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Safety Recommendation Details

Safety Recommendation A-10-130
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: Evaluate other helicopters with fuel flow control levers (FFCL) and detent tracks similar in design to those on Eurocopter AS350-series helicopters and require modification, as necessary, 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 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 Action)
Keyword(s): Aircraft Design

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/23/2015
Response: We note that your evaluation did not find any other helicopters with FFCLs or detent tracks similar in design to those of AH Model AS350 helicopters. Your actions satisfy Safety Recommendation A-10-130, which is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 11/14/2014
Response: -From Michael P. Huerta, Administrator: The FAA extensively evaluated other helicopters and is currently unaware of any other helicopter makes. series, or models wi th FFCL and detent tracks similar in design to AH Model AS350 helicopters. The AH Model AS350 helicopters have a unique FFCL and detent track, and as a result, we will not be requiring similar modifications on other helicopters at this time. 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: Depending on the outcome of discussions between the Board, EASA, and ECF on safety recommendation A-IO-129, we will assess any recommended changes for applicability to any other floor-mounted FFCLs. I will keep the Board informed of the FAA's progress on these safety recommendations, and will provide an update by December 29, 2012.

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: Depending on the outcome of our work on A-10-129 with EASA, we will assess any recommended changes for applicability to any other floor-mounted FFCLs. We will keep the Board informed of the FAA's progress on these safety recommendations.