Ocala Nat'l Forrest Fire Ctr Airport
Aircraft Accident/Incident Report

Altoona, Florida 32702
Tuesady, April 9, 2002 11:21 EDT

NTSB Narrative Summary Released at Completion of Accident

The accident pilot noted that the day before the accident date, the normal brakes were inoperative. Maintenance was notified of the brake discrepancy, and he was advised by maintenance personnel that the brakes would be inspected that evening during the planned 25-hour inspection. The next morning (day of the accident), he became aware the brakes had not been repaired and he believed he was informed while in dispatch of a search and rescue mission; the site was located approximately 40 miles from the helibase. He expressed concern to the chief pilot about operation of the helicopter with inoperative brakes, but the chief pilot felt it was alright for the flight to proceed. Since the assigned mission was for search and rescue, the chief pilot suggested and he concurred, "that due to possible lives at stake, I could accept the mission." The flight departed, proceeded to the search area with negative results, then elected to return to the helibase. After arrival at the helibase, he performed a hover power check. After completion of the hover power check, he maneuvered the helicopter over the landing pad. The chief pilot was standing by with chocks to chock the wheels upon landing as was previously arranged due to the inoperative brakes. He made a normal touchdown and as the nose gear lowered, he expected the chief pilot to chock the wheels. As the helicopter settled, it rolled forward towards the hangar, and he attempted to control the forward movement by positioning of the flight controls, aware of the cyclic limitations during ground operations. He could not arrest the forward movement and was concerned about contacting the hangar; the chocks were not in place. The next thing he recalled was feeling the helicopter vibrating, followed by the cyclic making extreme movements in the cockpit. The pilot also stated that the helicopter encountered what he felt were normal vibrations, and was not positive the helicopter encountered complete ground resonance. He attempted to lift to a hover to correct the situation but was not sure if the helicopter even became airborne. The passenger stated that after landing, he noticed out of the corner of his eye the helicopter appeared to be rolling forward. He later recalled the pilot stating that the helicopter was lifting. He noticed a vibration, and noted that the nose lifted to what he thought was a normal angle. The vibration turned into violent shaking which was throwing him around in his seat. The helicopter moved to over grass and started moving down a little faster. He noticed that parts from the helicopter started separating either when the helicopter quit moving towards the ground or the nose landing gear was fully compressed. An object hit his left arm and thigh coming to rest on the floor near his feet. He noted the pilot trying to secure the engine, smelled jet fuel, and evacuated the wreckage. The chief reported that the pilot made a normal approach which ended with a power check at a low hover. The pilot then maneuvered the helicopter over the helipad to land and after touching down, the helicopter began to roll forward slightly. He stated that the pilot attempted to pick up to a hover and when only the main landing gears were on the ground but fully extended, the helicopter began to shake. He reported hearing a loud sound or crash and the pilot and passenger exited the helicopter. He secured the engine with the emergency fuel shutoff lever. He further stated that with respect to the brakes, he and the director of maintenance (DOM) were both aware that the brakes were inoperative the day before, and on the day of the accident before the accident flight, he was made aware the brakes were not repaired. He called the DOM who advised the brakes would be fixed on the accident date, and he (chief pilot) considered the inoperative brakes to be a minor deficiency; the helicopter was not taken out of service. He further reported that due to the search and rescue mission, the urgency and considerations changed, and that he believed the inoperative brake situation needed to be addressed promptly but was not an airworthy issue when compared for example with a fixed wing airplane. Review of the "Aircraft Contract Daily Diary" sheet for the day before the accident revealed, "...Hydraulic brakes not working-mechanic notified." According to a FAA airworthiness inspector, maintenance personnel from the owner of the helicopter performed maintenance on the wheel brakes of the helicopter the day before the accident but did not have a proper fitting to bleed the brakes. Maintenance personnel were scheduled to bleed the brakes on the day of the accident but did not. No maintenance record entry was made in the permanent maintenance records indicating the brakes were inoperative. The helicopter did not have an FAA approved minimum equipment list (MEL).

NTSB Probable Cause Narrative

The intentional operation of the helicopter with known deficiencies in equipment (inoperative normal brakes), and the pilot's improper use of the cyclic flight controls after the helicopter started rolling following touchdown.

Event Information

Type of Event Accident
Event Date 4/9/2002
Event Day of the Week Tuesday
Time of Event 1121
Event Time Zone Eastern Daylight Time
Event City Altoona
Event State FLORIDA
Event Country --
Zipcode of the event site 32702
Event Date Year 2002
Event Date Month 4
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 290603N
Event Location Longitude 0813708W
Event Location Airport Ocala Nat'l Forrest Fire Ctr
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 50
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1055 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 274
Weather Observation Facility ID KOCF
Elevation of weather observation facility 89
Distance of event from weather observation facility (units?) 32
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 26
Dew Point at event time (in degress fahrenheit) 15
Wind Direction (degrees magnetic) 150
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 7
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 16
Altimeter Setting at event time (in. Hg) 30.27
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 1
Injury Total Serious 1
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 15333
NTSB Notification Source FAA Comm Center
NTSB Notification Date Apr 9 2002 12:00AM
NTSB Notification Time 1233
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Apr 28 2004 3:34PM
User who most recently changed record NTSB\MONR
Basic weather conditions Visual Meteorological Cond
FAA District Office Orlando, Florida

Aircraft Involved

Aircraft #1

Aircraft Registration Number N2UH
NTSB Number MIA02TA082
Missing Aircraft Indicator --
Federal Aviation Reg. Part Public Use
Type of Flight Plan filed Company VFR
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Aerospatiale
Aircraft Model SA319B Alouette III
Aircraft Series Identifier --
Aircraft Serial Number 2050
Certified Max Gross Weight 4960
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 100 Hour
Date of Last Inspection Jan 14 2002 12:00AM
Airframe hours since last inspection 57
Airframe Hours 3275
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Brainerd Helicopters, Inc.
Aircraft Owner Street Address 8850 Airport Blvd.
Aircraft Owner City Leesburg
Aircraft Owner State FL
Aircraft Owner Country USA
Aircraft Owner Zipcode 347884002
Operator is an individual? No
Operator Name U.S. Forest Service
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 1720 Peachtree Rd., N.W., Room 876S
Operator City Atlanta
Operator State GA
Operator Country USA
Operator Zip code 30367
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
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) Public Use
Second Pilot on Board No
Departure Point Same as Event Yes
Departure Airport Code --
Departure City Altoona
Departure State FL
Departure Country USA
Departure Time 939
Departure Time Zone EDT
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 Landing
Report sent to ICAO? No
Evacuation occurred Yes
Date of most recent change to record Mar 8 2004 9:37AM
User who most recently changed record KENJ
Since inspection or accident Time of Accident
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --