Pilot Debrief

AMERICAN EUROCOPTER CORP AS350B3 near Peach Springs, AZ — 2014-05-18

Final reportWPR14FA195
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Date
2014-05-18
Location
Peach Springs, AZ, USA
Airport
1G4
Aircraft
AMERICAN EUROCOPTER CORP AS350B3
Registration
N840PA
Category
Helicopter
Highest injury
Fatal
Fatalities
1
Phase of flight
Landing

Probable cause

The pilot’s decision to exit the helicopter while it was running and his failure to properly secure the flight controls with the engine operating at flight idle before exiting the helicopter.

NTSB narrative

The commercial pilot was repositioning the helicopter and advised ground personnel that he intended to land and perform a "fluid check." Company personnel reported that most pilots used this term when they intended to land away from the awaiting passengers and exit the helicopter to relieve themselves. The pilots would generally leave the engine running when outside the helicopter. The helicopter was equipped with an on board video recording system. The recording revealed that the pilot landed the helicopter in a location that had a direct buffeting crosswind. The pilot tightened the friction on the cyclic, which then did not move. The twist grip light illuminated, and engine audio was consistent with the throttle being moved toward ground idle. About 6 seconds later, the twist grip light extinguished, engine audio was consistent with an increase in power to flight idle; engine data parameters indicate that the twist grip was moved to flight idle. On the video, the collective position continued to increase. About 15 seconds later, the pilot exited the helicopter. External audio indicated a sound similar to N1 increasing. For the next 24 seconds, the video showed an increase in airframe buffeting. The helicopter then began to pitch nose down. One second later, the helicopter began to roll right; the roll increased, and the helicopter then began to yaw left. The sound of the door opening was heard, likely indicating that the pilot attempted to enter the helicopter. The helicopter continued to roll and yaw until noises consistent with the rotor blades impacting the ground were heard. The operator had a policy that required a pilot to always be at the controls of a running helicopter. However, according to pilot interviews, this policy was not generally followed, and the pilots would not shut down the helicopter when they needed to relieve themselves. However, pilots who were interviewed stated that they would leave the helicopter operating at ground idle. It could not be determined why the pilot would leave the helicopter while it was operating at flight idle without the flight controls properly secured.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should not have exited the helicopter while it was still running.

NTSB coding

Evidence available

  • FDR / data
  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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