Model/Series: 269C 1
Aircraft Category: Helicopter
Year of Manufacture: 2000
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 0109
Landing Gear Type: Skid
Seats: 2
Date/Type of Last Inspection: 08/17/2017, 100 Hour
Certified Max Gross Wt.: 1750 lbs
Time Since Last Inspection: 15 Hours
Engines: 1 Reciprocating
Airframe Total Time: 7899.2 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: Not installed
Engine Model/Series: HIO-360-C1A
Registered Owner: HERLIHY HELICOPTERS INC
Rated Power: 180 hp
Operator: Helicopter Flight Services
Operating Certificate(s) Held:  Pilot School (141)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KVAY, 53 ft msl
Distance from Accident Site: 2 Nautical Miles
Observation Time: 1254 EDT
Direction from Accident Site: 299°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 13 knots / 18 knots
Turbulence Type Forecast/Actual: / None
Wind Direction: 260°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 21°C / 9°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Medford, NJ (N14)
Type of Flight Plan Filed: None
Destination: Medford, NJ (N14)
Type of Clearance: None
Departure Time: 1245 EDT
Type of Airspace: Class G

Airport Information

Airport: FLYING W (N14)
Runway Surface Type: Asphalt
Airport Elevation: 49 ft
Runway Surface Condition: Dry; Vegetation
Runway Used: 01
IFR Approach: None
Runway Length/Width: 3496 ft / 75 ft
VFR Approach/Landing:  Forced Landing; Precautionary Landing

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 39.934167, -74.807222 (est)

Location: Medford, NJ
Accident Number: ERA17FA317
Date & Time: 09/08/2017, 1300 EDT
Registration: N204HF
Aircraft: SCHWEIZER 269C
Injuries: 2 Fatal
Flight Conducted Under:  Part 91: General Aviation - Personal 

On September 8, 2017, about 1300 eastern daylight time, a Schweizer 269C-1 helicopter, N204HF, operated by Helicopter Flight Services, was substantially damaged during collision with terrain while performing a forced landing to Runway 01 at Flying W Airport (N14), Medford, New Jersey. The commercial pilot and passenger were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight which was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the chief flight instructor for the operator, the purpose of the flight was to provide an orientation/pleasure flight to the passenger who was scheduled to perform in a concert on the airport later that evening.

Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported he could "roll" the twist-grip, but that there was no corresponding change in engine rpm when he did so.

The company flight instructor and another certificated helicopter flight instructor were monitoring the frequency and engaged the pilot in conversation about potential courses of action to affect the subsequent landing. Options discussed included a shallow approach to a run-on landing, or a power-off, autorotational descent to landing. The pilot elected to stop the engine and perform an autorotation, which was a familiar procedure he had performed numerous times in the past. Prior to entering the autorotation, the pilot was advised to initiate the maneuver over the runway.

The company flight instructor reported that the helicopter entered the autorotation about 950 ft above ground level, and that the helicopter was quiet during its descent "because the engine was off." During the descent, the rotor rpm decayed to the point where the instructor could see the individual rotor blades. The helicopter descended from view prior to reaching the runway threshold and the sounds of impact were heard. Both instructors reported that a high-pitched "whine" could be heard from the helicopter during the latter portion of the descent.

A video forwarded by local police showed the helicopter south of the runway as it entered what appeared to be a descent profile consistent with an autorotation. Toward the end of the video, the descent profile became more vertical and the rate of descent increased before the helicopter descended out of view. No sound could be heard from the helicopter.

The pilot held commercial and instructor pilot certificates, each with ratings for rotorcraft-helicopter and instrument helicopter. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued April 12, 2017.

Excerpts of the pilot's logbook revealed he had logged 480.9 total hours of flight experience. It was estimated that he had accrued over 300 total hours of flight experience in the accident helicopter make and model. The last entry logged was for 1.2 hours in the accident helicopter on the day of the accident.

The company training records indicated the pilot had received the training required by the operator for employment as a flight instructor, and his last airman competency check was completed satisfactorily on April 19, 2017 in the accident helicopter.

According to FAA records, the helicopter was manufactured in 2000 and had accrued approximately 7,900 total aircraft hours. Its most recent 100-hour inspection was completed August 17, 2017 at 7,884 total aircraft hours.

At 1254, the weather recorded at South Jersey Regional Airport (VAY), 2 miles west of N14, included clear skies and wind from 260° at 13 knots gusting to 18 knots. The temperature was 21°C, and the dew point was 9°C. The altimeter setting was 30.13 inches of mercury.

The wreckage was examined at the accident site, and all major components were accounted for at the scene. The initial ground scar was about 10 ft prior to the main wreckage, which was about 220 ft prior to the threshold of runway 01 and aligned with the runway.

The cockpit was significantly deformed by impact damage, and the tailboom was separated at the fuselage. The engine and main transmission remained mounted in the airframe, and all main rotor blades were secured in their respective grips, which remained attached to the main rotor head and mast. The pitch-change link for the yellow rotor blade was fractured, with fracture signatures consistent with overstress. Each of the three blades was bent significantly at its respective blade root. The blades showed little to no damage along their respective spans toward the blade tips, which was consistent with low rotor rpm at ground contact.

Flight control continuity was established from the individual flight controls, through breaks, to the main rotor head and tail rotor. Drivetrain continuity was also established to the main and tail rotors.

The engine was rotated by hand at the cooling fan, and continuity was confirmed from the powertrain through the valvetrain, to the accessory section. Compression was confirmed on all cylinders using the thumb method. The magnetos were removed, actuated with a drill, and spark was produced at all terminal leads. Borescope examination of each cylinder revealed signatures consistent with normal wear, with no anomalies noted.

The carburetor was separated from the engine, displayed impact damage, and was found near the initial ground scar. The throttle and mixture arms were actuated by hand and moved smoothly through their respective ranges. The filter screen was removed, and was absent of debris. The carburetor contained fuel which appeared absent of water and debris.

The collective control and jackshaft assembly as well as the associated throttle cable, push-pull tube, and bellcrank assemblies were retained for further examination at the NTSB Materials Laboratory.

Aircraft and Owner/Operator Information

Aircraft Manufacturer: SCHWEIZER
Registration: N204HF
Model/Series: 269C 1
Aircraft Category: Helicopter
Amateur Built: No
Operator: Helicopter Flight Services
Operating Certificate(s) Held:  Pilot School (141) 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KVAY, 53 ft msl
Observation Time: 1254 EDT
Distance from Accident Site: 2 Nautical Miles
Temperature/Dew Point: 21°C / 9°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 13 knots/ 18 knots, 260°
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 30.13 inches Hg
Type of Flight Plan Filed: None
Departure Point: Medford, NJ (N14)
Destination:  Medford, NJ (N14) 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  39.934167, -74.807222 (est)

https://www.courthousenews.com

Case ID: 180201141

Arthur Alan Wolk, Esquire
Michael S. Miska, Esquire
Attorney ID. Nos. 02091 and 309501 
THE WOLK LAW FIRM
1710-12 Locust Street
Philadelphia, PA  19103 
Attorneys for Plaintiffs

ANGELA K. GENTRY, Individually and as Executrix of the Estate of TROY LEE GENTRY, Deceased
Plaintiff.

v. 

SIKORSKY AIRCRAFT CORPORATION:  
110 East Stewart Huston Drive
Coatesville, PA  19320 
and 
SIKORSKY GLOBAL HELICOPTERS, INC.
110 East Stewart Huston Drive
Coatesville, PA  19320 
and
KEYSTONE HELICOPTER CORPORATION
110 East Stewart Huston Drive
Coatesville, PA  19320 
Defendants.

Jury Trial Demanded

https://www.courthousenews.com

PHILADELPHIA (Courthouse News) — Five months after country music star Troy Lee Gentry died in a helicopter crash, his widow filed suit Wednesday against the aircraft manufacturers.

One half of the duo Montgomery Gentry, 50-year-old Gentry was slated to perform on Sept. 8, 2017, at the Flying W Airport and Resort in Medford, New Jersey, when he was offered a private sightseeing tour of the area.

Represented the Wolk Law Firm, Gentry’s widow says the throttle cable jammed soon after takeoff and threw the engine of the Model 269 helicopter into high speeds.

Angela Gentry says the failure by Sikorsky Aircraft Corp. and Keystone Helicopter Corp. to make the aircraft crashworthy left occupants no chance of survival in case of an emergency.

“The dangers from the lack of crashworthiness and defects in the engine, transmission and sprag clutch, throttle cables, engine attachments and absence of crashworthy features were unknown to the average user and consumer of this helicopter but well known to these defendants who made it a point to hide and deny and problems that could and did cause serious personal injury and death,” the complaint states, filed in the Philadelphia Court of Common Pleas. Rather than correcting these design flaws, the complaint says Sikorsky and Keystone chose instead to “treat … the helicopter and its engine like an unwanted burden.”

Gentry’s widow says no recommendations on how to deal with the emergency were available in the pilot operating handbook, and that the course taken here — to shut down the engine at an altitude of 959 feet — proved fatal.

“Because of defects in the engine, throttle cable attachment and collective control, the helicopter did not enter autorotation as expected, it did not disengage smartly from the transmission so the engine the rotors slowed to a speed lower than would permit a safe autorotation, thus allowing the helicopter to drop like a stone to the ground below, killing all aboard,” the complaint states.

A Tennessee native, Troy Gentey was father to two daughters, ages 15 and 24. Montgomery Gentry was inducted into the Grand Ole Opry in 2009. The band recorded six albums and charted more than 20 singles on Billboard’s Hot Country list, “Something to be Proud Of” and “Lucky Man.”

Gentry’s bandmate Eddie Montgomery, the brother of country star John Michael Montgomery, continued to tour as a solo act but will reportedly not keep the band going.

Their final album, “Here’s To You,” was released on Feb. 2. The duo had been working on the album at the time of the crash.

Sikorsky spokeswoman Callie Ferrari declined to comment on the allegations pending an investigation by the National Transportation Safety Board.

“We are fully cooperating with the NTSB and cannot comment further due to the investigation,” Ferrari said in a statement.


Original article ➤ https://www.courthousenews.com



MEDFORD -- The pilot of the helicopter that crashed, killing him and country music star Troy Gentry, hovered for 10 minutes while he reviewed his option and waited for first responders to get on scene before he attempted an emergency landing, according to 911 calls. 

Gentry, one half of the country duo Montgomery Gentry, died after the helicopter crashed on Sept. 8. He was scheduled to perform at the airport and resort later that evening. 

The helicopter's pilot, James Evan Robinson, 30, was pronounced dead at the scene. He had taken Gentry up in the helicopter for a "spur of the moment" ride, officials said.  

A preliminary National Safety investigation into the incident determined that the helicopter crashed after experiencing a mechanical failure. 

Employees at the Flying W Airport and Resort placed three calls to 911 that afternoon. In the first, the airport's manager tells the the dispatcher that she plans to close the airport so the pilot can land on the runway, but wants to wait for the fire department before giving the pilot the OK to do so.

The manager calls back a second time, inquiring about the fire department's response time. 

"I have a helicopter hovering. He's going to make an emergency landing," she told the dispatcher. "I just want a fire truck here before I let him land." 

In a third call, a man from the airport says it's been 10 minutes since the first call was placed, and that no one had arrived at the scene yet. 

"I have a helicopter emergency. The fire department has been notified already," he said. "I'm curious about when they're getting here."

"We just dispatched them," a man answered. "You guys didn't give us an ETA of when the chopper was coming in. They're volunteers, so... but we did dispatch them." 

Medford Fire Chief Thomas Thorn said there was a delayed response that day after Lumberton firefighters were first dispatched. 

"This is unusual," he said, explaining that calls from the airport, which sits between Lumberton and Medford, prompt responses from both departments. Because Lumberton's fire department is comprised of volunteers, they generally take longer to arrive, while Medford has full-time staff that can respond immediately during the day.

Once Medford's firefighters received the call, they left the station within two minutes, Thorn said.

Still, he said, it's unlikely first responders could have assisted much at this type of scene, where impact, rather than fire and smoke, fatally injured Gentry and Robinson. 

He also said this is his first time in 30 years with the department that he can remember being called to the scene before a plane or helicopter crashes, as the department usually responds to the scene after a craft is down.  

"We were kind of blown away," Thorn said. 

While there's little to nothing firefighters could have done to keep the situation from turning fatal, it's also unclear what the pilot could have done differently. 

"It's like most of these aviation accidents," said Ladd Sanger, a Dallas-based aviation lawyer with Slack & Davis and licensed helicopter pilot who has experience with the type of helicopter Robinson flew that day. "There are a series of things that contribute to the outcome. [The throttle issue] set the sequence of events in motion. That's definitely not on the pilot."

With only a preliminary crash report, there's no concrete explanation of what caused the fatal crash, and Sanger said it's unclear whether the risky, emergency autorotation landing method was performed poorly, or if there was an additional tranmission failure that made the crash landing inevitable. 

While several options were discussed once Robinson realized there was a problem with the helicopter, he chose to kill the power and perform an autorotation, rather than a run-on landing. 

"While we train for them, [power-off autorotations] are a high-stress event," he said. "You have very little margin for error, and everything happens quickly." 

What strikes Sanger about the report, he said, is the fact that the helicopter attempted to land on the runway, but ended up in a field area nearby. If an autorotation was properly initiated over the runway, it's unlikely the helicopter would have crashed that far away, he said. 

As for hovering and waiting for the fire department to arrive, Sanger said he can see both pros and cons in making that decision. While firefighters can sometimes save lives at crashes with a quick response, continued hovering can further damage the engine, depending on what type of mechanical issue has occurred. 

"If it was a transmission issue, the longer that you let that run, the worst things are going to be," he said. "But it's unclear without knowing what the underlying mechanical issue is. It's easy to sit here after the fact and second-guess anybody."

Story, video and photo gallery:  http://www.nj.com

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Philadelphia, Pennsylvania
Sikorsky; Coatesville, Pennsylvania
Lycoming; Williamsport, Pennsylvania

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

Herlihy Helicopters Inc
Helicopter Flight Services
http://registry.faa.gov/N204HF

NTSB Identification: ERA17FA317
14 CFR Part 91: General Aviation
Accident occurred Friday, September 08, 2017 in Medford, NJ
Aircraft: SCHWEIZER 269C, registration: N204HF
Injuries: 2 Fatal.

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 either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On September 8, 2017, about 1300 eastern daylight time, a Schweizer 269C-1 helicopter, N204HF, operated by Helicopter Flight Services, was substantially damaged during collision with terrain while performing a forced landing to Runway 01 at Flying W Airport (N14), Medford, New Jersey. The commercial pilot and passenger were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight which was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the chief flight instructor for the operator, the purpose of the flight was to provide an orientation/pleasure flight to the passenger who was scheduled to perform in a concert on the airport later that evening.

Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported he could "roll" the twist-grip, but that there was no corresponding change in engine rpm when he did so.

The company flight instructor and another certificated helicopter flight instructor were monitoring the frequency and engaged the pilot in conversation about potential courses of action to affect the subsequent landing. Options discussed included a shallow approach to a run-on landing, or a power-off, autorotational descent to landing. The pilot elected to stop the engine and perform an autorotation, which was a familiar procedure he had performed numerous times in the past. Prior to entering the autorotation, the pilot was advised to initiate the maneuver over the runway.

The company flight instructor reported that the helicopter entered the autorotation about 950 ft above ground level, and that the helicopter was quiet during its descent "because the engine was off." During the descent, the rotor rpm decayed to the point where the instructor could see the individual rotor blades. The helicopter descended from view prior to reaching the runway threshold and the sounds of impact were heard. Both instructors reported that a high-pitched "whine" could be heard from the helicopter during the latter portion of the descent.

A video forwarded by local police showed the helicopter south of the runway as it entered what appeared to be a descent profile consistent with an autorotation. Toward the end of the video, the descent profile became more vertical and the rate of descent increased before the helicopter descended out of view. No sound could be heard from the helicopter.

The pilot held commercial and instructor pilot certificates, each with ratings for rotorcraft-helicopter and instrument helicopter. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued April 12, 2017.

Excerpts of the pilot's logbook revealed he had logged 480.9 total hours of flight experience. It was estimated that he had accrued over 300 total hours of flight experience in the accident helicopter make and model. The last entry logged was for 1.2 hours in the accident helicopter on the day of the accident.

The company training records indicated the pilot had received the training required by the operator for employment as a flight instructor, and his last airman competency check was completed satisfactorily on April 19, 2017 in the accident helicopter.

According to FAA records, the helicopter was manufactured in 2000 and had accrued approximately 7,900 total aircraft hours. Its most recent 100-hour inspection was completed August 17, 2017 at 7,884 total aircraft hours.

At 1254, the weather recorded at South Jersey Regional Airport (VAY), 2 miles west of N14, included clear skies and wind from 260° at 13 knots gusting to 18 knots. The temperature was 21°C, and the dew point was 9°C. The altimeter setting was 30.13 inches of mercury. Airmen's Meteorological Information (AIRMET) Sierra for instrument meteorological conditions and mountain obscurations was in effect for the area surrounding the accident site at the time of the accident.

The wreckage was examined at the accident site, and all major components were accounted for at the scene. The initial ground scar was about 10 ft prior to the main wreckage, which was about 220 ft prior to the threshold of runway 01 and aligned with the runway.

The cockpit was significantly deformed by impact damage, and the tailboom was separated at the fuselage. The engine and main transmission remained mounted in the airframe, and all main rotor blades were secured in their respective grips, which remained attached to the main rotor head and mast. The pitch-change link for the yellow rotor blade was fractured, with fracture signatures consistent with overstress. Each of the three blades was bent significantly at its respective blade root. The blades showed little to no damage along their respective spans toward the blade tips, which was consistent with low rotor rpm at ground contact.

Flight control continuity was established from the individual flight controls, through breaks, to the main rotor head and tail rotor. Drivetrain continuity was also established to the main and tail rotors.

The engine was rotated by hand at the cooling fan, and continuity was confirmed from the powertrain through the valvetrain, to the accessory section. Compression was confirmed on all cylinders using the thumb method. The magnetos were removed, actuated with a drill, and spark was produced at all terminal leads. Borescope examination of each cylinder revealed signatures consistent with normal wear, with no anomalies noted.

The carburetor was separated from the engine, displayed impact damage, and was found near the initial ground scar. The throttle and mixture arms were actuated by hand and moved smoothly through their respective ranges. The filter screen was removed, and was absent of debris. The carburetor contained fuel which appeared absent of water and debris.

The collective control and jackshaft assembly as well as the associated throttle cable, push-pull tube, and bellcrank assemblies were retained for further examination at the NTSB Materials Laboratory.


Medford Township Police Chief Richard Meder, center, speaks to media. At right is Lumberton Township Police Chief Tony DiLoreto. Burlington Prosecutor Scott A. Coffina is at left.


Burlington Prosecutor Scott A. Coffina is interviewed.











James Evan Robinson graduated from Middle Georgia State University with a Bachelor of Science degree in Aviation Science and Management. He was a commercial pilot and flight instructor having worked for Helicopter Flight Services in Medford, New Jersey.   
 
Troy Gentry, one half of the country duo Montgomery Gentry, died after the helicopter crashed on September 8th, 2017. He was scheduled to perform at the Flying W Airport (N14) and resort later that evening. 


The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Philadelphia, Pennsylvania
Sikorsky; Coatesville, Pennsylvania
Lycoming; Williamsport, Pennsylvania

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/N204HF



Location: Medford, NJ
Accident Number: ERA17FA317
Date & Time: 09/08/2017, 1300 EDT
Registration: N204HF
Aircraft: SCHWEIZER 269C
Aircraft Damage: Substantial
Defining Event: Hard landing
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

HISTORY OF FLIGHT

On September 8, 2017, about 1300 eastern daylight time, a Schweizer 269C-1 helicopter, N204HF, was substantially damaged during a collision with terrain while performing a forced landing to runway 01 at Flying W Airport (N14), Medford, New Jersey. The commercial pilot and passenger were fatally injured. The helicopter was owned by Herlihy Helicopters Inc and operated by Helicopter Flight Services under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight.

According to the chief flight instructor for the operator, the purpose of the flight was to provide an orientation/pleasure flight to the passenger, who was scheduled to perform in a concert on the airport later that evening.

Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported that he could "roll" the twist-grip but that there was no corresponding change in engine rpm when he did so.

The company flight instructor and another helicopter flight instructor, who was a designated pilot examiner (DPE), were monitoring the frequency and engaged the pilot in conversation about potential courses of action to accomplish a landing. A Federal Aviation Administration (FAA) inspector, who was also a helicopter instructor and examiner, joined the conversation on the radio.

Options discussed included a shallow approach to a run-on landing or a power-off, autorotational descent to landing. The instructors suggested that the pilot perform the run-on landing; however, the pilot reported that a previous attempt to perform a run-on landing was unsuccessful and announced that he would stop the engine and perform a power-off autorotation. The pilot stated that this was a familiar procedure he had performed numerous times in the past. When asked over the radio by the DPE when he had last performed an autorotation to touchdown, the pilot replied that 4 months had elapsed since his most recent touchdown autorotation. Subsequent attempts to convince the pilot to attempt a run-on landing were unsuccessful.

According to the DPE and the FAA inspector, the pilot was advised "multiple times" to aim to touch down "midfield" and not to initiate the engine shutdown and autorotation until over the runway. According to the DPE, his last reminder to the pilot came when the helicopter was on a 2-mile final approach.

A video forwarded to the NTSB by local police was recorded from a vantage point nearly abeam the approach end of runway 01. The video showed the helicopter about 1/4 mile south of the runway as it entered a descent profile consistent with an autorotation. Toward the end of the video, the descent profile became more vertical, and the rate of descent increased before the helicopter descended out of view. No sound could be heard from the helicopter.

During a postaccident interview with law enforcement, the company flight instructor reported that the helicopter entered the autorotation about 950 ft above ground level (agl) and that the helicopter was quiet during its descent "because the engine was off." During the descent, the rotor rpm decayed to the point where the instructor could see the individual rotor blades. The helicopter descended from view before reaching the runway threshold, and the sounds of impact were heard. Both the instructor and the FAA inspector reported that a high-pitched "whine" could be heard from the helicopter during the latter portion of the descent.

In a written statement, the flight instructor reported, "[the pilot] began the autorotative descent, but it was not long before it became apparent it was not being executed correctly. I began to see individual blades instead of a translucent disc. His vertical speed increased while his horizontal speed became almost non-existent. The nose of the [helicopter] rolled forward. Instead of being able to see the bottom of the [helicopter]… all I could see was the cockpit glass and rotor head."


James Evan Robinson

PERSONNEL INFORMATION

The pilot held commercial and flight instructor certificates, each with ratings for rotorcraft-helicopter and instrument helicopter. His most recent FAA second-class medical certificate was issued April 12, 2017.

Excerpts of the pilot's logbook revealed that he had logged 480.9 total hours of flight experience, of which about 300 hours were in the accident helicopter make and model. The last entry logged was for 1.2 hours in the accident helicopter on the day of the accident.

Company training records indicated that the pilot had received the training required by the operator for employment as a flight instructor, and his last airman competency check was completed satisfactorily on April 19, 2017, in the accident helicopter.

AIRCRAFT INFORMATION

The helicopter was a single-engine, two-seat, light utility helicopter constructed primarily of aluminum alloy and powered by an air-cooled, Lycoming HO-360-C1A, 180-horsepower engine. It was equipped with conventional collective and cyclic control sticks and tail rotor control pedals.

The main rotor was a fully articulated, three-bladed design, and the tail rotor was a two-bladed, semi-rigid, anti-torque rotor design. Power was transmitted from the engine to the rotor system through a V-belt drive, which incorporated a free-wheeling (one-way) sprag clutch, a main drive transmission, a tail rotor transmission, and shafts.

According to FAA records, the helicopter was manufactured in 2000, delivered to the owner/operator, and had accrued about 7,899 total aircraft hours. Its most recent 100-hour inspection was completed on August 17, 2017, at 7,884 total aircraft hours.

A review of maintenance records revealed that the helicopter's engine was replaced with factory rebuilt or overhauled engines at the manufacturer's recommended overhaul intervals. Engine changes occurred in 2003, 2006, and most recently, on September 24, 2011.

The records reflected numerous entries regarding carburetor discrepancies. Carburetors were adjusted or removed and replaced with loaner carburetors then reinstalled following repairs. In February 2014, the carburetor was removed, sent out for repair, and reinstalled by the operator.

On August 31, 2016, the operator installed a throttle control cable manufactured by McFarlane Aviation Products, as documented on an FAA Form 337. A cable from the original equipment manufacturer was not available per the operator, and the FAA approved the manufacture and installation, which required the cable's inspection at 25-hour intervals. The inspections were documented; the most recent was completed concurrent with the annual inspection conducted 15 hours before the accident.

The operator was interviewed during a meeting with NTSB investigators and FAA inspectors regarding the maintenance history of the accident helicopter. He was later interviewed by telephone to gain more detail about the disassembly/reassembly and rigging of the throttle during carburetor/engine changes.

According to the operator, when the engine was changed for overhaul, the carburetor traveled with the engine, and the throttle control arm was removed at the carburetor splined shaft. The throttle control bellcrank was removed from the front of the carburetor, and the entire throttle control system remained with the helicopter. The throttle control arm, the throttle tie rod, the throttle control bellcrank, and the throttle cable all remained attached to each other and to the helicopter. He stated that, because of this, there was no need to disconnect or adjust the throttle tie rod that connected the bellcrank and the throttle control arm.

He also stated that, when a new engine was installed, the correct "angle" was measured for the installation of the throttle control arm on the carburetor. Adjustment of idle and mixture set screws was often required, as the carburetors were often set at the factory "for airplanes."

When asked about the most recent installation of the throttle control cable, the operator stated that the cable was a fixed measurement and changing the cable did not change the rigging of the throttle. He said that, when the cable was changed, no throttle rigging adjustments were necessary; the cable was disconnected at the bellcrank upstream of the tie rod and throttle control arm. He repeated that the cable installation was "plug and play" and that no adjustments were necessary to achieve/maintain proper throttle rigging.

The operator was asked specifically about the throttle rigging and the nominal measurement of the tie rod during the throttle rigging procedure following the most recent engine change. He stated, "I don't know if I did. I'm sure I did, because that's part of the procedure, but I'm not 100 percent [sure]."

According to the manufacturer's maintenance manual, actions that required compliance with the throttle rigging procedure included:

1. Installation of a new engine (Section 3-15, page 3-26)
2. Installation of a new throttle control cable (Section 4-19, page 4-19)
3. Installation of a new carburetor (Section 5-55, page 5-21)

METEOROLOGICAL INFORMATION

At 1254, the weather recorded at South Jersey Regional Airport (VAY), 2 miles west of N14, included clear skies and wind from 260° at 13 knots gusting to 18 knots. The temperature was 21°C, and the dew point was 9°C. The altimeter setting was 30.13 inches of mercury.

AIRPORT INFORMATION

N14 was at 49 ft elevation and was equipped with a single runway, oriented 01/19. The operator's hangar was positioned at the south end of the field, approximately abeam the numbers for runway 01. A creek, oriented east/west, crossed about 200 ft south of the approach end of runway 01. The creek bed was lined with small trees and low brush and bisected the area between the runway and an open field immediately south of the airport.

The field was about 1,400 ft long and 300 ft wide at its narrowest point and was oriented in the same general direction as the runway. The surface was mowed grass or "scraped" and flattened soil.

WRECKAGE AND IMPACT INFORMATION

The wreckage was examined at the accident site and all major components of the helicopter were accounted for at the scene. The initial ground scar was about 10 ft before the main wreckage, which was about 220 ft from the threshold of runway 01 and aligned with the runway.

The cockpit was significantly deformed by impact damage, and the tailboom was separated at the fuselage. The engine and main transmission remained mounted in the airframe, and all main rotor blades were secured in their respective grips, which remained attached to the main rotor head and mast. The pitch-change link for the yellow rotor blade was fractured and displayed signatures consistent with overstress. Each of the three blades was bent significantly at its respective blade root. The blades showed little to no damage along their respective spans toward the blade tips, which was consistent with low rotor rpm at ground contact.

Flight control continuity was established from the individual flight controls through breaks to the main rotor head and tail rotor. The pilot's and co-pilot's throttles both moved together when the pilot's throttle was actuated by hand. The movement was limited due to damage on the pilot's collective; during the continuity check, an internal component of the pilot's collective disconnected and continuity between the two throttles was lost.

Continuity of the throttle control cable was confirmed from the collective jackshaft to the throttle bellcrank assembly, to which it remained securely attached. The throttle bellcrank assembly was intact, but separated from its mount, which was fractured. The internally threaded portion of the two-piece throttle control tie rod was securely attached to the throttle bellcrank assembly. The internally threaded portion of the tie rod was filled with an organic material that resembled the roots in the impact crater.

Drivetrain continuity was established to the main and tail rotors. The main gearbox housing was intact and attached to the bottom of the main rotor mast and to the center frame. The main gearbox rotated freely and exhibited continuity from input to the main rotor driveshaft, and the free-wheeling (one-way) sprag clutch operated correctly.

The engine was rotated by hand at the cooling fan, and continuity was confirmed from the powertrain through the valvetrain to the accessory section. Compression was confirmed on all cylinders using the thumb method. The magnetos were removed and actuated with a drill, and spark was produced at all terminal leads. Borescope examination of each cylinder revealed signatures consistent with normal wear, with no anomalies noted.

The carburetor was separated from the engine, displayed impact damage, and was found near the initial ground scar. The externally-threaded portion of the two-piece throttle control tie rod was still attached to the throttle arm. The throttle and mixture arms were actuated by hand and moved smoothly through their respective ranges. The filter screen was removed and was absent of debris. The carburetor contained fuel, which appeared absent of water and debris.

The collective control and jackshaft assembly with the associated throttle cable and bellcrank assemblies, as well as each half of the throttle tie rod, were retained for further examination at the NTSB Materials Laboratory.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of Medical Examiner, County of Burlington, New Jersey, performed an autopsy on the pilot. The cause of death was listed as "multiple injuries."

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The results were negative for the presence of drugs and alcohol.

TESTS AND RESEARCH

The throttle tie rod assembly was received separated at the threaded joint. The components were unbolted from the carburetor throttle arm and the throttle cable before receipt in the materials laboratory. The tie rod assembly consisted of an internally threaded rod attached to the bellcrank and an externally threaded rod-end bearing and jam nut attached to the throttle arm. The tie rod was separated at the threaded joint between the two pieces. The rod end jam nut was found about midway between the threaded end and the rod end bearing eye.

Magnified examinations of the externally threaded rod-end bearing threads revealed mechanical damage to the three end threads. The damage was consistent with thread-to-thread wear.

Visual examination of the internal threads in the rod revealed cellulose material (wood) imbedded into the threads. After brush cleaning, damage was visible to the three end threads. The damage included pock-marks and a reduced thread flank size, consistent with vibratory thread-to-thread wear. These three threads corresponded to the three worn threads on the bearing fitting. Threads further inside the rod were bright, shiny, and undamaged.

Once installed, each end of the throttle tie rod remained fixed and were unable to rotate.

An exemplar Schweizer 269C-1 helicopter was examined in Lancaster, Pennsylvania. The rigging of the throttle control arm and throttle tie rod (4.97 inches +/- .02 inch) was confirmed, and the helicopter was started and idled at a speed about 1,000 rpm. The engine was stopped, the throttle tie rod was disconnected and adjusted to the approximate operating length of the accident tie rod (5.5 inches) and reinstalled. The engine was started and idled at a speed about 1,100 rpm.

According to the Sikorsky maintenance manual for the Schweizer 269C-1 helicopter, after rigging the throttle control system, idle speed was adjusted to its prescribed rpm range (+/-200rpm) by idle/mixture screw adjustments of the carburetor.

The Sikorsky maintenance manual also required a 50-hour inspection of the engine in accordance with the engine manufacturer's publications and a 100-hour inspection of the fuel control linkage. The Sikorsky flight manual required an inspection of the general engine area before each flight.

On November 16, 2017, Sikorsky Aircraft Corporation issued Alert Service Bulletin ASB-C1B-048 for a one-time inspection of the throttle control tie rod assembly to verify the length of throttle control tie rod assembly dimension.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

The owner of Helicopter Flight Services held airline transport, commercial, and flight instructor certificates with multiple ratings for each. He also held a mechanic certificate with ratings for airframe, powerplant, and inspection authorization, and performed much of the maintenance of the accident helicopter, including the most recent throttle cable inspection.

ADDITIONAL INFORMATION

US Army Hughes TH-55A (Hughes/Schweizer 269) Manual (TM 55-1520-233-10) Chapter 9, Emergency Procedures, 9-12, Throttle Failure, stated, "If the throttle becomes inoperative in flight, continue to a landing area that will permit a shallow approach and running landing."

The manufacturer's Pilot's Flight Manual does did not contain an emergency procedure for throttle failure. An informal survey of two other manufacturers of piston-powered helicopters by the FAA inspector assigned to this accident revealed that neither published such a procedure in their flight manuals.

The US Army Training Circular (TC) 3-04.4, "Fundamentals of Flight," specified the following regarding autorotations:

1-123. During powered flight, rotor drag is overcome with engine power. When the engine fails or is deliberately disengaged from the rotor system, some other force must sustain rotor RPM so controlled flight can be continued to the ground. Adjusting the collective pitch to allow a controlled descent generates this force. Airflow during helicopter descent provides energy to overcome blade drag and turn the rotor. When the helicopter descends in this manner, it is in a state of autorotation. In effect, the aviator exchanges altitude at a controlled rate in return for energy to turn the rotor at a RPM [an rpm] that provides aircraft control and a safe landing. Helicopters have potential energy based on their altitude above the ground. As this altitude decreases, potential energy is converted into kinetic energy used in turning the rotor. Aviators use this kinetic energy to slow the rate of descent to a controlled rate and affect a smooth touchdown.

Circle of Action

1-139. The circle of action is a point on the ground that has no apparent movement in the pilot's field of view (FOV) during a steady-state autorotation. The circle of action would be the point of impact if the pilot applied no deceleration, initial pitch, or cushioning pitch during the last 100 feet of autorotation. Depending on the amount of wind present and the rate and amount of deceleration and collective application, the circle of action is usually two or three helicopter lengths short of the touchdown point.

Last 50 to 100 Feet

1-140. It can be assumed autorotation ends at 50 to 100 feet and landing procedures then begin. To execute a power-off landing for rotary-wing aircraft, an aviator exchanges airspeed for lift by decelerating the aircraft during the last 100 feet. When executed correctly, deceleration is applied and timed so rate of descent and forward airspeed are minimized just before touchdown. At about 10 to 15 feet, this energy exchange is essentially complete. Initial pitch application occurs at 10 to 15 feet. This is used to trade some of the rotor energy to slow the rate of descent prior to cushioning. The primary remaining control input is application of collective pitch to cushion touchdown. Because all helicopter types are slightly different, aviator experience in that particular aircraft is the most useful tool for predicting useful energy exchange available at 100 feet and the appropriate amount of deceleration and collective pitch needed to execute the exchange safely and land successfully.

FAA Advisory Circular (AC) 61-140, "Autorotation Training - Predominant Cause of Accidents/Incidents," states:

A review of NTSB reportable accidents and incidents during autorotation training/instruction indicates that the predominant probable cause is failure to maintain main rotor .... rpm (Nr) and airspeed within the Rotorcraft Flight Manual (RFM) or pilot's operating handbook (POH) specified range, resulting in an excessive and unrecoverable rate of descent."

According to the FAA Helicopter Handbook: "If too much collective pitch is applied too early during the final stages of the autorotation, the kinetic energy may be depleted, resulting in little or no cushioning effect available. This could result in a hard landing with corresponding damage to the helicopter."

The US Army Hughes TH-55A Manual (TM 55-1520-233-10) states in Chapter 9, Emergency Procedures, 9-12, Engine Failure – Cruise, "Collective pitch should never be applied to reduce rpm for extending glide distance because of the reduction in rpm available for use during touchdown. 

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 30, Male
Airplane Rating(s): None
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s): Helicopter
Second Pilot Present: No
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: Yes
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 04/12/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 04/19/2017
Flight Time: 480 hours (Total, all aircraft), 300 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: SCHWEIZER
Registration: N204HF
Model/Series: 269C 1
Aircraft Category: Helicopter
Year of Manufacture: 2000
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 0109
Landing Gear Type: Skid
Seats: 2
Date/Type of Last Inspection: 08/17/2017, 100 Hour
Certified Max Gross Wt.: 1750 lbs
Time Since Last Inspection: 15 Hours
Engines: 1 Reciprocating
Airframe Total Time: 7899.2 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: Not installed
Engine Model/Series: HIO-360-C1A
Registered Owner: HERLIHY HELICOPTERS INC
Rated Power: 180 hp
Operator: Helicopter Flight Services
Operating Certificate(s) Held:  Pilot School (141)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KVAY, 53 ft msl
Distance from Accident Site: 2 Nautical Miles
Observation Time: 1254 EDT
Direction from Accident Site: 299°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 13 knots / 18 knots
Turbulence Type Forecast/Actual: / None
Wind Direction: 260°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 21°C / 9°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Medford, NJ (N14)
Type of Flight Plan Filed: None
Destination: Medford, NJ (N14)
Type of Clearance: None
Departure Time: 1245 EDT
Type of Airspace: Class G

Airport Information

Airport: FLYING W (N14)
Runway Surface Type: Asphalt
Airport Elevation: 49 ft
Runway Surface Condition: Dry; Vegetation
Runway Used: 01
IFR Approach: None
Runway Length/Width: 3496 ft / 75 ft
VFR Approach/Landing:  Forced Landing; Precautionary Landing

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 39.934167, -74.807222 (est)






NTSB Identification: ERA17FA317
14 CFR Part 91: General Aviation
Accident occurred Friday, September 08, 2017 in Medford, NJ
Aircraft: SCHWEIZER 269C, registration: N204HF
Injuries: 2 Fatal.

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 either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On September 8, 2017, about 1300 eastern daylight time, a Schweizer 269C-1 helicopter, N204HF, operated by Helicopter Flight Services, was substantially damaged during collision with terrain while performing a forced landing to Runway 01 at Flying W Airport (N14), Medford, New Jersey. The commercial pilot and passenger were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight which was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the chief flight instructor for the operator, the purpose of the flight was to provide an orientation/pleasure flight to the passenger who was scheduled to perform in a concert on the airport later that evening.

Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported he could "roll" the twist-grip, but that there was no corresponding change in engine rpm when he did so.

The company flight instructor and another certificated helicopter flight instructor were monitoring the frequency and engaged the pilot in conversation about potential courses of action to affect the subsequent landing. Options discussed included a shallow approach to a run-on landing, or a power-off, autorotational descent to landing. The pilot elected to stop the engine and perform an autorotation, which was a familiar procedure he had performed numerous times in the past. Prior to entering the autorotation, the pilot was advised to initiate the maneuver over the runway.

The company flight instructor reported that the helicopter entered the autorotation about 950 ft above ground level, and that the helicopter was quiet during its descent "because the engine was off." During the descent, the rotor rpm decayed to the point where the instructor could see the individual rotor blades. The helicopter descended from view prior to reaching the runway threshold and the sounds of impact were heard. Both instructors reported that a high-pitched "whine" could be heard from the helicopter during the latter portion of the descent.

A video forwarded by local police showed the helicopter south of the runway as it entered what appeared to be a descent profile consistent with an autorotation. Toward the end of the video, the descent profile became more vertical and the rate of descent increased before the helicopter descended out of view. No sound could be heard from the helicopter.

The pilot held commercial and instructor pilot certificates, each with ratings for rotorcraft-helicopter and instrument helicopter. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued April 12, 2017.

Excerpts of the pilot's logbook revealed he had logged 480.9 total hours of flight experience. It was estimated that he had accrued over 300 total hours of flight experience in the accident helicopter make and model. The last entry logged was for 1.2 hours in the accident helicopter on the day of the accident.

The company training records indicated the pilot had received the training required by the operator for employment as a flight instructor, and his last airman competency check was completed satisfactorily on April 19, 2017 in the accident helicopter.

According to FAA records, the helicopter was manufactured in 2000 and had accrued approximately 7,900 total aircraft hours. Its most recent 100-hour inspection was completed August 17, 2017 at 7,884 total aircraft hours.

At 1254, the weather recorded at South Jersey Regional Airport (VAY), 2 miles west of N14, included clear skies and wind from 260° at 13 knots gusting to 18 knots. The temperature was 21°C, and the dew point was 9°C. The altimeter setting was 30.13 inches of mercury. Airmen's Meteorological Information (AIRMET) Sierra for instrument meteorological conditions and mountain obscurations was in effect for the area surrounding the accident site at the time of the accident.

The wreckage was examined at the accident site, and all major components were accounted for at the scene. The initial ground scar was about 10 ft prior to the main wreckage, which was about 220 ft prior to the threshold of runway 01 and aligned with the runway.

The cockpit was significantly deformed by impact damage, and the tailboom was separated at the fuselage. The engine and main transmission remained mounted in the airframe, and all main rotor blades were secured in their respective grips, which remained attached to the main rotor head and mast. The pitch-change link for the yellow rotor blade was fractured, with fracture signatures consistent with overstress. Each of the three blades was bent significantly at its respective blade root. The blades showed little to no damage along their respective spans toward the blade tips, which was consistent with low rotor rpm at ground contact.

Flight control continuity was established from the individual flight controls, through breaks, to the main rotor head and tail rotor. Drivetrain continuity was also established to the main and tail rotors.

The engine was rotated by hand at the cooling fan, and continuity was confirmed from the powertrain through the valvetrain, to the accessory section. Compression was confirmed on all cylinders using the thumb method. The magnetos were removed, actuated with a drill, and spark was produced at all terminal leads. Borescope examination of each cylinder revealed signatures consistent with normal wear, with no anomalies noted.

The carburetor was separated from the engine, displayed impact damage, and was found near the initial ground scar. The throttle and mixture arms were actuated by hand and moved smoothly through their respective ranges. The filter screen was removed, and was absent of debris. The carburetor contained fuel which appeared absent of water and debris.

The collective control and jackshaft assembly as well as the associated throttle cable, push-pull tube, and bellcrank assemblies were retained for further examination at the NTSB Materials Laboratory.