Aircraft Accident/Incident Report

Ketchikan, Alaska 99901
Saturday, September 23, 2000 13:45 AKD

NTSB Narrative Summary Released at Completion of Accident

Two commercial helicopter pilots, both certificated helicopter instructors, were in a turbine-powered helicopter practicing autorotations with a power recovery prior to touchdown. The flying pilot inadvertently activated the flight stop augmented fuel flow switch during a power recovery, and oversped the engine and main rotor. The other pilot joined him on the controls, and increased collective to reduce rotor rpm. The helicopter climbed abruptly to about 60 feet above the ground, where the tail rotor drive shaft separated. The engine subsequently lost power, and an autorotation was accomplished. Investigation disclosed that the engine and main rotor system had been exposed to significant overspeed conditions, resulting in a catastrophic failure of the turbine engine, and the tail rotor drive shaft coupling. The flight stop switch on the collective has no protective guard, and can be readily engaged, allowing the engine to enter the augmented fuel flow regime and, under certain conditions, causing the engine to overspeed. The switch has a history of inadvertent activation, and resultant engine overspeed events.

NTSB Probable Cause Narrative

The pilot's inadvertent activation of the collective flight stop/emergency fuel augmentation switch, which resulted in engine and main rotor overspeeds, thereby precipitating failures of the tail rotor drive shaft coupling and power turbine blades. A factor associated with the accident was the manufacturer's inadequate design of the flight stop switch, which has insufficient safeguards to preclude inadvertent activation.

Event Information

Type of Event Accident
Event Date 9/23/2000
Event Day of the Week Saturday
Time of Event 1345
Event Time Zone --
Event City KETCHIKAN
Event State ALASKA
Event Country --
Zipcode of the event site 99901
Event Date Year 2000
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Pilot
Time of the weather observation 0
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID
Elevation of weather observation facility 0
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation
Lighting Conditions Day
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 60
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) 280
Variable Wind Indicator Unknown
Wind Speed (knots) 10
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) --
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None 2
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 11348
NTSB Notification Source --
NTSB Notification Date Sep 25 2000 12:00AM
NTSB Notification Time 1000
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Feb 7 2002 7:47AM
User who most recently changed record NTSB\MONR
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N405AE
NTSB Number ANC00LA132
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Company VFR
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Eurocopter
Aircraft Model AS-350B-3
Aircraft Series Identifier AS-350B-3
Aircraft Serial Number 3286
Certified Max Gross Weight 4961
Aircraft Category Helicopter
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection AAIP
Date of Last Inspection Sep 20 2000 12:00AM
Airframe hours since last inspection 17
Airframe Hours 92
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name TEMSCO HELICOPTERS, INC.
Aircraft Owner Street Address PO BOX 5057
Aircraft Owner City KETCHIKAN
Aircraft Owner State AK
Aircraft Owner Country
Aircraft Owner Zipcode 99901
Operator is an individual? --
Operator Name
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code HXSA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation External Load
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code 6Z4
Departure City
Departure State AK
Departure Country
Departure Time 1335
Departure Time Zone ADT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code
Destination City
Destination State
Destination Country
Specific Phase of Flight Maneuvering
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Sep 28 2001 4:00AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --