NTSB Factual Report

HISTORY OF FLIGHT

On November 18, 2015, at 1623 Pacific standard time, an Airbus Helicopters AS350B3E, N711BE, departed controlled flight while landing on a dolly at Mc Clellan-Palomar Airport, Carlsbad, California. The private pilot and the pilot-rated passenger were fatally injured; the helicopter sustained substantial damage. The pilot, who was the owner, was operating the helicopter under the provisions of 14 Code of Federal Regulations Part 91. The local personal flight departed Carlsbad at 1412. Visual meteorological conditions prevailed, and no flight plan had been filed.

The purpose of the flight was for the pilot to gain familiarity with the helicopter, which he had recently purchased. The entire accident sequence was captured on a series of airport security cameras and the mobile phone cameras of multiple witnesses.

About 2 hours before the accident, the helicopter departed from its dolly on the east end of the Premier Jet fixed base operator (FBO) ramp, which was located midfield on the south side of runway 6/24. After departure, line crew moved the dolly to the west end of the ramp.

Upon returning, the helicopter approached the airport from the northeast and was cleared to land on runway 24. It descended to midfield, turned left at taxiway A3, and approached the ramp in a low hover via the parallel taxiway A. The helicopter then began an approach to the dolly from the east, directly toward the sun. The helicopter landed short of, and partially on, the dolly with the center of its skids contacting the dolly's aft edge. The helicopter immediately rocked back, pitching nose up, and its tailskid struck the ground. The helicopter then began a series of fore and aft oscillations, and the dolly broke free from its front left chock, rotated to the right, and pivoted around its rear right wheel. The helicopter spun rapidly with the dolly for the first quarter of the turn and then quickly spiraled upward 270° to the right. The dolly came to rest to the north, having rotated 180°. The pilot repositioned the helicopter and landed it on the ground, straddling the ramp and taxiway A. Just before landing, the pilot was queried by the air traffic control tower controller and responded, "yeah, they didn't chock my cart, and I was like a skateboard out here," The tower controller then requested that the pilot switch to the ground control frequency.

During the next 2 1/2 minutes, the line crew re-secured the dolly, installing chocks on three of the four wheels. The pilot then took off and climbed the helicopter to about 20 ft while it yawed to the left, and he repositioned it for an approach to the dolly now from the west. During the next 4 1/2 minutes, the pilot made three landing attempts, getting the helicopter to within about 5 ft vertically of the dolly on the first two attempts. After the first attempt, the pilot repositioned the helicopter by circling back around the dolly. After the second attempt, the pilot performed a hovering climb and backed the helicopter into position. A video of the third and final landing attempt was captured by a witness, who was located about 130 ft to the south. The witness was initially watching the helicopter from his airplane on the ramp, but he was concerned that the helicopter might crash, so he exited the airplane and positioned himself behind a car at the corner of the FBO's hangar.

The video revealed that the helicopter hovered over the dolly for about 60 seconds and then landed short, teetering on the aft edge of the dolly (Image 1). The tailskid almost struck the ground, and the helicopter then rapidly pitched forward (Image 2) and then aft again. The tailskid then struck the ground (Image 3), and the helicopter pitched forward, rolled right (Images 4 and 5), and climbed out of view behind the hangar. Security cameras revealed that the helicopter then spun 180° to the left, and the nose pitched up to a 45° attitude. The tail rotor and vertical stabilizer assembly then struck the ground and separated, and the helicopter hit the ground left side low, bounced, and rotated another 360° before landing hard on its belly. Once on the ground, the main rotor blades continued to spin, while the helicopter started spinning on its belly, as the engine continued to operate (Image 6).

The helicopter continued spinning at a rate of about one revolution per second for the next 5 minutes while incrementally sliding about 530 ft east along the ramp. The tailboom and horizontal stabilizer then separated, and the helicopter rolled onto its side, shedding the main rotor blades. The engine continued operating for another 30 seconds while the fire crew doused the helicopter. White smoke billowed from the engine's exhaust after the helicopter came to rest, but there was no fire.

PERSONNEL INFORMATION

The pilot was seated in the front right seat, and the pilot-rated passenger was seated in the front left seat.

Pilot

The pilot held a private pilot certificate with ratings for airplane single-engine land and sea, multiengine land, instrument airplane, and rotorcraft-helicopter. He also held a type rating for the Cessna Citation Jet (CE-525S).

The pilot held a third-class medical certificate issued on January 19, 2015, with the limitation that he must have available glasses for near vision.

No personal flight records were located for the pilot. At the time of his last medical application, he reported a total flight time of 25,000 hours, with 200 hours logged in the last 6 months. The pilot reported the same numbers on three other applications over the 5-year period preceding the accident, and 25,400 hours total time on his application dated January 18, 2011. His helicopter rating was issued in May 2001, at which time he reported on his rating application a total flight time of 14,000 hours in airplanes.

The pilot had previously owned and flown a Cessna Citation business jet airplane and a Bell 407 helicopter. His 2001 helicopter checkride flight took place in a Bell 206B3. At the time of the accident, he was receiving recurrent training for the Citation, with the most recent flight 2 days before the accident. The pilot purchased the accident helicopter on October 29, 2015, and had flown demonstration and familiarization flights in it since September 20. According to the helicopter's flight logs, those flights totaled about 8.8 hours and were all conducted with a flight instructor present. The pilot then flew the helicopter with another instructor for an additional 2 hours on November 13.

According to the two instructors who had flown with the pilot for the familiarization flights and the flight instructor who provided training in the Citation, the accident flight was the first time the pilot had flown in an AS350 without an instructor present. All had recommended that the pilot gain further instruction before flying without an instructor, and the pilot had concurred.

The three instructors shared similar insights into the pilot's flying skills, reporting that, while he appeared to have extensive flying experience, he was anxious about the handling characteristics of the AS350 compared to the Bell 407, particularly during landing. The pilot said that he was having difficulty anticipating flight control forces because the helicopter controls felt "backwards" due to the opposing rotor direction of the AS350 compared to the Bell 407. Furthermore, he was having trouble landing on the dolly partly because the tips of the skids were just behind his seating location in the AS350, as opposed to the Bell 407, where he could see the skids just forward and below. Both helicopter instructors reported performing multiple dolly and simulated dolly landings with the pilot, stating that, although the pilot was not completely at ease, he was able to ultimately land on the dolly unaided. The pilot told the Citation instructor that, although he had practiced many landings in the helicopter, he still did not feel proficient and thought that the helicopter was very unstable close to the ground, especially when it was close to the dolly.

One of the helicopter instructors reported that the pilot wanted to enable the helicopter's stability augmentation system (SAS) for landings because he had been told it would help his landings. The instructor stated that he wanted the pilot to be able to fly the helicopter proficiently without the use of the SAS. However, for demonstration purposes, they did two landings with the SAS enabled. During those attempts, the pilot appeared to be "fighting" against the SAS control inputs, with unsatisfactory results, and he did not understand how to use the SAS release button on the cyclic to override the SAS control inputs. Therefore, the pilot and instructor decided to turn the system off.

Both helicopter instructors reported that the pilot appeared to have suffered an injury that restricted movement of his left arm. He could use his left arm to operate the flight controls and reach the lower sections of the flight panel, but he could not reach the upper controls, including the engine start selector panel, without the supportive aid of his right arm. One instructor stated that because of the injury, the pilot was unable to climb up onto the helicopter to perform preflight examinations of the rotor head. One helicopter instructor and the Citation instructor stated that the pilot's hands often shook and that it was particularly obvious when he held a pen, although once he grasped the flight controls the shaking stopped.

Both helicopter instructors suggested that the pilot take formal factory-approved flight training, and one instructor stated that he had declined to provide any further instruction until the pilot had taken training at the Airbus Helicopters flight school. According to Airbus Helicopters, in early October, the pilot had signed up for a "B3 Pilot Transition Class" scheduled for November 2, but 2 days before the class he called to defer the training. No further communication from the pilot was received by Airbus Helicopters.

The Citation instructor, who had known the pilot for 6 years, reported that the pilot was becoming concerned that age was starting to affect his reaction time when flying. The instructor had observed the pilot's degrading flight performance and had conversations with him about how maintaining proficiency through regular flying could help. He stated that the pilot was no longer fully proficient in the Citation, that his reaction times were becoming slower, and that he would often let the airplane get ahead of him. As such, the instructor recommended that the pilot always fly with him. He stated that the pilot mentioned that he was going to fly the helicopter for practice with a friend on the day of the accident.

The pilot confided in all three instructors that, due to the difficulties he was having mastering the AS350, he was most likely going to sell it and buy another Bell 407. All three instructors stated that they had never seen the pilot's logbooks and had, therefore, never made any entries.

Pilot-Rated Passenger

The pilot-rated passenger held a private pilot certificate with ratings for airplane single-engine land and rotorcraft-helicopter. His first rating was for rotorcraft-helicopter, and it was issued in December 2004 following a checkride in a Bell 206B3. He was issued his airplane single-engine land rating in December 2014, and, at that time, he reported on his rating application a total rotorcraft flight time of 179.6 hours, including 163 solo hours.

He held a third-class medical certificate issued on May 29, 2014 with no limitations.

No personal flight records for the pilot-rated passenger were located, and his currency or recent flight experience could not be determined. At the times of issuance of his two prior FAA medical examinations in 2008 and 2012, he reported total flight times of 185 and 200 hours respectively, with no flight time in the preceding 6 months on both occasions.

HELICOPTER INFORMATION

The helicopter was manufactured in 2014 and equipped with a Turbomeca Arriel 2D engine. The helicopter had dual collective, cyclic, and foot pedal controls, with primary flight control intended from the right seat.

The helicopter was maintained under a continuous airworthiness program and had accrued 35.2 hours of total time since new when the accident occurred. The last inspection took place 20.6 flight hours before the accident on August 15, 2015.

The helicopter had undergone a series of twenty-three upgrades in May 2015, including the installation of an auxiliary side locker fuel tank, full length skid shoes, a radar altimeter, and a Genesys Aerosystems HeliSAS stability augmentation system and two-axis (pitch and roll) autopilot.

The HeliSAS system provided attitude stabilization and force feedback to the cyclic control, via electro-mechanical servo actuators connected in parallel to the flight controls. The systems technical overview documentation stated:

"The HeliSAS system is designed to be engaged at all times: "SAS" on before takeoff, and "SAS" off after landing. The "force feel" (force trim) feature enhances handling characteristics and mitigates inadvertent cyclic control inputs that could result in dangerous attitudes. The pilot may override the HeliSAS at any time with manual cyclic inputs. Only 3.5 lbs of pilot force in the pitch axis, and 3.0 lbs in the roll axis, at the cyclic control is required to override the system for pilot desired maneuvering when either the SAS or autopilot modes are engaged."

The helicopter was serviced with the addition of 70 gallons of Jet A fuel on the morning of the accident.

METEOROLOGICAL INFORMATION

According to the U.S. Naval Observatory's Astronomical Applications Department, the altitude of the sun when viewed from Carlsbad at 1620 would have been 4.3°, with an azimuth (E of N) of 243.7°.

FLIGHT RECORDERS

The helicopter was equipped with an Appareo Vision 1000 flight data monitor. The unit was capable of recording video, audio, GPS coordinates, and pitch, roll, yaw and acceleration data. The unit was mounted in the aft center ceiling of the cockpit.

The unit was sent to the NTSB Vehicle Recorders Division for data extraction, and a video group consisting of the NTSB investigator-in-charge and technical representatives from Turbomeca and Airbus Helicopters was convened to review the data.

The unit had recorded video and audio data, along with GPS coordinates for the entire flight. The field of view included over-the-shoulder video images of the forward cockpit, which included both cyclic controls and the right-seat collective and foot pedal controls, along with most of the instrument panel and a view out the lower forward portion of the windscreen. The unit did not record any radio or microphone audio. Only loud engine and transmission noises could be heard for the duration of the recording.

The video recording began at 1406:52 and depicted the helicopter stationary on the dolly at the east end of the FBO's ramp, with the engine running and the pilot configuring the avionics system. Six minutes later, the helicopter departed.

GPS data indicated that for the next 27 minutes the helicopter flew generally to the east and approached an open field at an elevation of about 4,500 ft mean sea level (msl), 4.5 miles south of the peak of Palomar Mountain. The helicopter then performed a left downwind landing approach into the field, lined up on final from the south, and landed at the far end of the field just short of the tree line. Twenty seconds after landing, the pilot turned on the SAS system. The pilot then initiated a hover, and the helicopter lifted off the ground and immediately yawed about 25° to the left, before setting back onto the ground. Thirty seconds later, the pilot began another hovering maneuver, and, after lifting off the ground, the helicopter immediately spun about 150° to the right before setting back onto the ground.

About 40 seconds later, at 1443:09, the helicopter lifted off the ground up uneventfully, and departed toward the southeast. For the next hour, the helicopter took a route toward the Salton Sea, then north along the coastline toward La Quinta, where it turned inland and began to

NTSB Probable Cause

The pilot's loss of control during landing on a dolly. Contributing to the accident were the pilot's decision to conduct the flight without an instructor despite multiple flight instructors' recommendations to the contrary, his failure to land on the ramp when he experienced difficulty landing on the dolly, and his impaired decision-making, judgment, and psychomotor performance, due to his use of a combination of two psychoactive drugs.