NYC06MA131

The operator's inadequate training program and the pilot's failure to maintain control of the helicopter following his inadvertent disabling of the No. 1 and then the No. 2 engine full authority digital engine control system.

The pilot reported that, during his first approach to the hospital helipad, the helicopter "shuffled," and the No. 1 engine rpm increased. The pilot stated that he increased collective pitch, reduced the throttle on the No. 1 engine, and aborted the landing. He noted that the No. 1 engine was no longer controlled by the full authority digital engine control (FADEC) system and that he had to control it manually. The pilot twice overflew the helipad, and, while maneuvering for another approach, he lost control of the helicopter, and it descended and struck a tree and the ground. Examination of the throttles, throttle linkages, engines, control systems, cockpit display system (CDS), and FADEC units revealed no evidence of any preimpact mechanical anomalies. Postaccident testing of the engines and analysis of data retrieved from the CDS and FADEC units revealed that the accident pilot had inadvertently moved the No. 1 throttle out of its neutral detent, placing the engine in manual mode and out of FADEC control. Although the pilot recognized that the No. 1 engine was no longer controlled by the FADEC, he responded with further manual throttle adjustments and did not perform the published procedure to restore FADEC control to the engine. The data showed that, as the pilot continued to manually control the No. 1 engine, he subsequently moved the No. 2 throttle out of its detent, placing that engine also in manual mode and out of FADEC control. With neither engine under FADEC control, the pilot attempted control of the rotor rpm while controlling both engines manually. This configuration resulted in a high-workload scenario in which it would be particularly challenging for the pilot to control the helicopter during the maneuvering and approach-to-land phases of flight. The accident helicopter was the only EC-135P1 CDS variant in the operator's fleet. Its engines, its displays, and its procedure for restoring FADEC control differed from the EC-135 variant in which the accident pilot was trained. According to the manufacturer's training guidelines, differences training is recommended before a pilot who is trained on another variant flies the EC-135P1 CDS. However, the investigation revealed that the operator provided the accident pilot only about an hour of formal differences training in the EC-135P1 CDS, and there was no evidence that the training adequately covered that variant's FADEC-restore procedures and other issues pertinent to flight safety. The pilot had accumulated about 914 hours of flight experience in EC-135s, with about 45 hours in the EC-135P1 CDS variant. The accident was not the first indication to the operator that pilots who were trained in another variant experienced difficulties with the accident helicopter. According to one other pilot and the accident pilot, they each previously experienced events involving loss of FADEC control in the accident helicopter (in November 2005 and March 2006, respectively) but completed successful landings. The operator determined no mechanical explanation for the events and did not report, and was not required to report, them to its Federal Aviation Administration (FAA) principal operations and maintenance inspectors. The other pilot reported that, at the time of his November 2005 event, he was untrained in the EC-135P1 CDS and was completely unfamiliar with the procedure required to restore FADEC control. That pilot reported that, during his event, he oversped the helicopter's engines and the main rotor, and, as a result, the operator removed the helicopter from service, conducted inspections of the engines and main rotor system, and determined that differences training was needed for the EC-135P1 CDS; however, the operator failed to adequately provide such training. Because the FAA had no knowledge of the previous events with the accident helicopter, it had no indication to suspect that the differences training implemented by the operator was deficient.

HISTORY OF FLIGHT On May 30, 2006, at 1645 eastern daylight time, a Eurocopter EC-135P1, N601FH, operated by CJ Systems, Inc., was substantially damaged when it collided with terrain while maneuvering to land at the Washington Hospital Center Helipad (DC08), Washington, D.C. The certificated airline transport pilot and two medical crewmembers were seriously injured. The critically ill patient on board the helicopter was fatally injured. Visual meteorological conditions prevailed for the flight that originated at Greater Southeast Community Hospital, Washington, D.C. A company flight plan was filed for the medical transport flight conducted under 14 CFR Part 135. The helicopter came to rest on the golf course at the Armed Forces Retirement Home, approximately 1/2 mile north of the helipad. The elevation at both the crash site and the hospital helipad was approximately 200 feet above mean sea level (msl). A review of radar data revealed that a target identified as the accident helicopter approached the helipad from the south, and overflew the helipad. The helicopter then completed a teardrop-shaped circuit on the north side of the hospital center, returned, and again over flew the helipad, traveling southbound. After crossing the helipad, a left-hand circuit that roughly resembled a standard airport traffic pattern was flown around the east side of the hospital grounds. The helicopter turned westbound in what approximated a base-leg turn, then the radar target was lost in the area of the crash site. The altitudes recorded from the first over flight of the helipad to the last radar target were between 200 and 300 feet msl. The pilot was able to recall portions of the flight, and recounted them during an interview with Safety Board investigators. On the day of the accident, he received the flight request, checked the weather, and performed a preflight inspection. He then performed a walk-around inspection with his crew prior to takeoff. The pickup of the patient and the flight to Washington Hospital Center were routine. The pilot reported that as the helicopter approached the helipad, it "shuffled" and the No. 1 engine rpm increased. The pilot increased collective pitch, and reduced the throttle on the No. 1 engine to control engine and rotor rpm, then aborted the landing. He was able to control the rpm, and did not recall any visual or aural warnings regarding rpm limits. He stated that for the remainder of the flight, the No. 1 engine was operated in manual mode, and the No. 2 engine remained in automatic mode. As the pilot maneuvered the helicopter over the golf course, the "shuffle" worsened, and the helicopter became uncontrollable. He remembered a building and a tree were in the helicopter's flight path as it descended. He maneuvered toward the tree, transmitted a "Mayday" call, and alerted his crew prior to impact. In an interview, the flight medic stated that as the helicopter terminated the first approach, he heard an audio alarm in his headset, and "it felt like the helicopter lost power." The helicopter circled for a second attempt, and as they approached the helipad, the medic again heard the audio alarm in his headset, and the landing was again aborted. The pilot announced that he was "losing power," and couldn't slow the helicopter. As the helicopter flew around the hospital center, the pilot announced that they would return and attempt to land at the lower helipad. Once over the golf course, the helicopter began to vibrate. The vibration increased, the nose yawed from side to side, and the helicopter "went into a spin." It descended vertically, struck a tree, then terrain, and rolled over on its side. The medic repeated several times that it "felt" and "sounded like" the helicopter was losing power. He added, "As long as he wasn't trying to land, he could keep flying. He couldn't slow it down, but we could have stayed up and [continued to fly]." The flight nurse's description of the flight was similar to the medic's, and she remembered two over flights of the upper helipad, and the pilot stating that they would attempt a landing at the lower helipad. She did not recall hearing an audio alarm in her headset, nor did she recall the pilot announcing a loss of power. As the helicopter approached the golf course, "it slowed, rocked, and started shaking." When asked about the sound of the engines, she said, "There was a lot of sputtering. They didn't sound like they were going fast like they usually did. There was that sputtering noise, then a metallic banging." Both the flight nurse and the medic stated that they could not view the instruments nor could they see the pilot manipulate the flight controls. In a telephone interview, a witness stated that he heard the helicopter "sputter" as it approached, and then the sounds of impact, but he did not see the accident. A second witness said she watched the helicopter over fly the golf course at low altitude, "up and down, kind of out of control. It seemed like they were struggling to maintain altitude." The helicopter flew out of view toward the hospital, and several minutes later, it returned over the golf course, and the sounds of impact were heard. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with a rating for airplane multi-engine land, and rotorcraft helicopter. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on November 8, 2005. A review of company training records revealed that the pilot had accumulated 15,613 total hours of flight experience, 12,413 hours of which were in helicopters, and 914 hours of which were in make and model. His most recent FAR Part 135 competency check was completed December 22, 2005, in the EC-135T1 helicopter, which was equipped with different engines and a different cockpit display than the EC-135P1 accident helicopter. When questioned in a follow-up interview with the Safety Board about his training in the EC-135 helicopter, the pilot said that all of his training was conducted in Turbomeca engine-equipped helicopters, and that he received no formal training in the EC-135P1 Cockpit Display System (CDS) Pratt and Whitney engine-equipped accident helicopter. Examination of the accident pilot's training records revealed that on December 27, 2005, he received 1 hour of "differences training" in N601FH. During that single hour of training, the pilot completed 30 minutes of "instrument" flight that included two Instrument Landing System approaches. The pilot did not specifically recall the flight, but was surprised at the notes because "N601FH was a VFR-only aircraft." The pilot reported that he received classroom instruction on the -P1 CDS model, but stated that he had "never" seen an EC-135P1 CDS training manual. AIRCRAFT INFORMATION A review of the flight manual and maintenance records revealed the accident helicopter was maintained according to a manufacturer's inspection program, and the most recent 50-hour inspection was completed May 19, 2006, at 2,977 aircraft hours. The helicopter had accrued 2,995 total flight hours at the time of the accident. The helicopter was not equipped or certified for IFR flight. The engines were equipped with Full Authority Digital Engine Controls (FADECs). The throttles were mounted on the collective. The forward throttle was for the No. 1 (left) engine, and the aft throttle was for the No. 2 (right) engine. For the throttles to be in the neutral position, a white line and the letter "N" on each throttle had to be aligned with a white arrow on the collective. There was a noticeable detent when the throttle was rolled across the neutral position, which matched the painted positions that were mid-way between the full open and minimum idle positions. Normal flight was conducted with the throttles in the neutral position, allowing the FADECs to con