WPR16LA019

The flight instructor's failure to perform simulated engine failure training in accordance with manufacturer guidance, including his improper recovery from the maneuver, which resulted in an overshoot of the intended landing zone when the engine did not respond as expected; his selection of an unsuitable landing area; and his decision to perform the maneuver near the helicopter's maximum gross weight, which resulted in a hard landing.

The purpose of the public helicopter flight was to perform a patrol mission with a tactical flight officer onboard, while the flight instructor also trained the pilot under instruction (PUI), who had recently been hired by the sheriff's department. The plan was to perform a routine patrol mission to introduce the PUI to the operation of the helicopter's systems, then practice autorotations, which the PUI had not previously performed in the accident helicopter make and model. After the patrol, they practiced a series of uneventful autorotations over flat areas. They then conducted an autorotation to a pinnacle in the middle of a peninsula. The flight instructor was flying the helicopter throughout the maneuver; during the power recovery phase of the autorotation, he applied engine power by moving the throttle twist grip from the idle to the flight position as the helicopter passed through 100 ft. The engine did not respond as he expected, and, unable to reach the pinnacle, he maneuvered the helicopter to a forced landing on downsloping terrain. The helicopter landed hard and tipped forward, resulting in substantial damage to the tailboom and aft fuselage structure. Postaccident examination of the engine and airframe did not reveal any anomalies that would have precluded normal operation, and the engine met its nominal performance parameters during a subsequent test run. The helicopter's flight manual recommended that autorotation training be conducted within gliding distance of a suitable running landing area. The flight instructor's choice of a raised landing area, which was surrounded by soft and rocky downsloping terrain, did not represent a suitable area for such practice. Additionally, the slope did not allow a sufficient maneuvering envelope for the appropriate control inputs required to safely control the helicopter in the event of a delayed engine response or loss of engine power. Also, although physically close to a town, the location was relatively remote, because accessing the site by road would have required a long on- and off-road drive by first response vehicles around the lake. Therefore, the chosen location placed the crew in additional danger should a more serious accident have occurred. About 3 months before the accident, the helicopter manufacturer issued a safety information notice regarding the high exposure to accidents and incidents during simulated engine-off landing training. The notice issued a series of procedural updates, including a recommendation that minimal crew be onboard, and that power recoveries should be initiated as the helicopter passed through 200 ft above ground level (agl) rather than 70 ft agl, as recommended in the flight manual. The notice reiterated the need to be prepared to conduct an engine-off landing if power recovery was unsuccessful, along with the reminder that a higher gross weight increases the risk of a hard landing. Therefore, the flight instructor's choice of a power recovery initiation altitude (100 ft) lower than recommended left him with a reduced margin for recovery when the anomaly occurred. Further, the decision to keep the tactical flight officer onboard during the autorotation portion of the training represented an unnecessary risk both to him and the mission. The helicopter was loaded near its maximum gross weight, increasing the risk of a hard landing. The flight instructor did not hold a valid medical certificate at the time of the accident due to a recent Type 1 diabetes diagnosis. However, as a public operation, the sheriff's department was responsible for oversight of its own operation and allowed the instructor to fly with another pilot present.  The instructor was not exhibiting any symptoms of the condition, and there was no evidence to suggest his diagnosis contributed to the outcome of the accident.

Flight Instructor At the time of the accident, the flight instructor's second-class medical certificate was suspended due to a diagnosis of Type 1 diabetes. FAA records indicated that at that time a review was underway to determine his eligibility for a special issuance medical certificate. According to the Air Unit Commander, the department was aware of the flight instructor's medical status, and they had made it a requirement that he show them his glucose levels throughout the day. Because he was not exhibiting symptoms, the decision was made to only allow the flight instructor to continue to fly the helicopter when a "safety pilot" was also on board. He also stated that they had been in contact with the local FAA Flight Standards District Office and had advised them of his status. He was subsequently issued a third-class medical certificate in August 2017. Based on the accounts of the helicopter's occupants, he was awake and alert both during and after the accident flight and was able to self-extricate himself from the helicopter. Flight Instructor The flight instructor had been a member of the air support unit since 2000; he was the chief, and only helicopter pilot for the Sheriff's department. He attended ground, flight, and recurrency training at the Airbus training facility four times since 2009, the most recent occurring in May 2014. The remainder of his currency training and checkrides he received from a variety of other law enforcement agencies typically twice per year, with his last flight review taking place with an officer from the Sacramento Police Department on September 17, 2015. He held a commercial pilot certificate and a flight instructor certificate, both with ratings for helicopter, and reported a total flight time of 5,580 hours in helicopters, 1,658 of which were in the AS350B3. Pilot Undergoing Instruction The PUI held a commercial pilot certificate with ratings for airplane single engine land, helicopter, instrument airplane, and instrument helicopter. He also held a type rating for Sikorsky S-65 (CH-53) helicopter. He reported a total flight time of 1,341.8 hours, with the majority of that time occurring in the CH-53 helicopter, and 12.2 hours in the AS350 series. The accident flight was the first time he had received autorotation training in the AS350 type. The helicopter, callsign Falcon 30, was manufactured in 2008 and equipped with a Turbomeca Arriel 2B1 engine. The helicopter was maintained under a continuous airworthiness program, and the last inspection occurred on October 9, 2015, 9.3 flight hours prior to the accident. The helicopter was equipped with the Airbus Helicopters maximum gross weight increase kit, which consisted of high skid landing gear, and a dual hydraulic system. The kit gave it a maximum internal gross weight of 5,225 pounds (compared to the standard configuration gross weight of 4,960 pounds). According to the flight instructor, the helicopter weighed 5,166 pounds at the time of the accident. On October 24, 2015, at 1633 Pacific daylight time, an American Eurocopter AS350B3 helicopter, N911WL, landed hard during a practice autorotation near Folsom, California. The flight instructor, pilot undergoing instruction (PUI), and tactical flight officer (TFO) were not injured; the helicopter sustained substantial damage. The helicopter was registered to Placer County, and operated by the Placer County Sheriff's Department, as a public aircraft flight. Visual meteorological conditions prevailed, and a company flight plan had been filed. The instructional flight departed Mc Clellan Airfield, Sacramento, California, at 1618. The purpose of the flight was to perform patrol missions, in addition to providing training for the PUI, who had recently been hired by the Sheriff's department. This was his first patrol training flight, and he was seated in the front left seat, with the flight instructor in the front right, and the TFO in the rear jump seat. The plan was to introduce the PUI to the helicopters systems while on patrol, and then perform a series of straight-in, 180°, and "enhanced" autorotation's. The flight instructor stated that an enhanced autorotation is a maneuver where a point is picked for an emergency landing, and the pilot is tasked with landing the helicopter at that point using whatever maneuvers are necessary. The crew departed from their base at Auburn Municipal Airport, Auburn, California about 1230, and initially performed routine patrol work. Once completed, they then transitioned to a series of autorotation's with power recoveries in a flat field, all of which were uneventful. They then landed at Mc Clellan Airfield, and serviced the helicopter with about 120 gallons of fuel. After departure, they flew to a peninsula on the northern shore of the Folsom Lake Reservoir with the intention of performing more enhanced autorotation training. The peninsula, which according to the flight instructor was an area for training approved by the department, was normally partially submerged in water but due to drought conditions, was fully exposed. They reported surveying the area and beginning the maneuver at 2,500 ft mean sea level (about 2,100 ft above the lake surface). The flight instructor stated that he was the pilot-in-command, and that the PUI was "shadowing" the controls. They surveyed the area and then performed an enhanced autorotation with a power recovery to the dry lakebed. The flight instructor stated that during this maneuver the PUI appeared overwhelmed. They then set up for another approach to the peninsula, and the flight instructor told him to just track rotor RPM and not to worry about foot pedal control, or aircraft attitude, as he demonstrated that rotor RPM could be controlled with both the cyclic and collective. The flight instructor reported that at about 1,000 ft agl, he felt the PUI was inadvertently hindering the controls, and he reached over and moved the PUI's hands away from the controls. The flight instructor stated that he was not concerned, and in his experience, this was not unusual while providing training. The rotor RPM remained within limits during the remainder of the descent, and as they approached 100 ft agl, the flight instructor verbalized his intentions to perform a power recovery, and began by turning the throttle twist grip control from idle to flight, while simultaneously initiating the flare. As the flare progressed he did not hear the engine fully regain its speed, and he checked the instruments, observing that the engine and rotor RPM needles were still "split". They were between 10 and 25 ft from the ground and he prepared for a full touchdown landing, but by now the helicopter had moved forward to an area of down-sloping terrain. He did not want to land in an unusual attitude, so aimed to touch down flat on the skids relative to the slope. He then pulled the collective control hard just before impact to cushion the landing. By now the engine had recovered to full operating speed and he immediately applied collective control lifting the helicopter back off the ground. He then maneuvered the helicopter for landing about 100 ft forward. After landing, he exited the helicopter and discovered that the aft airframe was wrinkled, and the tailboom had bent downwards at its intersection with the aft bulkhead. He was surprised the helicopter had sustained this damage because while the landing was hard, it did not feel hard enough to cause structural damage. He recounted having performed many autorotation's before, all without anomalies, and that this time the engine sound did not match his throttle control inputs. The flight instructor reported that during the autorotation he was focused on audio and visual external clues as he had done in the past, rather than examining the instruments during the descent. He did not hear any audible alerts during the flight, did not notice any lights on the annunciator pane