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Safety Recommendation Details

Safety Recommendation A-10-129
Details
Synopsis: On April 15, 2008, about 0923 Alaska daylight time, a Eurocopter AS350B2 helicopter, N213EH, experienced a loss of engine power during flight and sustained substantial damage during an emergency descent and impact with terrain about 34 miles east of Chickaloon, Alaska.1 The commercial pilot and three passengers were fatally injured, and one passenger was seriously injured. The on-demand air taxi flight was conducted under 14 Code of Federal Regulations (CFR) Part 135 in visual meteorological conditions. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the loss of engine power due to an overspeed of the helicopter’s turbine engine, precipitated by the inadvertent movement of the fuel flow control lever (FFCL) by the [front seat] passenger. Also causal was the manufacturer’s design and placement of the FFCL, which made it susceptible to accidental contact and movement by passengers. Contributing to the accident was the pilot’s failure to properly secure/stow the passenger’s backpack. Likely contributing to the severity of the occupant’s injuries was the helicopter operator’s failure to properly monitor its satellite flight-following system and to immediately institute a search once the system reported the helicopter was overdue.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require Eurocopter to review the design of the fuel flow control lever (FFCL) and/or its detent track on AS350-series helicopters and require modification to ensure that the FFCL is protected to prevent unintentional movement out of its detents and that it does not move easily to an unintended position.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: Chickaloon, AK, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: ANC08FA053
Accident Reports:
Report #: None
Accident Date: 4/15/2008
Issue Date: 10/20/2010
Date Closed: 1/23/2015
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Aircraft Design

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/23/2015
Response: We are aware that, on July 1, 2012, Eurocopter (now Airbus Helicopters) introduced a modification to the FFCL design for new Airbus Helicopter (AH) 350B2 type design helicopters; that the modification includes a locking feature for the IDLE, FLIGHT, and STOP positions of the FFCL; and that a separate locking device limits the FFCL’s access to the emergency range. We are also aware that moving the FFCL from the locked positions requires the operator to push either a start button or a dedicated push paddle. Although you did not require Eurocopter to redesign the FFCL, we believe that the company’s decision to do so and your involvement in the redesign process constitute an acceptable alternate solution to the problem. We are encouraged that, although you evaluated the AS350 fleet and found that mandatory retrofit to in-service helicopters was not supported by current data, you plan to continue to monitor the data for related events. Accordingly, Safety Recommendation A 10 129 is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.
From: FAA
To: NTSB
Date: 11/14/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has coordinated with the European Aviation Safety Agency (EASA) regarding the FFCL design. EASA states that Airbus Helicopter (AH), formerly Eurocopter, reviewed the design of the FFCL installed on AS350B2 and earlier AS350 model helicopters as a result of issues unrelated to this accident. As a result, AH developed a new FFCL design. After reviewing this issue and the new FFCL design, the FAA has determined that this new FFCL design meets the intent of this recommendation. The new FFCL design includes the following features: • The new design provides a locked IDLE position for Model AS350B2 helicopters; • Although EASA did not mandate it, AH modified the FFCL to add the locking feature for the FLIGHT and STOP detents. • The locking mechanism requires the pilot to push the strut button on the FFCL handle or push a locking release paddle when moving the FFCL lever from the STOP position. The pilot must also push the paddle to move the lever out of the IDLE or FLIGHT position; and • AH also added a blocking gate restricting access to the FFCL's EMERGENCY sector position. The pilot must manually flip the blocking gate open in order to move the FFCL to the EMERGENCY sector position. AH will offer the modification (AMS 07 3828) as a retrofit option for Model AS350B2 helicopters that are already in service. However, AH has not provided any information as to whether they intend to offer the modification for older AS350 models in service. Additionally, the FAA's system safety review of the AS350 fleet did not support mandatory action mandating a retrofit of this modification to the Model AS350 helicopters in service. However, in accordance with our safety risk management process, one of the four components of a safety management system, we will continue to monitor the aerospace system for related events and take appropriate action to mitigate any unacceptable risk that presents itself. I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.
From: NTSB
To: FAA
Date: 7/25/2012
Response: The FAA stated no significant progress to report (beyond its previously reported meetings with American Eurocopter on April 5, May 25, and October 21, 2010) in assessing the mechanisms through which the FFCL can be inadvertently moved out of its present position, particularly as the issue applies to this accident. We note (1) your continued coordination with the European Aviation Safety Agency (EASA) regarding the status of EASA’s design review with Eurocopter France (ECF) and the Direction Générale de l’ Aviation Civile and (2) that EASA is keeping the recommendation open, pending its analysis of the technical data it requested from us and the outcome of Eurocopter’s request for reconsideration. The FAA further stated that, as of January 11, 2012, EASA had not received further communications from the NTSB or ECF regarding the accident findings or our possible review of accident causes. However, we advised the former vice president of Fleet Safety, Eurocopter Fleet Safety Department, on January 19, 2012, that the requested reconsideration of the NTSB’s findings and probable cause regarding the FFCL in our investigation of the April 15, 2008, accident had been denied in its entirety. Copies of that letter were forwarded via e-mail to Mr. Bernard Bourbon and Mr. Julian Hall at EASA and to Mr. Ali Bahram, Manager, Aircraft Certification Service, FAA Transport Airplane Directorate, on May 30, 2012. We recognize the challenges that multi-national coordination poses, and we look forward to timely progress to complete the recommended actions. In the meantime, Safety Recommendations A-10-129 and -130 remain classified OPEN—ACCEPTABLE RESPONSE.
From: FAA
To: NTSB
Date: 4/3/2012
Response: -From Michael P. Huerta, Acting Administrator: We have no significant changes to report since our previous response in which we reported that we met with American Eurocopter on AprilS, May 25, and October 21, 2010, to assess the mechanisms through which the FFCL can be inadvertently moved out of a preset position, particularly as it applies to this accident. We continue to communicate with the European Aviation Safety Agency (EASA) regarding the status of their design review with Eurocopter-France (ECF) and the Direction Generale de l' Aviation Civile of France. EASA has communicated to us that they are keeping the recommendation open pending their final analysis of technical data they requested from the Board and the outcome of Eurocopter's request for reconsideration. On January 11,2012, EASA updated us that they had received no further communications from ECF or the Board about the accident findings or a possible Board review of the accident causes. While we are continuing to work with EASA and Eurocopter on this matter, we are unable to proceed with this safety recommendation until discussions between the Board. EASA, and ECF are complete.
From: NTSB
To: FAA
Date: 5/25/2011
Response: The NTSB notes that the FAA, in cooperation with its European counterparts and Eurocopter, continues to review the design of the AS350B2 FFCL. The FAA indicated that it would assess any recommended changes for applicability to other floor-mounted FFCLs, once the actions recommended in A-10-129 are complete. Pending our review of the FAA’s proposed modifications to the AS350B2 FFCL, and its subsequent evaluation and modifications to helicopters equipped with FFCLs and detent tracks of similar design, Safety Recommendations A-10-129 and -130 are classified OPEN – ACCEPTABLE RESPONSE.
From: FAA
To: NTSB
Date: 12/22/2010
Response: CC# 201100039: - From J. Randolph Babbitt, Administrator: The FAA met with American Eurocopter on April 5, May 25, and October 21, 2010 to assess the mechanisms wherein the FFCL can be inadvertently moved out of a preset position, particularly as it applies to this accident. We will continue to work with American Eurocopter on this matter and with the European Aviation Safety Agency (EASA), Eurocopter France, and the Direction Generale de l'Aviation Civile of France regarding the review of the design of the AS-350B2 FFCL. Our actions will be coordinated with EASA.