Individually Owned: 150,657
Corporate Owned: 137,281
March Air Reserve Base Airport
Aircraft Accident/Incident Report
Riverside, California 92518
Wednesday, February 23, 2011 16:15 PST
NTSB Narrative Summary Released at Completion of Accident
The flight instructor had briefed the flying pilot that he wanted him to perform a maximum performance takeoff simulating a 20- to 25-foot obstacle and that he was going to simulate a hydraulic failure during the maneuver by activating the hydraulic test switch. Prior to performing the maneuver, the pilot confirmed with the instructor that once the hydraulic failure warning activated he would accelerate to 40 knots before activating the hydraulic isolation switch. The instructor would need to reset the hydraulic test switch prior to the pilot activating the hydraulic isolation switch. After the briefing, the pilot initiated the maximum performance takeoff, and as the helicopter attained 20-25 feet, the instructor activated the hydraulic test switch. The pilot stated that as soon as the test switch was activated, he could no longer input right pedal because the control forces were too great. The helicopter began to yaw to the left, and the pilot then activated the hydraulic isolation switch because he thought the helicopter would be more controllable. The pilot did not consider that the hydraulic fluid had been evacuated from both the tail rotor accumulator and the yaw load compensator actuator due to the activation of the hydraulic test switch by the instructor, and the test switch had not yet been reset. As a result, the hydraulic boost from the normally closed yaw load compensator system was unavailable. The helicopter continued to yaw to the left and developed into a spin about its vertical axis. The instructor told the pilot to “fly the helicopter” and was hoping the pilot would recover from the loss of control condition. The pilot attempted to recover by following the direction of the nose of the helicopter to try to gain airspeed. The instructor attempted to intercede by inputting right cyclic, but since the pilot was applying left cyclic, the cyclic inputs were ineffective. The helicopter spun around several times before impacting the taxiway. According to the training procedure for a loss of hydraulic pressure, the instructor should have reset the hydraulic test switch prior to the pilot activating the hydraulic isolation switch. This flight manual specific sequence of switch selections and corresponding actions when simulating a hydraulic system failure were not followed by the pilots. Postaccident examination of the helicopter systems, including the hydraulic system, revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
NTSB Probable Cause Narrative
The failure of both pilots to follow proper procedures during a simulated hydraulic emergency that resulted in a loss of helicopter control. Contributing to the accident was the flight instructor’s delayed remedial action.
Event Information
| Type of Event | Accident |
| Event Date | 2/23/2011 |
| Event Day of the Week | Wednesday |
| Time of Event | 1615 |
| Event Time Zone | Pacific Standard Time |
| Event City | Riverside |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 92518 |
| Event Date Year | 2011 |
| Event Date Month | 2 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 335304N |
| Event Location Longitude | 1171510W |
| Event Location Airport | March Air Reserve Base |
| Event Location Nearest Airport ID | RIV |
| 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 | 1536 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1627 Pacific Standard Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | RIV |
| Elevation of weather observation facility | 1536 |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | PST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 5 |
| Air Temperature at event time (in degrees celsius) | 5 |
| Dew Point at event time (in degress fahrenheit) | 4 |
| Wind Direction (degrees magnetic) | -- |
| Variable Wind Indicator | -- |
| Wind Speed (knots) | -- |
| Wind Velocity Indicator | Calm |
| Wind Gust Indicator | -- |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 30.02 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | 4:27 AM 41.0 °F 39.2 °F 93% 30.02 in 5.0 miles |
| Event Highest Injury | Minor |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | 2 |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 30794 |
| NTSB Notification Source | FAA AWP Regional Operations Ce |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Jan 25 2013 10:37AM |
| User who most recently changed record | johb |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N965SD |
| NTSB Number | WPR11GA144 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Public Use |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | No |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | EUROCOPTER |
| Aircraft Model | AS 350 B2 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 3626 |
| Certified Max Gross Weight | 4961 |
| 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 | 6 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | 100 Hour |
| Date of Last Inspection | Feb 2 2011 12:00AM |
| Airframe hours since last inspection | -- |
| Airframe Hours | 6348 |
| ELT Installed | Yes |
| ELT Activated | Yes |
| ELT Aided Location of Event Site | No |
| ELT Type | Unknown |
| Aircraft Owner Name | COUNTY OF LOS ANGELES |
| Aircraft Owner Street Address | 3235 N LAKEWOOD BLVD |
| Aircraft Owner City | LONG BEACH |
| Aircraft Owner State | CA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 90808-1733 |
| Operator is an individual? | No |
| Operator Name | COUNTY OF LOS ANGELES |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | 3235 N LAKEWOOD BLVD |
| Operator City | LONG BEACH |
| Operator State | CA |
| Operator Country | USA |
| Operator Zip code | 90808-1733 |
| Operator Code | -- |
| Owner has at least one certificate | None |
| 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 | -- |
| 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 | RIV |
| Departure City | Riverside |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | -- |
| Departure Time Zone | PST |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | RIV |
| Destination City | Riverside |
| Destination State | CA |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Nov 29 2012 4:05PM |
| User who most recently changed record | coos |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | 30 |
| Runway Length | 3059 |
| Runway Width | 10 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |