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CEN14FA193 · Airbus AS350 B3E

9 Apr 2014 · Albuquerque, NM, United States

PHI Air Medical Airbus AS350 B3E · Accident: loss of control in flight during takeoff

From University of New Mexico Hospital Heliport (NM11) to Rio Rancho, NM

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Event

NTSB case
CEN14FA193
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Airbus AS350 B3E

Aircraft type
Airbus AS350
Category
Helicopter
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N395P
Onboard fatalities
Unknown
Route
From University of New Mexico Hospital Heliport (NM11), Albuquerque, NMTo Rio Rancho, NM
Aircraft age
About 1 year (built 2013)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Takeoff
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Loss of control in flight
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Not determined › Not determined

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

The commercial rated pilot planned to depart on a repositioning flight from a medical helipad located on a hospital rooftop with two medical technicians on board. The pilot reported that he completed all of the pretakeoff hydraulic checks and did not note any abnormities with the pedal movement. As the helicopter lifted from the helipad, the pilot expected a slight left turn; however, the helicopter kept turning. The pilot tried to stop the turn without success, and the helicopter then entered a left spin. The pilot reported that the (antitorque) pedals felt jammed or locked in the neutral position. The pilot added that, during the spin, he looked for a light but that he did not recall seeing any (warning) lights. Video footage from a security camera captured the helicopter completing several rotations before it impacted the rooftop and then came to rest adjacent to the helipad.

The helicopter was equipped with a dual (upper and lower) hydraulic system, and the lower system was used to power the single-servo tail rotor servo control and the yaw load compensator. Testing and examination of the lower hydraulic system did not reveal any abnormalities. Data from the helicopter's quick access recorder (QAR) and nonvolatile memory (NVM) from the engine controls were also downloaded; no abnormities were noted.

An examination of the cockpit found the yaw servo hydraulic switch on the collective in the "on" (flight) position, the correct position for the flight. The "ACCU TEST" switch, which controls the accumulator for the tail rotor, was also found in the normal (flight) position. The NVM does not record the positioning of the switches, and analysis of the recorded data provided no indication that the switches were activated during flight.

The investigation tried to determine a reason for the development of the helicopter's spin. Given the pilot's statement that the wind was "relatively calm," which was corroborated by the security camera video footage that showed the wind effect on the nearby smoke and water, a loss of tail rotor effectiveness likely did not occur. Drive continuity of the tail rotor and control continuity from the pedals to the tail rotor were established. No evidence of foreign object debris (FOD), including any witness marks that could be associated with the presence of FOD, was observed in the pedal control system, and there was no evidence indicating that a pedal had jammed.

During takeoff, it is likely that there was an absence of hydraulic boost to the tail rotor pedals, either from a misconfiguration of the yaw hydraulic isolation switch or a failure in the lower hydraulic system that was not evident during postaccident testing. Although the specific cause of the absence of hydraulic boost to the pedals could not be identified, there was no evidence of either abnormal functionality of the lower hydraulic system or a tail rotor hydraulic circuit misconfiguration. Additionally, by design, the helicopter's caution panel does not provide a warning indication when the yaw hydraulic isolation switch is activated.

The manufacturer had originally equipped the helicopter with a cockpit imaging system; however, the operator had removed the system. The removal of this system precluded a determination of the configuration of the hydraulic control switches before takeoff. Further, due to the lack of available cockpit images, the investigation was unable to verify the pilot's actions before takeoff, including whether he moved the hydraulic isolation to "off" before the loss of control.

Probable cause

The pilot's loss of yaw control during takeoff due to the absence of hydraulic boost to the tail rotor pedals for reasons that could not be determined based on the available information. A finding in the accident was the lack of a caution indicator to alert the pilot of the lower hydraulic system configuration.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record CEN14FA193
Event ID
20140409X31907
Case number
CEN14FA193
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 41621a296bb0e7fa5a99141dcce6917404bb67afee0c4dd97ddeaa35cc4c7f37; retrieved 2026-09-15T23:29:41.072Z.