Sunday, November 10, 2019

Abrupt Maneuver: Cirrus SR22T, N707DF; fatal accident occurred February 21, 2018 near Montgomery-Gibbs Executive Airport (KMYF), San Diego, California











Aviation Investigation Report: Loss of Engine Power due to Excessive Fuel Flow in Cirrus SR22T Aircraft 
The NTSB has released an Aviation Investigation Report (AIR-22-04) urging Cirrus Aircraft and the Federal Aviation Administration (FAA) to address safety issues identified in investigations involving Cirrus SR22T airplanes in which an excessive fuel condition led to a loss of engine power during the takeoff climb. We investigated six accidents involving Cirrus SR22T airplanes; in five of them, we were able to retrieve fuel flow data from the recoverable data modules (RDM) installed in the accident airplanes. In each case, the fuel flow data indicated an excessively high fuel flow (ranging from 42.2 to 50.1 gallons per hour [gph]) to the engine just before the loss of power.

What You Should Know

Our examination of these investigations suggests a lack of system safety assessments to identify the cause and reduce the potential of the hazard from occurring. We concluded:

the Cirrus SR22T can experience a loss of engine power due to excessive fuel flow and some causes of excessive fuel flow during takeoff and climb may not have been identified and mitigated. We have recommended that Cirrus Aircraft conduct a functional hazard assessment (FHA) to identify the causes, effects, and severity levels for the SR22T excessive fuel flow hazard condition during takeoff and climb phases of flight and, based on the FHA, update the system safety assessment. 

until the FAA requires implementation of appropriate mitigating actions to prevent the loss of engine power due to excessive fuel flow in the SR22T, additional accidents may occur due to this hazard. We have recommended the FAA review the functional hazard assessment (FHA) recommended in Safety Recommendation A-22-7 and ensure it meets the objectives of Advisory Circular 23.1309-1 E. Upon approval of the FHA, work with Cirrus to identify necessary mitigating actions and require their implementation through the appropriate means, such as an airworthiness directive. 

What You Can Do

We encourage all pilots and operators with Cirrus Aircraft to read this AIR and review the circumstances of the six accidents investigated by the NTSB.

Aviation Accident Final Report - National Transportation Safety Board

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; San Diego, California
Cirrus Aircraft; Duluth, Minnesota
Continental Motors; Mobile, Alabama
Hartzell Propeller; Piqua, Ohio

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

http://registry.faa.gov/N707DF

Location: San Diego, CA
Accident Number: WPR18FA093
Date & Time: 02/21/2018, 0631 PST
Registration: N707DF
Aircraft: CIRRUS DESIGN CORP SR22T
Aircraft Damage: Substantial
Defining Event: Abrupt maneuver
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The private pilot was taking off in the airplane when witnesses heard the airplane lose engine power at low altitude and described a sequence of events consistent with an aerodynamic stall/spin. Data retrieved from onboard the airplane recorded 47 power cycles, including the accident takeoff. The data revealed an abnormally high fuel flow, about 46 gallons per hour (gph), when takeoff power was applied, reaching 50.1 gph as the airplane entered the initial climb. About 300 ft above ground level (agl), the airplane experienced a total loss of engine power and began to decelerate and roll to the right. The airplane then entered a steep left bank and nearly vertical nose-down attitude as it descended to ground contact. The final data point at 50 ft agl indicated that the airplane was in an 81° nose-down pitch attitude and a 157° (inverted) left roll. The data is consistent with the pilot attempting to return to the runway following a loss of engine power at low altitude and an aerodynamic stall/spin when the pilot exceeded the airplane's critical angle of attack during the turn.

Examination of the engine revealed signatures consistent with an excessively rich fuel/air mixture. The fuel manifold and engine-driven fuel pump were removed from the engine and installed onto a slave engine for a test run, during which the slave engine began to surge when the power was increased to 2,300 rpm; the fuel pressure indicated 234 psi (about 39 gph); a nominal value was 210-220 psi. The engine-driven fuel pump adjustment screw was adjusted in the lean direction, and the engine operated within normal parameters; however, when the test cell fuel boost pump was turned on, the engine lost total power.

The airplane was equipped with an electric fuel boost pump that could be manually activated by the pilot via a cockpit switch. The pump had two modes; the BOOST position supplied an additional 4-6 psig at 19 gph to the engine and was used for vapor suppression when required and during takeoff, climb, landing, and when switching fuel tanks. The HIGH BOOST/PRIME position provided a capacity of 42 gph at 16 psig with a maximum full relief (no flow) pressure of 23 psig to the engine, and was used for priming the engine before start and suppressing vapor formation at flight altitudes above 18,000 ft with hot fuel.

It is likely that the excess fuel being delivered to the engine during the initial climb resulted in the total loss of power; however, the reason for the excessive fuel flow values could not be determined. According to the manufacturer, the initial fuel flow adjustments occurred at the factory about 4 months before the accident and before the pilot took delivery of the airplane. There were no maintenance logbook entries to indicate that the fuel flow had been adjusted since that time. The data did not indicate a gradual increase in fuel flow values over time; therefore, it is unlikely that the engine-driven fuel pump adjustment screw was becoming loose. It is possible that the pilot placed the fuel boost pump in the HIGH BOOST/PRIME position before takeoff, which would have increased fuel flow to about 42 gph, but this scenario does not account for the 50-gph fuel flow value reflected in the data. (The fuel boost pump position was not a recorded parameter and the position of the switch at the time of takeoff could not be determined.) Thus, based on the available information, the reason for the fuel flow rates being so high during the takeoff could not be determined.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's exceedance of the airplane's critical angle of attack during an attempted return to the runway following a total loss of engine power after takeoff, which resulted in an aerodynamic stall. Contributing to the accident was the excessive amount of fuel being delivered to the engine for reasons that could not be determined based on the available information.

Findings

Aircraft
Angle of attack - Capability exceeded (Cause)
Fuel - Fluid management (Factor)
Fuel pumps - Not specified

Personnel issues
Aircraft control - Pilot (Cause)

Not determined
Not determined - Unknown/Not determined (Factor)

Factual Information

History of Flight

Initial climb
Fuel related
Loss of engine power (total)

Approach
Abrupt maneuver (Defining event)
Aerodynamic stall/spin

Uncontrolled descent
Collision with terr/obj (non-CFIT) 

On February 21, 2018, about 0631 Pacific standard time, a Cirrus SR22T airplane, N707DF, impacted terrain shortly after takeoff from Montgomery-Gibbs Executive Airport (MYF), San Diego, California. The private pilot was fatally injured and the airplane sustained substantial damage. The airplane was registered to the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which was originating at the time of the accident.

Three witnesses provided statements regarding the accident. One stated that the airplane was "not very high" when the engine "went silent" and produced a small trail of black smoke that dissipated quickly. The airplane then entered a nose-down descent to ground contact. Another witness also described a sound consistent with a loss of engine power. The third witness recalled hearing the airplane's engine but stated that it was quiet. When the airplane was "just above the treeline," it turned right and shortly thereafter, "went straight down."

The airplane came to rest in a dirt construction site about 1/2 mile northwest of the departure end of MYF runway 5.

The airplane's recoverable data module (RDM) was removed for download at the National Transportation Safety Board Recorders Laboratory. The data revealed 47 power cycles. During the taxi, when the airplane turned to runway heading, the engine stabilized at a power setting of about 2,490 rpm and manifold pressure of about 35.3 inches of mercury (inHg). The fuel flow rate indicated over 46 gallons per hour (gph). As the airplane began its initial climb at 100 knots, the manifold pressure began to rise, reaching 36.6 inHg. The fuel flow also began to increase, reaching a peak value of 50.1 gph. Several seconds later, the manifold pressure decreased to its previous level of 35.3 inHg, and the fuel flow remained at 50.1 gph. Shortly thereafter, about 300 ft above ground level, the engine rpm, manifold pressure, exhaust gas temperature, and fuel flow began to decrease sharply. The airplane began to decelerate and rolled to the right. The airplane's left wing then dropped, and the airplane entered a nose-down pitch attitude. The final data point, at 50 ft agl, indicated that the airplane was in an 81°-nose-down pitch attitude with a 157° angle of bank.

The RDM captured two flights the day before the accident; review of the data revealed no anomalies. During those takeoffs, the engine stabilized at a power setting of about 2,490 rpm and 35.8 inHg manifold pressure; the fuel flow stabilized between 38 and 40 gph.

Pilot Information

Certificate: Private
Age: 61, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/26/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 03/28/2017
Flight Time:  2700 hours (Total, all aircraft), 1000 hours (Total, this make and model), 2600 hours (Pilot In Command, all aircraft), 15 hours (Last 90 days, all aircraft), 2 hours (Last 24 hours, all aircraft) 


Aircraft and Owner/Operator Information

Aircraft Make: CIRRUS DESIGN CORP
Registration: N707DF
Model/Series: SR22T
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1621
Landing Gear Type: Tricycle
Seats: 5
Date/Type of Last Inspection: 02/16/2017, Condition
Certified Max Gross Wt.:
Time Since Last Inspection: 2 Hours
Engines: 1 Reciprocating
Airframe Total Time: 66 Hours at time of accident
Engine Manufacturer: Continental Motors
ELT: C126 installed, not activated
Engine Model/Series: TSIO-550-K
Registered Owner: On file
Rated Power: 315 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane was manufactured in October 2017 and the pilot took delivery on November 1, 2017. The pilot had previously owned at least two Cirrus aircraft before the accident airplane; one was a SR22T and the other was a SR22. On November 4, 2017, the Cirrus Design Factory Service Center made a minor adjustment to the manifold pressure setting and subsequent ground engine run before the pilot's departure. According to a Cirrus Aircraft representative, the initial fuel flow adjustments occurred on October 11, 2017 at the Cirrus Aircraft factory.

At the accident site, the Hobbs meter read 66.1 hours and the flight meter indicated 52.7 hours. Review of the maintenance logs revealed a 50-hour inspection and oil change on February 16, 2018, which included an exhaust check and turbo check valve inspection.

The airplane's fuel system was equipped with an electric fuel boost pump, which could be manually activated by the pilot via a cockpit switch. The BOOST position supplied an additional 4-6 psig at 19 gph to the engine, which was used for vapor suppression when required, and during takeoff, climb, landing, and when switching fuel tanks. The HIGH BOOST/PRIME position provided a capacity of 42 gph at 16 psig with a maximum full relief (no flow) pressure of 23 psig to the engine; this position was used for priming the engine before start and for suppressing vapor formation at flight altitudes above 18,000 ft with hot fuel. Electric fuel boost pump operation was not recorded by the RDM.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dawn
Observation Facility, Elevation: MYF, 427 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 0653 PST
Direction from Accident Site: 240°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: Broken / 10000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 120°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 7°C / -4°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Diego, CA (MYF)
Type of Flight Plan Filed: None
Destination: Yuma, AZ (YUM)
Type of Clearance: None
Departure Time: 0630 PST
Type of Airspace:

Airport Information

Airport: Montgomery-Gibbs Executive Air (MYF)
Runway Surface Type: Asphalt
Airport Elevation:427 ft 
Runway Surface Condition: Dry
Runway Used: 5
IFR Approach: None
Runway Length/Width: 3400 ft / 75 ft
VFR Approach/Landing: None


Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 32.818889, -117.123056 (est) 

Along the northern side of the accident site was a line of undamaged trees and a light pole with right wing pieces embedded in its base. The first identified point of impact was a small crater from which two narrow indentations extended outward; one propeller blade came to rest next to the crater. Northwest of the small crater was a damaged fence and the outboard portion of the right wing. Southwest of the small crater was a damaged roadway curb with embedded white airframe fragments; other airframe fragments were noted in the immediate area. The main wreckage was located about 7 ft northeast of the initial impact point. The forward fuselage was heavily fragmented and the airframe around the cabin was destroyed. The left wing trailing edge was embedded in the dirt and the wing skin was fracture separated. The inboard right wing was still mostly secured to the airframe; however, the outboard portion was fracture separated. The aft fuselage and empennage were mostly intact and undamaged. The Cirrus Airframe Parachute System (CAPS) parachute was found extended from the aft fuselage; however, it was unopened.

Postaccident examination of the airframe revealed that the CAPS activation handle was stowed and the safety pin remained installed. Flight control continuity was established throughout the airframe. The flaps were in the retracted position. All three propeller blades sustained damage to the trailing edges; two blades were still attached to the propeller hub.

Postaccident examination of the engine revealed operating signatures consistent with an overly rich fuel/air mixture. The spark plugs were sooty and black in color. The cylinders were removed from the engine; the combustion chambers and valve heads were very sooty. In addition, the piston heads exhibited combustion deposits and were sooty. Examination of the turbocharger system revealed spiral streaking on the turbine housing outlet. The fuel manifold and engine-driven fuel pump were removed from the engine and installed onto a slave engine for an engine run.

The slave engine was installed onto a test bench and started normally. After idling for a short time, the power was increased to 2,300 rpm and the engine started to surge; the fuel pressure indicated 234 psi (about 39 gph) and the engine was unable to produce full power. The fuel pressure specification for the engine is 210-220 psi. The engine-driven fuel pump adjustment screw was measured and adjusted in the lean direction. The engine was restarted, and the engine operated up to 2,566 rpm (full power) with a fuel pressure reading between 200 and 213 psi. The test cell fuel boost pump was turned on and the engine lost all power. The engine-driven fuel pump was adjusted back to its original position and the engine was restarted. The throttle was increased to 2,404 rpm and the engine began to surge again. The fuel pressure gauge varied from 220 psi to 261 psi (about 44 gph). Toward the top of the surge, the fuel pressure gauge stayed between 250-260 psi when it would spike at about 260 psi, then return to about 220 psi.

Further examination of the fuel pump revealed that a green paint stripe was present on the adjustment screw and nut; the paint stripe had been previously broken and the paint on the nut did not match the paint on the screw (before adjusting it in the test cell). The green paint is consistent with being applied when the pump was assembled and tested. According to Cirrus Aircraft, once the engine is assembled, it is then shipped and installed onto the airplane, where Cirrus Aircraft employees make changes to the adjustment screw during the engine set up and precertification flight test. Cirrus does not apply torque stripe or paint after making these adjustments, nor are they required to. 


Medical And Pathological Information

An autopsy of the pilot was performed by the San Diego County Coroner, San Diego, California. The cause of death was listed as multiple blunt force injuries.

Toxicology testing was performed by the Federal Aviation Administration Forensic Sciences Laboratory with negative results for carbon monoxide, ethanol, and tested-for drugs.

Dr. John Harvey Serocki
Dr. Serocki graduated from the University of California, San Diego with a degree in applied mechanics and engineering sciences and went on to earn a master's degree in mechanical engineering from the Massachusetts Institute of Technology. He subsequently earned a medical degree from Northwestern University, Feinberg School of Medicine. He practiced as an orthopedic surgeon for more than 25 years with a specialization in Sports Medicine and Hand Surgery. 







Low Altitude Operation / Event: Sikorsky S-58JT, N827MW; accident occurred November 10, 2019 in Lebanon, Boone County, Indiana

View of damaged tailboom and trailer. 
 Federal Aviation Administration

 View of landing zone.
Federal Aviation Administration


Additional Participating Entity:  
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana 

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

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

https://registry.faa.gov/N827MW


Location: Lebanon, IN
Accident Number: GAA20CA063
Date & Time: 11/10/2019, 1316 EST
Registration: N827MW
Aircraft: Sikorsky S 58JT
Aircraft Damage: Substantial
Defining Event: Low altitude operation/event
Injuries: 3 Minor
Flight Conducted Under: Part 91: General Aviation - Positioning

The helicopter pilot reported that he did a low-reconnaissance flight over the intended landing site, just to the east of a building. Shortly after, he realized that the landing site was changed to the west side of the building. He maneuvered the helicopter to a hover over a new landing site west of the building, about 75 feet above the ground, and started a vertical decent. During the decent, a company mechanic seated in left seat of the cockpit told the pilot of an obstacle to the left of the helicopter. He acknowledged seeing the obstacle and continued to descend. Shortly after touchdown, as the pilot reduced the throttle setting to idle, the main rotor blades struck an empty tractor trailer, the helicopter yawed, and the tail rotor blades struck the trailer.

The helicopter sustained substantial damage to the main rotor and tail rotor systems.

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

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 50, Male
Airplane Rating(s): None
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s): Helicopter
Second Pilot Present: No
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 05/14/2019
Occupational Pilot: Yes
Last Flight Review or Equivalent: 07/23/2019
Flight Time:  (Estimated) 5500 hours (Total, all aircraft), 1450 hours (Total, this make and model), 4500 hours (Pilot In Command, all aircraft), 60 hours (Last 90 days, all aircraft), 20 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Sikorsky
Registration: N827MW
Model/Series: S 58JT ET
Aircraft Category: Helicopter
Year of Manufacture: 1958
Amateur Built: No
Airworthiness Certificate: Transport
Serial Number: 58827
Landing Gear Type: Tailwheel
Seats: 7
Date/Type of Last Inspection: 10/29/2019, Continuous Airworthiness
Certified Max Gross Wt.: 12500 lbs
Time Since Last Inspection:
Engines: 2 Turbo Shaft
Airframe Total Time: 20047 Hours at time of accident
Engine Manufacturer: Pratt & Whitney
ELT: C91A installed, not activated
Engine Model/Series: PT6T-3
Registered Owner: Midwest Truxton International Inc
Rated Power: 900 hp
Operator: Midwest Helicopter Airways, Inc.
Operating Certificate(s) Held: Agricultural Aircraft (137); Rotorcraft External Load (133); On-demand Air Taxi (135)
Operator Does Business As:
Operator Designator Code: JTKA

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KTYQ, 922 ft msl
Distance from Accident Site: 11 Nautical Miles
Observation Time: 1835 UTC
Direction from Accident Site: 92°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 240°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.93 inches Hg
Temperature/Dew Point: 12°C / 5°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Indianapolis, IN (UMP)
Type of Flight Plan Filed: None
Destination:
Type of Clearance: None
Departure Time: 1300 EST
Type of Airspace: Class G

Airport Information

Airport: Boone County (6I4)
Runway Surface Type: N/A
Airport Elevation: 959 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 2 Minor
Aircraft Fire: None
Ground Injuries:N/A 
Aircraft Explosion: None
Total Injuries: 3 Minor
Latitude, Longitude: 40.036111, -86.482222 (est)





LEBANON — Minor injuries were reported after a helicopter crashed Sunday afternoon near a Lebanon business.

According to information from the Lebanon Police Department, the helicopter crashed sometime after 1 p.m. near XPO Logistics at 135 S. Mt. Zion Road. The helicopter is a Sikorsky SK-58, according to the Federal Aviation Administration.

Three people coming from Chicago were aboard the helicopter when it attempted to land, LPD Lt. Ben Phelps said. The pilot suffered minor injuries and is receiving treatment at a local hospital.

The crew was contracted to do work at XPO Logistics, Phelps said.

Crews were going to use the helicopter for a heavy lift operation, according to the Federal Aviation Administration. It appears crews were attempting to land the helicopter when a blade struck a semi-trailer.

Federal Aviation Administration investigators will take over the investigation, Phelps said.

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

Loss of Control in Flight: McDonnell Douglas MD 600N, N602BP; fatal accident occurred April 08, 2018 in Smethport, McKean County, Pennsylvania

Shane Kenneth Filkins 
Shane died in a workplace accident on April 8th, 2018 doing the job he loved.  He was employed as an journeyman lineman.

Michael Lee Koon 
Michael passed away on April 8th, 2018.  He was a hard worker who was employed with JW Didado Electric, where he worked as a Transmission Journeyman Lineman. 
~

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

Additional Participating Entities: 

Federal Aviation Administration / Flight Standards District Office; Pittsburgh, Pennsylvania
Rolls-Royce; Indianapolis, Indiana
MD Helicopters; Mesa, Arizona

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/N602BP


Location: Smethport, PA
Accident Number: ERA18FA122
Date & Time: 04/08/2018, 1711 EDT
Registration: N602BP
Aircraft: MD HELICOPTER 600
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal, 1 Serious
Flight Conducted Under: Part 133: Rotorcraft Ext. Load 

On April 8, 2018, about 1711 eastern daylight time, an MD Helicopters 600N helicopter, N602BP, was destroyed when it collided with a wooden power line support structure and terrain in Smethport, Pennsylvania. The commercial pilot was seriously injured, and two linemen were fatally injured. The helicopter was being operated by High Line Helicopters, Inc., as Title 14 Code of Federal Regulations (CFR) Part 133 external load flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight departed from an unimproved landing zone adjacent to the accident site.

Three power lines, which were newly constructed in mountainous terrain and oriented approximately east/west, were supported by structures that were constructed of either wood (dual pole, H-frame) or steel (single pole). A static line was affixed to the top of the structures above the power lines. The purpose of the flight was to remove the static line from the wheeled pulley device (dolly) that temporarily secured the static line and permanently secure the static line to the structures ("clipping wire"). One lineman completed the task from the skid of the hovering helicopter, and another lineman inside the helicopter passed tools and equipment back and forth to the lineman on the skid.

The steps to complete the task on each support structure included wrapping the line with a spiraled wire coating (armor rod), attaching a safety strap (safety), ratcheting a chain lifting device (hoist) to the top of the structure pole, and placing the static line attachment device (shoe) to the line. Afterward, the line was hoisted into position and bolted to the structure, and the safety, hoist, and dolly were then removed from the structure and static line. The pilot then repositioned the helicopter so that the linemen could repeat the steps on the next structure.

During a postaccident interview, the pilot reported that he and the linemen (the crew) met earlier in the day and flew to one of the structures to assess the work and tools required to complete the task. The helicopter then returned to the landing zone and was refueled before departing on the accident flight. The crew completed one structure, and the pilot hovered the helicopter into position so that work could begin on the next structure. In a written statement, the pilot stated that the pole where the accident occurred was at "a slight inside angle" but was considered to be a "safe" area in which to work. According to the pilot and the operator, the helicopter was hovering "inside the bite," which was the triangular area comprising the wire from the uphill pole, the turn at the accident pole, and the wire to the downhill pole. The "base" of the triangle was the horizontal line from the uphill pole to the downhill pole. The operator indicated that the "bite" had a vertical dimension as well.

Once the helicopter was in position, the lineman on the helicopter skid attached the first half of the armor rod ahead of the dolly and manipulated the line and the dolly to complete the wrap. According to the pilot, the lineman opened the spring-loaded locking gate on the dolly above the static line to wrap the second half of the armor rod, which was "normal" before the attachment of the safety. About that time, the pilot felt the helicopter being "pulled" toward the structure. The pilot stated that he made full right cyclic and full left pedal inputs to avoid colliding with the structure but that "all I remember is rolling over the structure." The pilot said that he neither felt nor heard anything unusual before the helicopter was "pulled" toward the structure.

A witness to the accident stated that, while the helicopter was hovering, its nose turned away from the pole, and the helicopter "was violently forced back to the pole." The witness also stated that the tail section struck the pole and that the helicopter "broke in two," after which the helicopter appeared "to fall straight down." The witness did not see the helicopter's impact but stated that the engine "continued to surge."

The helicopter descended vertically between and adjacent to the dual-pole structure. The tailboom and the six rotor blades from the main rotor separated from the helicopter during the descent.

Pilot Information

Certificate: Commercial
Age: 30, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s): Helicopter
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 04/05/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  6200 hours (Total, all aircraft), 250 hours (Total, this make and model), 150 hours (Last 90 days, all aircraft), 50 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter. The pilot's most recent FAA second-class medical certificate was issued April 5, 2017. According to the operator, he had accrued about 6,200 hours of total flight experience, 250 hours of which were in the 600N helicopter. The operator estimated that that pilot had accrued 3,000 hours performing power line operations.

Aircraft and Owner/Operator Information

Aircraft Make: MD HELICOPTER
Registration: N602BP
Model/Series: 600 N
Aircraft Category:Helicopter 
Year of Manufacture: 1998
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: RN025
Landing Gear Type: Ski;
Seats:
Date/Type of Last Inspection: 02/04/2018, 100 Hour
Certified Max Gross Wt.: 4500 lbs
Time Since Last Inspection: 73 Hours
Engines:1 Turbo Shaft 
Airframe Total Time: 5203.6 Hours at time of accident
Engine Manufacturer: ALLISON
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: 250-C47
Registered Owner: FTAV LLC
Rated Power: 650 hp
Operator: High Line Helicopters, LLC
Operating Certificate(s) Held: Rotorcraft External Load (133)

The helicopter was manufactured in 1998 and was equipped with a Rolls-Royce/Allison 250-C47 600-horsepower turboshaft engine. At the time of the accident, the helicopter's Hobbs meter indicated a total of 5,203.6 hours.

Maintenance record excerpts showed that the helicopter's most recent 100-hour inspection was completed on February 4, 2018. The helicopter had accumulated 5,120.8 hours at that time.

An FAA airworthiness inspector reviewed the helicopter's maintenance records. The inspector found numerous record-keeping errors but overall compliance with hourly and calendar inspections as well as compliance with airworthiness directives.

The helicopter was installed with aluminum diamond-plate flooring, which required the removal of the left-side cabin door, and a 6061-T6 aluminum pipe. A search of the FAA's aircraft registry records and the helicopter's maintenance logbooks found no information regarding these installations. Also, no records were found showing FAA approval for these modifications or company documentation of weight and balance computations that reflected the changes.

According to section 2-1 of the MD 600N flight manual, operations with the left-side cabin door removed were authorized, but operations with the pilot (right) seat removed (resulting in a left-seat command configuration) were not. Neither of these modifications was reflected in the helicopter's weight and balance or aircraft records.

Title 14 CFR 91.107(a)(3) required that all passengers be seated in an approved seat and properly secured with a seatbelt during aircraft movement. The helicopter's cabin had no passenger seats installed.

Weight and balance computations based on pilot and lineman weights, cargo, and three different fuel states (full, one-half, and one-third tank) showed that the helicopter, as configured, was likely within weight, lateral, and longitudinal center-of-gravity limits for the accident flight.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: BFD, 2150 ft msl
Distance from Accident Site: 10 Nautical Miles
Observation Time: 2053 UTC
Direction from Accident Site: 260°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Overcast / 4100 ft agl
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual:/ None 
Wind Direction: 290°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.95 inches Hg
Temperature/Dew Point: -3°C / -12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Smethport, PA
Type of Flight Plan Filed: None
Destination: Smethport, PA
Type of Clearance: None
Departure Time: 1700 EDT
Type of Airspace: Class G 

At 1653, the weather reported at Bradford Regional Airport (BFD), Lewis Run, Pennsylvania, which was located 10 miles west of the accident site, included an overcast layer at 4,100 ft, 10 statute miles visibility, and wind from 290° at 10 knots. The temperature was -3°C, the dew point was -12°C, and the altimeter setting was 29.95 inches of mercury. 

Wreckage and Impact Information

Crew Injuries: 2 Fatal, 1 Serious
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal, 1 Serious
Latitude, Longitude: 41.828333, -78.419444 

The accident site was at an elevation of about 1,600 ft. All major components were accounted for at the scene. The wreckage was contained largely at the bottom of the wooden H-frame structure that was struck, with the six rotor blades separated at the hub and scattered at various distances on the south side of the power lines. One rotor blade traveled about 300 ft down the hill (west) of the structure. The tailboom separated and was found about 70 ft west of the structure. Striating marks consistent with wire contact were visible on top of the left skid forward of the front cross-tube.

The six main rotor blades remained inside their respective pitch housings, and the laminated steel strap sets ("strap packs") were fractured at the hub. The blades showed varying degrees of chordwise and spanwise twisting and bending. One of the rotor blades displayed a concave dent 2.25 inches from the tip. The dent was about 1 inch wide and 0.75 inch deep. The overall dimensions of the dent and the dimensions of the individual striating marks inside it were consistent with the total dimensions of the static line and its individual strands.

The safety strap was suspended from a cross-brace of the H-frame structure, and the hoist was found next to the fuselage. Both appeared undamaged. Examination of the structure poles and the static line revealed signatures consistent with blade strikes. Blemishes on the static line, about 11 feet uphill (east) of the structure where the dolly was mounted, displayed smearing signatures consistent with a high-speed, metal-to-metal strike.

Continuity of the flight control and drive systems was established through several breaks. The fractures and breaks all displayed features consistent with overstress. Examination of the wreckage revealed no preimpact mechanical anomalies.

The dolly was in its swiveling mount and was facing 180° from its operational position. Damage signatures to the pole above the dolly's mount matched the dimensions of the dolly. The dolly was recovered from the top of the structure and was found to be intact except for the locking gate, which was fractured. The fracture surfaces displayed features consistent with overstress. The dolly was retained for further examination at the National Transportation Safety Board (NTSB) Materials Laboratory where it was compared it with an exemplar dolly. The dolly assembly consisted of a circular pulley wheel with a U-shape groove for holding a cable that was surrounded by a block with a locking gate. The locking gate latch was spring loaded to stay in the closed position (when not being actuated) against a tab on the block. The latch, when resting against the tab, would be under a bending force with the tension side facing outward face and the compression side facing inward.

In the closed position, the locking gate latch would prevent the cable from leaving the groove on the pulley wheel. When the locking gate latch was actuated, it rotated inward to allow a cable to be moved either inward or outward.

Examination of the fracture surfaces on the locking gate latch with a scanning electron microscope revealed fractures consistent with overstress. The direction of the fractures on the latch remnants, and the smear marks on the pulley wheel guide outer corners, were from the pulley wheel moving outward. 

Tests And Research

The NTSB deployed two unmanned aircraft systems (UAS) to conduct aerial imaging of the power lines that the helicopter impacted and to map the terrain in the area in and around the power lines and supporting structures. The UAS flights were conducted 1 year after the accident; during that time, the construction work on the powerlines had been completed.

A mapping flight of an exemplar MD Helicopters 600N helicopter was conducted to create a three-dimensional point cloud/surface model of the helicopter. Photogrammetry software was used to process the data and imagery from the accident scene map along with the three-dimensional model of the helicopter. The three-dimensional model was used to demonstrate the relative position of the helicopter to the tower, wires, and the dolly as well as the clearances available between the main rotor blades and the static line.

Additional Information

Organizational Information

High Line Helicopters was hired as an independent contractor by J.W. Didado Electric, LLC, a subsidiary of Quanta Services, Inc., to transport J.W. Didado employees to job sites for new power line construction. First Energy Corporation hired J.W. Didado to perform the construction.

During a postaccident telephone interview, the NTSB asked the director of safety for High Line Helicopters about the task sequence and specifically why the safety strap was not installed first. He replied that the safety strap aboard the helicopter was "not long enough" to stay attached while the armor rod was being installed and that a "choker safety" should have been used. When asked if the company's standard operating procedures directed that the crew retrieve the choker safety, the director of safety replied, "that is more or less a contractor thing" and that High Line Helicopters did not have procedures for contractor equipment. When asked to describe operations "inside the bite," the safety director stated that it was the area where, once the helicopter was inside it, the wire would move toward the helicopter if the wire became loose from the dolly.

Quanta Services published a safety manual with detailed guidelines and a skills proficiency sheet, also referred to as a grade slip, for linemen who performed their work from helicopters. Section 14, Helicopter Safety, Rigging, page 14-10, states the following: "secondary securement systems shall be utilized in situations that can [a]ffect safe helicopter operations, such as clipping wire." Quanta Services further indicated that the safety manual was for "guidance only" and the training of linemen for helicopter operations was the responsibility of the helicopter contractor.

Previous Related Accidents

A review of the NTSB's accident database revealed that the operator was involved in three accidents within a 3-month period in 2018, including this accident. The first accident (ERA18LA091) occurred in San Juan, Puerto Rico on January 11, 2018, and the second accident (CEN18LA121) occurred in Blair, Wisconsin, on March 7, 2018, and involved the accident pilot. The accident in Smethport, Pennsylvania, occurred about 1 month later.

The first two accidents occurred during "human cargo external load operations." For the first accident (ERA18LA091), the NTSB found that probable cause was the helicopter pilot's improper decision to use an open-end grapple, instead of an A-frame attachment, to lift and move a ladder with a lineman on it and the lineman's improper decision to be lifted on a ladder via an open-end grapple, which were contrary to company policy and the Federal Aviation Regulations.

For the second accident (CEN18LA121) the NTSB determined that the probable cause was the pilot's failure to recognize and compensate for hazards during the human cargo external load operation, which led to a collision between a lineman, who was the external load, and a live power line. FAA inspectors determined the company's Rotorcraft External Load Flight Manual had inadequate procedures and training for human external cargo.

FAA Oversight

During the investigation, FAA aviation safety inspectors identified areas within the flight and maintenance departments for improvement. Inspectors visited the operator's facilities, presented a "maintenance demonstration," and provided templates for documents and standard operating procedures for recordkeeping and pilot training.

During a subsequent aircraft conformity inspection, an FAA aviation safety inspector (airworthiness) noted that the operator had incorporated the documents provided and that no deficiencies were noted.

As a result of this accident investigation, the president of High Line Helicopters mandated the installation of safety straps to wires before work begins. The safety straps are to remain in place until work is completed at each structure

Aerodynamic Stall/Spin: Glasair Sportsman GS-2, N24EP; accident occurred November 09, 2019 near Huntsville Municipal Airport (H34), Madison County, Arkansas

 









Aviation Accident Final Report - National Transportation Safety Board

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Little Rock, Arkansas

Investigation Docket - National Transportation Safety Board:


Location: Huntsville, Arkansas
Accident Number: GAA20CA064
Date & Time: November 9, 2019, 09:45 Local
Registration: N24EP
Aircraft: New Glasair SPORTSMAN GS-2 
Aircraft Damage: Substantial
Defining Event: Aerodynamic stall/spin
Injuries: 1 Minor, 1 None
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The pilot reported that, during the takeoff roll from a wet, turf runway, the airplane encountered mud and veered left. He applied aft pressure to the stick, and the airplane climbed into ground effect. The pilot pulled up and attempted to climb out of ground effect, but the airplane descended and impacted trees. The airplane sustained substantial damage to both wings and the fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain proper pitch control during takeoff from a muddy, turf runway and his exceedance of the airplane's critical angle of attack during the initial climb, which resulted in an aerodynamic stall. 

Findings

Aircraft Pitch control - Incorrect use/operation
Aircraft Angle of attack - Not attained/maintained
Personnel issues Aircraft control - Pilot
Environmental issues Wet surface - Effect on operation
Environmental issues Tree(s) - Contributed to outcome

Factual Information

History of Flight

Takeoff Aerodynamic stall/spin (Defining event)
Takeoff-rejected takeoff Nose over/nose down

Pilot Information

Certificate: Private 
Age: 57, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With waivers/limitations
Last FAA Medical Exam: November 13, 2018
Occupational Pilot: No 
Last Flight Review or Equivalent: September 9, 2019
Flight Time: (Estimated) 711 hours (Total, all aircraft), 32 hours (Total, this make and model), 711 hours (Pilot In Command, all aircraft), 32 hours (Last 90 days, all aircraft), 32 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: New Glasair
Registration: N24EP
Model/Series: SPORTSMAN GS-2 No Series 
Aircraft Category: Airplane
Year of Manufacture: 2018
Amateur Built: Yes
Airworthiness Certificate: Experimental (Special) 
Serial Number: 7466
Landing Gear Type: Tailwheel
Seats: 4
Date/Type of Last Inspection: May 1, 2019 Condition 
Certified Max Gross Wt.: 2500 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 62 Hrs at time of accident
Engine Manufacturer: Lycoming
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: YIO-390-EXP
Registered Owner: 
Rated Power: 210 Horsepower
Operator:
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: KASG, 1353 ft msl 
Distance from Accident Site: 18 Nautical Miles
Observation Time: 15:48 Local
Direction from Accident Site: 287°
Lowest Cloud Condition: Clear 
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 10 knots / 15 knots 
Turbulence Type Forecast/Actual:  /
Wind Direction: 230°
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.2 inches Hg
Temperature/Dew Point: 10°C / 3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Huntsville, AR (H34)
Type of Flight Plan Filed: None
Destination: Lakeview, AR (3M0)
Type of Clearance: None
Departure Time: 09:45 Local
Type of Airspace: Class G

Airport Information

Airport: Huntsville Muni H34
Runway Surface Type: Grass/turf
Airport Elevation: 1747 ft msl 
Runway Surface Condition: Soft; Wet
Runway Used: 21
IFR Approach: None
Runway Length/Width: 1250 ft / 60 ft 
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 1 None 
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor, 1 None
Latitude, Longitude: 36.078056,-93.754997(est)

Location: Huntsville, AR

Accident Number: GAA20CA064
Date & Time: 11/09/2019, 0945 CST
Registration: N24EP
Aircraft: New Glasair SPORTSMAN GS-2
Aircraft Damage: Substantial
Defining Event: Nose over/nose down
Injuries: 1 Minor, 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

The pilot reported that, during the takeoff roll from a wet turf runway, the airplane encountered mud, and veered left. He applied aft pressure to the stick and the airplane climbed into ground-effect. The pilot "pulled up" and attempted to climb out of ground effect, but the airplane descended and collided with trees.

The airplane sustained substantial damage to both wings and the fuselage.

The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Pilot Information

Certificate: Private
Age: 57, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 11/13/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 09/09/2019
Flight Time:   (Estimated) 711 hours (Total, all aircraft), 32 hours (Total, this make and model), 711 hours (Pilot In Command, all aircraft), 32 hours (Last 90 days, all aircraft), 32 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: New Glasair
Registration: N24EP
Model/Series: SPORTSMAN GS-2 No Series
Aircraft Category: Airplane
Year of Manufacture: 2018
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 7466
Landing Gear Type: Tailwheel
Seats: 4
Date/Type of Last Inspection: 05/01/2019, Condition
Certified Max Gross Wt.: 2500 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 62 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: YIO-390-EXP
Registered Owner: Bray-Bryn Llc
Rated Power: 210 hp
Operator: Bray-Bryn Llc
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KASG, 1353 ft msl
Distance from Accident Site: 18 Nautical Miles
Observation Time: 1548 UTC
Direction from Accident Site: 287°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 10 knots / 15 knots
Turbulence Type Forecast/Actual:
Wind Direction: 230°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.21 inches Hg
Temperature/Dew Point: 10°C / 3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Huntsville, AR (H34)
Type of Flight Plan Filed: None
Destination: Lakeview, AR (3M0)
Type of Clearance: None
Departure Time: 0945 CST
Type of Airspace: Class G

Airport Information

Airport: Huntsville Muni (H34)
Runway Surface Type: Grass/turf
Airport Elevation: 1747 ft
Runway Surface Condition: Soft; Wet
Runway Used: 21
IFR Approach: None
Runway Length/Width: 1250 ft / 60 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor, 1 None
Latitude, Longitude: 36.078056, -93.755000 (est)

HUNTSVILLE, Arkansas (KNWA) — One person suffered minor injuries after a small plane crash near Mitchusson Park in Huntsville on Saturday.

Fire Chief Kevin Shinn said two men were testing out a new plane when it crashed in a wooded area about two miles south of the airport in Huntsville on Saturday morning.

The pilot suffered lacerations to his head, but the passenger was uninjured.

Shinn said the Federal Aviation Administration is investigating the cause of the accident.

Original article can be found here ➤ https://www.nwahomepage.com