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Loss of Control at Takeoff, Air Methods Corporation, Airbus Helicopters AS350 Be, N390LG, Frisco, Colorado, July 3, 2015

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Loss of Control at Takeoff, Air Methods Corporation, Airbus Helicopters AS350 Be, N390LG, Frisco, Colorado, July 3, 2015 Loss of Control at Takeoff Air Methods Corporation Airbus Helicopters AS350 B3e, N390LG Frisco, Colorado July 3, 2015 Accident Report NTSB/AAR-17/01 National PB2017-101425 Transportation Safety Board NTSBAAR-17/01 PB2017-101425 Notation 56432 Adopted March 28, 2017 Aircraft Accident Report Loss of Control at Takeoff Air Methods Corporation Airbus Helicopters AS350 B3e, N390LG Frisco, Colorado July 3, 2015 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, DC 20594 National Transportation Safety Board. 2017. Loss of Control at Takeoff, Air Methods Corporation, Airbus Helicopters AS350 B3e, N390LG, Frisco, Colorado, July 3, 2015. Aircraft Accident Report NTSB/AAR-17/01. Washington, DC. Abstract: This report discusses the July 3, 2015, accident in which an Airbus Helicopters AS350 B3e, N390LG, registered to and operated by Air Methods Corporation, crashed into a parking lot shortly after lifting off from the Summit Medical Center Heliport, Frisco, Colorado. The pilot was fatally injured, and the two flight nurses onboard were seriously injured. The helicopter was destroyed by impact forces and a postcrash fire. Safety issues discussed in this report relate to the lack of a cockpit alert to pilots to indicate the loss of hydraulic boost to the pedal controls for AS350-series helicopters with a dual hydraulic system, the need for changes to the tail rotor flight controls of AS350-series helicopters with a dual hydraulic system to ensure pedal control hydraulic assistance and mitigate the possibility of pilot error during hydraulic system checks, the lack of readily available information for helicopter operators and customers regarding safety equipment and systems that would enhance a helicopter’s crashworthiness, the need for crash- resistant fuel systems for helicopters not covered by the November 1994 fuel system crashworthiness requirements, and the lack of requirements to install, on smaller aircraft, flight recorder systems that protect recorded data from crash impact damage and postcrash fire damage. The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b). For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and search for NTSB accident ID PB2017-101425. Recent publications are available in their entirety on the Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551 NTSB publications may be purchased from the National Technical Information Service. To purchase this publication, order product number PB2017-101425 from: National Technical Information Service 5301 Shawnee Rd. Alexandria, VA 22312 (800) 553-6847 or (703) 605-6000 http://www.ntis.gov/ NTSB Aircraft Accident Report Contents Figures ........................................................................................................................................... iii Tables ............................................................................................................................................ iv Abbreviations .................................................................................................................................v Executive Summary .................................................................................................................... vii 1. Accident Investigation and Analysis ........................................................................................1 1.1 The Accident ..............................................................................................................................1 1.1.1 Injury Information ...........................................................................................................3 1.1.2 Meteorological Information .............................................................................................3 1.2 Pilot Information ........................................................................................................................4 1.2.1 Preaccident Activities ......................................................................................................5 1.2.2 Medical and Pathological Information ............................................................................5 1.2.3 Analysis ...........................................................................................................................6 1.3 Helicopter Information...............................................................................................................6 1.3.1 General .............................................................................................................................6 1.3.2 Engine Information ..........................................................................................................7 1.3.2.1 Analysis..............................................................................................................8 1.3.3 Rotor Systems ..................................................................................................................8 1.3.3.1 Main Rotor .........................................................................................................9 1.3.3.2 Tail Rotor ...........................................................................................................9 1.3.3.3 Analysis............................................................................................................10 1.3.4 Flight Control System ....................................................................................................10 1.3.4.1 Analysis............................................................................................................13 1.3.5 Additional Helicopter Information ................................................................................14 1.3.5.1 Yaw Servo Hydraulic Check ...........................................................................14 1.3.5.2 Takeoff Procedures ..........................................................................................17 1.3.5.3 Previous Dual-Hydraulic AS350-Series Helicopter Events Involving Loss of Yaw Control .................................................................................................................17 1.3.5.4 Safety Information to Prevent Lack of Hydraulic Boost to Pedals ..................18 1.4 Tests and Research ...................................................................................................................21 1.4.1 Video Study ...................................................................................................................21 1.4.2 Aircraft Performance Study ...........................................................................................21 1.4.2.1 Additional Meteorological Information ...........................................................23 1.4.2.2 Analysis............................................................................................................24 1.4.3 Pedal Control Loads ......................................................................................................24 1.4.3.1 Pedal Loads to Maintain Heading at Takeoff ..................................................24 1.4.3.2 Pedal Loads During Hydraulic Check .............................................................25 1.5 Accident Scenario Analysis .....................................................................................................26 1.5.1 Loss of Tail Rotor Control .............................................................................................26 1.5.2 Performance of Yaw Servo Hydraulic Check ...............................................................28 i NTSB Aircraft Accident Report 1.5.2.1 Tail Rotor Hydraulic Circuit Design................................................................30 1.5.3 Decision to Continue Takeoff ........................................................................................32 1.5.4 Failure
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