N224GM

Substantial
None

Kaman K-1200 S/N: A94-0022

Accident Details

Date
Tuesday, April 21, 1998
NTSB Number
SEA98LA065
Location
LA GRANDE, OR
Event ID
20001211X09961
Coordinates
45.319408, -118.199119
Aircraft Damage
Substantial
Highest Injury
None
Fatalities
0
Serious Injuries
0
Minor Injuries
0
Uninjured
1
Total Aboard
1

Probable Cause and Findings

The pilot's inadvertent shutdown of the engine with the FUEL/OIL shutoff switch. Contributing to the accident were: the manufacturer's inadequate location and design of the FUEL/OIL shutoff switch; the FAA's inadequate determination of the type design's compliance with applicable airworthiness standards; and the helicopter's low altitude at the time of the power loss.

Aircraft Information

Registration
N224GM
Make
KAMAN
Serial Number
A94-0022
Engine Type
Turbo-shaft
Model / ICAO
K-1200 KMAX
Aircraft Type
Rotorcraft
No. of Engines
1

Registered Owner (Historical)

Name
US BANCORP LEASING & FINANCIAL
Address
825 NE MULTNOMAH ST STE 800
Status
Deregistered
City
PORTLAND
State / Zip Code
OR 97232-2151
Country
United States

Analysis

On April 21, 1998, approximately 1030 Pacific daylight time, a Kaman K-1200 "K-MAX" helicopter, N224GM, being operated by Grizzly Mountain Aviation of Prineville, Oregon, was substantially damaged in a forced landing following a loss of engine power approximately 15 miles west of La Grande, Oregon. The commercial pilot-in-command of the single-seat helicopter did not report receiving any injury in the accident. The 14 CFR 91 positioning flight originated at a logging camp approximately 1 mile from the accident site, and was en route to La Grande at the time of the accident. Visual meteorological conditions prevailed and no flight plan had been filed for the flight.

The pilot reported:

I took off from the job site...and called out the numbers for the power assurance check to the mechanic. The engine temp[erature] seemed a little high and he asked what all [sic] I had on. I told him I had only the particle separator on. I reached down and turned the particle separator off and immediately got low fuel pressure and [then] the engine quit. I was only about 200 feet AGL and I picked a spot and tried to autorotate. I hit hard and the aircraft rolled onto its right side. I got my seat belt loose and turned the batt[ery] switch [off] and got out of the aircraft. The only thing I can think of is that I turned the fuel off. The air was rough that close to the ground and I had hit a bump just as I was reaching down to turn the particle separator off and talking to the mechanic on the ground at the same time. The particle separator switch and the fuel control switch both work the same way but are shaped a little different. I was wearing flight gloves at the time and must [have] turned off the wrong switch.

On his NTSB accident report, the pilot reported his flight experience as over 13,000 hours of rotorcraft time (of which over 11,000 hours was pilot-in-command), including 1,250 hours in the K-1200. The pilot held a flight instructor certificate with a helicopter rating.

On-scene investigators did not report observing any evidence of mechanical anomalies with the helicopter's AlliedSignal T53-17A1 turboshaft engine. Review of the helicopter's maintenance records disclosed no evidence of recent problems with the engine, and indicated that the helicopter had recently received all required inspections. The pilot reported on his NTSB accident report that he took off with 1,400 pounds of Jet A fuel, and that no mechanical failure or malfunction was involved in the accident. On his NTSB accident report, the pilot recommended the following as to how this accident could have been prevented:

By moving the particle separator ON/OFF switch to the right side of the inst[rument] panel. There is lots of room on the right hand switch panel. There is no reason for it to be next to the fuel [shutoff] switch. The fuel [shutoff] switch should have a guard on it.

Post-accident photos of the helicopter's instrument panel taken by FAA investigators showed the FUEL/OIL switch, a two-position (on/off) lever-lock type switch, in the OFF position and the PART SEP switch, also a two-position (on/off) lever-lock type switch, in the ON position. Both switches are located in the lower left corner of the instrument panel, with the FUEL/OIL switch located approximately 2 inches directly above the PART SEP switch. Both switches throw in an up-and-down direction along a common axis, with the ON position being an upward throw and the DOWN position being a downward throw for both switches. The FUEL/OIL and PART SEP switches differ by shape, with the FUEL/OIL switch being triangular and the PART SEP switch being a "bullet" switch.

Technical personnel from Kaman Aerospace Corporation, the helicopter manufacturer, reported that in a post-accident examination of the helicopter, in addition to the above they found the fuel shutoff valve in the ON position, and that the valve actuated properly when electrical power was applied.

The K-1200 received FAA type certification (type certificate number TR7BO) as a normal-category helicopter on August 30, 1994 (the accident helicopter had been issued a normal-category FAA airworthiness certificate on April 25, 1997.) The type certificate data sheet (revision 1, dated March 10, 1997) lists the type's certification basis as 14 CFR 27, effective February 1, 1965, and amendments 27-1 through 27-28. Pursuant to this accident investigation, the NTSB investigator-in-charge of this accident reviewed the provisions of 14 CFR 27, "Airworthiness Standards: Normal Category Rotorcraft", and noted the following requirements:

Sec. 27.777 Cockpit controls. Cockpit controls must be--(a) Located to provide convenient operation and to prevent confusion and inadvertent operation....

Sec. 27.1189 Shutoff means.... (b) There must be means to guard against inadvertent operation of each shutoff, and to make it possible for the crew to reopen it in flight after it has been closed....

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# SEA98LA065