NTSB Factual Report

HISTORY OF FLIGHT

On January 15, 1994, about 1220 eastern standard time, a Bell 206L3, N86CE, registered to Johnston Coca Cola Bottling Company Inc., operating as a 14 CFR Part 91 corporate flight, crashed while attempting to pick up to a hover. The helicopter was destroyed. The commercial helicopter pilot-in-command was fatally injured. The airline transport airplane pilot sustained minor injuries. The flight was originating from an open field at the time of the accident.

The airline transport airplane pilot stated, that he was attempting to pick the helicopter up to a hover with the commercial helicopter pilot-in-command following him through on the flight controls. As the helicopter became light on the skids, the helicopter tilted to the left and he let go of the flight controls. The pilot-in-command remained on the flight controls. The main rotor blades collided with the ground and the helicopter rolled over on its right side.

PERSONNEL INFORMATION

Information pertaining to the pilot-in-command, Paul S. Chalet, and the second pilot, Thomas C. Swanberg, is contained in NTSB Form 6120.1/2, NTSB Form 6120.4, and NTSB Form 6120.4 Supplement E.

AIRCRAFT INFORMATION

The Bell Long Ranger III Rotorcraft Flight Manual, Section 1, Limitations states, the minimum flight crew consists of one pilot who shall operate the helicopter from the right crew seat. The airline transport airplane pilot stated that Coca-Cola Enterprises Inc., did not have an operations manual in effect at the time of the accident. The draft operations manual was on the CEO's desk. The manual does not specify who may operate the flight controls, and what seat the pilot-in-command will occupy when performing assigned duties. Additional information pertaining to the aircraft is contained in NTSB Form 6120.4, Aircraft Information, and NTSB Form 6120.1/2.

METEOROLOGICAL INFORMATION

Visual meteorological conditions prevailed at the time of the accident. The airline transport airplane pilot stated the winds at the time of the accident were out of the north-northwest at 10 knots. (For additional information see NTSB Form 6120.4).

WRECKAGE AND IMPACT INFORMATION

The wreckage of N86CE, was located in an open field south of County Line Road West, in the vicinity of Arcadia, Florida.

Examination of the crash site revealed the helicopter rolled over on its right side and came to rest on a heading of 235 degrees magnetic. The main rotor blades collided with the ground, upper wire cutter, and then penetrated the left forward cabin area fatally injuring the pilot-in-command. The main rotor mast separated at the seal bearing plate with both main rotor blades. The main drive shaft separated. The tailboom separated aft of the intermediate section of the fuselage, and the tailrotor driveshaft was fractured. The fuel system was not ruptured. The landing gear was attached with no evidence of lateral shift on the crosstube mounts.

Examination of the main rotor system and tailrotor system revealed no evidence to indicate a precrash failure or malfunction. The yellow main rotor blade was bent up about 15 to 18 degrees outboard of the doublers. Plexiglass transfer and blood stains were present on the rotor blade. Wire cutter impact marks were present on the doublers and on the rotor blade skin 8 feet outboard of the grip plate. The aft body of the white main rotor blade separated at the spar outboard of the doublers, and the spar separated 3 feet inboard from the blade tip. Wire cutter impact marks were present on the doublers. The tailrotor blades were not damaged.

Examination of the airframe, and the flight control system revealed no evidence to indicate any precrash mechanical failure or malfunction. All components necessary for flight were present at the crash site. Continuity of the flight control system was confirmed for pitch, roll, and yaw.

Examination of the main transmission, engine to transmission driveshaft, overrunning clutch, tailrotor transmission, and chip detectors revealed no evidence of any preimpact failure or malfunction.

Examination of the engine assembly and accessories revealed no evidence of a precrash failure or malfunction. The engine was removed and transported to an authorized repair facility in Miami, Florida, for an engine test run. The engine was run in a test cell on January 20, 1994. The engine started, ran, and developed power.

MEDICAL AND PATHOLOGICAL INFORMATION

Post mortem examination of the pilot-in-command, Paul S. Chalet, was conducted by Dr. James C. Wilson, Associate Medical Examiner, District Twelve, Sarasota, Florida, on January 16, 1994. The cause of death was severe traumatic injuries of the head and neck. Post mortem toxicology studies of specimens from the pilot were performed by the Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma. These studies were negative for neutral, acidic, and basic drugs. Methanol was detected in the blood and urine. Ethanol was detected in the urine, and may be the result of post mortem alcohol.

The second pilot, Thomas C. Swanberg, was transported to Desoto Memorial Hospital, Arcadia, Florida, treated for minor injuries and released. Toxicology studies of specimens from the second pilot were performed by the Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma. These studies were negative for neutral, acidic, and basic drugs.

TEST AND RESEARCH

A review of Advisory Circular 90-87, Helicopter Dynamic Rollover states, An increasing percentage of helicopter accidents are being attributed to dynamic rollover, a phenomenon that will, without immediate corrective action, result in destruction of the helicopter and possible serious injury....During normal or slope takeoffs and landings with some degree of bank angle or side drift with one skid/wheel on the ground, the bank angle or side drift can place the helicopter in a situation where it is pivoting (rolling) about a skid/wheel which is still in contact with the ground. When this happens, lateral cyclic control response becomes more sluggish and less effective for a free hovering helicopter. Consequently, if a roll rate is permitted to develop, a critical bank angle (the angle between the helicopter and the horizon) may be reached where roll cannot be corrected, even with full lateral cyclic, and the helicopter will roll over onto its side. As the roll rate increases, the angle at which recovery is still possible is significantly reduced. The critical rollover angle is also reduced. The critical rollover angle is further reduced under the following conditions:

a. Right side skid down condition; b. Crosswinds; c. Lateral center of gravity offset; d. Main rotor thrust almost equal to helicopter weight; and e. Left yaw inputs.

ADDITIONAL INFORMATION

The helicopter wreckage was released to Mr. Brian L. Ross, Director of Aviation, Cocoa Cola Enterprises Inc., on January 17, 1994. The engine was released to Mr. John McIntosh, General Manager, Airwork Inc., Miami, Florida, on January 20, 1994.

NTSB Probable Cause

THE PILOT-IN-COMMAND'S IMPROPER SUPERVISION OF AN UNQUALIFIED PILOT WHILE ATTEMPTING A TAKEOFF TO A HOVER. THIS RESULTED IN AN ON GROUND LOSS OF CONTROL (DYNAMIC ROLL OVER). THE IMPROPER FLIGHT CONTROL INPUT (CYCLIC AND COLLECTIVE) BY THE UNQUALIFIED PILOT AND PILOT-IN-COMMAND, AND THE LACK OF WRITTEN PROCEDURES (OPERATIONS MANUAL) APPROVED BY MANAGEMENT PERSONNEL WERE FACTOR IN THE ACCIDENT.