N4QX

Substantial
Fatal

MD HELICOPTERS INC 369HMS/N: 610209M

Accident Details

Date
Monday, January 15, 2018
NTSB Number
CEN18FA074
Location
Perrysburg, OH
Event ID
20180115X33637
Coordinates
41.501667, -83.445274
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
2
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
2

Probable Cause and Findings

A loss of engine power due to snow or ice ingestion at an altitude that was insufficient to allow for engine re-ignition. Contributing to the accident were conditions, including altitude and flat light conditions, that precluded a successful autorotation to the field.

Aircraft Information

Registration
N4QX
Make
MD HELICOPTERS INC
Serial Number
610209M
Year Built
1971
Model / ICAO
369HM

Registered Owner (Historical)

Name
VISTA I INC
Address
6024 N HONEYTOWN RD
Status
Deregistered
City
SMITHVILLE
State / Zip Code
OH 44677-9563
Country
United States

Analysis

HISTORY OF FLIGHTOn January 15, 2018, about 1136 eastern standard time, a MD Helicopters Inc. 369HM helicopter, N4QX, was substantially damaged when it impacted terrain near Perrysburg, Ohio. The commercial pilot and crewmember were fatally injured. The helicopter was owned and operated by Vista One Inc., under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as an aerial observation flight. Instrument meteorological conditions prevailed and no Federal Aviation Administration (FAA) flight was filed for the flight. The local flight departed Wood County Airport (1G0), Bowling Green, Ohio, at 1024.

According to the owner of Vista One Inc., the pilot departed from the company base at the Wayne County Airport (BJJ), Wooster, Ohio, on the morning of the accident. The pilot landed at 1G0 to pick up the powerline inspector. The pilot fueled the helicopter with 20.68 gallons of Jet A fuel at 1G0. The accident flight was the first leg of aerial inspections on the transmission towers for the Toledo Edison power grid. The team was scheduled to conduct aerial inspections from Bowling Green to the Indiana/Ohio border over the following 4 weeks.

A security camera at the Bowling Green Flight Center (1G0), located about ¼ mile from the fuel pumps, captured the arrival and departure of the helicopter. The helicopter arrived at 0920:56 and departed at 1023:53. About 1013, two people exited the building and moved towards the helicopter. They walked back and forth between the helicopter and the building and then walked around the helicopter for several minutes. Due to the distance of the helicopter from the camera, it is not clear what the specific preflight activities were. It appears that both people boarded the helicopter before the helicopter departed.

A witness, located just south of the accident site, observed the helicopter descend "at an angle" before it impacted terrain. The witness was indoors at the time and did not hear the helicopter.

A search of radar facilities did not find any primary or secondary radar targets consistent with the accident helicopter. Data recovered from a handheld global positioning system unit (GPS), located in the wreckage, started at 1017:14 at 1G0 and terminated at 1136:34, at the accident location. Track data illustrated the helicopter in multiple right turns consistent with line inspection operations. The last few minutes of the track data showed the helicopter at an altitude between 800 ft and 840 ft mean sea level (msl) or between 180 ft and 220 ft above ground level (agl) and at an airspeed of less than 10 knots. PERSONNEL INFORMATIONAt the time of his most recent medical certificate application, the pilot reported no chronic medical conditions and no medications. The medical certificate contained the limitation "Must wear corrective lenses."

The pilot's flight logbook contained entries dated between May 27, 2013, and December 28, 2017. The pilot had logged no less than 1,219.4 hours in helicopters; 212.7 hours of which were logged in the make and model of the accident helicopter. The pilot had logged 97.9 hours of simulated instrument flight time, and no flight time in actual instrument conditions. The last simulated instrument flight (0.4 hours dual received) was conducted September 30, 2015, in a Robinson R44 II helicopter.

The pilot started work at Vista One Inc. on September 6, 2017, and recorded a flight in his logbook, dated 9/6/17, of .5 hours with the note "Vista 1 First Day." The pilot had logged 309.3 hours of flight time in company helicopters between September 6, 2017, and December 28, 2017.

The company did not provide any training records for the pilot. The owner recalled conducting a training flight with the pilot the week before the accident but did not provide any specifics for that flight. This flight was not logged in the pilot's flight logbook. The owner mentioned that the pilot had difficulty recalling how to clear the GPS track just before the accident flight. He also stated that the pilot did not recall how to operate the throttle past the detent. He did not report any other concerns with the pilot's performance.

Crewmember

The powerline inspector worked for Vista One Inc. for 2 to 3 years. He lived in West Virginia and would drive to Ohio when it was time to work. According to the crewmember's family, he had been flying from platforms for line inspection and maintenance since 2004. The owner of Vista One Inc. stated that the crewmember drove from his home West Virginia the evening before the accident and met the pilot at 1G0 for work on the day of the accident. AIRCRAFT INFORMATIONAccording to the MD 500 Rotorcraft Flight Manual (RFM) the helicopter was certificated in the normal helicopter category for day and night visual flight rules (VFR) operations.

The helicopter was not equipped, nor was it required to be equipped, with either a radar altimeter or emergency locator transmitter.

The RFM stated that flight into known icing is prohibited. "Flight operation is permitted in falling and/or blowing snow only when the Automatic engine Reignition Kit and Engine Failure Warning System are installed and operable."

The helicopter was equipped with the late configuration warning and caution indicators which included a "flashing red engine out warning indicator" in addition to an "audible warning tone in headset." These indicators annunciate when gas generator speed (N1) falls below 55%.

The helicopter was equipped with the automatic engine reignition kit, a later modified system (250-C18 or C20). According to the RFM, this kit arms the automatic reignition system whenever there is transmission oil pressure and the ARMED (lower light) light is illuminated. Rotor speeds less than 98 +/- 1% of the power turbine speed (N2) or N1 speed is below 55%, the RE-IGN (upper light) is illuminated and the igniter is activated. The RE-IGN light only goes out when manually reset by the pilot.

The helicopter was also equipped with the anti-ice airframe fuel filter. This filter is designed to filter out ice particles and other solid contaminates from the fuel before it enters the engine fuel system. The RFM stated that use of this filter removes the requirement for using fuel containing anti-ice additives.

Rolls-Royce Engine

The Rolls-Royce M250-C20 Operations and Maintenance Manual contained several warnings regarding operations in snow and ice: "AT AMBIENT TEMPERATURES BELOW 4°C (40°F). SOME TYPE OF ANTI-ICE PROTECTION IS REQUIRED, SUCH AS AN ANTI-ICE ADDITIVE OR A MEANS OF AIRFRAME FUEL ICE ELIMINATION. ENGINE FLAMEOUT COULD RESULT FROM FAILURE TO USE ANTI-ICE PROTECTION."

It further notes that, "SNOW OR ICE SLUGS CAN CAUSE THE ENGINE TO FLAME OUT. BE SURE AVAILABLE PREVENTATIVE EQUIPMENT IS INSTALLED AND IN PROPER WORKING ORDER WHEN FLYING IN CONDITIONS WHERE SNOW OR ICE BUILD UP MIGHT OCCUR."

According to Rolls-Royce, a 1968 study showed that as little as 30 grams of snow/slush ingested in the engine inlet can induce a flameout in the Allison 250-series engines. METEOROLOGICAL INFORMATIONA weather study was conducted by the National Transportation Safety Board (NTSB) in support of this accident investigation and the detailed weather study is available in the public docket.

The National Weather Service (NWS) Surface Analysis Chart for 1000 local depicted a low-pressure system located over southern Wisconsin with its associated frontal boundary stretching northward into Canada and southward into Illinois, Indiana, and Missouri. A high-pressure system was located over central Virginia. The accident site was located in between the high- and low-pressure systems. The station models around the accident site depicted air temperatures in the mid to high teens (Fahrenheit (F)), dew point temperatures in the low teens, with temperature-dew point spreads of 5° F or less, an east-southeast wind of 5 to 10 knots, overcast sky cover, and light snow.

The Geostationary Operational Environmental Satellite-16 depicted abundant cloud cover above the accident site at the time of the accident, with that cloud cover moving from southwest to northeast. Infrared imagery indicated cloud tops at 13,000 ft msl.

There was a meteorological impact statement valid for the accident site at the time of the accident for areas of marginal visual flight rules and instrument flight rules with light snow spreading from west to east in addition to light to patchy moderate ice between 1,500 ft and 10,000 ft msl spreading from west to east. There were Airmen's Meteorological Information (AIRMET) Sierra and Zulu valid for the accident site at the accident time for IFR conditions due to precipitation and mist and moderate icing conditions below 15,000 ft msl.

A search of official weather briefing sources, such as contract Automated Flight Service Station (AFSS) provider Leidos weather briefings and the Direct User Access Terminal Service (DUATS), was done and the accident pilot did not request a weather briefing through Leidos or DUATS.

A search of archived ForeFlight information indicated that ForeFlight did not have any record of the accident pilot requesting a weather briefing before or during the accident flight. ForeFlight did record that the accident pilot accessed the Central Great Lakes NOAA Doppler radar loop weather Imagery at 0958:07. With no internet access while in flight, ForeFlight is still able to access weather information directly from the FAA but leaves no remote record of such access. It is unknown if the accident pilot checked or received additional weather information before or during the accident flight.

The weather conditions at 1G0 were visible in the security camera video. The visibility was reduced, and it was snowing. Witnesses at the airport characterized the weather at 1 ¼ to 1 ½ miles visibility, with moderate snow, and unknown ceilings. Photographs taken by law enforcement following the accident further illustrate falling snow and flat light and or w...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN18FA074