Kona International Arpt Airport
Aircraft Accident/Incident Report

Kailua Kona, Hawaii 96740
Tuesady, October 29, 2013 17:20 HST

NTSB Narrative Summary Released at Completion of Accident

During the flight, the flight instructor moved the governor switch from the “automatic” to the “manual” position, which disengaged the full authority digital engine control governor, so that the pilot receiving instruction could practice manual throttle control using the twist grip on the collective. This was the first time that the pilot had flown this make and model of helicopter in the manual mode. When the pilot performed left and right 360-degree hovering turns, he found it difficult to rotate the twist grip but was able to manipulate it and maintain main rotor rpm (NR) within normal limits. The instructor then asked the pilot to perform a left, closed traffic pattern back to the departure airport. The pilot and the instructor reported that the takeoff, transition into cruise flight on the downwind leg, and initial descent were uneventful. The pilot reported that the helicopter was on final approach below 400 feet above ground level (agl) when he noticed that the NR was decreasing. He rotated the twist grip to increase power, but the NR continued to decrease. The low NR audio warning then sounded, and the instructor joined the pilot on the controls. The two pilots lowered the collective to enter an autorotation. The pilot said that the NR never recovered to the normal range even though the twist grip was rotated to its maximum (full-open) position. The flight instructor reported that the helicopter was about 200 to 300 feet agl when the NR began to decrease rapidly. The instructor stated that he took the controls and attempted to roll on more throttle but found that the throttle was already fully open. He said that he lowered the collective in an attempt to conserve NR. Both pilots reported that they pulled up on the collective to cushion the landing but that insufficient NR was remaining to slow the descent. The helicopter landed hard, slid forward on the taxiway, and yawed about 90 degrees left. The instructor reported that, when the helicopter came to a stop, the engine was not running, and the pilot reported that he was unaware of the engine’s status. Postaccident examination revealed no binding or other anomalies with the operation of the manual throttle control system or the throttle friction control wheel on the right (pilot’s side) collective. Neither the helicopter’s vehicle engine multifunction display nor its digital engine control unit recorded any faults for the accident flight. The engine was installed in a test cell, started, and tested in both automatic and manual governor modes, and no anomalies or uncommanded shutdowns were experienced, and the engine’s performance met the manufacturer’s specifications. Given the engine’s satisfactory performance during the postaccident test run and the lack of mechanical anomalies with the manual throttle control system, it is likely that the pilot receiving instruction mismanaged the twist grip throttle control during the approach, which led to a decay in NR. The instructor apparently did not notice the decay in NR until the low NR audio warning sounded, at which point, the helicopter was at too low an altitude to correct the situation.

NTSB Probable Cause Narrative

The pilot receiving instruction’s failure to maintain main rotor rpm while practicing manual throttle control and the flight instructor’s delayed remedial action, which resulted in a hard landing.

Event Information

Type of Event Accident
Event Date 10/29/2013
Event Day of the Week Tuesday
Time of Event 1720
Event Time Zone Hawaii Standard Time
Event City Kailua Kona
Event State HAWAII
Event Country --
Zipcode of the event site 96740
Event Date Year 2013
Event Date Month 10
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 194342N
Event Location Longitude 1560238W
Event Location Airport Kona International Arpt
Event Location Nearest Airport ID KOA
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 1
Degrees magnetic from airport --
Airport Elevation 47
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1653 Hawaii Standard Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID KOA
Elevation of weather observation facility 47
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation HST
Lighting Conditions Day
Lowest Ceiling Height 9000
Lowest Non-Ceiling Height 2400
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) 28
Dew Point at event time (in degress fahrenheit) 21
Wind Direction (degrees magnetic) 240
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 11
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.96
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 1
Injury Total None 1
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 32923
NTSB Notification Source KOA, Arpt Ops
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jul 25 2014 3:26PM
User who most recently changed record eckd
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N985EW
NTSB Number WPR14LA038
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Company VFR
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name EUROCOPTER FRANCE
Aircraft Model AS 350
Aircraft Series Identifier B3
Aircraft Serial Number 3332
Certified Max Gross Weight 4960
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 --
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Oct 29 2013 12:00AM
Airframe hours since last inspection --
Airframe Hours 2634
ELT Installed Unknown
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name EAGLE AIR MED CORP
Aircraft Owner Street Address 10888 S 300 W
Aircraft Owner City SOUTH JORDAN
Aircraft Owner State UT
Aircraft Owner Country USA
Aircraft Owner Zipcode 840954043
Operator is an individual? No
Operator Name Air Medical Resource Group
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address 10888 S 300 W
Operator City SOUTH JORDAN
Operator State UT
Operator Country USA
Operator Zip code 840954043
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) Instructional
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code KOA
Departure City Kailua Kona
Departure State HI
Departure Country USA
Departure Time 1659
Departure Time Zone HST
Destination Same as Local Flt crash at destination city
Destination Airport Code KOA
Destination City Kailua Kona
Destination State HI
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jul 28 2014 5:34PM
User who most recently changed record coos
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 --