Pilot Debrief

HUGHES 369 near San Juan, PR — 2018-01-11

Final reportERA18LA091
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Date
2018-01-11
Location
San Juan, PR, USA
Aircraft
HUGHES 369
Registration
N571HH
Category
Helicopter
Highest injury
Serious
Fatalities
0
Phase of flight
Hover

Probable cause

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.

NTSB narrative

The commercial pilot was conducting helicopter operations to support electrical workers on utility towers. The support included lifting ladders and other equipment with an open-end grapple and lifting ladders with electrical workers (linemen) on them with an A-frame attachment. At the time of the accident, the helicopter was attempting to lift a ladder with a lineman on it using a grapple. The ladder became bound, and the helicopter pilot descended to lower the ladder back on the static arm. The ladder became free of both the grapple and static arm, which resulted in the ladder falling to the ground with the lineman on it, causing a serious injury to the lineman. Lifting workers with an open-end grapple versus an A-frame attachment was contrary to company policy and Federal Aviation Regulation 27.865(c)(2) because the grapple does not protect against falls. The pilot reported that he was using a grapple at the time of the accident because he thought that he was only lifting the ladder. However, video recorded by the accident lineman earlier that day revealed that the helicopter pilot had previously used a grapple to move a ladder with the lineman on it and that the lineman allowed this situation to happen. Specifically, the video showed the accident lineman giving hand signals to the helicopter pilot while the lineman was on a ladder and then the helicopter lifting the ladder with a grapple so that the ladder could be repositioned to a different location on the utility tower. The pilot and lineman likely continued this practice at the time of the accident. Bee nests at the job site required the linemen to wear bee suits, which might have degraded their ability to clearly communicate, verbally and with head and hand signals, with the helicopter pilot.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have used A-frame instead of grapple for human transport.

NTSB coding

Evidence available

  • Video
  • 13 docket documents
View NTSB final reportView NTSB docket

Docket documents13

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