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Safety Recommendation Details

Safety Recommendation A-17-008
Details
Synopsis: On July 3, 2015, about 1339 mountain daylight time, an Airbus Helicopters AS350 B3e helicopter, N390LG, registered to and operated by Air Methods Corporation, lifted off from the Summit Medical Center Heliport, Frisco, Colorado, and then crashed into a parking lot; the impact point was located 360 feet southwest of the ground-based helipad. The pilot was fatally injured, and the two flight nurses were seriously injured. The helicopter was destroyed by impact forces and a postcrash fire. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135 on a company flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require that existing Airbus Helicopters dual-hydraulic AS350-series helicopters be equipped with a visual and an aural alert for the loss of hydraulic boost to the pedal controls, which would result in increased pedal loads.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Frisco, CO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CEN15MA290
Accident Reports: ​Aircraft Accident Report: Loss of Control at Takeoff Air Methods Corporation Airbus Helicopters AS350 B3e, N390LG
Report #: AAR-17-01
Accident Date: 7/3/2015
Issue Date: 4/13/2017
Date Closed: 2/20/2019
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/20/2019
Response: We note that you issued Airworthiness Directive (AD) 2018-01-12 R1, “Airworthiness Directives; Airbus Helicopters,” effective on March 2, 2018, to combine the requirements found in Airbus Helicopters Service Bulletins (SBs) AS350-67.00.64 and AS350-67.00.65. These SBs mandate that affected helicopters be equipped with the following: • A flashing amber (caution) visual alert on the caution and warning panel when the hydraulic switch on the collective grip is set to “OFF.” • A light to indicate the status of the dual hydraulic system. • An accumulator test push on/push off button with a momentary push and hold on/release-off button. We point out that these modifications do not add the aural alert called for in Safety Recommendation A-17-8. You wrote that this is consistent with existing amber (caution) alerts that do not incorporate an aural alert; however, you believe the flashing nature of this warning light makes it more noticeable. Further, you believe that issuing the AD satisfies Safety Recommendation A 17 8, and you do not plan to take any further action. Safety Recommendation A 17 8 specifically recommends both a visual and aural alert based on our conclusion that there was a lack of “salient alerting.” In our October 24, 2017, comments about the notice of proposed rulemaking (NPRM) that was the basis for AD 2018 01 12 R1, we said that the proposed AD would not satisfy Safety Recommendation A 17 8; however, you did not make any changes to the AD. Therefore, Safety Recommendation A-17-8 is classified CLOSED--UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 10/3/2018
Response: -From Daniel K. Elwell, Acting Administrator: The federal Aviation Administration (FAA) notes that Airbus Helicopters published Service Bulletin (S B) AS350-67.00.64 and SB AS350-67.00.65 on February 25. 2015 and August 25. 2016. respectively. These SBs require affected helicopters to be equipped with a flashing amber (caution) visual alert on the caution and warning panel when the hydraulic switch on the collective grip is set to .. OFF .. ; an indicator light to indicate the status of the dual hydraulic system: and an accumulator test push-on/push-off button with a momentary push and hold-on/release-off button. The r AA subsequently issued Airworthiness Directive (AD) 2018-01-12. titled 'Airworthiness Directives; Airbus Helicopters, effective on March 2. 2018 (as corrected). This AD mandates incorporation of the airbus modifications noted above. While the modifications do not add an aural alert. this is consistent with existing amber (caution) alerts that do not incorporate an aural alert. However. the flashing nature of this visual alert is more noticeable than non-flashing amber alerts presented to the flight crew. AD 2018-01-12 can be found at the following website: http://rgl.faa.gov/Regulatoryand_Guidance_Library/rgad.nsf/AOCADSearch/D6413E98844ICEF7F8625824400526BA3?Open Document I believe the FAA has effectively addressed these safety recommendations and consider our actions complete.

From: NTSB
To: FAA
Date: 10/24/2017
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled, “Airworthiness Directives; Airbus Helicopters,” which was published at 82 Federal Register 42487 on September 8, 2017. The NPRM proposes to adopt a new airworthiness directive (AD) for Airbus Helicopters model AS350B3 helicopters with a dual hydraulic system installed. The proposed AD would supersede AD 2015-22-53, retaining its requirements while also mandating incorporation of a caution light when the yaw servo hydraulic switch is in the OFF position, as well as a monostable (push on, timer off) ACCU TST button. We are pleased that the proposed AD would require a modification to the ACCU TST push button such that it would automatically reset after activation, which would reduce the possibility of pilot error in forgetting to reset it while performing a check of the yaw load compensator. However, the NTSB notes that, while the proposed AD would mandate changes to improve pilots’ awareness of the position of the yaw servo hydraulic switch, the changes do not address the need for an alert when there is insufficient pressure in the tail rotor hydraulic circuit, which would lead to increased pedal loads. The NTSB believes that, for at least four events we’ve investigated in which the yaw servo hydraulic switch likely was not returned to its correct (ON) position before takeoff, a salient alert could have cued the pilots to insufficient hydraulic pressure in the tail rotor hydraulic circuit. This is a deficiency we also noted in our January 14, 2016, comments on AD 2015-22-53 and discussed in the Frisco, Colorado, accident report. As a result of that investigation, the NTSB issued Safety Recommendation A-17-8, which calls for both an aural and visual indication of a loss of hydraulic boost to the pedal controls. The proposed AD would not satisfy the intent of this recommendation. Further, the NTSB remains concerned that the proposed AD intends to retain the changes implemented by AD 2016-22-53 in still requiring a functional check of the yaw load compensator—which could be used during a critical situation during flight—as a postflight procedure. (Before AD 2016-22-53, the functional check of the yaw load compensator was performed during the preflight run-up procedures.) A postflight check of the yaw load compensator does not completely eliminate the risk of taking off without backup hydraulic boost to the pedals because the postflight check does not ensure that the yaw load compensator will remain functional for the next flight. This concern was the basis for issuing Safety Recommendations A-17-9 and 10 to Airbus Helicopters in connection with the Frisco, Colorado, accident investigation. In response to these recommendations, Airbus Helicopters stated that it is considering design revisions of the dual hydraulic system that may satisfy the recommendations and may result in revisions to the rotorcraft flight manual procedures that would address the NTSB’s concerns about performing the yaw load compensator check as a postflight procedure. We appreciate the opportunity to comment on this NPRM.

From: NTSB
To: FAA
Date: 8/17/2017
Response: We note that you are working with the European Aviation Safety Agency to ensure that Airbus Helicopters develops a system for existing AS350-series helicopters to provide a visual and an aural alert when there is a loss of hydraulic boost to the pedal controls. Pending completion of that development, and a requirement that the system be installed in all existing affected helicopters, Safety Recommendation A-17-8 is classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/14/2017
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) will work with the European Aviation Safety Agency (EASA) to recommend that Airbus Helicopters develop a solution to provide visual and aural alerting for the loss of hydraulic boost to the pedal controls. Once a solution is available, we will then determine our next step.

From: NTSB
To: FAA
Date: 4/13/2017
Response: On March 28, 2017, the National Transportation Safety Board (NTSB) adopted our report concerning the July 3, 2015, accident in which an Airbus Helicopters AS350 B3e helicopter, N390LG, registered to and operated by Air Methods Corporation, lifted off from the Summit Medical Center Heliport, Frisco, Colorado, and then crashed into a parking lot; the impact point was located 360 feet southwest of the ground-based helipad.1 Additional information about this accident and the resulting recommendations may be found in the report of the investigation, which can be accessed at our website, http://www.ntsb.gov, under report number NTSB/AAR-17/01. As a result of this investigation, we issued six new recommendations, including two to Airbus Helicopters; one to the Association of Critical Care Transport; one to the Association of Air Medical Services and the Air Medical Operators Association; and the following two recommendations to the Federal Aviation Administration, the latter of which was also issued to the European Aviation Safety Agency.