Medevac Helicopter Crashes With Patient Onboard
109,308
Published 2022-10-13
While en route, the pilot noticed a twist grip caution indication on the left engine (No. 1) cockpit display system (CDS) panel. The pilot also noticed a second indication but could not recall the specific caution. He stated that he then grabbed each engine throttle twist grip individually to gently verify if he could feel they were in or out of neutral detent, but did not notice any significant changes to the throttle position. The pilot decided to divert to a nearby airport, and, as he executed a turn toward the airport, he noticed the No. 2 engine indication no longer matched the No. 1, stating that "it was lower and oscillating."
Within ~1 minute, the pilot "heard the low rotor [rpm] horn," and lowered the collective to maintain rotor speed. The pilot located a "dark spot" on the ground, which he determined would give him the best opportunity to complete a full autorotation. As he started a turn toward his intended landing location, he felt the tail oscillate to the right and back and heard an oscillation in engine speed. When the helicopter was about 200' AGL, he thought he may land short of the intended location and adjusted the collective and cyclic to maintain rotor rpm and airspeed. The helicopter impacted terrain, rotated 180°, and came to rest upright. This video from a rail platform showed a fire near the right (No. 2) engine during the autorotation, and a flame burst after impact with terrain.
Examination of the aircraft revealed no evidence of pre-impact mechanical malfunctions or failures that would have precluded normal operation. Analysis of data retrieved from the CDS and EEC units revealed that, about 4 minutes after takeoff, the No. engine was placed in manual mode and out of EEC control, which indicates that the pilot had likely inadvertently moved the No. 1 engine throttle out of its neutral detent. The No. 2 engine was in manual mode for about 7 minutes before the pilot noted the CDS twist grip caution indication. The data showed that as the pilot continued to manually control the No. engine, the No. 2 engine was also placed in manual mode and out of EEC control, which indicates that the pilot moved the No. 2 throttle out of its neutral detent. The pilot attempted to maintain rotor and engine rpms while controlling both engines manually; it is not likely that he fully understood the nature of the problem.
The pilot misinterpreted an aural alert (low rotor rpm as opposed to high rotor rpm) when high rotor rpm existed, then lowered the collective, which created a rotor overspeed condition. This configuration resulted in a high-workload scenario in which it would be particularly challenging for the pilot to control the helicopter while maneuvering in low altitude and night visual conditions.
The pilot had accumulated about 300 hours in EC135s, with about 11 hours in the accident make and model. The accident helicopter was the only EC135 P1 variant in the operator's fleet. Its engines, displays, and throttle controls differed from the EC135 P2+ in which the pilot was formally trained. The pilot had completed an online self-study differences training presentation, and some informal familiarization training with other company pilots. No formal training was part of the differences training curriculum.
Because the throttle (twist grip) differs between the P1 and P2+ variants, it is likely that the pilot moved it into manual mode without realizing; he likely did not recognize this issue because he did not have as much experience or formal training in the P1 variant. Because the displays also differed between the variants, it could have been more difficult for the pilot to recognize and understand the indications he was receiving. Given the differences among the two variants regarding the displays and throttle controls, additional familiarization training, such as a familiarization flight with a company check pilot, would have provided the pilot with a better understanding of the key differences.
The helicopter manufacturer issued a voluntary service bulletin 10 years before the accident regarding collective throttle controls with grips that had an increased mechanical protection against unintentional adjustment.
The NTSB determined the probable causes of this accident to be the pilot's inadvertent disabling of the No. 1 and No. 2 engines' electronic engine control systems, which resulted in engine and rotor overspeed conditions, a subsequent autorotation, and a a hard landing. Contributing to the accident were the pilot's inexperience with the helicopter variant and the operator's lack of a more robust helicopter differences training program.
All Comments (21)
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These medical helicopter crews are some of the bravest and most amazing people ever. I'm thankful they all survived.
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That's the problem with having P1 backups when you have a P2+ fleet. It has so many subtle differences that it really increases the chances of unintentionally screwing something up. Having worked for an operator in this situation I know our pilots were always uncomfortable with the P1s because they had so few hours on them
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As a retired EMS helicopter pilot, I can relate to the differences training. One company had the BK117 series, one had the Bell 206 series, one had the Bell 412 series, etc....... Standardization is very important. Especially when you need to be somewhere quickly. ( That's the whole premise of why you call for a helo)! Follow that checklist, and practice. Just like being capable with your firearms. Practice, practice, practice 👍👍🇺🇸🇺🇸🇺🇸🇺🇸
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the absolute scenes when the patient who was being saved in the first place actually comes out with the least life threatening overall condition
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Reading the report by the pilot and all of the crew putting their patient 1st when they are all seriously injured themselves is a credit to the brave crew on board. I'm so glad they all survived, because although it was dark, it didn't look very survivable in the video footage. I've not read the cause of the incident fully yet though.
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HUGE shout out to the random motorist who helped them!! 👏 Great job!!
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Dude, what are the odds of the cop being right there on that ramp???? Crazy.
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I fueled N312SA many, many times including the day of the incident hours prior. I remember this incident very well.
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I’m not surprised and am also angered that he wasn’t given any formal training on the differing model. I’m a USCG helo mechanic and SAR hoist operator and upgrading from the mh65d to the mh-65e has been pathetic. NO formal training and just a quick 15 minute walk around by a training team is no substitution for formal training in a different/new model. The pilot in the video was failed by his company not providing adequate training in a different model…yes, subtle differences can be critical in aviation! “You’ll be alright” and “what, your not confident in your skills” can be a fatal perspective by leaders in aviation. 🤯
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11 hrs,night time,not properly trained using engines,and alone only 1 pilot flying. Not a great idea.poor pilot should had called in sick that night
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Taking the optimist's view, this pilot fixed the systemic problem identified by forcibly removing the only remaining P1 variant from his company's fleet. It's unfortunate that people were seriously hurt, and this shouldn't have happened. Thankfully, the pilot was able to make a survivable landing for all onboard.
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How ironic the patient was uninjured. And the entire crew became patients. But hey, those scratches on the helicopter will buff right out.
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That's really odd that the manufacturer would make it so easy to take the engines out of FADEC control just by slight twisting of the throttle. At night, unfamiliar with the system (which is different than the other very similar model the pilot normally flew) just seems like asking for problems. I can see having a manual over-ride in case the FADEC malfunctions...but having it down on the collective throttles like that...at night...when you can't see the line indicating Neutral and the detents were obviously not strong enough to prevent an inadvertent twisting out of Neutral....just smacks of dumb engineering. Yes...if you're going to operate ANY aircraft it's up to YOU to know how it works (looking at you 737 Max!) but obviously this throttle setup and FADEC defeat feature wasn't stressed enough in the pilot's familiarization training. This reminds me of the Airbus control logic which...to an American A&P mind isn't logical at all. Makes me wonder who is designing these things and how their brains operate...which seems to be different than many pilots who are then tasked with operating them.
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Every crash with aircraft I’ve seen usually catches fire upon impact . This helicopter looks like this pilot knew what he was doing ! Bravo sir !
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This report directs everything ! Thanks .
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Sure seems like a lot of opportunities for improvement. Slight twist of a grip and you can blow up an engine? Seems like a design problem - obviously they agree and changed it on later models, but didn't require a change to the earlier models.
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That was a damn good pilot .. bleeding off the air speed as much as he could to reduce impact .. bravo 👏
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As a long time military helicopter pilot, there are a lot of red flags here for me. First is the total number of flight hours this pilot has vs total number of pilot in command hours he has. Has to be a reason for that. Also, the lack of recent flight time in the last 30 and 90 days is a red flag. 1 hour in the last month and 8 in the last 90 days? You cannot stay proficient in the aircraft, much less a “backup” aircraft with that few hours. Proficiency is a product of recency. Also not having any type of flight simulator compounds the problem. It’s scary to imagine that this may be normal. I have many friends that have retired from the military and are flying civilian medical helicopters and it’s never crossed my mind to ask them how often they fly. It is fantastic they all walked away with minimal injuries from this and I have to credit the pilot for pulling it off even though it looks like he caused the accident originally. I do know how easy it is for me to be an armchair quarterback and there are probably many or their factors that we are not privy to.
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Did they get airlifted? 💀
