Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a...

19
CA 12-12a 20 NOVEMBER 2015 Page 1 of 19 Section/division Accident and Incident Investigations Division Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY Reference: CA18/2/3/9624 Aircraft Registration ZT-RAC Date of Accident 14 June 2017 Time of Accident 1030Z Type of Aircraft MD 500E Type of Operation Private (Part 91) Pilot-in-command Licence Type PPL Helicopter Age 28 Licence Valid Yes Pilot-in-command Flying Experience Total Flying Hours 1030 Hours on Type 2.9 Last point of departure Welkom Airport (FAWM)-Free State Province Next point of intended landing Christiana-North West Province Location of the accident site with reference to easily defined geographical points (GPS readings if possible) Bultfontein area on a national road at GPS: 28°13'32.18"S, 26° 7'28.70"E and a field elevation of 4491ft Meteorological Information Wind direction:195°; wind speed: 2-6kt; wind temperature:20°C: Visibility: CAVOK Number of people on board 1+2 No. of people injured 0 No. of people killed 0 Synopsis The pilot accompanied by two passengers was engaged on a private flight from FAWM to Christiana in the North West Province. According to the pilot they had also planned to fly over the area where his company was conducting road constructions on the regional road R700 in the area of Bultfontein for progress observation. Upon reaching the area, the pilot flew over the area as planned at approximately 80ft above ground level (AGL). He then made a turn to the right and the helicopter experienced an engine power loss and began spinning to the right. The pilot maintained control by stopping the spin and decided to execute a forced landing on a road. During a flare, the helicopter cushioning caused lot of dust which obscured the pilot vision and made it difficult to judge the height to the ground. Prior to contacting the ground it began to swing violently to the right due to the loss of tail rotor effectiveness. The helicopter contacted the ground hard with the right skid gear first which broke off., The aircraft was substantially damaged and neither the pilot nor passengers sustained injuries. The investigation revealed that the helicopter power loss was due to the pilot inadvertently cutting off the engine power, resulting in a rapid loss of height, a spin to the right followed by a hard impact with the road surface. Probable Cause Unsuccessful forced landing following a power loss due to the pilot inadvertent cutting off the engine power resulting in a rapid loss of height, a spin to the right followed by a hard impact with the road surface. Contributory factor: The Pilot used incorrect (Robinson R44) recovery technique instead of a correct (MD500E) recovery technique. SRP Date 10 October 2017 Release Date 08 January 2018

Transcript of Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a...

Page 1: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 1 of 19

Section/division Accident and Incident Investigations Division Form Number: CA 12-12a

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Reference: CA18/2/3/9624

Aircraft Registration

ZT-RAC Date of Accident 14 June 2017 Time of Accident 1030Z

Type of Aircraft MD 500E Type of Operation

Private (Part 91)

Pilot-in-command Licence Type PPL Helicopter Age 28 Licence Valid Yes

Pilot-in-command Flying Experience

Total Flying Hours

1030 Hours on Type 2.9

Last point of departure Welkom Airport (FAWM)-Free State Province

Next point of intended landing Christiana-North West Province

Location of the accident site with reference to easily defined geographical points (GPS readings if

possible)

Bultfontein area on a national road at GPS: 28°13'32.18"S, 26° 7'28.70"E and a field elevation of 4491ft

Meteorological Information Wind direction:195°; wind speed: 2-6kt; wind temperature:20°C: Visibility: CAVOK

Number of people on board 1+2 No. of people injured 0 No. of people killed 0

Synopsis

The pilot accompanied by two passengers was engaged on a private flight from FAWM to Christiana in the North West Province. According to the pilot they had also planned to fly over the area where his company was conducting road constructions on the regional road R700 in the area of Bultfontein for progress observation. Upon reaching the area, the pilot flew over the area as planned at approximately 80ft above ground level (AGL). He then made a turn to the right and the helicopter experienced an engine power loss and began spinning to the right. The pilot maintained control by stopping the spin and decided to execute a forced landing on a road. During a flare, the helicopter cushioning caused lot of dust which obscured the pilot vision and made it difficult to judge the height to the ground. Prior to contacting the ground it began to swing violently to the right due to the loss of tail rotor effectiveness. The helicopter contacted the ground hard with the right skid gear first which broke off., The aircraft was substantially damaged and neither the pilot nor passengers sustained injuries. The investigation revealed that the helicopter power loss was due to the pilot inadvertently cutting off the engine power, resulting in a rapid loss of height, a spin to the right followed by a hard impact with the road surface.

Probable Cause

Unsuccessful forced landing following a power loss due to the pilot inadvertent cutting off the engine power resulting in a rapid loss of height, a spin to the right followed by a hard impact with the road surface. Contributory factor: The Pilot used incorrect (Robinson R44) recovery technique instead of a correct (MD500E) recovery technique.

SRP Date 10 October 2017 Release Date 08 January 2018

Page 2: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 2 of 19

Section/division Accident and Incident Investigation Division Form Number: CA 12-12a

AIRCRAFT ACCIDENT REPORT

Name of Owner : Aircraft Assets Finance Corporation

Name of Operator : Private

Manufacturer : Macdonnel Douglas Helicopter INC

Model : MD 500E

Nationality : South African

Registration Marks : ZT-RAC

Place : Bultfontein area on a national road at GPS:

28°13'32.18"S, 26° 7'28.70"E and a field elevation of

4491ft

Date : 14 June 2017

Time : 1030Z

All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South

African Standard Time is UTC plus 2 hours.

Purpose of the Investigation:

In terms of Regulation 12.03.1 of the Civil Aviation Regulations (2011) this report was compiled in the

interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and

not to establish blame or liability.

Disclaimer:

This report is produced without prejudice to the rights of the CAA, which are reserved.

1. FACTUAL INFORMATION

1.1 History of Flight

1.1.1 The pilot accompanied by two passengers was engaged on a private flight to

Christiana in the North West Province. According to the pilot, they had planned to

fly pass the Bultfontein area where his company was conducting road constructions

on R700 to observe the progress. Upon reaching the area the pilot descended to

about 80ft AGL and commenced with his fly pass as planned and then made a right

Page 3: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 3 of 19

hand turn to follow the road. According to the pilot, during a turn the helicopter

engine out light illuminated associated with an audible sound through the

earphones and was followed by a loss of power. The helicopter then started

pitching the nose up and down and pulling left and right. The pilot immediately

rolled the throttle in an attempt to increase engine power and increased the

collective control without success. The pilot then entered into an autorotation

whereby the helicopter entered into a spin to the right. However the pilot was able

to contain the situation and regain control of the aircraft and stopped the spin. He

then further made a turn to the right as he passed a gravel road.

Figure 1: Shows the google view of the accident site and planned route

According to the eye-witnesses who was at the accident site at the time observed a

black helicopter flying pass on the left hand side along the road at a low height of

approximately 80ft AGL. When the helicopter was passing a T-junction, It was

observed making a turn to the right then suddenly it entered a spin before impacting

the ground.

1.1.2 According to the pilot he opted to execute a forced landing on a gravel road which

was perpendicular to R700. The aircraft came down at a high rate of descent while

rotating to the right. During a flare the aircraft entered a cloud of dust that was

caused by aircraft rotor downwash. The aircraft impacted the ground at high vertical

velocity and the right hand skid gear broke off on impact.

1.1.3 The main rotor blades also made contact with the ground while the aircraft was

skidding until it stopped at 2 meters before the road information board. The

helicopter sustained substantial damages to the right hand skid gear, bottom right

Page 4: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 4 of 19

edge of the fuselage and all five main rotor blades were also damaged.

1.1.4 The accident occurred during day light conditions on the road R700 facing in the

direction North West next to the road information board with GPS position

determined to be 28°13'32.18"S, 26° 7'28.70"E and a field elevation of 4491ft

Above mean sea level

1.2 Injuries to Persons

1.2.1 None of the occupants sustained any injuries during the accident sequence.

Injuries Pilot Crew Pass. Other

Fatal - - - -

Serious - - - -

Minor - - - -

None 1- - 2- -

1.3 Damage to Aircraft

Figure 2: Shows damages to the helicopter

1.3.1 The helicopter sustained substantial damages to the right hand skid gear, bottom

right edge of the fuselage and all five main rotor blades were also damaged

Page 5: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 5 of 19

1.4 Other Damage

1.4.1 None

1.5 Personnel Information

Nationality South African Gender Male Age 28

Licence Number 0272349499 Licence Type PPL

Licence valid Yes Type Endorsed Yes

Ratings Instrument

Medical Expiry Date 30 November 2017

Restrictions Corrective lenses

Previous Accidents None

Flying Experience:

Total Hours 1030.0

Total Past 90 Days 26.8

Total on Type Past 90 Days 2.9

Total on Type 2.9

1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the

available information, the pilot began his private pilot license on helicopter in 2015

on which he attained 60.1 hours on both R22/R44 helicopter types to date. On the

9th of June 2017 he then began with his conversion on the MD helicopter type and

accumulating 2.2hours when he was signed off on the 10th June 2017 by a qualified

type rated instructor allowing him to fly solo to build hours. The aircraft endorsement

records applications were submitted to SACAA on 14 June 2017. At the time of the

accident the application was still pending.

1.5.2 According to the pilot’s logbook the following were the hours accumulated as per

aircraft type flown:

Helicopter type Hours on type

Robinson R22 24.8

Kiss K-209 8.8

Robinson R44 35.3

MD500E 369E 2.9

Page 6: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 6 of 19

1.6 Aircraft Information

The information is extracted from: Rotorcraft Flight Manual: MD 500E (Model 369E)

Figure 3: Show three view dimensions of the helicopter type

1.6.1 The aircraft is an import from Namibia and was initially registered in the SACAA

register in 2016. The MD 500E, model 369E helicopter is a 5 seater, rotary wing

aircraft constructed primarily of aluminium alloy. The airframe structure is egg-

shaped and provides very clean aerodynamic lines. The fuselage is a semi-

monocoque structure that is divided into three sections. It is powered by Rolls

Royce model 250-C20B gas turbine engine. The main rotor is a fully articulated five

bladed system, with anti-torque provided by a 2 bladed semi-rigid type tail rotor.

Power from the turbo shaft engine is transmitted through the main drive shaft to the

main rotor transmission and from the main transmission through a drive shaft to the

tail rotor.

An overrunning (one way) clutch, placed between the engine and main rotor

transmission permits free-wheeling of the rotor system during autorotation. The

landing gear is a skid-type attached to the fuselage at 12 points and is not

retractable. Aerodynamic fairing covers the struts. Nitrogen charged landing gear

dampers act as spring and shock absorbers to cushion landings and provide ground

resonance stability. Provisions for ground handling wheels are incorporated on the

skid tubes.

Page 7: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 7 of 19

Airframe:

Type MD 500E (369E)

Serial Number 0210E

Manufacturer Macdonnel Douglas Helicopter Inc

Date of Manufacture 1998

Total Airframe Hours (At time of Accident) 3659.1

Last MPI (Date & Hours) 03 June 2017 3655.7

Hours since Last MPI 4.6

C of A (Issue Date/Expiry Date) 14June 2016/ 13 June 2018

C of R (Issue Date) (Present owner) 25 November 2016

Operating Categories Standard Part 127

Engine:

Type 250-C20B

Serial Number CAE-835774

Hours since New 3659.1

Hours since Overhaul Modular

Main Rotor:

Type 369D21100 (X5)

Serial Numbers H970;H971;H973;H974;H978

Hours since New 1805.1

Hours since Overhaul TBO not yet reached

Tail Rotor:

Type 369D21600-503 (X2)

Serial Numbers C244/ C245

Hours since New 5143.4

Hours since Overhaul TBO not yet reached

1.6.3 . The helicopter was involved in a main rotor incident strike at airframe hours 1854,4

on 14 February 1995 in the country of origin. All five main rotor blades were

changed with the currently installed. According to the available maintenance

records, the helicopter was maintained and equipped in accordance with

manufacture’s approved procedure by the regulator approved AMO. At the time of

the accident flight, the helicopter was just transferred from FALA to FAWM to the

new owner whose owner paperwork was still under process at CAA offices.

Page 8: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 8 of 19

1.7 Meteorological Information

1.7.1 The meteorological conditions as obtained from the pilot’s questionnaire

Wind direction 195° Wind speed (2-6)kt Visibility CAVOK

Temperature 20°C Cloud cover Unknown Cloud base Unknown

Dew point Unknown

1.8 Aids to Navigation

1.8.1 The helicopter was equipped with standard navigation equipment that meets the

requirement of the regulator. There were no reported defects with the navigation

equipment at the time of the accident.

1.9 Communications.

1.9.1 The helicopter was equipped with standard communication equipment that meets

the requirement of the regulator. There were no reported defects with the

communication equipment at the time of the accident.

1.10 Aerodrome Information

1.10.1 The accident occurred on the regional road R700 facing in the direction North

Westerly next to the road information board with GPS position of: 28°13'32.18"S,

26° 7'28.70"E and a field elevation of 4491ft.

1.11 Flight Recorders

1.11.1 The helicopter was not fitted with a cockpit voice recorder (CVR) or a flight data

recorder (FDR) and neither was required by the regulation to be fitted to this type of

helicopter.

Page 9: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 9 of 19

1.12 Wreckage and Impact Information

1.12.1 The helicopter accident occurred on a Regional road R700 which was under

construction (Refer to Figure 1). The area surrounding the accident site is private

farms with vegetation. According to the pilot, the flight was planned for them to fly

pass over the region to observe the progress on the road works and then proceed

to the landing destination. According to the pilot, the helicopter’s approach was at a

1000ft AGL and then descended to approximately 80ft AGL. Moments after a turn to

the right the engine experienced power loss.

Figure 4: Shows the ground scars caused by impact sequence

The helicopter impacted hard with the ground as a result of loss of control. The

impact marks on the road surface began at 1 to 2 meter from the helicopter

wreckage on the right hand side. According to the pilot, the helicopter at close

proximity to the ground whilst been cushioned caused lot of dust which obscured

him from making a clear judgement of the distance to the ground. The helicopter

began rotation to the right hand side direction due to loss of tail rotor effect and

suddenly contacted the ground hard where after it bounced on towards the tar road.

At the time the pilot noticed collision was evitable with the road signage on the side

of the road and then turned the helicopter toward the right hand side. The helicopter

contacted hard with the right hand skid gear first and began skidding where after it

broke off. The helicopter fuselage dropped to the right and began skidding along

with the main rotor contacting the ground. The helicopter came to a full stop 2m

from the road signage.

Page 10: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 10 of 19

Figure 5: Wreckage as it was found

Wreckage examination as it was found:

There was hard contact and skidding marks on the tar road edge leading

towards the right hand side of the wreckage.

The right landing skid gear broke-off from the root attachment points.

The right hand fuselage bottom edge was damaged due to scrapping along

the tar road.

All five main rotor blades made contact with the ground and got damaged.

The damage on the rotor blades are consistent with the damage caused by

auto-rotation.

All annunciating audible and warning lighting were serviceable.

The left front door was damaged by the main rotor during the accident

sequence.

1.13 Medical and Pathological Information

1.13.1 N/A

1.14 Fire

1.14.1 There was no evidence of pre or post impact fire during the accident.

Page 11: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 11 of 19

1.15 Survival Aspects

1.15.1 The accident was considered survivable. The cockpit was intact with no damages

sustained. The ELT did trigger following the accident in which the Search and

Rescue made some follow-up and then advised the AIID regarding the situation. A

location and time of the activation was provided to the investigating personnel.

1.16 Tests and Research

1.16.1 Following the reporting of the alleged engine power loss. The MD helicopter and the

engine manufacturers were invited to test both the fuel system on the airframe and

on the engine. None of the tests revealed any anomalies that could have

contributed to the accident.

Research (Refer to the Annexure A)

1.17 Organizational and Management Information

1.17.1 This was a private flight under provision of Part 91

1.17.2 According to the maintenance records, the helicopter was equipped and maintained

in accordance with the manufacture’s prescribed procedures by a regulator approved

aircraft maintenance organisation.

1.17.3 According to the available records, the helicopter was recently bought by a new

owner who resides in the area of Welkom in the Free State Province. The helicopter

was transferred on the 10th of June by the accident pilot and the instructor as part of

the training. The pilot was the only person available with helicopter flying

experience upon its transfer. His helicopter training conversion was conducted to

make him ready to operate the machine.

1.18 Additional Information

1.18.1 Pilot statement

According to the pilot during the reported power loss, he stated that he rolled the

throttle in an attempt to increase power on the helicopter engine however it was

unsuccessful.

Page 12: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 12 of 19

According to the manufacturer’s pilot, the use of throttle during normal operation is

not advisable. This is in relation with the helicopter type operating hand book which

only indicate the use of throttle twisting (rolling) during engine starting and engine

switching off.N1 and N2 governor control switches are provided to increase engine

power on demand during operation.

1.18.2 The pilot is more qualified on the piston engine helicopter type. The helicopter type

he was flying at the time of the accident was equipped with a turbine engine.

Throttle control differential as compared on both helicopters

Robinson R44 Helicopter: Information is extracted from Robinson POH Model

R44 II Page 3-2

Power failure between 8ft and 500ft AGL

Procedure:

Lower collective immediately to maintain rotor RPM

Adjust collective to keep RPM between 97 and 108 or apply fully down

collective if weight prevents attaining above 97

Maintain airspeed until ground approached then begin cyclic flare to reduce

rate of descent and forward speed.

At about 8feet AGL, apply forward cyclic to level ship and raise collective just

before touchdown to cushion landing. Touchdown in level attitude and nose

straight ahead.

Loss of tail rotor thrust during hover

1. Failure is usually indicated by right yaw which cannot be stopped by applying

left pedal.

2. Immediately roll throttle off into detent spring and allow aircraft to settle.

3. Raise collective just before touchdown to cushion landing.

1.18.3 UNANTICIPATED YAW / LOSS OF TAIL ROTOR EFFECTIVENESS (LTE)

Unanticipated yaw is the occurrence of an un-commanded yaw rate that does not

subside of its own accord and, which, if not corrected, can result in the loss of

helicopter control. This un-commanded yaw rate is referred to as loss of tail rotor

effectiveness (LTE) and occurs to the right in helicopters with a counter clockwise

rotating main rotor and to the left in helicopters with a clockwise main rotor rotation.

Page 13: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 13 of 19

Again, this discussion covers a helicopter with a counter-clockwise rotor system and

an anti-torque rotor. LTE is not related to an equipment or maintenance malfunction

and may occur in all single-rotor helicopters at airspeeds less than 30 knots. It is the

result of the tail rotor not providing adequate thrust to maintain directional control,

and is usually caused by either certain wind azimuths (directions) while hovering, or

by an insufficient tail rotor thrust for a given power setting at higher altitudes.

For any given main rotor torque setting in perfectly steady air, there is an exact

amount of tail rotor thrust required to prevent the helicopter from yawing either left

or right. This is known as tail rotor trim thrust. In order to maintain a constant

heading while hovering, you should maintain tail rotor thrust equal to trim thrust.

The required tail rotor thrust is modified by the effects of the wind. The wind can

cause an un-commanded yaw by changing tail rotor effective thrust. Certain relative

wind directions are more likely to cause tail rotor thrust variations than others. Flight

and wind tunnel tests have identified three relative wind azimuth regions that can

either singularly, or in combination, create an LTE conducive environment. These

regions can overlap, and thrust variations may be more pronounced. Also, flight

testing has determined that the tail rotor does not actually stall during the period.

When operating in these areas at less than 30 knots, pilot workload increases

dramatically.

1.19 Useful or Effective Investigation Techniques

1.19.1 None

2. ANALYSIS

2.1 According to the available information, the pilot is a private pilot license holder on

helicopter with 2.9 hours on the helicopter type. Prior to the accident flight, the pilot

flew the helicopter on two occasions during his helicopter type conversion and

accumulated 2.2 flying hours. He was then signed off to fly unsupervised by a

helicopter type rated instructor allowing him to building hours. It is the investigator’s

opinion that the insufficient training offered to the pilot was influenced by the

operational matters. The pilot was the only person who has helicopter flying

experience in which the helicopter was recently purchased and was delivered to

their facility. It is evident that the pilot training insufficient as per hours accumulated

by the pilot.

Page 14: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 14 of 19

2.2 The pilot was more experienced on flying a reciprocating engine equipped

helicopters (R44’s) which had a difference of engine power increase settings on

demand operations. On the R44 which is also fitted with a governor switch, raising a

collective control will increase engine power and also adjusting the blade pitch

symmetrically to maintain minimum required power to sustain lift. However on the

MD helicopter type to increase engine power demands are controlled by adjusting

either N1 or N2 governor switch allocated on the collective control column raising the

collective on the MD will only increase the pitch and not the power. The pilot stated

that during a turn, the helicopter commenced an un-commanded yaw to the right in

which afterwards he started operating the twist grip in an attempt to increase engine

power however was unsuccessful.

The recovery (procedure) technique used by the pilot to increase engine power on

the helicopter type by using twist grip either than the allocated governor switches N2

is used on an R 44 and not in the case of MD helicopter.

2.3 The pilot stated that during a turn to the right hand side, the helicopter experienced

an un-commanded yaw to the right. These actions are indicative to an unanticipated

yaw relating to the loss of tail rotor effectiveness. The helicopter is equipped with

five main rotor blade system that rotate counter clockwise. This will cause the nose

of the aircraft to have a turning effect to the right, therefore to counter act this

turning effect the use of the left anti-torque pedal will be required to compensate

this movement.

2.4 The manufacturer was invited to assist with the investigation of fuel system and

engine. The engine was removed and bench tested on a test cell. The engine was

performing in accordance with the manufacture’s specification. No anomalies were

noticed during any of the tests relating to the fuel system and reported engine

power loss and the flight control systems.

2.5 The reported weather condition at the time leading to the accident did not have any

contributions towards this accident.

3. CONCLUSION

3.1 Findings

3.1.1 The pilot was signed off to fly the helicopter solo for hour building by a helicopter

type rated instructor at approximately 2.2hours flying experience. The pilot’s flying

experience and familiarisation on the helicopter type was found to be insufficient at

Page 15: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 15 of 19

the time of the flight.

3.1.2 The helicopter type was not yet endorsed on his license at the time of the accident.

The application was submitted on the same date of the accident, however, he was

signed off by a type rated instructor allowing him to build hours unsupervised.

3.1.3 The pilot had more flying hours on the piston engine helicopters as compared to the

turbine engine equipped helicopters.

3.1.4 The helicopter was maintained and equipped by the regulator approved AMO in

accordance with manufacture’s approved procedures. The helicopter had enough

fuel at the time of the accident.

3.1.5 Good weather conditions prevailed in the surrounding area and it cannot be

attributed to the cause of the accident.

3.1.6 The pilot only had accumulated 2.9 hours on type which was inadequate to handle

any emergencies that may occur and control the situation safely.

3.1.7 The engine was removed and tested on test cell and it was running in accordance

with manufactures specification.

3.2 Probable Cause/s

3.2.1 The helicopter experienced engine power loss due to the pilot inadvertently cutting

off the engine power resulting in a rapid loss of height, a spin to the right followed by a

hard impact with the road surface.

Contributory factor:

3.2.2 The Pilot used incorrect (Robinson R44) recovery technique instead of a correct

(MD500E) recovery technique.

Page 16: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 16 of 19

4. SAFETY RECOMMENDATIONS

4.1 It is recommended to the DCA in the interest of aviation safety to review and

possibly impose the minimum hours required for conversation training of piston

helicopter to turbine powered helicopter. The turbine engine helicopter has more

functions and very complex systems and the pilot had only 2.2 hours for conversion

and it was evident during this accident that he had difficulties in handling the

emergencies and to land the helicopter safely.

5. APPENDICES

5.1 The information is extracted from: Rotorcraft Flight Manual: MD 500E (Model 369E)

Section 4 Pages (4-23, 4-24)

Page 17: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 17 of 19

5.1 Annexure A

5.1.1 The information is extracted from: Rotorcraft Flight Manual: MD 500E (Model 369E)

Section 4 Pages (4-23, 4-24)

Low rotor Speed

Indications: Red [Engine out] warning indicator ON and Audible warning in headset

Drop in RPM/ Change in noise level

Note: The LOW ROTOR warning is activated when Nr falls below 468.

Conditions: Low rotor RPM will most commonly be associated with the following

Engine failure

Transient rotor droops during large, rapid increases in power.

Governor failure producing an under speed.

Procedure:

Respond immediately to the low rotor RPM warning by adjusting collective to

maintain rotor RPM within limits.

Check other Caution/ Warning indicators and engine instruments to confirm

engine trouble and respond in accordance with appropriate procedures in

this section.

Low speed Manoeuvring

Manoeuvers that exceed thrust capability of the tail rotor should be avoided.

Note: Conditions where thrust limits may be approached are: High density altitude,

high gross weight, rapid pedal turns and placing the helicopter in a down wind

conditions. These conditions may exceed the thrust capability of the tail rotor.

Extreme aircraft attitudes and manoeuvres at low speeds should be avoided.

Warning: Un-coordinated turns/ manoeuvers may cause fuel starvation with less

than 35 pounds of fuel on board.

Warning: Observe the cross-hatched region of Height Velocity Diagram (Ref

Section V). These represent airspeed / altitude combinations from which a

successful autorotation may be difficult to perform. Operation within the cross

hatched area is not prohibited but should be avoided.

Page 18: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 18 of 19

Practice Autorotation

Warning Performance throttle rigging check prior to attempting practice auto

rotations. Mis-rigging of the throttle control may result in inadvertent

flameout during rapid closing twist grip to the ground idle position.

Uncoordinated turns/ manoeuvres may cause fuel starvation with less

than 35 LBS of fuel. Do not practice autorotation if the FUEL LEVEL

LOW caution indicator is ON.

Caution : Do not perform intentional full touchdown autorotation with blade

tracking reflectors installed on blade tips.

For autorotation decent, the twist-grip should be in the full open/ ground idle

position. However, if a practice autorotation landing (minimum engine power) is

desired, rotate the twist-grip to the ground idle position. Increase collective pitch

after establishing autorotation to prevent rotor over speed if flight is at high gross

weight or high density altitude. To reduce rate of descent or to extend gliding

distance, operate at minimum rotor rpm. Restore ROTOR RPM (NR) by lowering

collective prior to flare out. If a power recovery is desired, lower collective to full

down, rotate the twist-grip to the full open position, verify that N2 is between 102%

and 103% percent and that full engine power is available prior to increasing

collective.

Conduct practice autorotation at 131knots IAS or below (see Vne placards). Maintain

rotor between 420 and 523 by use of the collective control.

Note: Keeping the rotor above 420RPM will place the engine above the N2 speed

avoid range.

Caution: Refer to Section II “Power turbine (N2) speeds avoid ranges”.

Maximum glide distance is attained at 80knots and 410 rotor RPM.

Minimum rate of descent is attained at 60knots and 410 rotor RPM

Note: Glide distance attained during an actual engine autorotation may be less than

the glide distances achieved during practice autorotation’s when operating at

reduced RPM (N2/Nr needles joined).

Touchdown in a level attitude

Avoid use of aft cyclic control or rapid lowering of collective pitch during initial

ground contact or during ground slide.

Page 19: Section/division Form Number AIRCRAFT … and Incidents Reports/9624.pdf1.5.1 The pilot is also a commercial pilot license holder on aeroplanes. According to the available information,

CA 12-12a 20 NOVEMBER 2015 Page 19 of 19

Autorotation RPM

Normal rotor RPM (collective fully down) is 485±5 RPM at 2250 pound gross weight

at sea level, 60knots. Rotor speed will decrease approximately 10RPM for each 100

pounds reduction in gross weight and increase approximately 6.5 RPM for each

1000 foot increase in density altitude. For gross weights greater than 2250 pounds,

increase collective control as required to maintain approximately 485 RPM.