National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Frisco, CO

Accident Number:

CEN15MA290

Date & Time:

07/03/2015, 1339 MDT

Registration:

N390LG

Aircraft:

AIRBUS HELICOPTERS INC AS350B3E

Aircraft Damage:

Destroyed

Defining Event:

Loss of control in flight

Injuries:

1 Fatal, 2 Serious

Flight Conducted Under:

Part 135: Air Taxi & Commuter - Non-scheduled - Air Medical (Unspecified)

Analysis

 

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-17/01.

On July 3, 2015, about 1339 mountain daylight time, an Airbus Helicopters AS350 B3e helicopter, N390LG, registered to and operated by Air Methods Corporation, lifted off from the Summit Medical Center Heliport, Frisco, Colorado, and then crashed into a parking lot; the impact point was located 360 feet southwest of the ground-based helipad. The pilot was fatally injured, and the two flight nurses were seriously injured. The helicopter was destroyed by impact forces and a postcrash fire. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135 on a company flight plan. Visual meteorological conditions prevailed at the time of the accident.

 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
 

Airbus Helicopters' dual-hydraulic AS350 B3e helicopter's (1) preflight hydraulic check, which depleted hydraulic pressure in the tail rotor hydraulic circuit, and (2) lack of salient alerting to the pilot that hydraulic pressure was not restored before takeoff. Such alerting might have cued the pilot to his failure to reset the yaw servo hydraulic switch to its correct position during the preflight hydraulic check, which resulted in a lack of hydraulic boost to the pedal controls, high pedal forces, and a subsequent loss of control after takeoff. Contributing to the accident was the pilot's failure to perform a hover check after liftoff, which would have alerted him to the pedal control anomaly at an altitude that could have allowed him to safely land the helicopter. Contributing to the severity of the injuries was the helicopter's fuel system, which was not crash resistant and facilitated a fuel-fed postcrash fire.

 

Findings

Aircraft

Hydraulic power system - Design (Cause)

Hydraulic, indicating system - Design (Cause)

Fuel system - Design (Factor)

Personnel issues

Use of equip/system - Pilot (Cause)

Forgotten action/omission - Pilot (Cause)

Use of checklist - Pilot (Cause)

Aircraft control - Pilot (Cause)

Lack of action - Pilot (Factor)

Use of policy/procedure - Pilot (Factor)

Organizational issues

Equipment design - Manufacturer (Cause)

Design of document/info - Manufacturer (Cause)

Factual Information

 

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-17/01.

On July 3, 2015, about 1339 mountain daylight time, an Airbus Helicopters AS350 B3e helicopter, N390LG, registered to and operated by Air Methods Corporation, lifted off from the Summit Medical Center Heliport, Frisco, Colorado, and then crashed into a parking lot; the impact point was located 360 feet southwest of the ground-based helipad. The pilot was fatally injured, and the two flight nurses were seriously injured. The helicopter was destroyed by impact forces and a postcrash fire. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135 on a company flight plan. Visual meteorological conditions prevailed at the time of the accident.

 

 

History of Flight

Takeoff

Preflight or dispatch event

Loss of control in flight (Defining event)

Uncontrolled descent

Collision with terr/obj (non-CFIT)

Post-impact

Fire/smoke (post-impact)

 

 

Pilot Information

Certificate:

Airline Transport; Commercial

Age:

64, Male

Airplane Rating(s):

Single-engine Land

Seat Occupied:

Front

Other Aircraft Rating(s):

Helicopter

Restraint Used:

3-point

Instrument Rating(s):

Airplane; Helicopter

Second Pilot Present:

No

Instructor Rating(s):

None

Toxicology Performed:

Yes

Medical Certification:

Class 2 With Waivers/Limitations

Last FAA Medical Exam:

01/12/2015

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

03/22/2015

Flight Time:

13231 hours (Total, all aircraft), 5231 hours (Total, this make and model), 13131 hours (Pilot In Command, all aircraft), 20 hours (Last 90 days, all aircraft), 12 hours (Last 30 days, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

AIRBUS HELICOPTERS INC

Registration:

N390LG

Model/Series:

AS350B3E

Aircraft Category:

Helicopter

Year of Manufacture:

2013

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

7595

Landing Gear Type:

High Skid

Seats:

5

Date/Type of Last Inspection:

07/02/2015, AAIP

Certified Max Gross Wt.:

5225 lbs

Time Since Last Inspection:

 

Engines:

1 Turbo Shaft

Airframe Total Time:

487.4 Hours at time of accident

Engine Manufacturer:

Turbomeca

ELT:

C126 installed, activated, did not aid in locating accident

Engine Model/Series:

Arriel 2D

Registered Owner:

AIR METHODS CORP

Rated Power:

802 hp

Operator:

AIR METHODS CORP

Operating Certificate(s) Held:

Rotorcraft External Load (133); On-demand Air Taxi (135)

Operator Does Business As:

 

Operator Designator Code:

QMLA

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Day

Observation Facility, Elevation:

KCCU, 12028 ft msl

Distance from Accident Site:

7 Nautical Miles

Observation Time:

1335 UTC

Direction from Accident Site:

200°

Lowest Cloud Condition:

Scattered / 6000 ft agl

Visibility

10 Miles

Lowest Ceiling:

None

Visibility (RVR):

 

Wind Speed/Gusts:

19 knots / 24 knots

Turbulence Type Forecast/Actual:

/ None

Wind Direction:

280°

Turbulence Severity Forecast/Actual:

/ N/A

Altimeter Setting:

30.62 inches Hg

Temperature/Dew Point:

18°C / -2°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

Frisco, CO (91CO)

Type of Flight Plan Filed:

Company VFR

Destination:

Gypsum, CO

Type of Clearance:

None

Departure Time:

1338 MDT

Type of Airspace:

Class G

 

Airport Information

Airport:

SUMMIT MEDICAL CENTER (91CO)

Runway Surface Type:

Asphalt; Concrete

Airport Elevation:

9042 ft

Runway Surface Condition:

Dry

Runway Used:

H1

IFR Approach:

None

Runway Length/Width:

100 ft / 100 ft

VFR Approach/Landing:

None

 

Wreckage and Impact Information

Crew Injuries:

1 Fatal

Aircraft Damage:

Destroyed

Passenger Injuries:

2 Serious

Aircraft Fire:

On-Ground

Ground Injuries:

N/A

Aircraft Explosion:

On-Ground

Total Injuries:

1 Fatal, 2 Serious

Latitude, Longitude:

39.568611, -106.079444 (est)

 


 


Administrative Information

Investigator In Charge (IIC):

Jennifer Rodi

Report Date:

05/09/2017

Additional Participating Persons:

Matt Rigsby; FAA AVP-100; Washington, DC

Phil Potter; FAA Denver FSDO; Denver, CO

Seth Buttner; Airbus; Grand Prairie, TX

Brian Larimore; Turbomeca; Grand Prairie, TX

Dennis McCall; Air Methods Corporation; Denver, CO

Ed Stenby; OPEIU - Local 109; Denver, CO

Vincent Ecalle; BEA

Publish Date:

05/09/2017

Note:

The NTSB traveled to the scene of this accident.

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=91489