MIA02TA082 · Aerospatiale SA319B Alouette III

The accident pilot noted that the day before the accident date, the normal brakes were inoperative. Maintenance was notified of the brake discrepancy, and he was advised by maintenance personnel that the brakes would be inspected that evening during the planned 25-hour inspection. The next morning (day of the accident), he became aware the brakes had not been repaired and he believed he was informed while in dispatch of a search and rescue mission; the site was located approximately 40 miles from the helibase. He expressed concern to the chief pilot about operation of the helicopter with inoperative brakes, but the chief pilot felt it was alright for the flight to proceed. Since the assigned mission was for search and rescue, the chief pilot suggested and he concurred, "that due to possible lives at stake, I could accept the mission." The flight departed, proceeded to the search area with negative results, then elected to return to the helibase. After arrival at the helibase, he performed a hover power check. After completion of the hover power check, he maneuvered the helicopter over the landing pad. The chief pilot was standing by with chocks to chock the wheels upon landing as was previously arranged due to the inoperative brakes. He made a normal touchdown and as the nose gear lowered, he expected the chief pilot to chock the wheels. As the helicopter settled, it rolled forward towards the hangar, and he attempted to control the forward movement by positioning of the flight controls, aware of the cyclic limitations during ground operations. He could not arrest the forward movement and was concerned about contacting the hangar; the chocks were not in place. The next thing he recalled was feeling the helicopter vibrating, followed by the cyclic making extreme movements in the cockpit. The pilot also stated that the helicopter encountered what he felt were normal vibrations, and was not positive the helicopter encountered complete ground resonance. He attempted to lift to a hover to correct the situation but was not sure if the helicopter even became airborne. The passenger stated that after landing, he noticed out of the corner of his eye the helicopter appeared to be rolling forward. He later recalled the pilot stating that the helicopter was lifting. He noticed a vibration, and noted that the nose lifted to what he thought was a normal angle. The vibration turned into violent shaking which was throwing him around in his seat. The helicopter moved to over grass and started moving down a little faster. He noticed that parts from the helicopter started separating either when the helicopter quit moving towards the ground or the nose landing gear was fully compressed. An object hit his left arm and thigh coming to rest on the floor near his feet. He noted the pilot trying to secure the engine, smelled jet fuel, and evacuated the wreckage. The chief reported that the pilot made a normal approach which ended with a power check at a low hover. The pilot then maneuvered the helicopter over the helipad to land and after touching down, the helicopter began to roll forward slightly. He stated that the pilot attempted to pick up to a hover and when only the main landing gears were on the ground but fully extended, the helicopter began to shake. He reported hearing a loud sound or crash and the pilot and passenger exited the helicopter. He secured the engine with the emergency fuel shutoff lever. He further stated that with respect to the brakes, he and the director of maintenance (DOM) were both aware that the brakes were inoperative the day before, and on the day of the accident before the accident flight, he was made aware the brakes were not repaired. He called the DOM who advised the brakes would be fixed on the accident date, and he (chief pilot) considered the inoperative brakes to be a minor deficiency; the helicopter was not taken out of service. He further reported that due to the search and rescue mission, the urgency and considerations changed, and that he believed the inoperative brake situation needed to be addressed promptly but was not an airworthy issue when compared for example with a fixed wing airplane. Review of the "Aircraft Contract Daily Diary" sheet for the day before the accident revealed, "...Hydraulic brakes not working-mechanic notified." According to a FAA airworthiness inspector, maintenance personnel from the owner of the helicopter performed maintenance on the wheel brakes of the helicopter the day before the accident but did not have a proper fitting to bleed the brakes. Maintenance personnel were scheduled to bleed the brakes on the day of the accident but did not. No maintenance record entry was made in the permanent maintenance records indicating the brakes were inoperative. The helicopter did not have an FAA approved minimum equipment list (MEL).

Verbatim NTSB analysis and probable cause from the NTSB dataset