Eurocopter Deutschland EC 135 P2+ near Pottsville, PA — 2008-05-31

Probable cause

The pilot’s failure to ensure that both engine switches were in the FLIGHT position for takeoff.

NTSB narrative

After taking off on a helicopter emergency medical service mission, the twin-engine helicopter climbed approximately 75 feet. The pilot lowered the nose, but the helicopter would not climb or accelerate normally. The pilot saw 125 percent on one of his gauges, but was not sure which gauge it was as he was looking outside. A "gong" sounded, similar to what the pilot had heard when doing "max takeoffs," but he did not hear an engine-out horn or see any warning lights. The pilot also noticed that one torque indication was declining to "near zero" percent, and the helicopter began to yaw. The pilot was able to correct the yawing moment with anti-torque inputs, and remembered lowering the collective and "pulling pitch" before the helicopter impacted the ground in a level attitude. The No. 1 engine was running as the pilot exited the helicopter, but the No. 2 engine was not. Examinations at the accident site revealed that the helicopter, after lifting off from the heliport, flew out of ground effect over down-sloping terrain, settled, then struck a parked semi-trailer about 80 feet below the heliport. No preimpact mechanical anomalies of the helicopter, engines, or engine switches were found. As part of the pre-takeoff confirmation check, the pilot was required to ensure that both main engine switches were in the FLIGHT position; however, onboard recorded data revealed that the No. 2 main engine switch was in the IDLE position during the takeoff.

Analysis

Primary failure mode

Human factors

First missed decision gate

Pilot failed to perform a hover check before takeoff as required by the flight manual.

NTSB coding

• Collision with terr/obj (non-CFIT) · Takeoff

Evidence available

• Photos
• 21 docket documents

Docket documents21

• NTSB Report Statement - Helicopter Operator Informationform
• Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1form
• Statement of Party Representatives to NTSB Investigationinterview
• Witness Statements and Interview Summariesinterview
• Air Methods Corporation Operations Manual - Before Start / Before Takeoff Confirmation Checkother
• Air Methods Corporation Operations Manual - Pilot-In-Command (Utilization of Safety Equipment)other
• Air Methods Memorandum (Subject: Before Takeoff Checks)other
• Air Methods Pre-takeoff Confirmation Checkother
• Air Methods Quality Alert Noticeother
• EC135 P2+ Normal Takeoff Proceduresother
• Eurocopter ASIL (EC135 - A110)other
• Eurocopter EC135 Alert Service Bulletin (EC135-31A-045)other
• Excerpts from EC135 P2+ Flight Manualother
• Photo - EC135 Cockpit Indications of One Engine at Idle following Engine Power Checkphotos
• Photograph of Exemplar Main Engine Switch No. 2 (Close-Up)photos
• Photograph of Exemplar 20VE Switch Panelphotos
• Photograph of Exemplar Main Engine Switch No. 1 (Close-Up)photos
• Photograph of Main Wreckagephotos
• Excerpts from VEMD and CAD Examination Reportreport
• Group Chairman's Factual Report of Investigation - Switch Unit 20VEreport
• Weather Reports and Recordsreport

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