Photo of accident helicopter configured for FlyNYON doors-off operation.

​​Accident helicopter configured for FlyNYON doors-off operations.

Source: Eric Adams (Photograph cropped and faces redacted by NTSB)

Inadvertent Activation of the Fuel Shutoff Lever, Subsequent Loss of Engine Power, and Ditching on the East River, Liberty Helicopters Inc.

What Happened

​​On March 11, 2018, about 1908 eastern daylight time, an Airbus Helicopters AS350 B2, N350LH, lost engine power during cruise flight, and the pilot performed an autorotative descent and ditching on the East River in New York, New York. The pilot sustained minor injuries, the five passengers drowned, and the helicopter was substantially damaged. The FlyNYON-branded flight was operated by Liberty Helicopters Inc. (Liberty), per a contractual agreement with NYONair; both companies considered the flight to be an aerial photography flight operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual flight rules (VFR) weather conditions prevailed, and no flight plan was filed for the intended 30-minute local flight, which departed from Helo Kearny Heliport, Kearny, New Jersey, about 1850.

Liberty operated the accident flight as a FlyNYON-branded, doors-off helicopter flight that allowed the five passengers (one in the front seat, four in the rear seats) to take photographs of various landmarks while extending their legs outside the helicopter during portions of the flight. For the accident flight (and other FlyNYON flights that Liberty operated), Liberty configured its Airbus AS350 B2 helicopter with the two right and the front left doors removed and the left sliding door locked open. Before departure, each passenger was fitted with a NYONair-provided harness/tether system that NYONair developed with the intent to prevent passengers from falling out of the helicopter. The harness/tether system used on the accident flight consisted of a full-body, workplace fall-protection harness that was secured (with a locking carabiner) to a tether, the other end of which was secured (with another locking carabiner) to an anchor point in the cabin. Each passenger also wore the helicopter’s installed, Federal Aviation Administration (FAA)-approved restraints. The pilot (who was seated in the front right seat) wore only an installed, FAA-approved restraint.

After the flight departed, it traveled past various scenic landmarks. Consistent with the standard operating procedures (SOPs) used for FlyNYON flights, the passengers were allowed (when instructed by the pilot) to position themselves to extend their legs outside the helicopter. The two passengers who had been seated in the rear inboard seats removed their installed, FAA-approved restraints and sat on the cabin floor, wearing their harness/tether systems. The passengers seated in the outboard seats were allowed to rotate outboard in their seats. To enable such freedom of movement, the SOPs allowed the passengers to wear their installed, FAA-approved restraint with the lap belt adjusted loosely and the shoulder harness routed under the arm.

A review of radar data and onboard video showed that, when the flight was proceeding northwest over Manhattan toward Central Park at an altitude of 1,900 ft mean sea level, the front passenger, who was facing outboard in his seat with his legs outside the helicopter, leaned back several times to take photographs using a smartphone. The onboard video showed that, each time he leaned back, the tail of the tether attached to the back of his harness hung down loosely near the helicopter’s floor-mounted controls. At one point, when he pulled himself up to adjust his seating position, the tail of his tether remained taut but appeared to pop upward. Two seconds later, the helicopter’s engine sounds decreased, and the helicopter began to descend. 

​As the pilot performed the emergency procedures to perform an autorotation and address the apparent loss of engine power, he noticed that the fuel shutoff lever (FSOL) was in the shutoff position and that it had been inadvertently moved to that position by the tail of the front passenger’s tether, which had become caught on it.

Although the pilot pushed the FSOL down to restore fuel flow to the engine and attempted to relight the engine, the helicopter was too low to allow engine power to be restored in time to prevent the emergency landing. The pilot pulled the activation handle to deploy the helicopter’s emergency flotation system, and he ditched the helicopter on the East River. However, the helicopter’s floats did not fully inflate, and the helicopter rolled right in the water and became fully inverted and submerged about 11 seconds after it touched down.

The pilot was able to release his installed, FAA-approved restraint after he was under water and successfully egress from the helicopter; however, none of the passengers were able to egress, and they all drowned.

What We Found

The probable cause of this accident was Liberty Helicopters Inc.’s use of a NYONair-provided passenger harness/tether system, which caught on and activated the floor-mounted engine fuel shutoff lever and resulted in the in-flight loss of engine power and the subsequent ditching. Contributing to this accident were (1) Liberty’s and NYONair’s deficient safety management, which did not adequately mitigate foreseeable risks associated with the harness/tether system interfering with the floor-mounted controls and hindering passenger egress; (2) Liberty allowing NYONair to influence the operational control of Liberty’s FlyNYON flights; and (3) the Federal Aviation Administration’s inadequate oversight of Title 14 Code of Federal Regulations Part 91 revenue passenger-carrying operations. Contributing to the severity of the accident were (1) the rapid capsizing of the helicopter due to partial inflation of the emergency flotation system and (2) Liberty and NYONair’s use of the harness/tether system that hindered passenger egress.​

What We Recommended

​​To the Federal Aviation Administration

  • Modify the supplemental passenger restraint system (SPRS) approval process to (1) require letter of authorization (LOA) applicants to specify a need for and the intended use of an SPRS for each aircraft; (2) require the Federal Aviation Administration to evaluate and review, for each specified aircraft, the need for the SPRS on that aircraft for all intended uses; all SPRS design, manufacture, installation, and operational considerations, including, at a minimum, the potential for passengers to become entangled during emergency egress; the adequacy of passenger emergency egress briefings; and the potential for the SPRS to interfere with aircraft controls; and (3) ensure that each LOA lists the specific aircraft on which the holder is authorized to use an SPRS. (A-19-24)
  • Until you implement the supplemental passenger restraint system (SPRS) approval process as recommended in Safety Recommendation A-19-24, prohibit the use of SPRS for passenger-carrying doors-off operations. (A-19-25)
  • Review the activation system designs of Federal Aviation Administration-approved rotorcraft emergency flotation systems for deficiencies that may preclude their proper deployment, such as a lack of a means to identify high pull forces on manual activation handles or inadequate guidance on the intended use of the activation system, and require corrective actions based on the review findings. (A-19-26)
  • Revise Miscellaneous Guidance 10 in Advisory Circular (AC) 27 and AC 29 to include design objectives for emergency flotation systems that consider human factors design objectives, such as activation handle pull-force characteristics; provisions for clear, unambiguous, and positive feedback to pilots to indicate that the float system was successfully deployed; and inspections to ensure that an installation of a manual activation system does not preclude a pilot’s ability to deploy the floats, as designed, after it has been fielded. (A-19-27)
  • Require all commercial air tour operators, regardless of their operating rule, to implement a safety management system. (A-19-28)
  • Revise Title 14 Code of Federal Regulations 1.1, “General Definitions,” to include definitions for the terms “aerial work” and “aerial photography” that specify only business-like, work-related aerial operations, as originally intended. (A-19-29)
  • ​Revise Order 8900.1, Flight Standards Information Management System, to include guidance for inspectors who oversee Title 14 Code of Federal Regulations (CFR) Part 91 operations conducted under any of the 14 CFR 119.1(e) exceptions to identify potential hazards and ensure that operators are appropriately managing the associated risks. (A-19-30)
  • Develop and implement national standards within Title 14 Code of Federal Regulations (CFR) Part 135, or equivalent regulations, for all air tour operations with powered airplanes and rotorcraft to bring them under one set of standards with operations specifications, and eliminate the exception currently contained in 14 CFR 135.1. (A-19-31)
  • After the actions requested in Safety Recommendation A-19-32 are completed, require owners and operators of existing AS350-series helicopters to incorporate the changes. (A-19-33)
  • Develop guidance on how to identify intoxicated or impaired passengers, and distribute it to operators who carry passengers for hire under Title 14 Code of Federal Regulations Part 91 and Part 135. (A-19-34)

To Airbus Helicopters

  • Modify the floor-mounted fuel shutoff lever in AS350-series helicopters to protect it from inadvertent activation due to external influences. (A-19-32)

To the European Union Aviation Safety Agency

  • After the actions requested in Safety Recommendation A-19-32 are completed, require owners and operators of existing AS350-series helicopters to incorporate the changes. (A-19-35)

To Liberty Helicopters Inc.

  • Establish a safety management system. (A-19-36)
  • Train your employees to identify signs of impairment and intoxication in passengers and to deny those passengers boarding, when appropriate. (A-19-37)

To NYONair

  • Establish a safety management system. (A-19-38)
  • Train your employees to identify signs of impairment and intoxication in passengers and to deny those passengers boarding, when appropriate. (A-19-39)