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NTSB investigation record

ERA13LA022

Completed

Hughes 369A· N369SN, Hughes/helicopter assocs inc 369A· N546

Date
October 13, 2012
Location
West Chester, PA
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

Aircraft 2 The other pilot’s failure to see and avoid the preceding helicopter while maneuvering for landing. Contributing to the accident were the flight lead pilot’s inadequate preflight briefing and in-flight instruction to the formation pilots, which resulted in the loss of the formation flight's integrity and the pilots’ situational awareness within the flight. --- Aircraft 1 The pilot’s failure to see and avoid the preceding helicopter while maneuvering for landing. Contributing to the accident were the flight lead pilot’s inadequate preflight briefing and in-flight instruction to the formation pilots, which resulted in the loss of the formation flight's integrity and the pilots’ situational awareness within the flight.

Investigator assessment

Analysis narrative

The formation flight of helicopters, designated Chalk 1 through 5, was en route to an annual airshow. The lead helicopter (Chalk 1) was on the left base leg of the traffic pattern at the nontower-controlled destination airport when the Chalk 3 helicopter pilot identified and announced that an airplane was on final approach for the landing runway. The Chalk 1 helicopter pilot announced that he was conducting a go-around and turned the helicopter left, inside the landing runway, and proceeded upwind. About the same time, the flight lead pilot, who was traveling in the trail position (Chalk 5), instructed the other helicopter pilots to "break left or land." The flight lead pilot's ambiguous instruction resulted in the breakdown of the formation flight's integrity. Instead of a flight of five helicopters and one airplane attempting to avoid conflict in the traffic pattern, each of the six individual aircraft were immediately placed in a position in which the pilots had to avoid potential collisions with the other aircraft. The Chalk 4 pilot subsequently lost sight of the Chalk 3 helicopter as the pilots of both helicopters were maneuvering for landing. The Chalk 4 helicopter pilot then landed the helicopter and was hover-taxiing to park when the helicopter collided with the Chalk 3 helicopter as its pilot was maneuvering it to land on the runway. Before the flight, the flight lead pilot presented briefing slides to the group of pilots; however, the slides did not provide any procedures for a loss of visual contact while flying in formation.

Source record

Factual narrative

Aircraft 2 On October 13, 2012, about 0920 eastern daylight time, two helicopters in a flight of five, a Hughes 369A, N369SN (Chalk 3), and another Hughes 369A, N546 (Chalk 4), collided during hover-taxi while landing at Brandywine Airport (OQN), West Chester, Pennsylvania. The 3 occupants in Chalk 3 and the 2 occupants in Chalk 4 were not injured. Chalk 4 sustained substantial damage to all four main rotor blades and the tail pylon. Chalk 3 sustained substantial damage to the left landing skid. Both helicopters were operated under the provisions of 14 Code of Federal Regulations Part 91as personal flights. Visual meteorological conditions prevailed. The helicopters were part of a flight of 5 helicopters that attended an annual all-helicopter airshow.The pilots of Chalk 1, 3, and 4 provided written statements and their statements were consistent throughout. They each said that "Flight Lead" was in Chalk 5; the trail aircraft. According to their statements, the flight arrived in trail formation and overflew runway 09 at 1200 feet and 60 knots. Chalk 1 stated he entered left traffic, and while on the left base leg for landing, Chalk 3 announced airplane traffic on final approach to Runway 09. Chalk 1 stated he turned left prior to the runway, and initiated a go-around on the north side of the runway. Flight lead, in the trail aircraft, then announced over the flight's internal radio frequency to, "Break left or land." According to Chalk 3, he then "initiated a steep approach" to land on runway 09, and while he maintained visual separation from Chalk 2, noticed the rotor disk of another helicopter immediately below and to the right of his just as contact between the two was made, which separated the left landing gear skid. Chalk 3 then egressed his passengers from a hover, and repositioned the helicopter back to LNS in order to avail him of air traffic control and crash/fire/rescue services. The helicopter landed without further incident. According to Chalk 4, Chalk 1 announced a go-around, but Chalk 5 gave the command to break left or land. At that point, he had Chalks 1, 2, and 3 in sight. Chalk 4 then confirmed the airplane traffic was "no factor" and had initiated a go-around on the south side of the runway. When he looked back on the formation in front of him, he had only Chalk 2 in sight, and had lost visual contact with Chalks 1 and 3. Chalk 4 then performed a "normal" approach to a 5-foot hover over the runway centerline, began a hover-taxi to parking, and about 20 seconds later "felt" the contact with the other helicopter. He then landed the helicopter without further incident. The pilot of Chalk 4 held a private pilot certificate, with a rating for a rotorcraft-helicopter. He reported 586 total hours of flight experience, of which 253 hours were in the accident helicopter make and model. The pilot of Chalk 3 held a commercial pilot certificate, with a rating for a rotorcraft-helicopter. He reported 1,617 total hours of flight experience, 92 hours of which were in the accident helicopter make and model. Each of the accident helicopters had 100-hour inspections performed during the year prior to the accident, and each pilot reported there were no mechanical deficiencies with either helicopter that would have prevented normal operation. Examination of the Rotorfest 2012 Briefing slides revealed that the Chalk order briefed on the slides was not the Chalk order flown. There was no slide that provided guidance for loss of visual contact or inadvertent IMC procedures. There was no slide that identified "Flight Lead" would fly from the trail position of the formation. Examination of military and Formation and Safety Team (FAST) training documents revealed that flight lead was always the lead aircraft in a given multi-ship formation. While the air mission commander (AMC) may fly from any position in the formation, the lead aircraft always maintained the role of flight lead. Following in-flight formation changes, the aircraft assuming the lead position in the flight, assumed the role of flight lead. Army Field Manual (FM 3-04.203) Fundamentals of Flight, Chapter 6, Multi-Aircraft Operations stated: FLIGHT LEAD (TEAM LEAD) 6-8. Flight (team) lead and wingman are roles flight members fulfill based upon their positions within the flight. Team lead is used to denote the flight lead for two aircraft operating in teams. Flight lead is the formation leader designated by the AMC and is generally the most proficient PC (pilot in command). Flight leads are selected based on ability and demonstrated knowledge of missions and tactics, and local SOPs. The flight lead's responsibilities include navigation, en route communication (between flight members, ATC, and supported units), obstacle and threat avoidance, wingmen position awareness, and the energy states of all aircraft. The AMC may delegate some of these duties throughout the flight. Chalk 2 should always be prepared to lead the flight. FORMATION LANDING 6-41. All aircraft touch down at the same time while maintaining their relative positions within the flight. The rate of closure throughout approach and landing is somewhat slower at night than during the day. Flight lead should maintain straight-and-level flight until the desired approach angle is intercepted. Lead then maintains a constant approach angle and, where terrain and obstacles permit, makes the approach to the ground avoiding hovering turbulence and brownout or whiteout conditions. If the rate of closure is too fast, the aviator should avoid S-turns to lose airspeed. Instead, execute a go-around if unable to slow to the appropriate airspeed, especially with heavily loaded aircraft. 6-42. Lead must plan to touch down far enough forward in the PZ/LZ to provide sufficient landing space for the entire flight. --- Aircraft 1 On October 13, 2012, about 0920 eastern daylight time, two helicopters in a flight of five, a Hughes 369A, N369SN (Chalk 3), and another Hughes 369A, N546 (Chalk 4), collided during hover-taxi while landing at Brandywine Airport (OQN), West Chester, Pennsylvania. The 3 occupants in Chalk 3 and the 2 occupants in Chalk 4 were not injured. Chalk 4 sustained substantial damage to all four main rotor blades and the tail pylon. Chalk 3 sustained substantial damage to the left landing skid. Both helicopters were operated under the provisions of 14 Code of Federal Regulations Part 91as personal flights. Visual meteorological conditions prevailed.The flight of helicopters, each designated "Chalk 1" through "Chalk 5," were enroute to an annual all-helicopter airshow. The pilots of Chalk 1, 3, and 4 provided written statements, and their statements were consistent throughout. They each said that "Flight Lead," Chalk 5 was flying in the trail aircraft position. According to their statements, the flight arrived in trail formation and overflew runway 09 at 1,200 feet and 60 knots. Chalk 1 stated he entered left traffic, and while on the left base leg for landing, Chalk 3 announced airplane traffic on final approach to Runway 09. Chalk 1 stated he turned left prior to the runway, and initiated a go-around on the north side of the runway. Flight lead, in the trail aircraft, then announced over the flight's internal radio frequency to, "Break left or land." According to Chalk 3, he then "initiated a steep approach" to land on runway 09, and while he maintained visual separation from Chalk 2, noticed the rotor disk of another helicopter immediately below and to the right of his just as contact between the two was made, which separated the left landing gear skid. Chalk 3 then egressed his passengers from a hover, and repositioned the helicopter back to LNS and sought the assistance air traffic control (ATC) and crash/fire/rescue services. The helicopter landed without further incident. According to Chalk 4, Chalk 1 announced a go-around, but Chalk 5 gave the command to break left or land. At that point, he had Chalks 1, 2, and 3 in sight. Chalk 4 then confirmed the airplane traffic was "no factor" and had initiated a go-around on the south side of the runway. When he looked back on the formation in front of him, he had only Chalk 2 in sight, and had lost visual contact with Chalks 1 and 3. Chalk 4 then performed a "normal" approach to a 5-foot hover over the runway centerline, began a hover-taxi to parking, and about 20 seconds later "felt" the contact with the other helicopter. He then landed the helicopter without further incident. The pilot of Chalk 4 held a private pilot certificate, with a rating for a rotorcraft-helicopter. He reported 586 total hours of flight experience, of which 253 hours were in the accident helicopter make and model. The pilot of Chalk 3 held a commercial pilot certificate, with a rating for a rotorcraft-helicopter. He reported 1,617 total hours of flight experience, 92 hours of which were in the accident helicopter make and model. Each of the accident helicopters had 100-hour inspections performed during the year prior to the accident, and each pilot reported there were no mechanical deficiencies with either helicopter that would have prevented normal operation. Examination of briefing slides provided to the group by the flight lead (Chalk 5) revealed that the aircraft position order briefed on the slides was not the order flown. There were no slides that provided guidance for loss of visual contact or an inadvertent encounter with instrument meteorological conditions. There was no slide that identified flight lead would fly from the trail position of the formation.

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