Accident Details
Probable Cause and Findings
The pilot’s failure to maintain terrain clearance during a low-level course reversal.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On July 17, 2009, about 0830 coordinated universal time (1130 local time), an MD Helicopters MD-530 (369FF), N974BW, operated by Presidential Airways, Inc., was destroyed when it impacted terrain at Camp Butler, about 20 miles east of Baghdad, Iraq. The copilot and the left door gunner were fatally injured, while the pilot in command (PIC) and the right door gunner were seriously injured. The right door gunner subsequently succumbed to his injuries on February 8, 2010. The aerial gunnery training flight was operating on a company flight plan under military training range regulations.
Under the provisions of Annex 13 to the Convention on International Civil Aviation, and by mutual agreement, the Iraqi government delegated the investigation to the United States. The Iraq Civil Aviation Authority designated an accredited representative to the investigation on behalf of the government of Iraq.
According to the PIC, his was one of two helicopters that had arrived at Camp Butler from Baghdad, each with two pilots and two door gunners onboard. Crewmembers of the other helicopter reported that the accident helicopter first landed at the range to provide a radio to range personnel, while the second helicopter loitered to the south. After the radio transfer, both helicopters proceeded to the range, and conducted a "range sweep." Both helicopters subsequently completed firing runs, and while the accident helicopter was conducting additional training, the second helicopter was orbiting off range, to the south, and none of its crewmembers saw the accident.
During a telephone interview, the PIC of the accident helicopter stated that the gunnery range included an east-west track, approximately 1 mile long, with four targets just to the north of the track and three targets just to the south of it. Each target would be engaged as it came into range, with fire coming from both sides of the helicopter. After engaging all of the targets along the track, the helicopter would reverse course and commence another firing run.
The PIC also noted that a total of eight tracks were flown prior to the accident, four in each direction. The first two tracks were flown at 60 knots, the second two at 70 knots, the third two at 90 knots, and during the last two tracks, the helicopter decelerated as it approached each target. All of the eastbound tracks were flown by the copilot, and all the westbound tracks were flown by the PIC. After the completion of each track, the pilots transferred control of the helicopter, and the new pilot at the controls would execute the course reversal.
In regards to the accident sequence, the PIC recalled that after the copilot had completed the final eastbound track, he transferred the controls to the PIC. The PIC, seated in the right seat, then began a left-turning course reversal at an altitude approximately 100 feet above the ground. The next thing the PIC remembered was that, while in the turn, and “like a hazy dream,” he saw the copilot’s finger moving toward the instrument panel, and after that, “being dragged, shaken, and bumped along the ground.”
In a subsequent response to written questions, the PIC stated that he believed the copilot was directing his attention to "a situation of decaying rotor and/or engine rpm...which would have been associated with a rapid nose tuck [and] rapid loss of altitude."
When asked if he had flown the training profiles previously, the PIC responded that he had done so many times. Firing range training was normally scheduled once a week, and would have been completed each week "unless something else came up." The PIC also noted that in the almost 2 years he had been there, the tactics had been modified “very little.”
The PIC further recalled that a “pretty standard” preflight briefing had been conducted, with both flight crews present, and which included actual threats (low), weather (good), and temperatures (in the low 100s - normal for that time of year). The briefing also included the routes to be flown, training elements to be performed, actions in the event of hostile contact, and downed aircraft recovery procedures.
When asked about engine power checks, the PIC noted that military-type “HIT” checks were not conducted prior to each flight of the day; however, hover power checks were completed prior to all takeoffs. The PIC subsequently calculated the density altitude to be approximately 3,100 feet at the time of the accident.
When asked how the helicopter was operating, the PIC stated that although he had a “very hazy gray recollection,” as far as he could recall, the helicopter was operating "properly," with no warnings, cautions, or changes in sound. He also noted that even though the copilot appeared to be pointing at something, the copilot did not speak or otherwise indicate that anything was wrong.
According to the father of the door gunner who initially survived, his son did not recollect anything about the accident.
Neither the PIC, nor any other witness, indicated that hostile fire was present about the time of the accident.
PERSONNEL INFORMATION
The PIC, age 62, held an airline transport pilot certificate with airplane single engine land, and rotorcraft-helicopter ratings. He also had commercial pilot privileges for airplane multi-engine land, and held a flight instructor certificate for airplane single and multi-engine, rotorcraft-helicopter, and instrument airplane and helicopter. According to the operator, the PIC had accrued 18,600 total flight hours, with 6,500 flight hours in make and model. Operator records indicated that the PIC had flown 66 hours within the preceding 90 days, but had not flown within the previous 30 days.
The PIC's latest FAA second class medical certificate was issued on January 6, 2009.
The PIC stated that he had accrued about 19,000 hours of flight time during a 41-year period, and never previously had an accident, incident or violation. He further noted that the copilot and both gunners were ex-military and very experienced. In addition, he noted that crews were assigned together on a random basis, and that he had flown with the copilot "approximately four times previously."
The copilot, age 42, held a commercial pilot certificate with rotorcraft-helicopter, and instrument helicopter ratings. He also had private pilot privileges for airplane single engine land and instrument airplane. The operator did not provide the copilot's total flight experience; however, on his application for his latest FAA Second Class Medical Certificate, dated December 5, 2008, the copilot indicated 6,275 hours of total flight time. Operator flight records indicated that the copilot had flown 15 hours within the preceding 30 days.
AIRCRAFT INFORMATION
The helicopter was powered by a single Rolls Royce 250-C30 engine, capable of 650 shaft horsepower (shp) with 425 shp usable at takeoff. The operator reported 2,662 hours of airframe time, and 1,148 hours of engine time since overhaul. The helicopter's latest annual inspection occurred on May 25, 2009.
METEOROLOGICAL INFORMATION
According to the operator, the 0900 weather observation at Baghdad included clear skies, with no restrictions to visibility, winds from 340 degrees at 15, gusting to 25 knots. No turbulence, temperature 38 degrees C, and an altimeter setting of 29.75 inches Hg.
WRECKAGE AND IMPACT INFORMATION
A description of the accident scene was provided in a draft (no final was produced) U.S. State Department, Diplomatic Security Service Memorandum Report of Investigation:
"It appeared as though the aircraft was traveling in a westward direction upon impact. The first point of impact appears to be…on the east edge of the dried-up pond; the pond stretches 17 meters from west to east. The initial point of impact appear to show disturbance in the dirt where the two skids (right and left) impacted the edge of the pond; approximately 1 meter east from the impact of the skids is a disturbance in the dirt which clearly shows feathering on the dirt, indicative of the spinning tail rotor making contact with the ground. The second point of impact appears on the west edge of the same dried up pond. No impacts were found within the pond itself though some large pieces of debris were found between point of impact one and two. Distance between point of impact one and the eventual resting point of the bulk of the fuselage is approximately 44 meters. South of the fuselage approximately 20 meters is the remains of the tail boom. East of the tail boom approximately 24 meters is the remains of the tail rotor."
The draft Memorandum also noted that, according to a person in the area at the time, it was "extremely unlikely" that any hostile action caused the accident. The perimeter was maintained by U.S. and Iraq Army personnel, the terrain was flat and expansive, and was treated as an active firing range.
According to contacts in Iraq, to protect the helicopter wreckage, it was loaded into a secure storage container at Camp Butler on the day of the accident. It was subsequently trucked, still in the storage container, to secure storage in Baghdad. The wreckage was eventually shipped to the United States, and arrived at Anglin Aircraft Recovery Services, LLC, Clayton, Delaware, in late January, 2010.
On February 17, 2010, the wreckage was examined with NTSB participation. The wreckage was removed from the sealed storage container and laid out for examination. The fuselage had been mostly consumed by fire. The tail boom exhibited fire damage at the point it where it was separated from the main fuselage. There was another separation of the tail boom, with mechanical twisting and crushing consistent with main rotor blade strikes, about 2 feet forward of the vertical stabilizer.
The left landing gear was separated, with fractures of the fore and aft gear struts consistent with overstress. The right landing gear, displaying contact and the...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA09FA419