ERA10FA283
ERA10FA283

HISTORY OF FLIGHT

On May 26, 2010, at 1645 eastern daylight time, a Schweizer 269C-1, N73SJ, operated by Blue Hill Helicopters, was substantially damaged during an impact with terrain in Boxborough, Massachusetts. The Federal Aviation Administration (FAA) check pilot was fatally injured and the certificated commercial pilot received serious injuries. Visual meteorological conditions prevailed and no flight plan was filed for the instructional flight which was conducted under the provisions of 14 Code of Federal Regulations Part 91.

The purpose of the flight was for the check pilot, who was an FAA inspector, to conduct a practical examination for the commercial pilot to obtain her flight instructor certificate.

According to the commercial pilot, the practical examination began at Laurence Hanscom Field Airport (BED), Bedford, Massachusetts. A designated pilot examiner (DPE) accompanied her while she performed two touchdown autorotation maneuvers. Due to FAA policy, the FAA check pilot was prohibited from performing this maneuver in the helicopter, so he observed them from the ground.

Upon completion of the autorotation maneuvers, the DPE exited the helicopter and the FAA check pilot boarded the helicopter.

The commercial pilot then departed from the ramp and made a “left” departure toward Minuteman Airfield (6B6), Stow, Massachusetts. She completed a “settling with power” maneuver on the way to 6B6 and then several maneuvers once they arrived there, such as hovering flight, steep and normal approaches. After the maneuvers were completed, the commercial pilot departed from 6B6. After departure, the FAA check pilot stated, “ok we’re done, let’s go home.” The commercial pilot reported that she felt confident that she had passed the checkride at this point. She departed and turned the helicopter toward BED.

The FAA check pilot then stated, “this will be a simulated engine failure,” and he proceeded to “chop the throttle.” The commercial pilot lowered the collective and looked at the rotor RPM gauge which was “good.” She also noted that the engine RPM gauge read “0,” and she informed the FAA check pilot that she thought they were experiencing a real engine failure. The FAA check pilot told her to “recover,” and she “rolled on the throttle,” but nothing happened. The FAA check pilot then said “let me try,” and he joined her on the controls. He continued to troubleshoot the problem to regain engine power, while the commercial pilot looked for a landing spot.

The commercial pilot believed they were still in a turn when the FAA check pilot initiated the simulated engine failure. When they rolled out of the turn, the commercial pilot picked a straight section of road for the forced landing area. She selected a parking lot to the left of the road and a field to the right as alternate landing locations. The commercial pilot remembered the winds were calm at 6B6 when she departed, so she prepared for a straight-in approach to the road. She continued to scan the horizon, the landing spot and her instruments, noting the rotor RPM was “still good.” She also knew she would have a “long run,” since it was a “hot, calm day,” and based on her previous touchdowns that day.

As she prepared for the landing on the road, the FAA check pilot asked, “where are you going?” The commercial pilot told him she was going to the road and he responded, “we need to turn right to be into the wind.” The commercial pilot thought to herself that there was little/no wind and the landing surface was a more important factor. The FAA check pilot stated they needed to turn to the right and the commercial pilot stated she was going to the straight part of the road. This exchange occurred several times during the descent.

The next thing she remembered, the helicopter was facing to the right, and the commercial pilot was looking at the tops of the trees (which she knew were to her right previously). She saw the tree they were going to hit, and announced that they were going to impact it. The FAA check pilot confirmed they were going to strike the trees and shortly after the impact occurred.

According to firefighters who were first on-scene, the commercial pilot was extricated from the helicopter and stated she wanted to tell someone what happened prior to the accident. She said, “I was in my final training flight before being certified as an instructor...we were performing a simulated engine stall and while performing the maneuver the engine actually stalled for real.” She continued, “I was attempting to make a landing on the road, when the examiner instructed me to turn into the wind.” She stated “there was not enough wind and I was trying for the road.” According to the commercial pilot, at some point “the examiner took control of the helicopter,” at which time she stated to the examiner, “we’re going to hit the trees,” and he responded “yes we’re going to.”

According to radar data provided by the FAA, a target identified as the accident helicopter was observed at 1637 in the vicinity of Minuteman Airport. Between 1637 and 1644, the helicopter climbed to an altitude of 2,500 feet while completing a series of turns. During the final 60 seconds of the radar track, the helicopter performed a 180-degree turn, and descended from 2,500 feet to 700 feet, before the target was lost. The distance between the last radar target and the crash site was about 300 feet.

One witness was walking to his car in a parking lot near the accident site. He observed the helicopter over his right shoulder, headed south. The helicopter then turned 180-degrees back to the north and descended out of view. The helicopter briefly reappeared above the tree line "to get to the field beyond the trees.” He then observed the helicopter descend into the trees and shortly afterward heard a woman yell for help.

Two other witnesses were walking near the same parking lot. They reported hearing the helicopter overhead, flying about 100 feet above the trees. The witnesses reported hearing the helicopter's engine "sputtering," and "cutting in and out." Shortly after, the helicopter initiated a turn away from the trees and toward a field. The witnesses lost sight of the helicopter as it descended into the trees.

PILOT INFORMATION

FAA Inspector

The FAA inspector conducting the exam held a flight instructor certificate with ratings for airplane single and multiengine land, rotorcraft-helicopter, instrument airplane and instrument helicopter. He also held an airline transport pilot certificate with ratings for airplane single and multiengine land, and rotorcraft-helicopter. His most recent FAA second-class medical certificate was issued on May 19, 2009. At that time, he reported 8,865 hours of total flight experience.

The inspector began his employment with the Boston flight standards district office (FSDO) on June 23, 2008, and entered the FAA "4040" program (Flight Standards Flight Program) on the same date. Prior to beginning employment at the FAA, the inspector held various positions at a Part 135 helicopter emergency medical services (HEMS) operator, including: pilot, training captain, check airman, and chief pilot, from May 2000 – June 2006. Prior to working for the HEMS Part 135 operator, the inspector was employed with the FAA Milwaukee FSDO as a Principal Operations Inspector and Geographical Inspector from 1997-1998.

Examination of the FAA inspector's pilot logbook revealed entries from June 20, 2003 to May 25, 2010. The first page of the logbook indicated 7,705 hours of total experience carried over from a previous logbook. According to the logbook, the FAA inspector had accumulated 8,898 hours of total flight experience as of May 25, 2010. An entry on June 17, 2008 (0.7 hours logged in an EC-135 helicopter) included a comment which indicated it was the pilot's last flight with his former HEMS employer.

Further examination of the logbook entries revealed the inspector had accumulated 2.3 hours of flight time in make and model of the accident helicopter as follows:

0.4 hours logged (in the accident helicopter) on January 21, 2009
0.5 hours logged (in the accident helicopter) on March 25, 2009
0.7 hours logged in a Schweizer 300CBi on January 13, 2010
0.7 hours logged in a Schweizer 300CBi on January 13, 2010

According to the FAA inspector's personal logbook, during the time period which the inspector was employed by the FAA (June 2008 – May 2010), he logged 77 hours of total flight experience.

Since his employment began with the Boston FSDO, the inspector had accumulated 27.9 hours of pilot-in-command flight experience and the accident flight was the first helicopter checkride he had conducted.

Commercial Pilot

The flight-instructor applicant held a commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter. Her most recent FAA first-class medical certificate was issued on March 24, 2009. At that time, she reported 80 hours of total flight experience.

Examination of the commercial pilot's logbook revealed entries from January 7, 2006 to May 24, 2010. During that time period, she logged 206 total flight hours, all of which were in helicopters.

The commercial pilot completed her instrument rating checkride on December 19, 2009, and her commercial pilot checkride on March 20, 2010. She logged 128 hours in the accident helicopter make and model, which she flew exclusively since July 4, 2009. In the previous 90 days, the commercial pilot accumulated 29.6 hours of total flight experience, and in the previous 30 days she accumulated 8 hours of total flight experience.

AIRCRAFT INFORMATION

The helicopter was manufactured in 2008 and had accumulated 957 total aircraft hours. The most recent 100-hour inspection was completed on April 12, 2010, at 875 total aircraft hours. According to the airframe logbook, the transponder was tested on the day of the accident at 956.2 hours.

According to the owner/operator, he departed Blue Hill Helicopters at Norwood Airport (OWD) on the morning of the accident with 30 gallons of fuel in the helicopter, for the 18-mile flight to BED.

METEOROLOGICAL INFORMAITON

At 1656, weather reported at BED, at 133 feet elevation, included wind from 340 degrees at 6 knots, 10 miles visibility, clear skies, temperature 34 degrees Celsius (C), dew point 17 degrees C, and an altimeter setting of 29.66 inches of mercury.

The estimated density altitude at BED was 2,869 feet.

WRECKAGE INFORMATION

The helicopter impacted the edge of a wooded area, about 50 yards prior to a field, oriented on a heading of approximately 300 degrees. All components of the helicopter were located in a compact area. There was no wreckage path, and only the trees directly above the helicopter were disturbed.

The helicopter came to rest upright, leaning about 45 degrees to its right side. The right side of the helicopter exhibited lateral crushing deformation and the plexiglass canopy was completely fragmented. Examination of the instrument panel revealed the vertical speed indicator read 0 feet per minute, and the altimeter read 50 feet, with 29.66 displayed in the Kollsman window. The throttle was in the idle position and the friction was off. The collective was in the mid-range position. Both the left and right cyclic controls were separated at their respective bases, at the push-pull tube attachment.

The tail boom was separated from the fuselage at its fuselage attachment. The tail rotor drive shaft was separated in two pieces at the same location. Examination of the fracture surfaces revealed torsional overload signatures. The tail boom was intact and displayed minimal damage. The tail rotor and horizontal stabilizer remained attached to the tail boom, displaying virtually no impact damage.

All three main rotor blades remained attached to the hub, and displayed no leading edge damage. Minimal chordwise scratching was observed on the blades, and one of the blades was bent aft about one foot from the hub.

The helicopter was removed from the accident site and further examined in a secure facility. Tail rotor control continuity was confirmed from the cockpit to the tail boom separation point and from the separation point to the tail rotor. Cyclic and collective flight control continuity was confirmed from the cockpit to the flight controls.

The main rotor blades were removed and then engine was test run on the helicopter. It started immediately, accelerated smoothly, and ran continuously without interruption at 1,600 RPM. Additionally, the spark plugs were removed and displayed normal wear. A borescope examination of the cylinders revealed no anomalies.

MEDICAL AND PATHOLOGICAL INFORMATION

The Commonwealth of Massachusetts, Office of the Chief Medical Examiner performed an autopsy on the pilot on May 27, 2010.

The FAA Bioaeronautical Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing on the pilot. The results were negative for drugs or alcohol.

ADDITIONAL INFORMATION

FAA Inspector Currency Policy

According to FAA Order 4040.9D, FAA Aircraft Management Program, FAA inspectors were required to satisfactorily complete at least one check flight every 12 calendar months in each category of aircraft in which they will be conducting checkrides. There is no requirement to maintain currency in each make and model of aircraft flown.

Additionally, FAA inspectors who conduct pilot evaluations were required to maintain currency through the FAA Event Based Currency (EBC) Program. The program required inspectors to perform a specific number of tasks each quarter proficiently. According to the EBC guidelines, when the inspector believed he or she had reached proficiency in a task, he or she may consider that task complete. No specific, or minimum number of flight hours were required. Two maneuvers required to be performed as part of the EBC Program are: "(1) autorotation to a power recovery, and (2) autorotation to a touchdown for ASI's giving single engine CFI checks." Additionally, the flight standards office must approve all inspectors who conduct touchdown autorotations.

The FAA inspector involved in the accident completed his most recent 4040 check flight on January 25, 2010 in a Bell 206 turbine-powered helicopter. As of this check flight, the inspector was not approved to conduct touchdown autorotations. However, examination of his 4040 check flight paperwork from the previous year (dated January 7, 2009), revealed he was approved to conduct touchdown autorotations as of that date. The 2009 check flight was also conducted in a Bell 206 helicopter.

According to FAA guidance for CFI checkrides, an inspector not authorized to conduct touchdown autorotations would allow the CFI candidate to perform the maneuver alone in the helicopter, or with a designated pilot examiner or safety pilot.

The CFI checkride was the only checkride which required demonstration of the full touchdown autorotation.

Designated Pilot Examiner Policy

The FAA routinely appoints designated pilot examiners (DPE) to complete certification activities on their behalf, in accordance with FAA policy and guidance.

An examination of FAA Order 8900.2, General Aviation Airman Designee Handbook, revealed DPEs that conduct practical tests in a specific make and model of helicopter are required to have logged at least 5 hours of PIC flight time in that specific helicopter make and model/type.

Risk Assessment

At the time of the accident, the FAA had no risk management policy for inspectors to evaluate or mitigate risks during the performance of evaluations in aircraft for which they may not have recent or total flight experience.

FAA CFI Practical Test Standards (PTS)

The CFI PTS established the flight tasks by which CFI candidates were evaluated. The "Power Failure at Altitude" Task required the examiner to direct the applicant to "demonstrate and simultaneously explain a simulated power failure at altitude from an instructional standpoint."

The PTS also stated that the examiner should terminate the task with a power recovery at an altitude high enough to ensure a safe touchdown in the event of an actual power failure.

Review of the PTS did not reveal an instruction for examiners to initiate a simulated engine failure and evaluate how the CFI would recover from the maneuver.

Operator/Flight School Autorotation Procedures

The flight instructor who trained the commercial pilot was also the owner of the flight school. In reference to simulated engine failure training, he reported that the students and instructors "never conduct throttle chops." According to the flight instructor, if the throttle is reduced too abruptly in the Schweizer 269, the engine can quit. He teaches students to reduce the power to 2,000 RPM (for power recovery) and descend to a decision altitude of 300 feet. He always announces this maneuver and never surprises the student with a simulated engine failure. He also teaches the maneuver with a suitable landing area within gliding range. The flight instructor has never experienced an engine failure while simulating this maneuver.

The DPE who flew with the commercial pilot during part of her checkride reported that his role on the day of the accident was as a “safety pilot,” because FAA inspectors were prohibited from performing touchdown autorotations in the helicopter during a checkride. The commercial pilot performed two straight-in touchdown autorotations at the request of the FAA inspector. Her technique was “smooth and coordinated,” and she “did not chop the throttle."

The DPE additionally reported that the commercial pilot's technique was consistent with her instructor’s technique. He had flown with the commercial pilot's instructor on the morning of the accident to familiarize himself with the helicopter. The DPE and instructor performed eight autorotations in the helicopter that morning. The DPE stated the helicopter performed “fine” during both flights he participated in prior to the accident flight.

The flight school's published procedure for performing a simulated engine failure was as follows:

"Simulated Engine Failure: Unless approved by the Chief Flight Instructor:
1. Perform a controlled throttle roll off when the collective is almost full down.
2. Hover autorotations are to be performed over suitable paved landing areas ONLY between 3-5 feet AGL.
3. No simulated engine failures BELOW 1000 FT AGL, unless performed as a pattern autorotation maneuver.
4. Recovery of simulated engine failure must be completed by no less than 500FT AGL.
5. Intentions must be announced prior to beginning maneuver. "3, 2, 1 Engine Failure"
6. Student must verbally acknowledge his preparation
7. An announcement of "3, 2, 1 engine failure" must be made prior to rolling off the throttle
8. Throttle chops are not to be performed with primary students
9. UNDER NO CIRCUMSTANCES shall the instructor carelessly chop the throttle – a controlled but rapid throttle closing is necessary, only with warning to the student."

Schweizer Flight Manual Excerpt

Review of the Schweizer 300CB Model 269C-1 Pilot's Flight Manual revealed a warning in Section III (Emergency and Malfunction Procedures), under the "Engine Idle at Altitude" section which stated "WARNING: AVOID THROTTLE CHOPS TO FULL IDLE ABOVE 3750 FEET DENSITY ALTITUDE, TO AVOID POSSIBILITY OF ENGINE STOPPAGE."

The same warning was listed in section IV (Normal Procedures), under the "Engine Idle at Altitude" section.

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