Aviation Accident Summaries

Aviation Accident Summary LAX97GA105


Aircraft #1


McDonnell Douglas 369D


The sheriff's pilot and qualified observer attempted a takeoff from a hover at a remote canyon in night visual meteorological conditions. The crew was using the helicopter's search light within the previous 15 minutes and the pilot's eyes were not dark adapted. The searchlight was turned off by the observer during the takeoff and the pilot became disoriented. The helicopter descended vertically, struck the ground, and bounced over 100 feet rearward. The public-use agency's training program did not provide for night recurrent emergency procedure training, recurrent night physiology training, or crew resource management training for night flight.

Factual Information

History of the Flight On February 16, 1997, about 1944 hours Pacific standard time, a McDonnell Douglas, 369D (MD 369), N5200Y, operated by the San Diego Sheriff's Department Aviation Division (ASTREA) collided with the terrain during a night takeoff from a field near Santee, California. The helicopter was substantially damaged. The pilot received serious injuries, and the observer was fatally injured. The flight was destined for Gillespie Field, El Cajon, California. Night visual meteorological conditions prevailed at the time. At 1848, the ASTREA aircrew was at Gilliespie Field when they received a request from the Oceanside Police Department asking for assistance to search for a missing child. At 1851, the aircrew departed Gilliespie Field and headed north towards the search area. At 1901, the helicopter was over Escondido, California, when the aircrew received a radio transmission canceling their response to search for the missing child. The pilot reversed course and headed back towards Gilliespie Field. As the helicopter approached the airport, the aircrew noticed a campfire in the Sycamore Canyon Area located about 3.7 miles north of the airport. The aircrew elected to investigate the fire and descended into the canyon terminating the approach to an out-of-ground effect hover. The observer illuminated the campfire area with helicopter's searchlight. The aircrew determined the activity around the campfire was normal and did not make contact with the persons on the ground. During the investigation of the campfire, the pilot noticed a reflection in some nearby trees. The aircrew then hovered over to the reflection at tree top level and discovered a vehicle. The aircrew circled the vehicles several times illuminating it with the search light and saw two men come out of the vehicle. The pilot landed the helicopter and the observer exited. The pilot remained in the helicopter allowing it to continue to operate. The observer returned to the helicopter after completing law enforcement work with the vehicle occupants. The aircrew was in contact with a sheriff's ground patrol unit at the time however, the ground unit was unable to access the remote area. The aircrew decided to return to Gilliespie Field to meet with the ground patrol and complete the law enforcement work. The pilot executed a takeoff from a hover and climbed to 500 feet above ground level (agl) in a right climbing spiral at which time he saw three lights he thought were motorcycles. (Motorcycles are not permitted in the canyon area.) The pilot aborted the climb and headed in a southeasterly direction towards the lights in a "slow descent." About 3/4 mile from the lights, at 200 feet agl and 20 to 30 knots forward airspeed, the aircrew identified the lights as belonging to bicycles. The pilot then aborted the approach and planned a spiraling climb back to 500 feet agl. The pilot indicated that the searchlight was turned off by the observer during the attempted takeoff from the out-of-ground effect hover. After adding power, the pilot noticed the helicopter was continuing to descend. According to the pilot, he added more power but the helicopter did not respond and began to yaw back and forth. The pilot indicated he applied forward cyclic, but "nothing happened." The pilot further stated, "We hit the ground and instantly began violent spinning." According to the pilot, after the helicopter came to rest the engine was still running and he had to use the emergency fuel shutoff valve to turn it off. The three cyclists on the ground witnessed the helicopter accident. Inspectors from the Federal Aviation Administration's (FAA) San Diego Flight Standards District Office interviewed the cyclists. The cyclists told the FAA inspectors they observed the helicopter on the ground about 3/4 mile away. They watched the helicopter takeoff in a near vertical ascent to approximately 100 to 150 feet agl. The helicopter then turned left and headed towards the cyclists shining the landing light on them. The cyclists thought the helicopter was going to land across the dirt road in that they were traveling and check them out. The helicopter was then observed to turn right while hovering at an out-of-ground effect and start to descend. According to the FAA, all three cyclists described the initial rate of descent as slow and rapidly increasing. The cyclists then took cover and watched as the helicopter descended and contacted the ground. They indicated that about 25 to 30 feet above the ground the tailboom dropped about 10 degrees [tail low]. The tail rotor struck the ground and the tailboom bent up into the main rotor blades. The main rotor blades severed the tailboom. The helicopter rolled onto its right side and the rotor blades struck the ground flipping the helicopter onto its left side. The helicopter appeared to cartwheel across the ground coming to rest about 75 feet east of the dirt road. The cyclists heard the engine continue to run at high speed for 90 to 120 seconds. After the engine noise stopped one of the three cyclists went for help while the other two approached the helicopter. The cyclists aided the pilot and observer egress from the helicopter's wreckage. The pilot pointed out a first aid kit and a hand held VHF radio. The cyclists administered first aid to the more serious injured observer while the pilot called for help on the radio. The cyclists indicated that they had ridden in the canyon area in the past and observed sheriff's helicopter operations in the area before. The three cyclists told the FAA inspectors that there were no unusual engine sounds and that they heard no other sounds indicating a problem with the helicopter before the collision with the ground. Aircrew Information Pilot The pilot was employed by the San Diego County Sheriff's Department on June 15, 1979, as a deputy sheriff. In September 1986, he joined ASTREA and was trained as an observer. He started the Sheriff's Department flight training syllabus October 1989, and completed the training on September 16, 1991, with the issue of an FAA pilot certificate. He then was assigned pilot duties within ASTREA. The pilot suffered an on-the-job injury in April 1993, and was removed from pilot flight status until June 1996. The pilot holds a commercial pilot certificate with a Rotorcraft-Helicopter rating. The most recent second-class medical certificate was issued on September 30, 1996, and contained the limitation that correcting lenses be worn while exercising the privileges of his airman certificate. The pilot was off duty the day before the accident and had reported to work about 1330 to work the night shift to 2400. The pilot indicated in his written accident report that his total aeronautical experience consists of about 1,095 flight hours, of which about 950 were accrued in the MD 369 series helicopters. The pilot had accrued about 144 hours of night flight experience, of which 56 were in the past 90 days. The pilot, represented by counsel, was interviewed by Safety Board investigators after the accident. Present during the interview was an ASTREA Sheriff's Deputy who performed collateral duties as unit safety officer. The pilot was asked questions specific to the history of the accident flight and his aeronautical training. The pilot stated that during his initial training with the Sheriff's Department he did not perform any night autorotations, or any autorotations other than hovering autorotations, in the MD 369 series helicopters. The pilot indicated he was sent to Western Helicopters, Rialto, California, for recurrent training at which time he accomplished day autorotations in the MD 369. The pilot stated that he has not had any night emergency training. During the interview, the pilot was asked if he had received any additional night training administered by the Sheriff's Department. The pilot indicated he had flown night patrol with another pilot in August 1996. The pilot further stated that on September 11, 1996, he had night training at Gilliespie Field and in Sycamore Canyon. He indicated the training covered night low level flying and night takeoff and landings in unlit areas. The pilot agreed during his interview to answer questions to test his aeronautical knowledge. The questions covered basic helicopter aerodynamics and night physiology topics found in FAA Advisory Circulars (AC); AC 61-13B, "Basic Helicopter Handbook" and AC 67-2, "Medical Handbook For Pilots." Both publications are applicable to FAA certification of commercial helicopter pilots. The pilot was able to answer less than half the questions. He was unable to demonstrate rotorcraft aeronautical knowledge concerning effective translational lift, transverse flow effect, and translating tendency. The pilot was also unable to correctly answer questions involving dark adaptation, anatomy of the eye, and autokinesis. Observer The observer was employed by the San Diego County Sheriff's Department in May 1988. In March 1995, he joined ASTREA and was trained as an observer. The observer held a private pilot certificate with an airplane rating for single engine land prior to joining ASTREA, and was working towards a commercial pilot certificate. The observer had accrued about 874 hours flight experience as a civil pilot and about 1,312 flight hours as an observer. The observer was off duty the 3 days before the accident. He reported to work at 1330 to work the night shift to 2400. Crew Training and Management Oversight The Safety Board reviewed the pilot's training records to determine what training he received from his employer after he obtained his commercial pilot certificate. On March 13, 1992, and March 10, 1993, the pilot attended emergency procedure training at Western Helicopters, Inc. Rialto. The pilot was also evaluated by ASTREA on March 12, 1993. During this internal evaluation, the pilot flew for 1.0 hours. The training records reflect "settling with power" was discussed at the time of the ASTREA evaluation. On April 8, 1993, the pilot sustained an on-the-job injury that resulted in both temporary and permanent disabilities. After the pilot recovered from the temporary disability, the pilot passed an FAA Class II medical examination September 6, 1994, and petitioned to be reinstated as an ASTREA pilot. The San Diego County Sheriff's Department reviewed the pilot's petition in light of his permanent disability and returned him to pilot status on April 18, 1995. The pilot then began an ASTREA specified recurrent flight training program. On July 17, 1995, the pilot had completed 5 hours of dual flight instruction and 2 hours of ground school. The pilot's flight skills and aeronautical knowledge were identified as being deficient. A decision was made to give the pilot additional flight instruction. The pilot was "assigned to review the ground school materials for the entire commercial certificate." Another ASTREA deputy sheriff who was assigned duties as a flight instructor and who possessed a current FAA flight instructor certificate for both airplanes and helicopters administered the training. On September 18, 1995, the pilot had completed 8.4 hours of dual instruction toward returning to pilot-in-command status. He also completed an FAA biennial flight review (BFR) within the 8.4 hours. Also included in this time were 1.3 flight hours at Western Helicopters, Inc. There was no evidence in the records provided to the Safety Board that the pilot had completed the annual emergency training at Western Helicopters, Inc. The ASTREA flight instructor indicated to his sergeant and captain that the Western Helicopters, Inc. flight instructor stated the pilot "has no basic flying skills." The flight instructor was told to continue training the pilot. The Safety Board contacted the Western Helicopter's Inc. flight instructor concerning the accident pilot, however, he declined making a statement. On October 12, 1995, the pilot had completed another 12.5 hours of dual flight instruction since September 18, 1995. The training encompassed patrol operations, mountain flying, straight and level flight, constant airspeed climbs and descents, orbits, emergency procedures, navigation by pilotage, collision avoidance, and controlled airspace operations. According to the ASTREA flight instructor, during the 12.5 hours of additional dual flight instruction the pilot had difficulty maintaining airspeed during descents, lost control during an autorotation, entered controlled airspace without authorization, and had difficulty with communications and position reporting at uncontrolled airports. The flight instructor indicated he had to take control of the helicopter to avoid a collision with an airplane. The flight instructor also indicated the pilot had accumulated 842.8 hours of flight experience in helicopters, of which 221.3 were with an instructor. On January 16, 1996, the ASTREA flight instructor recommended to the San Diego County Sheriff's Department sergeant and captain who oversees ASTREA, that the pilot not be returned to flight status. In his letter to the captain, the flight instructor stated that the pilot exhibited a lack of judgement and a lack of proficiency in flying. The flight instructor stated the pilot "is more likely to be an accident waiting to happen." On March 26, 1996, the pilot began training with the ASTREA sergeant who also possessed an FAA helicopter flight instructors rating. During the course of the training on April 17, 1996, the pilot attended Emergency Procedures/Touchdown Autorotations Refresher Course provided by Western Helicopters, Inc. According to the sergeant, the Western Helicopters, Inc. instructor indicated the pilot "performed as well as any other of our pilots." The pilot's requalification training was completed on June 3, 1996, with the completion of an ASTREA administered flight check. The sergeant who administered the test indicated, "All maneuvers met or exceeded the standards described in the FAA's helicopter Practical Test Standards." Review of the sergeant's flight training records for the pilot did not indicate that tasks concerning "Settling with Power" and "Physiological Aspects of Night Flying" were covered during the training. The Safety Board asked if ASTREA had a plan of action for requalification and/or recurrent training for its pilots. The ASTREA safety officer indicated there were no organizational published tasks, conditions, and standards. The unit relied on the FAA Practical Test Standards and the emergency training courses offered by outside contractors. The Safety Board also asked if ASTREA had developed any published tasks, conditions, and standards for the law enforcement mission areas of operation or crew resource management, according to the ASTREA Safety Officer; they had not. The Safety Board investigators talked to several other sheriff's deputies assigned pilot duties in ASTREA. Two deputies were asked about recurrent training and were asked to submit to a short oral examination to test their aeronautical knowledge concerning helicopter aerodynamics and physiological aspect of night flying. Both deputies confirmed ASTREA did not have a formalized recurrent training program and also lacked aeronautical knowledge similar to the accident pilot. Aircraft Information The helicopter had accumulated a total time in service of 4,816 hours. The helicopter was operated by the San Diego County Sheriff's Department as a public-use aircraft. The Sheriff's Department contracted the helicopter's maintenance and provided their own oversight by assigning a pilot/deputy as the maintenance officer. According to the Sheriff's Department, the manufacturer's inspection program was used to perform preventative maintenance on the helicopter. A 300-hour inspection was accomplished on February 10, 1997, about 10.3 hours prior to the accident. During the inspection one of the main rotor blades was replaced. The main rotor system was tracked and the helicopter was released for service in an airworthy condition. The engine had accrued a total time in service of 1,921 hours. A major overhaul of the engine was a

Probable Cause and Findings

Spatial disorientation and temporary visual impairment that led to a loss of aircraft control as result of difficulty to light adaptivity. Contributing was the crew coordination and inadequate night flight recurrency training.


Source: NTSB Aviation Accident Database

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