SEA06FA015 · Agusta A109E

In preparation for departure from the hospital's second story roof helipad, the pilot stated that once both engines were running he put both engine control switches to FLIGHT and verified that there were no caution lights. The aircraft's DO/VERIFY checklist was then verified after all pre-takeoff items had been completed. He then set the rotor rpm switch to the 102% position, pulled enough collective to bring the helicopter to a hover, and then verified 102% rpm before pulling collective for takeoff power and adding forward cyclic to start the climb-out. As the aircraft started its forward motion the pilot heard "ROTOR LOW" in his headset as the helicopter began to settle. The aircraft's tail rotor subsequently impacted the helipad's concrete barrier, resulting in the helicopter descending over a dirt filled courtyard, which was bordered on the east by a building approximately 40 feet away. The aircraft subsequently impacted the building, coming to rest on its right side after spinning around 180 degrees. There was no post-crash fire. The pilot then shut down both engines and aided in the evacuation of the helicopter's occupants. A post-accident examination conducted by an FAA inspector shortly after the accident revealed that both engine control switches were in the OFF position. Testing of various components and both engines failed to reveal any anomalies which would have precluded normal operation of the helicopter. Data from the Enhanced Ground Proximity Warning System (EGPWS) revealed that the number 1 engine was producing normal and abnormally high torque values during the takeoff sequence, while a zero torque value but proper Ng values were observed from data on the number 2 engine during takeoff; this is consistent with the number 2 engine control switch remaining in the IDLE position. The pilot's total time in all helicopters was 7,923 hours, with 15 hours in make and model. The pilot reported that during both his transition ground school training and flight training courses on the type accident helicopter, he had questioned the instructors about previous accidents involving the position of the engine control switches during the start sequence. A comparison of the Agusta Rotorcraft Flight Manual and the Agusta General Familiarization Training Manual revealed they provided inconsistent instructions about when to move the engine control switches from the IDLE to the FLIGHT position. The pilot also revealed that the operation of the limit override switch was never demonstrated during his training and remembered that it was in an awkward position. The limit override switch was not activated during the takeoff sequence, as the pilot was unsuccessful in locating it.

Verbatim NTSB analysis and probable cause from the NTSB dataset