Lake Palourde Base Heliport Airport
Aircraft Accident/Incident Report

Morgan City, Louisiana 70680
Sunday, January 4, 2009 14:09 CST

NTSB Narrative Summary Released at Completion of Accident

A Sikorsky S-76C++ departed on an air taxi flight from PHI, Inc.’s heliport en route to an offshore oil platform with two pilots and seven passengers. Data from the helicopter’s flight data recorder indicated that the helicopter established level cruise flight at 850 feet mean sea level and 135 knots indicated air speed. About 7 minutes after departure, the cockpit voice recorder recorded a loud bang, followed by sounds consistent with rushing wind and a power reduction on both engines and a decay of main rotor revolutions per minute. Due to the sudden power loss, the helicopter departed controlled flight and descended rapidly into marshy terrain. Examination of the wreckage revealed that both the left and right sections of the cast acrylic windshield were shattered. Feathers and other bird remains were collected from the canopy and windshield at the initial point of impact and from other locations on the exterior of the helicopter. Laboratory analysis identified the remains as coming from a female red-tailed hawk; the females of that species have an average weight of 2.4 pounds. No defects in the materials, manufacturing, or construction were observed. There was no indication of any preexisting damage that caused the windshield to shatter. Thus, the fractures at the top of the right section of the windshield and damage to the canopy in that area were consistent with a bird impacting the canopy just above the top edge of the windshield. The fractures in the other areas of the windshields were caused by ground impact. The S-76C++ helicopter has an overhead engine control quadrant that houses, among other components, two engine fire extinguisher T-handles and two engine power control levers (ECL). The fire extinguisher T-handles, which are located about 4 inches aft of the captain’s and first officer’s windshields, are normally in the full-forward position during flight, and each is held in place by a spring-loaded pin that rests in a detent; aft pulling force is required to move the T-handles out of their detents. If the T handles are moved aft, a mechanical cam on each T-handle pushes the trigger on the associated ECL out of its wedge-shaped stop, allowing the ECL to move aft, reducing fuel to the engine that the ECL controls. (Flight crews are trained to move an engine’s fire extinguisher T-handle full aft in the event of an in-flight fire so that the ECL can move aft and shut off the fuel flow to the affected engine.) The impact of the bird on the canopy just above the windshield near the engine control quadrant likely jarred the fire extinguisher T-handles out of their detents and moved them aft, pushing both ECL triggers out of their stops and allowing them to move aft and into or near the flight-idle position, reducing fuel to both engines. A similar incident occurred on November 13, 1999, in West Palm Beach, Florida, when a bird struck the windshield of an S-76C+ helicopter, N276TH, operated by Palm Beach County. The bird did not penetrate the laminated glass windshield, but the impact force of the bird cracked the windshield and dislodged the fire extinguisher T-handles out of their detents; however, in that case, the force was not great enough to move the ECLs. Maintenance records indicated that PHI replaced the original laminated glass windshields delivered on the accident helicopter with after-market cast acrylic windshields about 2 years before the accident. The after-market windshields provided a weight savings over the original windshields. PHI again replaced the windshields (due to cracking) with cast acrylic windshields about 1 year before the accident. Aeronautical Accessories Incorporated (AAI) designed and produced the after-market windshields and obtained supplemental type certificate (STC) approval from the Federal Aviation Administration (FAA) in April 1997. AAI did not perform any bird-impact testing on the cast acrylic windshields supplied for the S-76C++, and the FAA’s approval of the STC did not require such testing. PHI also replaced the original windshields on other helicopters with the cast acrylic windshields; one of these helicopters experienced a bird-strike incident about 2 years before the accident. Postincident examination revealed a near-circular hole with radiating cracks near the top center of the right windshield. The bird penetrated the windshield and pushed the right-side T-handle. The trapped remains of the bird prevented the right-side throttle from being reengaged, but the pilot was able to land the helicopter safely. In 1978, when the S-76 was certificated, there were no bird-strike requirements. Currently, 14 Code of Federal Regulations 29.631 (in effect since August 8, 1996) states that, at a minimum, a transport-category helicopter, such as the S-76C++, should be capable of safe landing after impact with a 2.2-pound bird at a specified velocity. This requirement includes windshields. Current FAA requirements for transport-category helicopter windshields also state that “windshields and windows must be made of material that will not break into dangerous fragments.” About 4 months after this accident, Sikorsky issued a safety advisory to all operators of the S-76C++ regarding the reduced safety of acrylic windshields (both cast and stretched) compared to the helicopter’s original windshield. According to the advisory, the S-76C++’s laminated glass windshield demonstrated more tolerance to penetrating damage from in-flight impacts (such as bird strikes) compared to acrylic windshields. Sikorsky expressed concern in the safety advisory that the presence of a hole through the windshield, whether created directly by object penetration or indirectly through crack intersections, may cause additional damage to the helicopter, cause disorientation or injury to the flight crew, increase pilot workload, or create additional crew-coordination challenges. The investigation revealed that, following this accident, PHI is replacing all of the windshields in its S 76 helicopters with windshields that meet European bird-strike standards. Based on main rotor speed decay information provided by Sikorsky, the accident flight crew had, at most, about 6 seconds to react to the decaying rotor speed condition. Had they quickly recognized the cause of the power reduction and reacted very rapidly, they would likely have had enough time to restore power to the engines by moving the ECLs back into position. However, the flight crewmembers were likely disoriented from the bird strike and the rush of air through the fractured windshield; thus, they did not have time to identify the cause of the power reduction and take action to move the ECLs back into position. The accident helicopter was not equipped with an audible alarm or a master warning light to alert the flight crew of a low-rotor-speed condition. An enhanced warning could have helped the accident flight crew quickly identify the decaying rotor speed condition and provided the flight crew with more opportunity to initiate the necessary corrective emergency actions before impact.

NTSB Probable Cause Narrative

(1) the sudden loss of power to both engines that resulted from impact with a bird (red-tailed hawk), which fractured the windshield and interfered with engine fuel controls, and (2) the subsequent disorientation of the flight crewmembers, which left them unable to recover from the loss of power. Contributing to the accident were (1) the lack of Federal Aviation Administration regulations and guidance, at the time the helicopter was certificated, requiring helicopter windshields to be resistant to bird strikes; (2) the lack of protections that would prevent the T handles from inadvertently dislodging out of their detents; and (3) the lack of a master warning light and audible system to alert the flight crew of a low-rotor-speed condition.

Event Information

Type of Event Accident
Event Date 1/4/2009
Event Day of the Week Sunday
Time of Event 1409
Event Time Zone Central Standard Time
Event City Morgan City
Event State LOUISIANA
Event Country --
Zipcode of the event site 70680
Event Date Year 2009
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 393120N
Event Location Longitude 0910403W
Event Location Airport Lake Palourde Base Heliport
Event Location Nearest Airport ID 7LS3
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 14
Degrees magnetic from airport --
Airport Elevation 5
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1430 Central Standard Time
Direction of event from weather observation facility (degrees) 345
Weather Observation Facility ID 7R3
Elevation of weather observation facility 5
Distance of event from weather observation facility (units?) 12
Time Zone of the weather observation CST
Lighting Conditions Day
Lowest Ceiling Height 10000
Lowest Non-Ceiling Height 1500
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 24
Dew Point at event time (in degress fahrenheit) 19
Wind Direction (degrees magnetic) 160
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 6
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.03
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report SPECI K7R3 041858Z 16004KT 10SM BKN014 OVC021 23/1
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 8
Injury Total Minor --
Injury Total None --
Injury Total Serious 1
Injury Total All 9
Investigating Agency NTSB
NTSB Docket Number (internal use) 27381
NTSB Notification Source Regional Operations Center, FT
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Nov 23 2010 2:05PM
User who most recently changed record broda
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N748P
NTSB Number CEN09MA117
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed Company VFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire Unknown
Aircraft Explosion None
Aircraft Manufacturer's Full Name SIKORSKY
Aircraft Model S-76C
Aircraft Series Identifier --
Aircraft Serial Number 760629
Certified Max Gross Weight 11700
Aircraft Category Helicopter
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 2
Cabin Crew Seats --
Passenger Seats 14
Total number of seats on the aircraft 14
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection AAIP
Date of Last Inspection --
Airframe hours since last inspection --
Airframe Hours 3288
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type C126
Aircraft Owner Name PHI INC
Aircraft Owner Street Address 2001 SE EVANGELINE TRWY
Aircraft Owner City LAFAYETTE
Aircraft Owner State LA
Aircraft Owner Country USA
Aircraft Owner Zipcode 70508-2156
Operator is an individual? No
Operator Name PHI INC
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address 2001 SE EVANGELINE TRWY
Operator City LAFAYETTE
Operator State LA
Operator Country USA
Operator Zip code 70508-2156
Operator Code --
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Non-scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code 7LS3
Departure City Amelia
Departure State LA
Departure Country USA
Departure Time 1202
Departure Time Zone CST
Destination Same as Local Flt --
Destination Airport Code 301B
Destination City Tambelier 301B
Destination State GM
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Sep 13 2010 12:22PM
User who most recently changed record gamw
Since inspection or accident Time of Accident
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --