National Transportation Safety Board

Aviation Incident Final Report

Location: Fresno, CA Incident Number: LAX08IA042

Date & Time: 12/14/2007, 1620 PST Registration: N414HP
Aircraft: Eurocopter France AS350 B3 Aircraft Damage: None
Defining Event: Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Public Aircraft - State

Analysis
The certified flight instructor (CFI) configured the helicopter for a practice emergency
maneuver with the hydraulic system off. Upon disengaging the hydraulics, he immediately
noticed that an abnormal force was required on the cyclic control to prevent the helicopter's
nose from pitching up and to the left. He elected to continue the landing with the hydraulics off
and began to slow the airspeed as the helicopter adjoined final approach. He was convinced
that he would not be able to land the helicopter without it incurring damage due to the severe
control restriction. He managed to complete a run-on landing without mishap by maintaining
an airspeed of about 10 kts. When the helicopter came to rest, the pressure was released on the
cyclic and the second pilot restored the hydraulics via the collective switch. Immediately
thereafter, the cyclic began a hard over and displaced to the left against the CFI's leg. He
attempted to center the cyclic with both hands, but he was unable to move the control. After 40
seconds the pressure released and the second pilot centered the cyclic with ease. The hydraulic
servos were tested and a complete teardown of each servo was performed. The pressure testing
of one of the servos revealed that the unlocking pressure was out of tolerance (too high). Upon
disassembly of this servo, wear was observed on the conical surface of the locking finger and on
the diameter in contact with the bearing. According to the servo manufacturer, the wear
resulted in excessive friction in the bearing, which led to the high unlocking pressure.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this incident to be:
Malfunction of a hydraulic servo while on final approach due to excessive wear of the locking
finger.

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Findings

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTION

Phase of Operation: APPROACH - VFR PATTERN - FINAL APPROACH

Findings
1. (C) HYDRAULIC SYSTEM,ACTUATOR - WORN
2. (C) HYDRAULIC SYSTEM - JAMMED
3. AIRCRAFT CONTROL - REDUCED - PILOT IN COMMAND

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Factual Information
HISTORY OF FLIGHT
On December 14, 2007, about 1620 Pacific standard time, a Eurocopter AS350 B3, N414HP,
experienced an in-flight control restriction while performing a practice emergency maneuver
with the hydraulic system off at the Fresno Yosemite International Airport, Fresno, California.
California Highway Patrol (CHP) Air Operations was operating the helicopter under the
provisions of 14 Code of Federal Regulations Part 91. The certificated flight instructor (CFI)
and commercial pilot undergoing instruction (second pilot) were not injured; the helicopter
was not damaged. The local public-use instructional flight departed Fresno about 1600. Visual
meteorological conditions prevailed, and a flight plan had not been filed.
In a written statement, the CFI reported that the purpose of the flight was for the CFI to give
training to the second pilot, who was positioned in the right seat. Prior to departure, the CFI
discussed the proper procedures for performing practice hydraulic-off emergency procedures,
as the second pilot was completing pilot phase-training, which required the achievement of
such a maneuver.
The CFI further stated that he opted to perform the first hydraulics-off maneuver and
demonstrate the correct procedures. After departure, he adjoined the helicopter with the right
downwind leg of a traffic pattern for taxiway "C", where he planned a final touchdown at area
5. With the helicopter at 800 feet mean sea level (msl) and 90 knots (kts), the CFI initiated the
maneuver by activating the hydraulic test push button (HYD TEST). After the illumination of
the hydraulic pressure light, he configured the helicopter to an airspeed of 60 knots (kts) and
instructed the second pilot to turn the hydraulics off [the right-seated pilot has the hydraulic
cut-off switch on their respective collective]. The CFI immediately noticed that an abnormal
force was required on the cyclic control to prevent the helicopter's nose from pitching up and to
the left.
The CFI elected to continue the landing with the hydraulics off and began to slow the airspeed
as the helicopter adjoined final approach. He was concerned that he would not be able to land
the helicopter without it incurring damage due to the severe control restriction. He managed to
complete a run-on landing without mishap by maintaining an airspeed of about 10 kts. When
the helicopter came to rest, the pressure was released on the cyclic and the second pilot
restored the hydraulics via the collective switch. Immediately thereafter, the cyclic began a
hard over and displaced to the left against the CFI's leg. He attempted to center the cyclic with
both hands, but he was unable to move the control. After 40 seconds the pressure released and
the second pilot centered the cyclic with ease.
HELICOPTER INFORMATION
The helicopter was a Eurocopter AS350B3, serial number 3378. It was manufactured in 2000,
and had accrued a total time in service of 9,019 hours at the time of the last 100-hour
inspection, which was completed November 12, 2007. The Turbomeca Arriel 2B engine, serial
number 22436, had accumulated a total time in service of 4,790 hours.
TESTS AND RESEARCH
Following the incident, the three control servos were removed and sent to France, where a
complete teardown inspection was conducted at the Goodrich Actuation Systems facilities

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under the auspice of a Bureau d'Enquêtes et d'Analyses (BEA) investigator.
The following SAMM (Goodrich) servo accumulators were tested as per the Acceptance Test
Procedure (ATP):
Part# SC5083 Serial# 724
Part# SC5083 Serial# 1228
Part# SC5084 Serial# 491
The pressure testing of servo 724 revealed that the unlocking pressure was out of tolerance (too
high); the unit was noted to be dirty. Upon disassembly, wear was observed on the conical
surface of the locking finger and on the diameter in contact with the bearing. According to the
servo manufacturer, the wear resulted in excessive friction in the bearing, which led to the high
unlocking pressure.
Servo 724 had accumulated 4,681 total flight hours. It flew 2,199 hours on another AS350 B3
helicopter between September 1998 and January 2006; then it was installed on the accident
helicopter and accumulated 2,482 hours between March 20, 2006, and the time of the
accident.
The servo manufacturer’s report concluded that the wear pattern on the locking finger was
unusual and most likely "related to abnormal external pollution associated with intensive use
of the locking device." The complete test examination report is contained in the public docket
for this accident.

Flight Instructor Information

Certificate: Flight Instructor; Commercial Age: 38, Male
Airplane Rating(s): Seat Occupied: Left
Other Aircraft Rating(s): Helicopter Restraint Used: Seatbelt, Shoulder
harness
Instrument Rating(s): Helicopter Second Pilot Present: Yes
Instructor Rating(s): Helicopter Toxicology Performed: No
Medical Certification: Class 2 Without Last FAA Medical Exam: 03/13/2007
Waivers/Limitations
Occupational Pilot: Yes Last Flight Review or Equivalent: 12/11/2006
Flight Time: 1669 hours (Total, all aircraft), 2877 hours (Total, this make and model), 4332 hours (Pilot In
Command, all aircraft), 101 hours (Last 90 days, all aircraft), 35 hours (Last 30 days, all
aircraft), 2 hours (Last 24 hours, all aircraft)

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Pilot Information
Certificate: Commercial Age: 32, Male
Airplane Rating(s): Seat Occupied: Right
Other Aircraft Rating(s): Helicopter Restraint Used: Seatbelt, Shoulder
harness
Instrument Rating(s): Helicopter Second Pilot Present: Yes
Instructor Rating(s): None Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations Last FAA Medical Exam: 02/08/2007
Occupational Pilot: Yes Last Flight Review or Equivalent: 11/19/2007
Flight Time: 188 hours (Total, all aircraft), 31 hours (Total, this make and model), 155 hours (Pilot In
Command, all aircraft), 28 hours (Last 90 days, all aircraft), 14 hours (Last 30 days, all
aircraft), 2 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Eurocopter France Registration: N414HP
Model/Series: AS350 B3 Aircraft Category: Helicopter
Year of Manufacture: Amateur Built: No
Airworthiness Certificate: Normal Serial Number: 3378
Landing Gear Type: High Skid Seats: 2
Date/Type of Last Inspection: 11/12/2007, 100 Hour Certified Max Gross Wt.: 4961 lbs
Time Since Last Inspection: 216 Hours Engines: 1 Turbo Shaft
Airframe Total Time: 9019 Hours as of last Engine Manufacturer: Turbo Mecca
inspection
ELT: Installed, not activated Engine Model/Series: Arriel 2B
Registered Owner: California Highway Patrol Rated Power: 847 hp
Operator: California Highway Patrol Operating Certificate(s) None
Held:

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Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions Condition of Light: Day
Observation Facility, Elevation: FAT Distance from Accident Site:
Observation Time: 1555 PST Direction from Accident Site:
Lowest Cloud Condition: Thin Overcast / 12000 ft Visibility 10 Miles
agl
Lowest Ceiling: Overcast / 12000 ft agl Visibility (RVR):
Wind Speed/Gusts: 3 knots / Turbulence Type /
Forecast/Actual:
Wind Direction: Variable Turbulence Severity /
Forecast/Actual:
Altimeter Setting: 30.24 inches Hg Temperature/Dew Point: 10°C / -1°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Fresno, CA (FAT) Type of Flight Plan Filed: None
Destination: (FAT) Type of Clearance: VFR
Departure Time: 1600 PST Type of Airspace:

Airport Information
Airport: Fresno Yosemite International (FAT) Runway Surface Type:
Airport Elevation: 336 ft Runway Surface Condition:
Runway Used: N/A IFR Approach: None
Runway Length/Width: VFR Approach/Landing: Stop and Go; Straight-in;
Traffic Pattern

Wreckage and Impact Information

Crew Injuries: 2 None Aircraft Damage: None
Passenger Injuries: N/A Aircraft Fire: None
Ground Injuries: N/A Aircraft Explosion: None
Total Injuries: 2 None Latitude, Longitude: 36.776111, -119.718056 (est)

Administrative Information
Investigator In Charge (IIC):
Additional Participating Persons:
Publish Date:
Investigation Docket:
Zoe Xiola Keliher Report Date: 12/24/2008
Lindsay Cunningham; American Eurocopter; Grand Prairie, TX
Mark Nalley; California Highway Patrol; Sacramento, CA
12/24/2008
NTSB accident and incident dockets serve as permanent archival information for the NTSB’s
investigations. Dockets released prior to June 1, 2009 are publicly available from the NTSB’s
Record Management Division at pubinq@ntsb.gov, or at 800-877-6799. Dockets released after
this date are available at http://dms.ntsb.gov/pubdms/.

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by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine
the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate
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