Pilot Debrief

EUROCOPTER AS365N3 near Dayton, OH — 2010-07-04

Final reportCEN10IA372
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Date
2010-07-04
Location
Dayton, OH, USA
Airport
I73
Aircraft
EUROCOPTER AS365N3
Registration
N520CF
Category
Helicopter
Highest injury
None
Fatalities
0
Phase of flight
Cruise

Probable cause

The unintentional movement of the jettison handle in-flight due to the pilot’s dropping of a manual that impacted the handle and released the door window, which then impacted the horizontal stabilizer. Contributing to the accident was the jettison handle guard not being installed by maintenance personnel.

NTSB narrative

The emergency medical services transport helicopter sustained minor damage when a door window separated in-flight. The pilot dropped a flight manual during cruise flight that impacted the right center door jettison handle, allowing the window to separate and impact the horizontal stabilizer. The required jettison handle guard was not installed. The helicopter’s maintenance manual directs that the crew and passenger doors be checked every 600 hours of flight time or every two years. The manual requires the following steps to reinstall the doors, "Install the Plexiglas protective cover." Subsequent to the accident, the helicopter manufacturer issued Safety Information Notices which described the incident and reminded mechanics that while performing routine maintenance procedures, in particular assembly procedures, “it is important to strictly comply with all applicable maintenance procedures, including the most basic and simple ones, to ensure proper helicopter performance and flight safety.”

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Installation of the protective cover for the jettison handle was not completed.

NTSB coding

  • Part(s) separation from AC · Enroute

Evidence available

  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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