What the heck happened here?

iChris · January 24, 2013

Im still hoping to hear what those with direct experience with this incident have to say about it

We took care of that in post# 23. The rest was an excellent academic discussion into the human factors and science, which sparked everyone’s brainpower, intellect, and discernment. We covered it from right-to-left and top-to-bottom. You can’t get that anywhere else, splendid job.

What caused this to happen was an accident chain. The pilot did not use the head working skills that he possessed and put the helicopter in a position of non-performance capability. The DA was high, the GW was too high (an extra pax, too much fuel) and wind conditions that hindered performance. The helicopter did not have the power to perform (fly) under these conditions!

Why did this happen? Those of you that were at my FAASTeam "Wings" presentation prior to Heli Success this past November heard me review an accident with tragic results. I challenged the audience to have a Personal Fatigue Risk Management System and to apply it at all times.

This event in this video took place because of an accident chain consisting of the following links: poor rest the night before, fatigue and stress from many flights previous to this one, lack of food and a non recognized desire to perform the flight. Flight planning and performance considerations were hindered or did not exist at many levels.

I remember working a fire some years ago with a Bell 212 out of a small airport. It was a good season with lots of 12-14 hour duty days (extended over time) and the opportunity most days to get the max 8-hours of flight time pay.

I had been flying the last three days with a water bucket on a 100’ long line. On that third day, after the second re-fuel, I took off and drug that bucket down the runway. I had forgotten, for that moment, that I had a bucket attached to a longline. I caught it in time and there wasn’t much damage to the bucket except for road rash, it was still usable.

I got the cue, after landing, I told the heli-base manager; I’m done for the day. Then called the shop and told them; I’m done for the day. I had the fuel truck driver take me back to the hotel and I took the rest of the day off. I was pushing to hard, two many 12x2s.

You can’t maintain the high levels of concentration and Situational Awareness needed to safely operate helicopters under the stresses of fatigue.

Edited January 25, 2013 by iChris

RkyMtnHI · January 25, 2013

Some say that i pour too much of my heart out on this forum, i risk that because i sincerely want to help everyone out there, and our industry, and hopefully make us all safer. I am not posting this to start sh*t, or to make anyone mad, and if laying it all out there is more than most would do then i accept that. Know that his happened well over a year ago and i forget stuff.. it has been tough bringing it all back up (but important i think) and i had even remembered some things differently than they were (minor stuff). It has taken me a week to put this together and i’ve changed it many times to be more politically correct or more accurate. If i missed something please be nice, especially to the PIC.

I am very happy to see how this topic has progressed, and appreciate the high timers speaking up to try and educate the rest of us further, as i said earlier, i wish i would have started this months ago to educate folks. There were many bad things that came from this and it was a shitty few months, to see it come up constantly is just a reminder (i guess that can be a good thing). Here we are finding good in it and hopefully helping others avoid similar situations. Pat, if you are reading this, and i know you are, you should use the video in your presentations.. i would not mind.

The pilot was NOT trained in an SBT environment. This was tragic for Mike’s amazing push to make better pilots everywhere as people with their own agenda’s used that to slam both of us on JH & VR and most likely hurt his mission on some levels, which wasn’t fair or even correct (one guy was even hired to do so by our competition, a true and documented story). Since Mike’s involvement at CHO we have never had better CFIIs and are producing exceptional pilots (five check rides this week alone). The PIC was trained at sea level, i think he had between 100 and 200 hours up here, but i am just not sure, (that is, i cannot remember). The PIC was a great pilot, and before this never made any bad decisions that i knew of. He wasn’t cocky, reckless or unsafe in any way that i saw, and i pay attention, he was always respectful in every way. He is an adult, has children, was always professional and everyone loved him (that is to say that he didn’t have an ego, wasn’t one to take unnecessary chances and always set a good example; one of the LAST persons i would have expected this to happen to)! He now has a non aviation job that makes his wife and family very happy (law enforcement, benefits and a steady paycheck!). We miss his energy a lot around Heli-Ops (he also kept the office extremely clean and organized)!

Many pilots have had issues in this same place, on this hill or one in that area. A Schweizer 300 and an Enstrom both had very hard landings on a pad up there (the CFI in the Enstrom flew it back, the 300 was completely totaled), and an MD500 lost control and almost crashed (he pulled out of it just before they hit the side of the mountain, LTE i think), there was also a similar hard landing in another R44 further South... and those are the ones that i know about, i was told by an old timer that there have been many more in the past. I am not saying that as an excuse or to blame, just to point out that it’s easy, even for higher time pilots, to get into trouble in an area like this. For us, it’s really not IN the mountains, but, in fact, it might as well be since it gets up to 9K all up and down that ‘foothills’ range (saying that thinking it’s only the ‘foothills’ and not the mountains might be contributing factors to incidents).

I think the PIC had about 1700 hours at the time, he was very humble and it didn’t seem to matter to him, (the time), a few months before this he turned down a turbine job who’s mins were 1500. They had flown up to the spot a couple of weeks prior and flown the route (i think with only two pilots and no photog on board but i’m not sure about that), the temp was more than ten degrees warmer the day of the crash than the day of the first flight.

One very important point that i want to make here is that THERE WERE TWO RATED HELICOPTER PILOTS IN THE AIRCRAFT. One with ~1700 hours and one with ~150. The lower time pilot has said, ‘I thought the CFII would take care of me’. OUCH, when i think of that i want to scream at all of the pilots that go thru our training, and i have to admit i bring it up a lot. Never lose the PIC mentality when you are in an aircraft, no matter where you are sitting and WHO is sitting next to you. Maybe if their communication had been better, if the lower time pilot had asked more questions.. Every time one of our CFIIs are going out flying with a higher time pilot, or an owner of an aircraft, or the owner of a company, or another CFII, i remind them that they are the PIC, that they have to be present every second and discuss who is in charge (before they get in the aircraft, sometimes i will do it for them). We did have a meeting the month before the flight and planned it out in the classroom with other CFIIs present. The lower time pilot is still flying and no action was taken against him.

It was the second flight of the day, the first one was flown by another CFII. The PIC routinely drove 2.5 hours to work, getting up very early to do so. On this day he had worked five or six days in a row. He was fatigued and most likely dehydrated (something we pay very close attention to now). He was in great physical condition. On that note, I have a lot of friends that travel long distances before flying (a probable contributing factor to Drew’s crash IMHO) and i bring that up to them constantly. If this is you, even tho you are young and in great shape, it does effect you on some levels, and it only takes one second in this biz.. one second, and it can be fatal to you and others (not only in the bird, but below you as in this video and the recent London crash). Remember the Sacred Trust.

Many things stick with me about this;

The PIC lost his dream (after all the work and dedication, and money, it went away in one second), the lady that called from Texas, the phone call that i got from the pilot right after the crash (now i cringe when i get a call on the weekend or shortly after someone has taken off, that will most likely never go away), the sheriff’s deputy that was a total tool on the mountain, the last thing i said to the PIC on the phone before he took off... and many more things.

We attend a local 135 operators safety meeting every year, mostly EMS, Military and Law Enforcement, we’re the only flight school that shows up, the meeting that year was two days after the crash, we all went, even the PIC, there were ~25 people in the room, it was tough to sit there, everyone in the room knew it was us, yet he took it like a man.

He lost his dream: his eight year old came home from school and said; ‘dad, did you crash a helicopter?’ He hadn’t told his kids of the incident, yet, it made it to their school almost another state away. When he admitted to his son that it was true, the boy said; ‘dad, i don’t want you to die’. I think that was the moment he decided to stop flying... You can imaging all the stuff that comes with that, whether true or not; letting your family down, letting your students down, letting the operator down, but so tough here was his son’s comment. The PIC made one or two flights after that day, they suspended his commercial until the 709, i got the impression it was mostly because he was low and there were people everywhere (a note here; he may have gotten sited even if there wasn’t a crash, not completely sure about that, but i can guarantee you that i would have at least gotten a visit from our POI after he saw the video !!).

The PIC was offered two different turbine jobs the week after the crash, one who knew him even flew all the way from Nevada and walked in our front door, he told the PIC, in front of everyone there, that he’d hire him on the spot. The other i had never met or spoken to before but some of you know him for sure, he called me personally and asked if i minded if he offered him a job.

One of our new rules; never fly in the vicinity of more than 100 video cameras :-).. and they are fn everywhere, i think i have posted in one of my rants here to be careful what you do because now days there is a video camera in everybody's pocket, and if you do something that reflects negatively on you it could be on youtube before you get back to the ramp. And the point here is that we all represent each other... here we were, trying to be the best, trying to change the way some things were done (in Colorado anyway), and WE ended up being that company that made us all look bad.

This flight was a favor, for the photog, a friend of the lower time pilot, and the photog has used the video he took, and all that he could scrape up from the ground, to further his career.. over and over, never thinking or caring what it would do to the pilots or us (just saying). Our competition has used this quite a bit to try and trash us as well. Some of it deserving yes, but this kind of stuff hurts us all, we have survived and become ever stronger and smarter, but i am saying this so that you think about the far reaching consequences of ‘a momentary lapse of mental stamina’. Ok, before you start, i’m not saying that this was only because of one second and one mistake, it started a month before in my opinion. Not enough attention to many details, but in the aircraft things happened very quickly... in fact, when i watch the videos it’s shocking how fast it happened.

A couple of days after the crash a lady called from somewhere in South Texas, she was the mother of one of the kids on the road, she was a former EMS pilot and was in tears, she called to thank the pilot for saving her son’s life (not crashing onto them). This was when it really hit me how close it was to hurting other people. You get it when you are on the scene, when you watch the videos over and over, but when a mother calls you crying it hits you like a brick. Just think if someone had been killed or hurt..

They shut the race down (the Sheriff's dept), but that didn’t stop the boarders, they went to another location and finished the last race. but, the point is, they shut down the whole event (luckily it was almost over, but something you should consider). The helicopter landed on protected ‘open space’, and if the fire department wouldn’t have been there quickly to clean up the fuel spill it could have been very expensive to do so, and of course, our responsibility.

He was a great CFII and pilot and i tried hard to keep him flying and keep him on our team after the incident... i tried so much here, and a point i feel i should share, that in trying to help facilitate his 709 ride since he was out of town, the FSDO told me to let it go, that they wanted pilots that wanted it bad enough to fight for it. i got that, because i think if i were in that situation i would have camped out on the POIs door step to make that ride happen (notice i put ‘think’ because i don’t think we really know, even tho we were very close to the situation, i wasn’t in the bird). Although he would have passed it with flying colors, he never did take that ride (in his defense, at the time there wasn’t anyone at the FSDO here that was qualified in the Robinson to give him the ride, he had to wait months for that to be cleared up, and by then, he was working full time and happy). He did continue to drive up and help out for months, he had a good attitude and busted his ass, but he didn’t instruct after that.

He didn’t do a power check on the way to the site, something we had discussed in the brief... don’t know why really, he forgot, they were late, i can tell you tho that it wasn’t because of anti-authority or macho attitude... i know they were late getting there as they arrived just in time for the last race, maybe they were waiting for the helo to show up to start it.. i am not sure about that... but if you get one thing from this, get this. Know what the helicopter is really going to do, not what you ‘think’ it will do. If you are new and reading this, and don’t know how to do a power check, make sure it’s part of your training. A few years ago a local pilot had a hard run-on landing onto a golf course after a wedding shuttling the bride and groom to the reception. One kinda high time pilot (~4K), and another CFII were up front, they had calculated the performance and knew what they thought the ship would do, but they didn't think about all the sprinklers and the high humidity and were short on power for departure.. they were lucky that there was a flat spot to run on to.. the manager of the course wasn’t very happy tho to have two long ruts in their beautiful green (another subject for you high timers; humidity). This also backs up my earlier comment about always having the PIC mentality when you are in the aircraft. The lower time CFII told the higher time pilot that they should use a different, safer departure route, but the high time pilot wanted to fly by the crowd... he should have listened to the lower time, but more current pilot. And, just for the record, the hight time pilot tried to blame the incident on the lower time CFII, i was in the room when he did it... after getting caught and confronted by the lower time guy he admitted it was ‘probably’ his fault.

Back to the crash; they did do performance planning, we do it on a computer and on paper both, and we print out the computer report... i think there was an issue on the planning with the amount of fuel but i’m not sure, however, in my opinion the planning was clearly inadequate. One thought i just had, we loaned the photog a gryo stabilizer that we have, it’s about 25lbs with the battery back, i do not know if they accounted for that. Please note that the investigation of the flight was between the pilot and the authorities, we were not invited into the room either time, i can tell you that although it was nice and professional, it didn’t look very pleasant. They did have more fuel than they needed on board, and, on that subject, when the bird leaned forward after stopping, fuel came out of the caps and ran down the front of the windscreens, i think this contributed to everyone running from the bird in a fast, almost uncontrolled manner and could have caused more trouble (the PIC did tell them to exit to the rear sides and to watch out for the tail rotor, you could hear it on the video from inside the cabin, at that time the PIC didn’t know it but the tail rotor was no longer attached to the tail boom and was no longer turning, it was about ten feet from the ship and was also completely unscathed). It was pretty amazing how calm the PIC remained, at least thats my recollection of what it sounds like from the video (NO i won’t post that, first, it’s not my video, and i’m really not sure where it is now, i will however try to find it and see if i can give you an idea when the low rotor horn came on, i think you can hear it on the video). Oh yeah, it appeared that the bird stopped it’s forward down hill slide or motion because the left skid hit a rock, a pretty big one, not sure what would have happened if it would have been ten inches to one side or the other. I am also not sure, i didn’t get there for 20 minutes after the crash, it was six miles from my house, but i think he cut the tail off pulling back on the cyclic to try & stop the forward roll, it may have been intact after the landing had he not done so, but, again, i am not sure. I do not think the ship would have rolled forward even tho it was on a steep slope. The main rotor clipped a tree on the decent, didn’t do much to the tree or the main but making a point that his options were fairly small. I will also say here that we pay much more attention to each other on a daily basis, and everyone asks questions constantly, and, as Mike has said a million times, a working SMS might have prevented the whole thing.

The FAA and the NTSB were there very quickly, they were nice, professional and even supportive.. it was Mother’s Day, yet they all showed up within an hour. My insurance guy was at the office and answered the phone when i called, even on a Sunday and Mother’s Day.. he’s the best in the biz if you need a good one. The PIC was also covered by Xinsurance, it’s a requirement at our school, they paid easily and quickly which helped a lot with the deductible.

Our competition quickly got on the TV news that afternoon and talked about how it was SWP and lack of experience (when we had the same opportunity a few months ago after they had one come apart on their ramp (ground resonance) we of course declined all requests from the media). Just saying that this sort of publicity hurts us all and the less there is the better we all are.

The left skid, which hit the rock, dug in for about seven feet to a depth of about six to eight inches, it was bent up about 60 degrees right in front of the forward down tube (i think from hitting the rock, but might have been the part that impacted first), the right skid didn’t seem to cut much of a trough and was not bent in the front. The photog was in the back left seat.

Oh yeah, just before the flight the PIC called me from the ramp and said they were taking off.. the last thing i said to him was; ‘cool, be safe, and what ever you do, don’t slow down’! I was trying so hard to lighten up on the flight ops, i had been accused of micro managing, being too careful, asking too many questions and not having ‘faith or confidence’ in my crew. I even had one cfi quit and say that i was ‘too much’ and expected too much when it came to safety, (when i grounded him for attitude and safety issues he left, he WAS snapping his tail and flying cocky, but only in the Schewizer). The team i have now, fostered by Mike, always talk to each other, and never ever reacts to questions about operations or safety, they are all in it to be the best that we can.

IMHO, if you are talking to someone about safety, asking questions about flight planning, weather, weight and balance, performance, decisions, etc, and they object or have an issue with that approach. F*cking fire them on the spot or don’t fly with them if you aren’t in the position to make those decisions. The PIC on this flight was never that person, ever, no ego, no attitude, and yet he still got caught not being totally present (for lack of a better way of putting it). There is just no room in our business for ego or attitude.. and the pilots with it will most likely be taken out by natural selection...

I will always wish that i had asked more questions on that day.

And i am forever thankful that no one was hurt.

sincerely,

dp