Individually Owned: 150,657
Corporate Owned: 137,281
Santa Maria Public Airport
Aircraft Accident/Incident Report
Santa Maria, California 93455
Friday, April 9, 2010 1:24 PDT
NTSB Narrative Summary Released at Completion of Accident
On April 5, the pilot reported for work at 0730 to begin a daytime work shift. He was off duty on April 6 and 7, and on the 7th he went to bed at midnight. In the morning, he awoke at 0800. According to the pilot, he was aware that on the 8th he was scheduled to work a nighttime shift, but he remained awake all day. He reported for work at 1930 to begin his nighttime shift. During his preflight inspection at the beginning of his shift, he noted that both the tail rotor and a main rotor blade were tied down. He stated that he went to sleep at 2300 after being awake for 15 hours. On April 9, after sleeping about 2 hours, he received a duty call about 0110 and was dispatched for the accident flight. During a walk-around inspection in the dark, he observed a flight nurse proceed to the opposite side of the helicopter. According to the pilot, he assumed that the flight nurse had untied the tail rotor tie-down strap. He only removed the main rotor blade's tie-down strap. The pilot's failure to ensure that the tail rotor blade's tie down was removed was an error of omission, indicative of fatigue impairment. During the engine start operation, the tail rotor's strap broke. This resulted in damage to a tail rotor blade and all of the pitch change links. The pilot was unaware of this event, and he flew to the designated hospital to pick up a patient. With the patient on board during the subsequent engine start operation, a flight nurse observed broken tie-down strap material wrapped around the tail rotor driveshaft. The pilot shut down the engine. With the assistance of the flight nurse, the pilot removed the tie-down material. He then flew the patient on the prescribed emergency medical services flight and landed uneventfully at the next hospital. Thereafter, the pilot reinspected the helicopter and observed that it was damaged. The company's director of maintenance inspected the helicopter and found it unairworthy. The damaged tail rotor blade and pitch change links were unserviceable and were discarded. The blade was observed to be scratched, and it had voids in its composite material structure. The pitch change links were bent and their bearings were seized, compromising the flight control system.
NTSB Probable Cause Narrative
The pilot's inadequate preflight inspection to ensure that all tie-down straps were removed prior to flight. Contributing to the accident was the pilot's improper management of sleep opportunities during the preceding rest period, which likely contributed to the development of fatigue.
Event Information
| Type of Event | Accident |
| Event Date | 4/9/2010 |
| Event Day of the Week | Friday |
| Time of Event | 124 |
| Event Time Zone | Pacific Daylight Time |
| Event City | Santa Maria |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 93455 |
| Event Date Year | 2010 |
| Event Date Month | 4 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 345356N |
| Event Location Longitude | 1202727W |
| Event Location Airport | Santa Maria Public |
| Event Location Nearest Airport ID | SMX |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | -- |
| Airport Elevation | 261 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 51 Pacific Daylight Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | SMX |
| Elevation of weather observation facility | 261 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | PDT |
| 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) | 4 |
| Air Temperature at event time (in degrees celsius) | 8 |
| Dew Point at event time (in degress fahrenheit) | 7 |
| Wind Direction (degrees magnetic) | 260 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 5 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.94 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | METAR KSMX 090651Z AUTO 28007KT 4SM BR CLR 08/07 A |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 3 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 28086 |
| NTSB Notification Source | AWP-6 Communication Center |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Mar 1 2011 6:29PM |
| User who most recently changed record | coos |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N222UT |
| NTSB Number | WPR10LA200 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | Company VFR |
| Flight plan Was Activated? | Yes |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | BELL |
| Aircraft Model | 222U |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 47559 |
| Certified Max Gross Weight | 8250 |
| Aircraft Category | Helicopter |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 5 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | AAIP |
| Date of Last Inspection | Apr 9 2010 12:00AM |
| Airframe hours since last inspection | 10 |
| Airframe Hours | 13298 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | Unknown |
| Aircraft Owner Name | CALIFORNIA SHOCK TRAUMA AIR RESCUE |
| Aircraft Owner Street Address | 4933 BAILEY LOOP |
| Aircraft Owner City | MCCLELLAN |
| Aircraft Owner State | CA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 95652-2516 |
| Operator is an individual? | No |
| Operator Name | CALIFORNIA SHOCK-TRAUMA AIR RESCUE |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | 4933 BAILEY LOOP |
| Operator City | MCCLELLAN |
| Operator State | CA |
| Operator Country | USA |
| Operator Zip code | 95652-2516 |
| Operator Code | STRA |
| 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 | STRA290I |
| 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 | Yes |
| Departure Airport Code | SMX |
| Departure City | Santa Maria |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | 124 |
| Departure Time Zone | PDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | ICL8 |
| Destination City | Santa Maria |
| Destination State | CA |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Apr 28 2011 4:40PM |
| User who most recently changed record | grol |
| 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 | Yes |
| Medical Flight | -- |