Final Report: Inadequate training blamed in fatal crash

 - April 2, 2008, 10:46 AM

Eurocopter EC 135P1, Washington, D.C., May 30, 2006–The NTSB determined the probable cause of the EMS helicopter crash to be the operator’s inadequate training program and the pilot’s failure to maintain control following his inadvertent disabling of the full authority digital engine control (Fadec) system.

The CJ Systems helicopter was substantially damaged when it hit a tree while maneuvering to land at the Washington Hospital Center Helipad. The ATP-rated pilot and two medical crewmembers were seriously injured; the critically ill patient was killed.

During his first approach, the pilot reported that the helicopter “shuffled,” and the No. 1 engine rpm increased. He increased collective pitch, reduced the throttle on the No. 1 engine, inadvertently moving the throttle out of its neutral detent, and aborted the landing, noting that the No. 1 engine was no longer controlled by Fadec and that he had to control it manually. He then moved the No. 2 throttle out of its detent, taking that engine out of Fadec control. The pilot then attempted manual control of both engines, resulting in a high workload. The pilot did not perform the published procedure to restore control, which requires reaching up to the overhead panel and resetting the Fadec switch, which is in a guarded cover.

The helicopter was the only P1 variant in the operator’s fleet. Its engines, displays and procedure for restoring Fadec control differed from those of the T1 in which the pilot was trained. The manufacturer’s training guidelines recommend differences training before flying the P1; the pilot had received about an hour of that training, which did not cover Fadec-restore procedures. The pilot had 15,613 total hours, including 12,413 hours in helicopters, 914 in make and model, and 45 in the P1.
Investigators found no evidence of any pre-impact mechanical anomalies.