NTSB Factual Report

***This report was modified on November 24, 2015, and September 6, 2016. Please the docket for this accident to view the original report.***

HISTORY OF FLIGHT

On March 18, 2014, about 0738 Pacific daylight time (PDT), an Airbus Helicopters (formerly Eurocopter) AS 350 B2, N250FB, was destroyed when it impacted terrain following takeoff from the KOMO TV Heliport (WN16), Seattle, Washington. The helicopter was registered to, and operated by, Helicopters Incorporated, Cahokia, Illinois, under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot and one passenger were fatally injured, and one person, located in a stationary vehicle, was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local repositioning flight, which was originating at the time of the accident. The pilot's intended destination was the Renton Municipal Airport (RNT), Renton, Washington.

The Electronic News Gathering (ENG) equipped helicopter had landed on the KOMO News helipad about 30 minutes prior to the accident. The purpose was to refuel for its repositioning flight to RNT. A witness who was located on the south side of the helipad reported that he observed the helicopter initially lift off of the helipad to about 15 ft, followed by a muffled sound like a car backfiring. The witness opined that after lifting off it immediately pointed nose up, and began rotating counter-clockwise, after which it rotated out of sight. A second witness, who was stationed in a crane a few hundred feet to the northeast of the helipad, reported that he observed the helicopter lift up off of the helipad, turn toward the west, and then shot straight back with its nose up, and out of control. It then nosed down into the street below. The helicopter descended into an occupied automobile near a main street intersection, after which a postimpact fire ensured.

During the investigation, a review of three security camera recordings, which were provided to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) by the Seattle Police Department, revealed that the helicopter initially landed on the helipad, and remained stationary for about 15 minutes. The helicopter lifted off and simultaneously began to rotate counter-clockwise in a near level attitude. The helicopter continued to rotate counter-clockwise for about 180 degrees while it ascended slightly above the elevated helipad, after which it began to ascend further while moving slightly away from the elevated helipad. After the helicopter completed about a 360-degree rotation, the helicopter transitioned to a nose-low (tail-high) attitude while it continued to rotate counter-clockwise. The helicopter rotated counter-clockwise another 180 degrees, and then began to lose altitude while moving rapidly away from the elevated helipad. The helicopter then descended until ground impact.

Examination of the accident site revealed that the helicopter came to rest on its right side, oriented on a magnetic heading of about 050 degrees. A vehicle located east of the main wreckage was fire damaged. Another vehicle, which was located immediately west of the main wreckage and oriented on a southerly heading, exhibited impact damage. All major structural components of the helicopter were located in the immediate area of the main wreckage. Wreckage debris was located within an approximate 340 foot radius to the main wreckage.

The helicopter was recovered to a secured location for further examination.

PERSONNEL INFORMATION

Pilot in Command

General

The pilot, age 59, possessed a commercial pilot certificate with a helicopter instrument rating. He also held a helicopter flight instructor certificate with an instrument helicopter rating. His most recent second-class medical certificate was issued on February 6, 2014, with the limitation, "Must wear corrective lenses and possess glasses for near and intermediate vision." The pilot successfully completed his most recent flight review in the accident helicopter on February 8, 2014.

A review of the pilot's personal pilot logbooks revealed that as of February 7, 2014, he had accumulated a total flight time of 6,538.8 hours, all in rotorcraft-helicopters. Additionally, the pilot had accumulated 6,295.5 hours as pilot-in-command, 2,841 hours of instruction given, 1,047 hours in the Airbus AS350-D, and about 5.5 hours in the Airbus AS350-B2 helicopter. Additionally, the pilot had logged 1,122 hours in the Bell 206 helicopter, and a total of 1,092 hours flight time in the Bell 407.

A family member revealed during an interview with NTSB investigators that the pilot worked part time as an ENG pilot on the early morning shift. He would normally awaken between 0300 and 0400, and report for work at 0500, normally Monday thru Friday, but sometimes on weekends if there was a need. He would normally return home from his full time job as an engineer for a local airplane manufacturing company, and predictably go to bed at 2000. The family member said that the pilot was in excellent health, had no sleep disorders, and had performed this schedule for many years. Additionally, the family member opined that the pilot was looking forward to flying full time after retiring from his full time job.

Pilot's ENG Operational Experience

A further review of the pilot's recorded personal logbook entries revealed that he had started ENG flight operations in a Bell 206 on May 30, 2002, accumulating a total of 1,090 hours in this make and model helicopter, prior to transitioning to the Airbus AS350-D model on August 16, 2004. The pilot then operated this make and model helicopter in ENG operations until July 9, 2008, having accumulated a total time of 1,047 hours in the AS350-D.

Prior to concluding ENG flight operations in the AS350-D during July 2008, the pilot received Bell 407 transition training with Bell Helicopters on April 26, 2006. The pilot then flew the Bell 407 on a limited basis from August, 2006 to January 2008, accumulating a total of about 24 hours of flight time during this period. On January 21, 2008, the pilot attended Bell 407 recurrent training, having received 2.5 hours of flight training. The pilot subsequently began flying the Bell 407 helicopter in ENG flight operations on March 24, 2008, with his last flight logged in this make and model helicopter on February 7, 2014. At this time, the pilot had accumulated a total flight time of 1,092 hours in the Bell 407.

Pilot's Airbus AS350 B2 Training

According to Helicopters Incorporated personnel, the accident helicopter arrived at the company's Renton base of operations on January 30, 2014. The helicopter had been ferried from St. Louis, Missouri, to Renton by a part time company Check Airman, and the Renton based pilot who shared flying duties with the accident pilot; this pilot normally flew the afternoon shift, relieving the accident pilot about 1000.

According to training records supplied to the NTSB IIC at the request of Helicopters Incorporated, the pilot began Airbus AS350-B2 training January 31, the day after the helicopter arrived at the Renton base. At this time the Check Airman gave the pilot 0.5 hours of recurrent training. Subsequently, on February 8, the accident pilot received an additional 3.0 hours of flight instruction, which was inclusive of a check ride. The pilot satisfactorily passed the check ride, as well as the Airbus AS350 limitations written test. The pilot next flew the accident helicopter on the day of the accident, March 18, which would have been 39 days after his most recent flight in the helicopter.

Airbus AS350 B2 Checklists Used During Training

During the postaccident examination of the helicopter, inclusive of the onsite and follow-up layout examinations, the helicopter's checklist was not observed. In several discussions with the Helicopters Incorporated Assistant Director of Operations and the company's Director of Safety, it was frequently stated that the Abbreviated Checklist for the AS350 BA/B2, Revision 1 (an internal document), dated June 30, 2009, which was a two-sided laminated checklist with a Federal Aviation Administration (FAA) Approved Date of August 20, 2009, and signed by an FAA inspector assigned to the St. Louis (STL) Missouri Flight Standards District Office, had been delivered with the helicopter when it arrived at the Renton base. Additionally, the Renton-based pilot (who had ferried the helicopter from St. Louis to Renton with the part-time company Check Airman, when interviewed by the NTSB IIC and asked which checklist would have been in the helicopter at the time of the accident), revealed that it was a two-sided, laminated checklist, and that it had an FAA approved stamp on it.

At the time of the accident, the most current revision to the AS350-B2 Rotorcraft Flight Manual (RFM) was Revision 4, dated the 11th week of year 2010. Revision 3, dated the 21st week of year 2006, contained changes to Paragraph 3 ("Starting") of Section 4.1 ("Operating Procedures") to set the fuel flow control lever (FFCL) to a position between the "OFF" and "FLIGHT" detents in order to achieve a gas generator speed (Ng) of between 67-70% before performing the hydraulic system checks. According to the airframe manufacturer, an Ng of 67-70% will result in a corresponding main rotor speed (Nr) of about 270 rotations per minute (RPM). According to the RFM, 100% Nr on the ground at low pitch is between 375-385 RPM. The previous procedure (Revision 2 and prior) was to set the FFCL to the "FLIGHT" detent, about 82% Ng, resulting in 100% Nr, prior to performing the hydraulic system checks. According to the airframe manufacturer, the change to the starting procedures in the RFM was a result of several events where the helicopter became unintentionally airborne due to the collective stick becoming unlocked during the hydraulic system checks. By performing the hydraulic system checks at 67-70% Ng, the helicopter should not become airborne if the collective stick was not locked, or becomes unlocked during the hydraulic system checks.

According to the airframe manufacturer, six copies of Revision 3 to the RFM were mailed to the operator on May 12, 2010. However, there was no evidence that the previous edition of the checklist, the Abbreviated Checklist dated June 30, 2009, had been revised to reflect the lower Ng setting prior to conducting the hydraulic system checks.

When the part-time Check Airman, who provided the recurrent flight training for the accident pilot was asked during a meeting of parties to the investigation on May 22, 2014, which checklist he used during training, the Check Airman stated that he used the procedures that were outlined in Revision 3 of the RFM. Additionally, the Check Airman stated that he had instructed both the accident pilot and the second pilot who shared the local ENG duties with the accident pilot, to use the procedures outlined in Revision 3 of the RFM (Ng of 67-70%). In addition, an FAA inspector recalled that during the conference meeting, the Check Airman mentioned that the checklist used had the hydraulic checks being conducted with the engine throttle in the Flight Gate (Ng about 82%). Further, the Check Airman stated that after Revision 3 became active, he notified the operator's Chief Pilot of the change to the Ng setting prior to performing the hydraulic system checks; however, the checklist in use at the time was not revised. The operator opined that the Abbreviated Checklist was neither revised nor removed from their AS350 B2 fleet as a result of an oversight.

When the part time Check Airman, who provided the recurrent flight training for the accident pilot was asked several weeks after his initial statement to the investigative team on May 22, 2014, if he remembered if the Abbreviated Checklist was in the accident helicopter, either during the ferry flight to Renton from St. Louis, or during the training he conducted after he had arrived back to the Renton base following the ferry flight, he said that he could not recall.

AIRCRAFT INFORMATION

General

The helicopter, an Airbus Helicopters AS350-B2, serial number (S/N) 3669, was equipped with a Turbomeca Arriel 1D1 engine. A review of the maintenance records revealed that the helicopter had accumulated a total time of 7,706.5 hours at the time of the accident. Additionally, the engine, S/N 9849, had accumulated 7,122.9 hours since new, and 538 hours since it last overhaul.

Maintenance

According to the operator, the helicopter was maintained in accordance with the Manufacturer's Inspection Program. On March 13, 2014, at an aircraft total time (ATT) of 7,698.5 hours, the most recent inspection was performed and documented per a Maintenance Log Entry. The inspection revealed the following:

• a 30-hour check of the tail rotor blades in accordance with (IAW) Chapter 64-10 of the Eurocopter Airworthiness Limitations Section, Rev. 004, dated June 6, 2013, with no defects noted.

• Complied with Eurocopter Alert Service Bulletin 05.00.60, Rev. 0, tail rotor pitch change links check, with no defects noted.

• Complied with Airworthiness Directive (AD) 2011-22-05, inspection of tail rotor pitch change links, with no defects noted.

• Performed 30-hour engine inspection IAW Turbomeca Arriel 1D1 Maintenance Manual, update #17, dated October 30, 2013, with no defects noted.

• Complied with AD 2003-02-05, Sliding Door Rail Inspection, with no defects noted.

• Complied with Eurocopter Alert Service Bulletin 05.00.74 Rev. 1, Tail Rotor Pitch Horn Inspection, with no defects noted.

• Complied with 100-hour inspection items that have no margin in the Eurocopter Airworthiness Limitations Section 04-20-00, Rev. 4 dated June 6, 2013, with no defects noted. This was accomplished in order to extend the 100-hour inspection by using the 10-hour tolerance.

On March 5, 2014, at an ATT of 7,676.1 hours, the operator complied with FAA Airworthiness Directive (AD) No. 2014-02-05, a recurrent inspection of the clearance between the main rotor collective control lever and the collective locking stud. The AD specifically defined an unsafe condition as the main rotor collective pitch lever (collective) locking stud inadvertently locking in the low pitch position, which could result in a subsequent loss of control of the helicopter. (Refer to the AD, which is appended to the docket for this report.)

On March 29, 2012, at an ATT of 6,548.0 flight hours and a component total time (CTT) of 6,007.0 hours, a tail rotor servo control, S/N 1298, was installed on the accident helicopter. The tail rotor servo control was overhauled on February 21, 2012 by UTAS in Vernon, France.

COMPANY OVERVIEW

The operator of the helicopter, Helicopters Incorporated, was founded in 1978 by a private individual. As of August 14, 2014, it was reported that the company operated more than 70 ENG helicopters in 36 markets nationwide. In calendar year 2013, the company flew over 35,000 hours in support of ENG operations.

The company's organization consists of the following:

• Director of Operations

• Assistance Director of Operations

• Chief Pilot

• Director of Maintenance

• Director of Safety

• ADPM & Security Coordinator

The company's employment base consisted of the following:

• Pilots – 149

• Maintenance support personnel – 49

• Total employees – 285

The company's complement of aircraft/helicopters includes the following:

• Bell 206B – 24

• Bell 206L3 – 2

• Bell 206L4 – 26

• Bell 407 – 11

• Airbus AS350BA – 3

• Airbus AS350B2 – 6

• Airbus AS350B3 – 1

Total number of aircraft – 73

AERODROME INFORMATION

WN16 was activated on May 1982. The address of the heliport was 100 4th Avenue North, Seattle, Washington, and was located at coordinates 47 degrees, 37.30 minutes north latitude and 122 degrees, 20.68 minutes west longitude. The estimated elevation above mean sea level (msl) was reported as 363 feet. The height above the street level where the helicopter came to rest was about 85 ft. The operational surface area of the heliport, constructed of concrete, was about 65 feet in diameter. The heliport incorporated edge lighting around its perimeter. It als

NTSB Probable Cause

The loss of helicopter control due to a loss of hydraulic boost to the tail rotor pedal controls at takeoff, followed by a loss of hydraulic boost to the main rotor controls after takeoff. The reason for the loss of hydraulic boost to the main and tail rotor controls could not be determined because of fire damage to hydraulic system components and the lack of a flight recording device.