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Safety Recommendation Details

Safety Recommendation A-17-011
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 AND THE EUROPEAN AVIATION SAFETY AGENCY: After the actions requested in Safety Recommendation A-17-10 are completed, require operators of Airbus Helicopters dual-hydraulic AS350-series helicopters to incorporate changes to the dual hydraulic system to both ensure pedal control hydraulic assistance and mitigate the possibility of pilot error during any check of the hydraulic system.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await Response
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:
Addressee(s) and Addressee Status: European Aviation Safety Agency (Open - Await Response)
FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/20/2019
Response: We note that you believe AD 2018-01-12 R1 provides mitigations—such as moving the yaw load compensator test procedure to a postflight check, changing the hydraulic test activation switch to momentary activation, and adding a caution light to the annunciation panel—that prevent takeoff without hydraulic boost due to pilot omission. We do not agree that the AD’s requirements minimize the probability of takeoff without yaw pedal boost to a level that eliminates the unsafe condition. We note that you believe that you have satisfied this recommendation and consider your actions complete. Safety Recommendation A-17-11 asks you take action after Airbus Helicopters completes its action in response to Safety Recommendation A-17-10, which recommended that, in its dual hydraulic AS350-series helicopters, Airbus assess and change the dual hydraulic system to ensure pedal control hydraulic assistance and mitigate the possibility of pilot error during hydraulic system checks. On August 17, 2017, we pointed out that, in its initial response, Airbus Helicopters indicated it was exploring several options to further improve the dual-hydraulic system, including adding a system that would allow the yaw load compensator accumulator pressure to be checked. We have not received any further information from Airbus Helicopters since then, nor do we believe that Airbus Helicopters has completed its action in response to Safety Recommendation A 17-10. AD 2018-01-12 R1 superseded AD 2015-22-53 but retained its rotorcraft flight manual (RFM) provisions. In our August 17, 2017, letter to you about Safety Recommendation A-17-11, and in our October 24, 2017, comments about the NPRM, we pointed out that one of the revisions you made to the RFM procedures in AD 2015-22-53 was to replace the preflight yaw servo hydraulic check with a postflight yaw load compensator check. In our report on the Frisco, Colorado, accident, we said that this action did 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 at the start of the next flight. Also, your revisions did not address the possibility that the postflight check might be performed incorrectly, or that the functionality of the yaw load compensator might not have been verified. We emphasized that if Airbus’s revised hydraulic system design continued to require a yaw load compensator check, RFM revisions must require a preflight check of the yaw load compensator’s functionality to satisfy this recommendation. AD 2018-01-12 R1 requires that a blinking light be added to indicate if the switch is set to OFF during the postflight check. The switch is unlikely to be manipulated with a postflight check, whereas the preflight check required switch manipulation. Although Airbus Helicopters has not yet completed action in response to Safety Recommendation A-17-10, and despite that the action you took retains the postflight check rather than the preflight check that we said was necessary, you consider your actions to satisfy this recommendation to be complete. Consequently, Safety Recommendation A 17-11 is classified CLOSED--UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 10/3/2018
Response: -From Daniel K. Elwell, Acting Administrator: The FAA previously issued AD 2015-22-53, which mandated certain rotorcraft flight manual (RFM) procedure changes designed to reduce the probability of a pilot initiating takeoff with pedal hydraulic assistance turned off. On March 2, 2018. the FAA issued superseding AD 2018-01-1 2. which retains the RFM procedures required by AD 20 15-22-53 and mandates incorporation of available modifications to these aircraft. J\D 2018-01-12 RI provides mitigation that is designed to prevent takeoff without hydraulic boost due to pilot omission by moving the yaw load compensator test procedure to post flight. changing the hydraulic test activation switch to a momentary activation. and adding a caution light to the annunciation panel. Incorporating this modification as required by the AD. minimizes the probability of' takeoff without yaw pedal boost to a level that eliminates the unsafe condition as specified by the AD. This ensures that pedal control hydraulic assistance remains available during helicopter operation and mitigates pilot error. The European Aviation Safety Agency (EASA) issued AD 20 16-0220, effective on November 18. 20 16. which mandates incorporation of SB AS350-67.00.64 and SB AS350-67.00.65. EASA AD 2016-0220 can be found at the following Web site: https://ad.easa.europa.eu/ad/2016-0220. Existing RFM procedures combined with these SB changes mitigates the risk of pilot error during or after hydraulic system checks. 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. NTSB Safety Recommendation A-17-11 calls for the FAA and the European Aviation Safety Agency to require operators of dual-hydraulic AS350-series helicopters to incorporate changes that satisfy the intent of A-17-10. The NTSB understands that the FAA cannot take action on this recommendation until Airbus Helicopters completes its action.

From: NTSB
To: FAA
Date: 8/17/2017
Response: We understand that you cannot take action on this recommendation until Airbus Helicopters completes its action on Safety Recommendation A-17-10 (which recommends that, in its dual-hydraulic AS350-series helicopters, Airbus assess and change the dual hydraulic system to ensure pedal control hydraulic assistance and mitigate the possibility of pilot error during hydraulic system checks). In its initial response, Airbus Helicopters indicated that it was exploring several options to further improve the dual hydraulic system, including adding a system that would allow the yaw load compensator accumulator pressure to be checked. We note that you may supersede Airworthiness Directive (AD) 2015-22-53, “Airworthiness Directives; Airbus Helicopters,” with an AD that, while retaining the existing AD’s rotorcraft flight manual (RFM) provisions, also incorporates the modifications Airbus makes to satisfy Safety Recommendation A-17-10. We point out that one of the revisions you made to the RFM procedures in AD 2015-22-53 was to replace the preflight yaw servo hydraulic check with a postflight yaw load compensator check. In our report on the Frisco, Colorado, accident, we said that this action did 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 at the start of the next flight. Also, your revisions did not address the possibility that the postflight check might be performed incorrectly, or that the functionality of the yaw load compensator might not have been verified. As a result, we concluded that the Airbus Helicopters dual-hydraulic AS350-series design did not account for the possibility of pilot error in configuring the tail rotor hydraulic circuit or assessing the functionality of the yaw load compensator, and efforts to address these safety issues had thus far been insufficient. Airbus is currently considering which design revisions to the hydraulic system will satisfy Safety Recommendation A-17-10, and this may result in revisions to the RFM procedures. For example, the development of a dual cylinder tail rotor servo would eliminate the need for the yaw load compensator and the associated check. However, if the yaw load compensator is retained in Airbus’s revised design, a check will likely be retained in the RFM. We emphasize that if the revised hydraulic system design continues to require a yaw load compensator check, RFM revisions must require a preflight check of the yaw load compensator’s functionality to satisfy this recommendation. Pending your issuance and our review of the revised AD, Safety Recommendation A 17 11 is classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/14/2017
Response: -From Michael P. Huerta, Administrator: The FAA issued Airworthiness Directive (AD) 2015-22-53, titled 'Airworthiness Directives; Airbus Helicopters, . effective on December 16, 2015. AD 2015-22-53 mandates changes to certain rotorcraft flight manual (RFM) procedures to reduce the probability of a pilot initiating takeoff with pedal hydraulic assistance turned off. The FAA is considering superseding this AD with an AD that would retain those RFM procedures and mandate incorporation of available modifications to these aircraft. AD 2015-22-53 is available at: http://rgl.faa.gov/Regulatory and_ Guidance_ Library/rgad.nsf/ AOCA0Search/5C0490703 F2A523486257FOE005F 111 D?OpenDocument. The FAA notes that EASJ\ issued AD 2016-0220. effective on November 18, 2016. This EASA AD mandates the incorporation of Airbus Helicopters Service Bulletin (SB) J\S350-67.00.64 and SB AS350-67.00.65, which provide in-service modification instructions. EASJ\ AD 2016-0220 is available at: https://ad.easa.europa.eu/ad/2016-0220. Existing RFM procedures combined with these SB changes would mitigate the risk of pilot error during or after hydraulic system checks. I will keep the Board informed of the FAA· s progress on these recommendations and provide an update by June 2018.

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.

From: NTSB
To: European Aviation Safety Agency
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 two recommendations to the Federal Aviation Administration, one of which is also issued to EASA, as indicated below.