NYC08FA198

The pilot’s failure to ensure that both engine switches were in the FLIGHT position for takeoff.

After taking off on a helicopter emergency medical service mission, the twin-engine helicopter climbed approximately 75 feet. The pilot lowered the nose, but the helicopter would not climb or accelerate normally. The pilot saw 125 percent on one of his gauges, but was not sure which gauge it was as he was looking outside. A "gong" sounded, similar to what the pilot had heard when doing "max takeoffs," but he did not hear an engine-out horn or see any warning lights. The pilot also noticed that one torque indication was declining to "near zero" percent, and the helicopter began to yaw. The pilot was able to correct the yawing moment with anti-torque inputs, and remembered lowering the collective and "pulling pitch" before the helicopter impacted the ground in a level attitude. The No. 1 engine was running as the pilot exited the helicopter, but the No. 2 engine was not. Examinations at the accident site revealed that the helicopter, after lifting off from the heliport, flew out of ground effect over down-sloping terrain, settled, then struck a parked semi-trailer about 80 feet below the heliport. No preimpact mechanical anomalies of the helicopter, engines, or engine switches were found. As part of the pre-takeoff confirmation check, the pilot was required to ensure that both main engine switches were in the FLIGHT position; however, onboard recorded data revealed that the No. 2 main engine switch was in the IDLE position during the takeoff.

HISTORY OF FLIGHT On May 30, 2008, at 2050 eastern daylight time, a Eurocopter Deutschland EC135 P2+, N238AM, operated by Air Methods Corporation as "MedEvac 7" incurred substantial damage during an emergency landing after takeoff from Mazzuca Heliport (PS95), Pottsville, Pennsylvania. The certificated airline transport pilot, flight nurse, and flight paramedic received minor injuries. Visual meteorological conditions prevailed, and a company visual flight rules (VFR) flight plan was filed for the air medical flight, which was responding to a motor vehicle accident in Wayne Township, Pennsylvania. The air medical flight was conducted under Title 14 Code of Federal Regulations Part 91. According to the pilot, after liftoff from PS95 he climbed to approximately 75 feet above ground level. As he lowered the nose of the twin-engine helicopter to transition to forward flight, he realized that something was "wrong" and the helicopter would neither climb, nor accelerate normally. He saw 125 percent on one of his gauges, but was not sure which gauge it was as he was "looking outside" the helicopter at the time. He looked at the first limit indicator (FLI) gauge and observed that one of the needles was "falling to zero." A "gong was going off," similar to what he had heard when doing "max takeoffs;" however, he did not hear any "engine out horn," nor see any warning lights. The pilot noticed that one "torque" was moving down to near "zero percent," and the helicopter started to yaw. He was able to correct the yawing moment with the anti-torque pedals, and the cyclic and collective controls "seemed to function correctly." The pilot recalled "lowering the collective" and "pulling pitch" before the helicopter impacted the ground in a level attitude, and that the helicopter "spun to the right" before coming to rest on its left side. As he exited the helicopter, the pilot noticed that the left engine was operating, but the right engine was not. The pilot went back to the helicopter and helped the other crewmembers egress, and could not "get the switch off to stop the engine." He recalled that after the impact, he tried to "put the engine to idle," but the "seatbelts were locked," preventing him from reaching the switch panel. The left engine was eventually shut down by the fire department by flooding it with water. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) and pilot records, the pilot held an airline transport pilot certificate with multiple ratings, including rotorcraft helicopter. He had accumulated 7,000 total hours of flight experience, 6,100 hours in rotorcraft, and 125 hours in the accident helicopter make and model. AIRCRAFT INFORMATION The helicopter was configured for emergency medical service operations. It was powered by two Pratt & Whitney PW2062B2 engines; each controlled by an Electronic Engine Control (EEC) unit. It was equipped with a dual hydraulic system, and a dual electrical system. The rigid main rotor system was of a 4-bladed, all-composite, bearingless design, and its anti-torque system utilized a fenstron. It was certificated for single pilot operations. According to FAA and operator records, the helicopter was manufactured in 2007. The helicopter's most recent continuous airworthiness inspection was completed on May 29, 2008, and at the time of the accident, it had accumulated 162 total hours of operation. METEOROLOGICAL INFORMATION A weather observation taken about 4 minutes after the accident, at Reading Regional Airport (RDG), Reading, Pennsylvania, located approximately 22 nautical miles southeast of the accident site, recorded the wind as 210 degrees at 7 knots, visibility 10 miles, clear skies, temperature 23 degrees C, dew point 15 degrees C, and an altimeter setting of 29.97 inches of mercury. AIRPORT INFORMATION According to the Airport Facility Directory, PS95 was a private use, unattended heliport, located 810 feet above sea level, 2 miles southeast of Pottsville, Pennsylvania. The sole helipad at PS95 was asphalt and measured 25 feet wide by 25 feet long. WRECKAGE AND IMPACT INFORMATION Examination of the accident site and wreckage by an FAA inspector revealed that the helicopter, after lifting off from the heliport, had traveled approximately 100 feet forward before striking a semi-trailer, which was parked at an adjacent commercial loading dock approximately 80 feet in elevation below the heliport. The fuselage displayed varying degrees of impact damage and the left landing skid had spread and collapsed in an upward direction. The tail boom was wrapped around the aft portion of the fuselage, and the vertical fin with its integrated tail rotor, had come to rest next to the belly of the helicopter. Two complete circumferential breaks were evident. One break was discovered to be just aft of the fuselage and the other break just forward of the vertical fin. All four main rotor blades were broken. One blade was severed approximately 1 foot outboard of the main rotor hub, and one blade was severed approximately 3 feet outboard of the main rotor hub. The two other blades were severed at the main rotor hub. During the on-site examination of the wreckage by the FAA, no preimpact mechanical malfunctions of the flight controls, main rotor, tail rotor, or drive systems were discovered. Engine Examinations External examination of the engines on-site revealed that the left engine exhibited rotational damage but the right engine did not. At the request of the NTSB investigator in charge, both engines were removed from the wreckage and shipped to Pratt & Whitney Canada Corporation's manufacturing facility for examination. Examination of the left engine revealed that the drive shaft and mating spline were damaged which was indicative of a sudden stoppage of the engine. Examination of the right engine did not reveal any anomalies. Recorded Data Download of the Data Collection Unit (DCU) revealed that at the time of the accident, the left engine was operating in the high power range with its main engine switch in the FLIGHT position, and that the right engine was operating with its main engine switch set in the IDLE position. The DCU data also revealed that the left engine torque had peaked at 151 percent. Download of the Vehicle and Engine Multifunction Display (VEMD) and the Caution Advisory Display (CAD) indicated that the helicopter had been in that configuration for approximately 1.5 minutes prior to ground impact. SURVIVAL FACTORS The helicopter was equipped with crash resistant fuel cells. The fuselage and seats were of an energy absorbing design. Both the flight paramedic and flight nurse were wearing flight helmets; however, the pilot was not. TESTS AND RESEARCH Published Guidance According to the operator's EC135 Pre-Takeoff Confirmation Check, the pilot was supposed to assure that the main engine switches were in the FLIGHT position, the "Systems" were checked, and that the "Torques Respond," prior to takeoff." Review of the helicopter manufacturers EC135 P2+ Flight Manual revealed that during the takeoff, the pilot is required to first enter a hover, then check that the rotor speed (Nr) and power turbine (N2) indications are within parameters, the FLI needles are matched at the same parameters, and that all warning, CAD, and VEMD indications are checked. No data indicative of a hover check being performed was discovered during review of the downloaded data. According to the helicopter manufacturer, if a hover check had been performed, five independent cockpit indications would have been presented to the accident pilot: - The N2 indication needle of the engine would have been at idle, indicating approximately 74 percent. - The N2 indication needle of the engine in flight mode would have indicated approximately 100 to 103 percent. - There would have been a split between the FLI