Aircraft Accident/Incident Report

Apache Junction, Arizona 85220
Tuesady, December 14, 2004 22:37 MST

NTSB Narrative Summary Released at Completion of Accident

The emergency medical services helicopter crashed while attempting to land in a mall parking lot to pickup an accident victim. Witnesses reported that the helicopter overflew the landing zone in right turns, then approached from the northeast. During the final approach at 100 feet agl, the helicopter was observed to become unstable. It rolled right about 30 degrees, then left about the same, then right about 45 degrees, pitched nose up to the left, and then descended while spinning to the left. The helicopter impacted the parking lot in a nose down attitude on the left side. In an interview several days after the accident, the pilot said she was at about 100 feet agl, and had slowed to 20 - 25 knots when she felt the helicopter nose come up and to the right gently, but not as a yaw or a roll. She said she corrected left with the cyclic, and the helicopter responded with a significant and violent roll to the left. She remembered the helicopter starting to spin (at least once), and saw the buildings of the strip mall. She then put the cyclic to the full left to avoid the building. She said she saw the hydraulic caution light on, but did not hear the aural warning. She then grabbed the cyclic with both hands and pulled back and right, but it didn't move. The anti-torque pedals appeared to work and stopped the spin. The helicopter then impacted the ground. The engine continued to run after the ground impact, and a surviving passenger and multiple rescue personnel moved numerous switches in the cockpit in an attempt to shutdown the engine, hence all postimpact switch positions are unreliable. A guarded hydraulic system on/off toggle switch is mounted on the end of the collective control that allows the pilot to manually turn off the hydraulic system. The collective control and the switch guard were damaged in the impact sequence; the hydraulic switch was found in the OFF position. The systems control panel on the center pedestal has 36 back-lighted, mechanically latched push-on/push-off switches. The hydraulic test switch, which deactivates the hydraulic system for a preflight check of the accumulator pressures, is located diagonally next to the landing light switch. The pedestal switch positions were documented the morning after the accident, and the hydraulic test switch was in the OFF position (OFF is normal, ON turns the system off). In the 3 months prior to the accident, four discrepancies were written against the helicopter for various control system problems, including stiff flight controls, excessive control inputs required for normal flight, and nuisance hydraulic warning light and horn activations. The most recent write-up was 1 month prior to the accident. The company maintenance department's corrective actions included cleaning the control system bearings, replacing the left hand and collective hydraulic system actuators, and repairing damaged electrical wiring and cannon plugs. No evidence of preimpact failure or malfunction was found in examinations of the control system and functional testing of the hydraulic system components. The hydraulic system accumulators were found to still have an unquantified amount of pressure after the accident. After this accident, the operator installed guards over the hydraulic test switch to prevent inadvertent activation.

NTSB Probable Cause Narrative

A loss of control during the final approach to land for undetermined reasons.

Event Information

Type of Event Accident
Event Date 12/14/2004
Event Day of the Week Tuesday
Time of Event 2237
Event Time Zone Mountain Standard Time
Event City Apache Junction
Event State ARIZONA
Event Country --
Zipcode of the event site 85220
Event Date Year 2004
Event Date Month 12
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 332430N
Event Location Longitude 1112709W
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 Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 2256 Mountain Standard Time
Direction of event from weather observation facility (degrees) 265
Weather Observation Facility ID KPHX
Elevation of weather observation facility 2133
Distance of event from weather observation facility (units?) 23
Time Zone of the weather observation MST
Lighting Conditions Night/Dark
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) 14
Dew Point at event time (in degress fahrenheit) 8
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator Light and Variable
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.21
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious 2
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 21264
NTSB Notification Source FAA
NTSB Notification Date Dec 14 2004 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Apr 25 2007 2:54PM
User who most recently changed record NTSB\lema
Basic weather conditions Visual Meteorological Cond
FAA District Office FSDO Scottsdale, AZ

Aircraft Involved

Aircraft #1

Aircraft Registration Number N971AE
NTSB Number LAX05FA053
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
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 Eurocopter
Aircraft Model AS-350-B3
Aircraft Series Identifier --
Aircraft Serial Number 3230
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 4
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection AAIP
Date of Last Inspection Nov 1 2004 12:00AM
Airframe hours since last inspection 77
Airframe Hours 1826
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Petroleum Helicopters, Inc.
Aircraft Owner Street Address --
Aircraft Owner City --
Aircraft Owner State --
Aircraft Owner Country --
Aircraft Owner Zipcode --
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 2001 SE Evangeline Trwy
Operator City Lafayette
Operator State LA
Operator Country USA
Operator Zip code 70508
Operator Code HEEA
Owner has at least one certificate --
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) Positioning
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code IWA
Departure City Phoenix
Departure State AZ
Departure Country USA
Departure Time 2229
Departure Time Zone MST
Destination Same as Local Flt crash at destination city
Destination Airport Code NONE
Destination City Apache Junction
Destination State AZ
Destination Country USA
Specific Phase of Flight Landing
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Mar 6 2007 3:47PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight Medical Emergency