NATIONAL TRANSPORTATION SAFETY BOARD Office of Aviation Safety Washington, DC 20594 Specialist’s Factual Report October 4, 2011

OPERATIONAL FACTORS/HUMAN PERFORMANCE
A. ACCIDENT Location: Date: Time: Aircraft: NTSB Number: B. New York, New York October 4, 2011 1525 Eastern Daylight Time Bell 206B, N63Q ERA12MA005

OPERATIONAL FACTORS/HUMAN PERFORMANCE STAFF Specialist: Carrol A. Smith, Senior Air Safety Investigator National Transportation Safety Board Eastern Regional Office Atlanta, Georgia Heidi E. Moats National Transportation Safety Board Ashburn, Virginia John W. Galligan FAA FSDO Farmingdale, New York Farmingdale, New York

Intern:

Member:

C.

SUMMARY

On October 4, 2011, at 1525 eastern daylight time, a Bell 206B, N63Q, registered to a private owner, crashed into the East River during takeoff from East 34th Street Heliport (6N5), New York, New York. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The helicopter sustained substantial damage to the airframe. The certificated commercial pilot and one passenger were not injured. 1

One passenger sustained serious injuries and two passengers were killed. The flight originated from 6N5 at 1524. D. 1.0 DETAILS OF THE INVESTIGATION HISTORY OF FLIGHT

On October 4, 2011, at 1525 eastern daylight time, a Bell 206B, N63Q, registered to a private owner, crashed into the East River during takeoff from East 34th Street Heliport (6N5), New York, New York. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The helicopter sustained substantial damage to the airframe. The certificated commercial pilot and one passenger were not injured. One passenger sustained serious injuries and two passengers were killed. The flight originated from 6N5 at 1524. A lineman stated the four passengers arrived at the heliport 30 minutes before the helicopter. No passenger briefing was provided by 6N5 personnel. The helicopter arrived at 1517. The passengers were escorted to the helicopter while it was running at parking pad 4. The helicopter picked up to about a 60-foot hover while moving backwards slowly out over the river. The helicopter made a left pedal turn facing parallel to the ramp. It started forward and the nose dipped down, the helicopter spun to the left one and a half turns and appeared to be out of control before it collided with the river. The pilot stated he used the checklist to complete the before takeoff check. He picked the helicopter up to a 3 to 5 foot hover, made a right pedal turn, and attempted to depart into the wind. He initiated a takeoff to the northeast and continued to turn north into the wind. The helicopter climbed to an altitude between 30 to 50 feet over the East River. The pilot felt a small left yaw and applied right anti torque pedal. He initially thought the helicopter was weather vaning. He heard the engine out audio sound and thought he had an engine failure. The pilot believed the yaw was an engine out yaw, not weather vaning. He immediately initiated a hard right turn back to the heliport while lowering the collective pitch. He then observed the N1 and it was still up. The pilot concluded the initial yaw was weather vaning and not an engine failure. He increased collective pitch with the intention of conducting a normal landing back at the heliport. The nose of the helicopter started a turn to the right and suddenly snapped into a spin. Attempts to correct the spinning with the anti-torque pedal were unsuccessful. He thought he had a tail rotor failure or he encountered loss of tail rotor effectiveness (LTE). He lowered the collective pitch and just prior to water contact he raised the collective to cushion the impact. The helicopter entered the water and rolled over inverted. 2.0 PILOT ACCIDENT INFORMATION

Review of records on file with the Federal Aviation Administration (FAA) Airman Records revealed the pilot has not been involved in a prior aircraft accident or incident.

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3.0

PILOT CERTIFICATE INFORMATION

At the time of the accident, the pilot held a FAA commercial pilot certificate with ratings for rotorcraft-helicopter, airplane single-engine land, and airplane multiengine land issued on April 25, 2011. The pilot failed his initial commercial pilot check ride in a Robinson R44 with an FAA designated pilot examiner (DPE) for his certificate action from a private pilot to a commercial pilot on April 21, 2011. The oral examination lasted for 4 hours and the flight check lasted for 1 hour and 20 minutes. The DPE indicated on the pilot’s “NOTICE OF DISAPPROVAL/APPLICATION,” “Upon reapplication you will be reexamined on the following: takeoffs, landings and go-arounds.” During reexamination on April 25, 2011, the pilot received a one hour oral examination and 30 minute flight examination by the same DPE. The pilot successfully passed the check ride. A review of FAA airmen records indicated the following chronology of acquired airman certificates:
Table 1. FAA Airmen Record Data

AIRMAN CERTIFICATE
Private Pilot – Rotorcraft Helicopter Private Pilot-Airplane Single-Engine Land Private Pilot-Airplane Multiengine Land Commercial Pilot – Rotorcraft Helicopter Private Pilot – Airplane Single-Engine Land Private Pilot- Airplane Multiengine Land

ORIGINAL ISSUE DATE
October 25, 1987 December 23, 1986 May 22, 1997 April 25, 2011 April 25, 2011 April 25, 2011

3.1 Medical Information The pilot held a second-class medical certificate issued June 23, 2001, with no limitations. As of that date, his height was 70 inches and his weight was 203 pounds. A review of the pilot’s FAA medical file revealed his medical certificate had never been suspended, denied, or revoked. 3.2 Pilot Flight Time According to the pilot’s logbook, the pilot had logged the following time:
Table 2. Pilot's Flight Experience (Hours)

Total Flight Experience Total Pilot In Command Experience Bell 206B Total Time in Bell 206B Total Flying Time Last 90 days Last 30 days

2,287 420 420 9.7 All Aircraft, 5.1 hours in Bell 206B, 4.6 airplane multiengine 4.4 All Aircraft, 1.7 Bell 206B, 2.7 airplane multiengine

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3.3 Pilot Training The pilot received his initial helicopter transition training at Bell Helicopter Factory School on January 8, 2007. He completed the Bell factory recurrent training at Bell on April 15, 2008. The pilot’s last recurrent training was on April 27, 2009. The pilot completed the Robinson Helicopter factory training on November 29, 2007. According to Bell Helicopter, tail rotor malfunctions (loss of tail rotor drive shaft and anti-torque stuck pedal procedures) were covered in the initial and recurrent training at the Bell Helicopter Training Facility. Unanticipated right yaw/LTE is not a new phenomenon, and is covered in the FAA Rotorcraft Flying Handbook FAA-H-8083-21, and Advisory Circular 90-95, Unanticipated Right Yaw in Helicopters. Robinson Helicopters stated with a pilot in training, the goal is for a pilot to understand how the tail rotor works and a better understanding of the causes of LTE and how to avoid LTE. The FAA Rotorcraft Flying Handbook and FAA Advisory Circular 90-95 may be utilized. The DPE who conducted the initial check ride and the re-examination stated that tail rotor malfunctions and LTE were covered during the pilot’s oral examination. The pilot’s last flight review was conducted on April 20, 2011 in a Robinson R44 helicopter. 3.4 72-Hour Pilot History According to information provided by the pilot, his most recent duty time was as follows: 10/04/11 Awake 07:30 AM, Bed 01:00 10/05/11 10/03/11 Awake 06:15 AM, Bed 11:00PM 10/02/11 Awake 08:00 AM, Bed 1030PM 10/01/11 Awake 07:30 AM, Bed 11:00 PM 4.0 WEATHER INFORMATION

The New York City Central Park 1551 surface weather observation, located 2 nautical miles to the northeast of 6N5, reported wind variable at 4 knots, visibility 10 miles, ceiling 5,000 feet broken, 6,500 feet overcast, temperature 17 degrees C, dew point 11 degrees C, and an altimeter setting of 30.01 inches of mercury. The LaGuardia, New York, 1551 surface weather observation, located 5 nautical miles northeast of 6N5, reported wind 330 degrees at 9 knots gusting to 17 knots, visibility 10 miles, scattered clouds at 3,500, ceiling 7,000 feet broken, broken at 9,000 feet, temperature 17 degrees C, dew point 9 degrees C, and an altimeter setting of 29.98 inches of mercury. 4

The pilot stated in an initial interview with the New York Police Department that the windsock at 6N5 indicated a south wind prior to his landing. 5.0 WITNESS OBSERVATIONS

Several witnesses reported that the helicopter landed at East 34th Street Heliport around 1515 in order to pick up four passengers. The heliport employees reported that the pilot did not shut down the helicopter's engine or exit the helicopter. He and a heliport employee then assisted in loading the passengers. The male passenger was seated in the front passenger seat, and the three female passengers were seated in the back of the helicopter. The heliport employee reported that all three rear seat passengers were wearing restraints. The helicopter departed about five minutes after landing. Several witnesses reported that after the helicopter lifted off the helipad, at an altitude of about 20-40 feet, it backed up over the East River and began to rotate. It rotated several times before it impacted the water. Many witnesses reported that the engine sounded normal and there was no smoke coming from the helicopter. 6.0 WEATHER RESOURCES AVAILABLE TO THE PILOT

The pilot had many sources available to check the weather prior to launch. The primary tools used by pilots in the local area were Direct User Access Terminal System (DUATS), Lockheed Martin, and Weather Service Information (WSI) available on the computer at 6N5. There was no record on file indicating the pilot had used the resources, and the pilot stated he did not check weather or file a flight plan before departure. 7.0 HELIPORT INFORMATION

The heliport, N65, was located five miles southwest of LaGuardia Airport, New York City, New York, at an elevation of 10 feet. The heliport was owned by Economic Development Corporation and operated by Mac Quarie Aviation, New York, New York. Five helipads were located on site labeled H1 through H4 and T for Transient. The pilot landed and departed from H4. The heliport was open Monday through Friday from 08:00 AM to 8:00 PM, and was closed on weekends. The heliport was open to the public and did not have a control tower. Pilots arriving and departing used UNICOM frequency 123.075. No weather recording capabilities were available at 6N5. Radio communications at 6N5 were not recorded. The video camera did not scan parking pad for H4.

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Figure 1: Overhead view of heliport.

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Figure 2: Parking Ramp.

8.0

AIRCRAFT EQUIPMENT

The helicopter was equipped with standard instrument gauges, an overhead circuit breaker panel, and a rotor brake. A Garmin Global Positioning System with no memory, VHF radio with Com 1, Com 2, VOR with glide slope receiver, transponder and a Turbine Outlet Temperature exceedance light were installed. No nonvolatile memory was located in the cockpit. 9.0 WEIGHT AND BALANCE

The maximum gross weight for the Bell 206 B was 3,200 pounds. The useful load of the helicopter was 1,285.45 pounds using an aircraft weight and balance form dated October 21, 2008. According to the Bell 206B Flight Manual, the forward center of gravity (CG) limit was 106 inches, and the aft CG limit 114.2 inches. The aft CG limit tapers to 111.4 inches between 2,350 pounds and maximum gross weight. The pilot stated he determined the load with his passengers and fuel was 1,131 pounds. The pilot stated in an interview that he weighed 190 pounds and his front seat passenger informed him the night before the accident that he weighed 210 pounds. He further stated that a rear seat passenger informed him before takeoff that the three rear seat passengers weighed 154 pounds each. The takeoff weight calculated by the pilot was 3,045.52 pounds. The calculated CG at the time of the accident was 107.1 inches, which was within the Bell 206B forward and aft CG limits for the takeoff weight of 3,045.52 pounds. NTSB calculations revealed the pilot and passenger’s weight was 862 pounds, per passenger weight estimates the pilot had before the flight. The pilot weighed 190 pounds. The front seat passenger weighed 210 pounds and the combined weight of all three passengers in the back was 462 pounds. The empty weight of the helicopter was 1914.52 pounds. The pilot indicated he had 33 gallons of fuel at takeoff. The weight of the fuel was calculated to be 224.4 pounds (33 gallons of Jet A fuel at 6.8 pounds per gallon). The takeoff weight based on these calculations was 3,000.92 pounds. See Weight and Balance Table 3.
Table 3. NTSB Calculated Weight and Balance using weights given to the pilot by passengers.

Item Pilot Weight Front Seat Passenger Weight (per front seat passenger night before accident) Rear Seat Passengers Weight (per rear seat passenger, 154 pounds each)

Weight (lbs) 190 210 462

Fuel Weight (33 gallons of Jet A fuel at 6.8 pounds per gallon) Helicopter Empty Weight Total Helicopter Weight

224.4 1,914.52 3,000.92

The calculated CG at the time of the accident was 107.2 inches, which was within the Bell 206B forward and aft CG limits for the weight of 3,000.92 pounds. 8

NTSB personnel interviewed the front seat passenger. The passenger stated he and his wife weighed 225 pounds each. The daughter's weight obtained from the Medical Examiner was 265 pounds. According to the front seat passenger, the remaining passenger weighed 168 pounds. According to the pilot, his weight was 190 pounds. The fuel weight was 224.4 pounds. The takeoff weight calculated from the weights provided by the front seat passenger and fuel weight from the pilot revealed the takeoff weight was 3,211.92 pounds, which was 11.92 pounds beyond the maximum gross weight of 3,200 pounds. See Table 4.
Table 4. Weight and Balance Calculation using weights obtained by NTSB personnel after the accident.

Item Pilot Weight Front Seat Passenger Weight (per front seat passenger after the accident) Rear Seat Passengers Weight (225+265+168 pounds, per front seat passenger and medical examiner)

Weight (lbs) 190 225 658

Fuel Weight (33 gallons of Jet A fuel at 6.8 pounds per gallon) Helicopter Empty Weight Total Helicopter Weight

224.4 1,914.52 3,211.92

No published center of gravity limit data existed for weights above maximum takeoff weight. An FAA inspector interviewed the front seat passenger, who informed the inspector that his weight at the time of the accident was 223 pounds. He further stated his wife’s weight was 253 pounds. The medical examiner informed the FAA inspector that the back seat passenger's weight was 265 pounds and her friend’s weight was 185 pounds. The pilot’s weight on his medical was 203 pounds. The pilot informed all personnel that his weight at the time of the accident was 190 pounds. The fuel weight at takeoff was 224.4 pounds. The takeoff weight provided by the front seat passenger and the medical examiner using 190 pounds for the pilot’s weight was 3,254.92 pounds. The takeoff weight provided by the front seat passenger and the medical examiner using 203 pounds for the pilot’s weight was 3,267.92 pounds. See Table 5.
Table 5. Weight and Balance Calculation using weights obtained by FAA personnel after the accident.

Item Pilot Weight (per pilot statement/per pilot medical) Front Seat Passenger Weight (per front seat passenger after the accident) Rear Seat Passengers Weight (265+253+185 pounds, per front seat passenger and medical examiner)

Weight (lbs) 190 223 703

Weight (lbs) 203 223 703

Fuel Weight (33 gallons of Jet A fuel at 6.8 pounds per gallon) Helicopter Empty Weight Total Helicopter Weight

224.4 1,914.52 3,254.92

224.4 1,914.52 3,267.92 9

The helicopter was weighed on October 6, 2011, two days after the accident. Some standing water was observed on the floor and back seat bench. The seat cushions and carpet were water soaked. It was unknown how much water weight the helicopter carried at the time of the weighing. The helicopter empty weight was 1,960 pounds without the main rotor blades. Each rotor blade weighed 93.4 pounds for a total of 186.8 pounds, per Bell Helicopter. The pilot and four passengers weighed 1,090 pounds according to pilot, passenger, and medical examiner statements. The fuel weight at takeoff was 224.4 pounds. The takeoff weight was calculated to be 3,461.2 pounds. See Table 6.
Table 6. Weight and Balance Calculation using helicopter weight after extracted from water.

Item
Helicopter Empty Weight (after accident, without rotor blades) Rotor Blades (93.4 pounds each, per Bell Helicopter) Pilot Weight (per pilot statement)

Weight (lbs) 1960 186.8 190

Front Seat Passenger Weight (obtained by NTSB personnel) Rear Seat Passengers Weight (225+265+185 pounds, per front seat passenger and medical examiner) Fuel Weight (33 gallons of Jet A fuel at 6.8 pounds per gallon) Total Helicopter Weight

225 675 224.4 3,461.2

Since the calculated takeoff weight of the helicopter for this scenario was well above the maximum gross weight of the helicopter, the calculation of the CG location from the Flight Manual through extrapolation would not be valid.

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Figure 3: Weight and Balance Calculated on October 21, 2008. 10.0 PERFORMANCE PLANNING:

Advisory Circular No. 90-95, UNANTICIPATED RIGHT YAW IN HELICOPTERS states in paragraph: 4. a. LTE is a critical; low-speed aerodynamic flight characteristic which can result in an uncommanded rapid yaw rate which does not subside of its own accord and, if not corrected, can result in the loss of aircraft control…. 5. UNDERSTANDING LTE PHENOMENA…. c Tail rotor thrust is the result of the application of anti-torque pedal by the pilot. If the tail rotor generates more thrust than is required o counter the main rotor torque, the helicopter will yaw or turn to the left about the vertical axis. If less tail rotor thrust is generated, the helicopter will yaw or turn to the right. By varying the thrust generated by the tail rotor, the pilot controls the heading when hovering…. e. The environment in which helicopters fly, however, is not controlled. Helicopters are subjected to constantly changing wind direction and velocity. The required tail rotor thrust in actual flight is modified by the effects of the wind. If an uncommanded right yaw occurs in flight, it may be because the wind reduced the tail rotor effective thrust…. 11

6. CONDITIONS UNDER WHICH LTE MAY OCCUR. a Any maneuver which requires the pilot to operate in a high-power, low-airspeed environment with a left crosswind or tailwind creates an environment where unanticipated right yaw may occur…. b. There is greater susceptibility for LTE in right turns. This is especially true during flight at low airspeed since the pilot may not be able to stop rotation. The helicopter will attempt to yaw to the right. Correct and timely pilot response to an uncommanded right yaw is critical. The yaw is usually correctable if additional left pedal is applied immediately. If the response is incorrect or slow, the yaw rate may rapidly increase to a point where recovery is not possible. 7. FLIGHT CHARACTERISTICS UNANTICIPATED RIGHT YAW IN HELICOPTERS (LTE)…. b. Although specific wind azimuths are identified for each region, the pilot should be aware that the azimuths shift depending on the ambient conditions. The regions do overlap. The most pronounced thrust variations occur in these overlapping areas. c. These characteristics are present only at airspeeds less than 30 knots and apply to all single rotor helicopters. d. The aircraft characteristics and relative wind azimuth regions are: (1) Main rotor disc vortex interference (285” to 315”). (See figure 1.) NTSB Figure 4 (a) Winds at velocities of about 10 to 30 knots from the left front will cause the main rotor vortex to be blown into the tail rotor by the relative wind. The effect of this main rotor disc vortex is to cause the tail rotor to operate in an extremely turbulent environment. (b) During a right turn, the tail rotor will experience a reduction of thrust as it comes into the area of the main rotor disc vortex. The reduction in tail rotor thrust comes from the air flow changes experienced at the tail rotor as the main rotor disc vortex moves across the tail rotor disc. The effect of this main rotor disc vortex is to increase the angle of attack of the tail rotor blades (increase thrust). (2) Weathercock stability (120” to 240”). (See figure 2.) NTSB Figure 5 (a) Tailwinds from 120’ to 240”, like left crosswinds, will cause a high pilot workload. The most significant characteristic of tailwinds is that they are a yaw rate accelerator. Winds within this region will attempt to weather-vane the nose of the aircraft into the relative wind. This characteristic comes from the fuselage and vertical fin. (b) The helicopter will make a slow uncommanded turn either to the right or left depending upon the exact wind direction unless a resisting pedal input is made. If a yaw rate has been established in either direction, it will be accelerated in the same direction when the relative winds enter the 120’ to 240’ area unless corrective pedal action is made.

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(c) If the pilot allows a right yaw rate to develop and the tail of the helicopter moves into this region, the yaw rate can accelerate rapidly. It is imperative that the pilot maintain positive control of the yaw rate and devote full attention to flying the aircraft when operating in a downwind condition.

AC Figure 1. (NTSB Figure 4) Main Rotor Disc Vortex Interference.

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AC Figure 2 (NTSB Figure 5). Weathercock Stability

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11.0

FLIGHT FOLLOWING

The pilot did not use any flight following for the flight from Linden Airport (LDJ), Linden, New Jersey to 6N5. 12.0 FAA SURVEILLANCE

Review of records on file with the FAA revealed the pilot was subject to an unannounced line check on April 4, 2008. Five major repair alteration avionics inspections were conducted on December 14, 2007.

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LIST OF ATTACHMENTS

ATTACHMENT ATTACHMENT 1 NTSB Pilot/Operator Accident Report with Pilot Statement ATTACHMENT 2 Statements ATTACHMENT 3 Metro Port 6N5 Daily Report 10/04/11 ATTACHMENT 4 Extract Pilot Logbook and Flight Experience ATTACHMENT 5 Pilot Certification Documents ATTACHMENT 6 Pilot Training Records ATTACHMENT 7 Aircraft Weight and Balance ATTACHMENT 8 911 Emergency Operator Log ATTACHMENT 9 Weather ATTACHMENT 10 Extract 206B Flight Manual ATTACHMENT 11 Advisory Circular 90-95 Unanticipated Right Yaw in Helicopters ATTACHMENT 12 Extract FAA Rotorcraft Flying Handbook

Number of Pages

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35

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77

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ATTACHMENT 13 Extract Bell Helicopter 206A, 206B, Maintenance and Overhaul Instructions

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