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|
Attributes | |
ACN | 748135 |
Time | |
Date | 200708 |
Local Time Of Day | 1801 To 2400 |
Place | |
State Reference | NC |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air taxi |
Make Model Name | Jet Ranger Undifferentiated or Other Model |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : parked |
Flight Plan | VFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain instruction : instructor oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 80 flight time total : 8566 flight time type : 475 |
ASRS Report | 748135 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer instruction : trainee |
Events | |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was training a pilot (captain) for a 2 pilot EMS helicopter operation on the bell 430. We had just completed a simulated single engine landing and had moved off the runway to the grass just off a taxiway. The captain trainee was on the controls and he did not call for the after landing checklist; nor did I as the training captain remind him to do so. While repositioning to the grass I glanced at the automated flight control system mode select panel to see if the automated flight control system was in stability augmentation or autoplt. I saw the green stability augmentation light on. While I functioned as the sic the captain directed me to set up the radios for our departure and next arrival. While doing so; he (still in command of the flight controls) was verifying what I had done. He must have let go of the controls. Next thing I knew I heard loud pounding and grabbed for the flight controls. I found the cyclic control to be nearly full forward. I suspected the rotor system had come in contact with the upper wire cutter assembly. Upon shutdown and inspection I confirmed this. As is always the case; several things led to this incident: 1) when I looked at the automated flight control system mode panel and saw the green stability augmentation light on; I assumed the pilot had turned the autoplt off and engaged stability augmentation. He had not. He was holding the cyclic force trim button down. This causes the automated flight control system to revert to stability augmentation from autoplt only while the button is being held down. 2) the autoplt; still being engaged drove the cyclic forward in an attempt to follow the last assigned duty; a descent. 3) I didn't follow up on the 'captain' to ensure he called for the after landing checklist. 4) even though we had briefed a 3-WAY flight control exchange; the captain let go of the controls without telling me. In the dark cockpit; I didn't notice this. 5) the hospital based EMS program aircraft was OTS; so I was under (self-imposed) pressure to train several replacements to get the program back in service quickly. 6) under this self-imposed pressure; I had been working 6 days with each day being more than 11 hours; and in some cases; 14 hour duty days while conducting ground and flight training. Between the 2 days prior to the incident and the day of the incident; I had flown 18.3 hours. 7) temperatures had been mid 80's to mid 90's with high humidity. 8) the night before the incident; I had developed a sore throat and sour stomach resulting in a fitful night's sleep. There are enough links in this chain to build 2 mishaps much less the one that happened.
Original NASA ASRS Text
Title: BELL 430 INSTRUCTOR RPTS ROTOR DAMAGE AFTER SIMULATED ENG OUT LNDG WHEN CYCLIC IS RELEASED WITH AUTOPLT ENGAGED.
Narrative: I WAS TRAINING A PLT (CAPT) FOR A 2 PLT EMS HELI OP ON THE BELL 430. WE HAD JUST COMPLETED A SIMULATED SINGLE ENG LNDG AND HAD MOVED OFF THE RWY TO THE GRASS JUST OFF A TXWY. THE CAPT TRAINEE WAS ON THE CTLS AND HE DID NOT CALL FOR THE AFTER LNDG CHKLIST; NOR DID I AS THE TRAINING CAPT REMIND HIM TO DO SO. WHILE REPOSITIONING TO THE GRASS I GLANCED AT THE AUTOMATED FLT CTL SYS MODE SELECT PANEL TO SEE IF THE AUTOMATED FLT CTL SYS WAS IN STABILITY AUGMENTATION OR AUTOPLT. I SAW THE GREEN STABILITY AUGMENTATION LIGHT ON. WHILE I FUNCTIONED AS THE SIC THE CAPT DIRECTED ME TO SET UP THE RADIOS FOR OUR DEP AND NEXT ARR. WHILE DOING SO; HE (STILL IN COMMAND OF THE FLT CTLS) WAS VERIFYING WHAT I HAD DONE. HE MUST HAVE LET GO OF THE CTLS. NEXT THING I KNEW I HEARD LOUD POUNDING AND GRABBED FOR THE FLT CTLS. I FOUND THE CYCLIC CTL TO BE NEARLY FULL FORWARD. I SUSPECTED THE ROTOR SYS HAD COME IN CONTACT WITH THE UPPER WIRE CUTTER ASSEMBLY. UPON SHUTDOWN AND INSPECTION I CONFIRMED THIS. AS IS ALWAYS THE CASE; SEVERAL THINGS LED TO THIS INCIDENT: 1) WHEN I LOOKED AT THE AUTOMATED FLT CTL SYS MODE PANEL AND SAW THE GREEN STABILITY AUGMENTATION LIGHT ON; I ASSUMED THE PLT HAD TURNED THE AUTOPLT OFF AND ENGAGED STABILITY AUGMENTATION. HE HAD NOT. HE WAS HOLDING THE CYCLIC FORCE TRIM BUTTON DOWN. THIS CAUSES THE AUTOMATED FLT CTL SYS TO REVERT TO STABILITY AUGMENTATION FROM AUTOPLT ONLY WHILE THE BUTTON IS BEING HELD DOWN. 2) THE AUTOPLT; STILL BEING ENGAGED DROVE THE CYCLIC FORWARD IN AN ATTEMPT TO FOLLOW THE LAST ASSIGNED DUTY; A DSCNT. 3) I DIDN'T FOLLOW UP ON THE 'CAPT' TO ENSURE HE CALLED FOR THE AFTER LNDG CHKLIST. 4) EVEN THOUGH WE HAD BRIEFED A 3-WAY FLT CTL EXCHANGE; THE CAPT LET GO OF THE CTLS WITHOUT TELLING ME. IN THE DARK COCKPIT; I DIDN'T NOTICE THIS. 5) THE HOSPITAL BASED EMS PROGRAM ACFT WAS OTS; SO I WAS UNDER (SELF-IMPOSED) PRESSURE TO TRAIN SEVERAL REPLACEMENTS TO GET THE PROGRAM BACK IN SVC QUICKLY. 6) UNDER THIS SELF-IMPOSED PRESSURE; I HAD BEEN WORKING 6 DAYS WITH EACH DAY BEING MORE THAN 11 HRS; AND IN SOME CASES; 14 HR DUTY DAYS WHILE CONDUCTING GND AND FLT TRAINING. BTWN THE 2 DAYS PRIOR TO THE INCIDENT AND THE DAY OF THE INCIDENT; I HAD FLOWN 18.3 HRS. 7) TEMPS HAD BEEN MID 80'S TO MID 90'S WITH HIGH HUMIDITY. 8) THE NIGHT BEFORE THE INCIDENT; I HAD DEVELOPED A SORE THROAT AND SOUR STOMACH RESULTING IN A FITFUL NIGHT'S SLEEP. THERE ARE ENOUGH LINKS IN THIS CHAIN TO BUILD 2 MISHAPS MUCH LESS THE ONE THAT HAPPENED.
Data retrieved from NASA's ASRS site as of January 2009 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.