ASRS Report Set - Rotary Wing Aircraft Flight Crew Reports by jianghongl

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									                                                 ASRS Database Report Set

                       Rotary Wing Aircraft Flight Crew Reports


Report Set Description.........................................A sampling of reports from flight crew of rotary wing
                                                               aircraft.

Update Number....................................................20.0

Date of Update .....................................................December 2, 2011

Number of Records in Report Set........................50

Number of New Records in Report Set ...............40

Type of Records in Report Set.............................For each update, new records received at ASRS will
                                                          displace a like number of the oldest records in the
                                                          Report Set, with the objective of providing the fifty
                                                          most recent relevant ASRS Database records. Records
                                                          within this Report Set have been screened to assure
                                                          their relevance to the topic.
National Aeronautics and
Space Administration

Ames Research Center
Moffett Field, CA 94035-1000




TH: 262-7


MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data

SUBJECT: Data Derived from ASRS Reports

The attached material is furnished pursuant to a request for data from the NASA Aviation Safety
Reporting System (ASRS). Recipients of this material are reminded when evaluating these data
of the following points.

ASRS reports are submitted voluntarily. The existence in the ASRS database of reports
concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem
within the National Airspace System.

Information contained in reports submitted to ASRS may be amplified by further contact with
the individual who submitted them, but the information provided by the reporter is not
investigated further. Such information represents the perspective of the specific individual who is
describing their experience and perception of a safety related event.

After preliminary processing, all ASRS reports are de-identified and the identity of the individual
who submitted the report is permanently eliminated. All ASRS report processing systems are
designed to protect identifying information submitted by reporters; including names, company
affiliations, and specific times of incident occurrence. After a report has been de-identified, any
verification of information submitted to ASRS would be limited.

The National Aeronautics and Space Administration and its ASRS current contractor, Booz
Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be
made by others of any material or data furnished by NASA in response to queries of the ASRS
database and related materials.




Linda J. Connell, Director
NASA Aviation Safety Reporting System
                       CAVEAT REGARDING USE OF ASRS DATA

Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and
thus cannot be considered a measured random sample of the full population of like events. For
example, we receive several thousand altitude deviation reports each year. This number may
comprise over half of all the altitude deviations that occur, or it may be just a small fraction of
total occurrences.

Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other
participants in the aviation system are equally aware of the ASRS or may be equally willing to
report. Thus, the data can reflect reporting biases. These biases, which are not fully known or
measurable, may influence ASRS information. A safety problem such as near midair collisions
(NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because
the airmen who operate in area “A” are more aware of the ASRS program and more inclined to
report should an NMAC occur. Any type of subjective, voluntary reporting will have these
limitations related to quantitative statistical analysis.

One thing that can be known from ASRS data is that the number of reports received
concerning specific event types represents the lower measure of the true number of such
events that are occurring. For example, if ASRS receives 881 reports of track deviations in
2010 (this number is purely hypothetical), then it can be known with some certainty that at
least 881 such events have occurred in 2010. With these statistical limitations in mind, we
believe that the real power of ASRS data is the qualitative information contained in report
narratives. The pilots, controllers, and others who report tell us about aviation safety
incidents and situations in detail – explaining what happened, and more importantly, why it
happened. Using report narratives effectively requires an extra measure of study, but the
knowledge derived is well worth the added effort.
Report Synopses
ACN: 972197          (1 of 50)


Synopsis
 Two BK-117 pilots failed to notice on preflight inspection that a mechanic had
 installed the left dual cyclic control backwards. The error was noted prior to flight.


ACN: 971468          (2 of 50)


Synopsis
 A Eurocopter pilot reported an NMAC with another Eurocopter on approach to the
 LAS airport.


ACN: 971467          (3 of 50)


Synopsis
 A BK-117 pilot suffered disorientation and vertigo on a dark night flight and
 descended within 400 FT off the surface before realizing his dilemma and regaining
 control and a safe altitude.


ACN: 970080          (4 of 50)


Synopsis
 A Helicopter pilot reported diverting to check out a change in pressure or possible
 fuel gauge problem. After ground inspection, the reporter continued to his
 destination.


ACN: 969689          (5 of 50)


Synopsis
 An EMT helicopter, crossing the departure end of a major airport runway and in
 radar contact with Approach Control suffered Near Mid Air Collision with a business
 jet departing from that runway. Approach Control provided no traffic information to
 either aircraft.


ACN: 969545          (6 of 50)


Synopsis
 An R-44 helicopter instructor engaged in pilot training filed an IFR flight plan.
 During the flight he refused ATC instruction to descend out of VMC into IMC since
 the aircraft was not certified for IFR flight.


ACN: 969372          (7 of 50)


Synopsis
 Tower Controller described a conflict between a VFR helicopter departure and an
 IFR arrival, the reporter noting increases vigilance and improved scanning on his
 part may have prevented this occurrence.
ACN: 968719          (8 of 50)


Synopsis
 MKC Controller voiced concern regarding the Conflict Alert (CA/CA) and it's viability,
 noting distractions caused by constant unnecessary alerts.


ACN: 968512          (9 of 50)


Synopsis
 ZHU Controller reported an unsafe condition involving helicopter operations in the
 Gulf Of Mexico suggesting improved radio coverage and the elimination of similar
 callsigns.


ACN: 968463          (10 of 50)


Synopsis
 The pilot of an "electronic news gathering" helicopter expressed concern that area
 law enforcement agencies were improperly demanding that their operations over
 criminal activities and associated police actions be restricted by ATC. The reporter
 contends that a TFR must first be activated before news agencies can be excluded
 from the vicinity of any news worthy event, including those that put them
 potentially in harm's way from criminal activites.


ACN: 968239          (11 of 50)


Synopsis
 A BK-177 Pilot aborted an engine start after the number two engine N1 failed to
 rotate and the TOT rose abnormally because the tail rotor tie down was not
 removed.


ACN: 967135          (12 of 50)


Synopsis
 Newly hired helicopter pilot reports tail stinger contact with a fence during landing.
 No abnormal handling or vibration is felt and the aircraft is flown, with passengers,
 to the next destination. Post flight inspection reveals no damage but the reporter is
 terminated two days later.


ACN: 967078          (13 of 50)


Synopsis
 An EMS helicopter pilot addressed his concerns about the use of non certified
 medical equipment aboard EMS aircraft while in flight.


ACN: 965814          (14 of 50)


Synopsis
 Two captains report about a Sikorsky S61N helicopter that had been flying for a
 week after a pitch link had been changed on the #1 engine stator gang assembly
 without a topping check being accomplished.


ACN: 965318          (15 of 50)


Synopsis
 CRQ Controller witnessed a loss of separation event between an arrival and
 departure during a training session.


ACN: 963717          (16 of 50)


Synopsis
 The Instructor Pilot failed to intervene in a timely manner when the pilot flying
 commercial student let the main rotor RPM drop excessively during low altitude
 orbit practice. The main rotor struck "vegetation" before the instructor was able to
 recover. No injuries or significant damage to the rotor system occurred.


ACN: 963041          (17 of 50)


Synopsis
 After the 100 hour scheduled maintenance service and while on a ferry flight to its
 base, a tail rotor drive shaft cowling came off striking the main and tail rotors of an
 AS350.


ACN: 962902          (18 of 50)


Synopsis
 An AS332 pilot reported that after takeoff, he was putting his kneeboard on when it
 was sucked out by the slip stream of an open door which is normally closed but
 open for this flight because of the heat.


ACN: 962890          (19 of 50)


Synopsis
 An SK-76C helicopter flight crew followed appropriate emergency procedures and
 landed using single engine techniques following receipt of a chip detector warning
 in the number two engine.


ACN: 960711          (20 of 50)


Synopsis
 A Base Mechanic reports finding a 13mm wrench on the left-hand side of the Main
 Transmission Deck of an EC135 Eurocopter during a daily Maintenance Check.


ACN: 959905          (21 of 50)
Synopsis
 A helicopter pilot reported a near miss with an airplane at about 1,700 FT during a
 VFR departure in JNU airspace with no ATC traffic reports or communications from
 the other aircraft.


ACN: 959755          (22 of 50)


Synopsis
 A helicopter instructor pilot reported a near miss with an agricultural helicopter in a
 rural California area.


ACN: 959551          (23 of 50)


Synopsis
 A ZDV Controller issued an ILS Approach when in fact the ILS was NOTAMed "Out
 of Service". The reporter noted the volume of NOTAMS listed in the ERIDS, and the
 lack of listing priority, as a contributing factor to the oversight.


ACN: 957774          (24 of 50)


Synopsis
 A news helicopter pilot covering an auto accident near EQY reported an intentional
 near miss with a C172 whose pilot was irritated by the helicopter's presence.


ACN: 957763          (25 of 50)


Synopsis
 R44 pilot observes a Main Rotor Chip Light and lands on a closed runway after
 experiencing very stiff controls.


ACN: 957608          (26 of 50)


Synopsis
 A helicopter pilot at 6,800 FT had a near miss over BDU with a NORDO tow aircraft
 and radio equipped glider under tow only to find out that an established FAA tow
 pattern is approved in which pilots make no calls once airborne.


ACN: 956485          (27 of 50)


Synopsis
 Helicopter pilot at 650 MSL experiences a NMAC with a Cessna departing Runway
 17. The reporter had received a clearance through the Class D and a squawk two
 minutes prior to the incident. Evasive action was taken by both aircraft.


ACN: 954870          (28 of 50)
Synopsis
 After takeoff on the fifth flight during a 12 hours shift, an Agusta 109E helicopter
 pilot inadvertently moved the Engine Control Switch to the Idle position. He caught
 the error quickly when the engine sound changed.


ACN: 952309           (29 of 50)


Synopsis
 A helicopter pilot on a practice ILS reported traffic confliction with a training aircraft
 which overtook him and then overflew the airport in a show of frustration. There is
 no report of ATC guidance during this event.


ACN: 949343           (30 of 50)


Synopsis
 A Lead Mechanic reported a chronic intercom failure between the front seat pilots
 and the back seat Medic and Flight Nurse on a Eurocopter AS-350. He also noted
 the lack of support from his Management to perform proper troubleshooting and
 pressure to continue deferring the intercom discrepancy.


ACN: 948560           (31 of 50)


Synopsis
 A BK117 pilot discovered a possible delamination in one of the tail rotor blades
 while conducting the sixth walk around of the day. The flaw was very difficult to
 detect until daylight at the correct angle revealed a shadow which, when examined,
 revealed the flaw.


ACN: 947974           (32 of 50)


Synopsis
 EMS helicopter pilot reports NMAC with another helicopter apparently rubber
 necking an accident scene.


ACN: 946265           (33 of 50)


Synopsis
 Medevac helicopter pilot reports airborne conflict with another opposite direction
 helicopter at 5500 feet.


ACN: 946202           (34 of 50)


Synopsis
 A BK-117 Pilot elected to land at the nearest suitable airport when a tail rotor chip
 light illuminated and would not fuzz burn off, only to learn the selected airport was
 closed due to an earlier runway excursion. The Local Controller opted to clear the
 helo for the landing at the helipad for safety of flight concerns.
ACN: 944804          (35 of 50)


Synopsis
 LAX Controllers described a potential conflict event between an air carrier departure
 from the south complex and a helicopter on a photo mission between the runway
 complexes, both reporter's recommending no future photo missions.


ACN: 944481          (36 of 50)


Synopsis
 R44 pilot reports a precautionary off airport landing due to airspeed indicator failure
 and thunderstorms in the area.


ACN: 943861          (37 of 50)


Synopsis
 Two mechanics report finding unapproved access holes in the lower belly section of
 the external fuselage skin of various Eurocopter BK-117 helicopters. The holes were
 used to access the fuel transfer tube attach clamps that tend to leak fuel when
 flying from warm weather to frigid winter weather states.


ACN: 942396          (38 of 50)


Synopsis
 Tower Controller described a confused SVFR event when both the ATC personnel
 and the pilot were apparently unfamiliar with SVFR requirements and conditions.


ACN: 941070          (39 of 50)


Synopsis
 VFR helicopter pilot arriving perpendicular to the active runways reports NMAC with
 VFR CE525 on low missed approach.


ACN: 939468          (40 of 50)


Synopsis
 An EMS helicopter pilot reported an NMAC with two T-45s at low altitude and high
 speed over a Naval Air Station.


ACN: 936369          (41 of 50)


Synopsis
 TOL Controller providing OJT described a possible loss of separation event involving
 a helicopter taxiway departure along side of an Air Carrier departure, noting the
 required separation criteria is less than clear.
ACN: 936206          (42 of 50)


Synopsis
 Controller described a possible conflict between traffic on the ILS Runway 6
 approach executing a missed approach and traffic on the ILS for another airport.
 Confusion exists regarding the altitude for the missed procedure.


ACN: 935710          (43 of 50)


Synopsis
 Tower Controller described a harrowing event when an inbound SVFR Helicopter
 became disorientated an entered a spinning descent for landing.


ACN: 935390          (44 of 50)


Synopsis
 DCA Controller reported a TCAS RA event experienced by a River Visual arrival
 during operations utilizing combined Local and Helicopter positions, suggesting the
 an increase in the use of the Helicopter position.


ACN: 934278          (45 of 50)


Synopsis
 Mechanic reports he was instructed by his Shop Supervisor to reset the Total Outlet
 Temperature (TOT) Overtemp light that had illuminated during an engine start on a
 Bell 206 L-4 helicopter with an Allison/Rolls Royce engine. He failed to ask the pilot
 if the engine had actually overtemped, which would require a Hot Start Inspection.


ACN: 933511          (46 of 50)


Synopsis
 DCA Controller described a TCAS RA event involving an arrival to Runway 19 and a
 helicopter landing at Georgetown Hospital, the helicopter climbing unexpectedly
 after granting a frequency change.


ACN: 932794          (47 of 50)


Synopsis
 A Bell 206B3 battery overheated on approach and melted an adjacent plastic
 component causing smoke. The pilot removed the melted component and returned
 to base where a faulty battery was replaced but he later questioned his return
 flight's legality prior to maintenance.


ACN: 931477          (48 of 50)


Synopsis
 An EMS helicopter pilot reported that some hospitals use green helipad perimeter
 lights which are not visible to pilots wearing night vision goggles. The FAA Safety
 Alert for Operators (SAFO) does not address avoiding the green 490-550
 nanometer visible light range.


ACN: 930446          (49 of 50)


Synopsis
 An S-76 helicopter pilot diverted to a nearby airport when air conditioning fumes
 misidentified as smoke filled the cabin shortly after takeoff from a nearby heliport.


ACN: 930339          (50 of 50)


Synopsis
 An Air Carrier Captain and LAS Tower Controller report a departing helicopter
 approached the 1R departure path after the jet's takeoff causing a TCAS TA.
Report Narratives
ACN: 972197

Time / Day
 Date : 201109
 Local Time Of Day : 1801-2400

Place
 Altitude.AGL.Single Value : 0

Aircraft
 Reference : X
 Make Model Name : Helicopter
 Mission : Ambulance
 Flight Phase : Parked

Component
 Aircraft Component : Cyclic Control
 Aircraft Reference : X

Person
 Reference : 1
 Location Of Person : Gate / Ramp / Line
 Location In Aircraft : Flight Deck
 Reporter Organization.Other
 Function.Flight Crew : Captain
 ASRS Report Number.Accession Number : 972197
 Human Factors : Confusion
 Human Factors : Workload
 Human Factors : Training / Qualification
 Analyst Callback : Completed

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : Maintenance
 Detector.Person : Flight Crew
 When Detected : Pre-flight
 Result.General : Maintenance Action

Assessments
 Contributing Factors / Situations   :   Equipment / Tooling
 Contributing Factors / Situations   :   Aircraft
 Contributing Factors / Situations   :   Procedure
 Contributing Factors / Situations   :   Human Factors
 Primary Problem : Procedure

Narrative: 1
 I arrived at work for night shift. Upon completion of signing in, checking the aircraft
 logbook, getting a flight release, checking NOTAMs and TFRs, checking weather,
 performing the pilot brief, briefing the communications staff, and briefing the
 medical crew, I drove to the Helipad and performed what I thought to be a
 thorough preflight. It was dark due to the time of day and misting due to an
 approaching thunderstorm. I used a flashlight and I paid particular attention to the
 maintenance that had been done that day involving the #2 Engine Fuel Pump
 replacement. I was aware that the Dual Controls had also been installed that day
 per the logbook entry and that both the Fuel Pump and Dual Controls Installation
 had been checked by the day shift pilot. I completed the preflight noting nothing
 out of the ordinary. I did not fly during my shift as weather was below my
 minimums. After leaving work the following morning I drove home and later that
 day received a call from the day shift pilot informing me that the mechanic had
 installed the cyclic backwards and that we had all missed this error during the
 installation phase and during my and his preflights. The day pilot found the error
 prior to any damage or injuries while preparing to depart on a patient flight. The
 mechanic was notified; he installed the cyclic correctly. The flight was delayed
 approximately 20 minutes for this error. Suggestions: 1. Each pilot should sit at
 each pilot station that has a set of controls during preflight to ensure that the
 controls are mounted correctly and a full flight control function check (at each
 station) should be performed each time the duals are removed or installed. 2. To
 completely avoid this error it may be appropriate for the manufacturer to re-
 engineer the way flight controls are mounted so that they can only be installed the
 correct way. The adage "Change is written in blood" certainly could have applied
 had this error not been detected prior to takeoff.

Callback: 1
 Reporter stated that the left cyclic control was installed backwards and that if the
 left seat was moved forward, movement of the cyclic could be hindered by contact
 with the seat.

Synopsis
 Two BK-117 pilots failed to notice on preflight inspection that a mechanic had
 installed the left dual cyclic control backwards. The error was noted prior to flight.
ACN: 971468

Time / Day
 Date : 201109
 Local Time Of Day : 1201-1800

Place
 Locale Reference.ATC Facility : LAS.Tower
 State Reference : NV
 Altitude.AGL.Single Value : 100

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 10
 Light : Daylight
 Ceiling.Single Value : 10000

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : LAS
 Aircraft Operator : Air Taxi
 Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Passenger
 Flight Phase : Final Approach
 Route In Use.Other
 Airspace.Class B : LAS

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : LAS
 Aircraft Operator : Air Taxi
 Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Passenger
 Flight Phase : Takeoff
 Route In Use.Other
 Airspace.Class B : LAS

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Commercial
 Experience.Flight Crew.Total : 4076
 Experience.Flight Crew.Last 90 Days : 95
 Experience.Flight Crew.Type : 2376
 ASRS Report Number.Accession Number : 971468

Events
 Anomaly.Conflict : NMAC
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 425
 Miss Distance.Vertical : 50
 When Detected : In-flight
 Result.Flight Crew : Took Evasive Action

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Primary Problem : Ambiguous

Narrative: 1
 On final approach to the south to the transient parking ramp, a fast moving,
 climbing helicopter became visible to my 3 O'clock position from behind a hangar. I
 decelerated and turned right. Before I could make a radio call over the Tower
 frequency the other pilot performed a quick-stop maneuver and reversed course. I
 returned to finish my approach on a slightly modified course and taxied back to the
 company parking area. The operator that I am employed by, the other operator,
 and our designated FAA POI have discussed the occurrence and made procedural
 changes. We hope that these changes--now in effect--will prevent a similar
 occurrence in the future. The new procedure includes an additional radio call to
 alert helicopters in take-off position of an aircraft on base turn, and a different
 approach course to increase visibility for one aircraft to see the other from either
 side of the hangar (per McCarran Tower LOA, radio calls between aircraft are
 allowed to aid in maintaining adequate separation).

Synopsis
 A Eurocopter pilot reported an NMAC with another Eurocopter on approach to the
 LAS airport.
ACN: 971467

Time / Day
 Date : 201109
 Local Time Of Day : 1801-2400

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Relative Position.Angle.Radial : 150
 Relative Position.Distance.Nautical Miles : 20
 Altitude.MSL.Single Value : 700

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 5
 Work Environment Factor : Poor Lighting
 Light : Night
 Ceiling.Single Value : 800

Aircraft
 Reference : X
 Aircraft Operator : Government
 Make Model Name : MBB-BK 117 All Series
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission : Passenger
 Flight Phase : Cruise
 Route In Use : Direct
 Airspace.Class E : ZZZ

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Government
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Multiengine
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Instrument
 Qualification.Flight Crew : Rotorcraft
 Experience.Flight Crew.Total : 10000
 Experience.Flight Crew.Last 90 Days : 80
 Experience.Flight Crew.Type : 2500
 ASRS Report Number.Accession Number : 971467
 Human Factors : Physiological - Other
 Human Factors : Human-Machine Interface
 Human Factors : Confusion

Events
 Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown
 Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
 Detector.Person : Flight Crew
 Were Passengers Involved In Event : N
 When Detected : In-flight
 Result.Flight Crew : Regained Aircraft Control
 Result.Flight Crew : Returned To Departure Airport

Assessments
 Contributing Factors / Situations : Environment - Non Weather Related
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 While enroute to pick up a patient I encountered a visual illusion of a false horizon
 resulting in a right descending turn. At approximately 400 AGL I recognized the
 conflict between what appeared to be happening and what the instruments were
 telling me. I initiated an immediate climb. Since, for most of our operational area,
 the MSA is 2,000 MSL this was my default target altitude. After arriving at that
 altitude and giving myself time to master control of the aircraft by instruments, I
 confirmed my position with my dual GPS systems as well out over the water. I then
 descended to 1,200 MSL at which altitude I reestablished VFR flight and returned to
 my home airport.

Synopsis
 A BK-117 pilot suffered disorientation and vertigo on a dark night flight and
 descended within 400 FT off the surface before realizing his dilemma and regaining
 control and a safe altitude.
ACN: 970080

Time / Day
 Date : 201109
 Local Time Of Day : 1201-1800

Place
 Locale Reference.ATC Facility : ZSU.ARTCC
 State Reference : PR

Environment
 Weather Elements / Visibility.Visibility : 5
 Light : Daylight
 Ceiling.Single Value : 2500

Aircraft
 Reference : X
 ATC / Advisory.Center : ZSU
 Aircraft Operator : Personal
 Make Model Name : Helicopter
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Mission : Personal
 Route In Use : Direct

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Personal
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Rotorcraft
 Qualification.Flight Crew : Private
 Experience.Flight Crew.Total : 2000
 Experience.Flight Crew.Last 90 Days : 20
 Experience.Flight Crew.Type : 800
 ASRS Report Number.Accession Number : 970080
 Human Factors : Human-Machine Interface

Events
 Anomaly.Aircraft Equipment Problem : Less Severe
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.Flight Crew : Diverted
 Result.Flight Crew : Landed As Precaution
 Result.Air Traffic Control : Issued New Clearance

Assessments
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Aircraft
 Primary Problem : Aircraft

Narrative: 1
 On a flight from San Martin to Isla Grande Airport I noticed a change in pressure or
 a fuel gauge problem. As soon as I noticed this situation I reported it to San Juan
 Center, but that it was not an emergency. However, I felt uncomfortable with the
 gauge situation so I made a request to land at Seiba to check the aircraft fuel
 gauge problem. After landing and discussing this with US Customs I continued to
 Isla Grande Airport.

Synopsis
 A Helicopter pilot reported diverting to check out a change in pressure or possible
 fuel gauge problem. After ground inspection, the reporter continued to his
 destination.
ACN: 969689

Time / Day
 Date : 201109
 Local Time Of Day : 0601-1200

Place
 Locale Reference.ATC Facility : ZZZ.Tower
 State Reference : US
 Altitude.MSL.Single Value : 2400

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Flight Phase : Cruise

Aircraft : 2
 Reference : Y
 Make Model Name : Light Transport

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Rotorcraft
 Qualification.Flight Crew : Commercial
 ASRS Report Number.Accession Number : 969689
 Human Factors : Situational Awareness
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : Flight Crew

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Conflict : NMAC
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 0
 Miss Distance.Vertical : 499
 Were Passengers Involved In Event : Y
 When Detected : In-flight
 Result.Flight Crew : Took Evasive Action

Assessments
 Contributing Factors / Situations   :   Airspace Structure
 Contributing Factors / Situations   :   Airport
 Contributing Factors / Situations   :   Procedure
 Contributing Factors / Situations   :   Human Factors
 Primary Problem : Ambiguous

Narrative: 1
 On climbout from the Medical Center, which is within the Class C, I contacted
 Approach and advised them of my position and destination. The Controller came
 back with radar contact, the current altimeter and cleared me on course. The
 heading that I was using was about 220 degrees, I was following the readout on
 the G430 as well as the G500. This heading took me to about 2-3 miles north of
 the departure ends of XXL and XXR. After I was cleared on course by approach I
 climbed to an indicated altitude of 2400 feet for the westbound heading. As I got
 within two miles of the departure end of XXR I saw what appeared to be a jet on
 takeoff roll on XXR. I was not advised of this by either Approach Control or the
 Tower. As I continued I saw this Business Jet lift off and immediately began a left
 turn and climb out. I continued to monitor the flight path of this jet, still with no
 traffic advisory from either approach or tower. With the appearance that there was
 an impending traffic conflict I immediately began a descent. I was able to descend
 from 2400 down to about 2000 indicated before the jet passed directly overhead at
 what appeared to be less than 500 feet vertical separation. I did get an indication
 from the G430 and G500 of a traffic advisory. It is my opinion that the pilots of this
 jet never saw our helicopter and I don't know if they were given traffic advisories
 by the tower as I was still up on approach control frequency. I never had contact
 with approach control again until he released me to squawk VFR and change to
 advisory at the outer limits of his control area. This type of event has never
 happened to me before, usually approach control will hand me off to the tower if
 there is traffic in the pattern or traffic that will be taking off in my flight path
 direction. I believe we needed better communication between controlling
 authorities and the pilots.

Synopsis
 An EMT helicopter, crossing the departure end of a major airport runway and in
 radar contact with Approach Control suffered Near Mid Air Collision with a business
 jet departing from that runway. Approach Control provided no traffic information to
 either aircraft.
ACN: 969545

Time / Day
 Date : 201108
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : SBM.Airport
 State Reference : WI
 Relative Position.Distance.Nautical Miles : 20
 Altitude.MSL.Single Value : 3000

Environment
 Weather Elements / Visibility : Haze / Smoke
 Weather Elements / Visibility : Cloudy
 Weather Elements / Visibility.Visibility : 3
 Ceiling.Single Value : 3300

Aircraft
 Reference : X
 ATC / Advisory.TRACON : MKE
 Aircraft Operator : FBO
 Make Model Name : Robinson R44
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : IFR
 Mission : Training
 Flight Phase : Descent
 Route In Use : Direct
 Airspace.Class E : MKE

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : FBO
 Function.Flight Crew : Pilot Not Flying
 Qualification.Flight Crew : Rotorcraft
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Instrument
 Experience.Flight Crew.Total : 1920
 Experience.Flight Crew.Last 90 Days : 25
 Experience.Flight Crew.Type : 100
 ASRS Report Number.Accession Number : 969545
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party2 : ATC

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Deviation - Altitude : Overshoot
 Anomaly.Deviation - Procedural : Clearance

Assessments
 Contributing Factors / Situations :   Weather
 Contributing Factors / Situations :   Procedure
 Contributing Factors / Situations :   Human Factors
 Contributing Factors / Situations :   Aircraft
 Primary Problem : Human Factors

Narrative: 1
 I was on an IFR training flight with a student. We had filed an IFR flight plan and
 were proceeding to our first stop. ATC had taken us out over a lake at an altitude of
 6,000 FT MSL. We continued on our flight and after a while they directed us to
 descend to 3,000 FT. I advised "unable" as it would take us into the clouds. When
 queried as to why, I advised that we needed to stay in VMC as the aircraft is not
 certified for IFR flight. This seemed to upset them and they advised to let them
 know when we could descend. When we arrived over an area that we were able to
 descend we advised and proceeded down to 3,000 FT. The descent was a little too
 fast and we wound up going lower than the requested 3,000 MSL down to 2,500
 MSL. I immediately requested an altitude lower than 3,000 FT and they gave me
 2,700 FT. I went there and proceeded with the approach to SBM. Therefore, I
 unintentionally had an altitude deviation. I attribute part of the issue to ATC's lack
 of knowledge of the ability of non-IFR certified aircraft to file IFR and their attitude
 towards the situation, as well as the request to call them after landing (frankly it
 was rather upsetting) to be at least partially to blame for the altitude deviation. Of
 course, the other part of the issue would be a hurried attempt to lose the requested
 altitude, therefore going to low. To combat this issue in the future I will lose
 altitude at a more moderate rate, therefore avoiding the issue altogether.

Synopsis
 An R-44 helicopter instructor engaged in pilot training filed an IFR flight plan.
 During the flight he refused ATC instruction to descend out of VMC into IMC since
 the aircraft was not certified for IFR flight.
ACN: 969372

Time / Day
 Date : 201109
 Local Time Of Day : 0001-0600

Place
 Locale Reference.ATC Facility : ZZZ.Tower
 State Reference : US
 Altitude.MSL.Single Value : 2600

Aircraft
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Make Model Name : Helicopter
 Flight Plan : VFR
 Flight Phase : Initial Climb
 Route In Use : None

Person
 Reference : 1
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 969372
 Human Factors : Situational Awareness

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Conflict : Airborne Conflict
 Anomaly.Deviation - Procedural : FAR
 Anomaly.Deviation - Procedural : Clearance
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 I was working Local Control (LC), Helicopter called and asked for VFR departure to
 the NE. I gave him the standard, maintain VFR at or below 40, departure frequency,
 squawk assigned. The helicopter read back correctly. General Aviation Ramp is
 behind LC position about 1/2 NM. Since the helicopter did not request take off
 clearance, I did not look to see where they were on the ramp. Those of us in the
 Tower were discussing a new procedure implemented in the Tower recently when
 an arrival was switched over from RADAR to LC, I glanced at the D-Brite and
 noticed that the helicopter was going to be a conflict with the arrival. I obtained the
 helicopter's position and immediately issued traffic. Both aircraft saw each other
 and passed after Conflict Alert (CA/CA's) went off. Advise aircraft to call when
 ready at end of clearance and scan entire airport more frequently.

Synopsis
 Tower Controller described a conflict between a VFR helicopter departure and an
 IFR arrival, the reporter noting increases vigilance and improved scanning on his
 part may have prevented this occurrence.
ACN: 968719

Time / Day
 Date : 201109
 Local Time Of Day : 0001-0600

Place
 Locale Reference.Airport : MKC.Airport
 State Reference : MO
 Altitude.MSL.Single Value : 1400

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : MKC
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Flight Phase : Initial Approach
 Airspace.Class D : MKC

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : MKC
 Make Model Name : PA-44 Seminole/Turbo Seminole
 Crew Size.Number Of Crew : 1
 Flight Plan : VFR
 Flight Phase : Final Approach
 Airspace.Class D : MKC

Person
 Reference : 1
 Location Of Person.Facility : MKC.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 968719
 Human Factors : Other / Unknown

Events
 Anomaly.ATC Issue : All Types
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings
 Primary Problem : ATC Equipment / Nav Facility / Buildings

Narrative: 1
 The PA44 was on a straight-in to Runway 01, on about a 1 1/2 mile final. The
 helicopter was doing left traffic pattern work to the intersecting runway, Runway 03,
 but he was only using half the runway and was holding short of Runway 01. At the
 moment of the erroneous Conflict Alert, the helicopter was on a down wind for
 Runway 03 and abeam the numbers. This means that he was at least 2 miles
 laterally from the PA44, and this distance was increasing. The computer did not
 know the helicopter would soon turn base, so there's no reason for the computer to
 even think that the aircraft were a factor for each other at all. Good grief, 2 miles
 and increasing, 300 FT and increasing, and then the CA/CA goes off? And on
 another day targets will merge with a scant 100 FT and an "I got him in sight" and
 the alarm will never go off. The CA/CA in the terminal environment is completely
 useless. I cannot remember if MCI called on this one or not. Sometimes they call,
 sometimes they don't. At this point it doesn't matter whether they do or not
 because we know they're required to, so we're anticipating the call every time the
 MSAW or CA/CA sounds, and anticipating having to answer it so they'll shut up.
 Therefore, the mental distraction occurs by default either way. It's just worse when
 they call, because then they also step over live traffic. Recommendation, 1) The
 Centers have an awesome CA/CA system. Why can't we have a program like that
 one? It works great, with only a couple very rare situations that generate
 anomalies. 2) The MCI SOP paragraph 2-1-6, sentence 2, which requires MCI
 controllers to call MKC on the shout line every single time one of these erroneous
 alarms occurs, is an unsafe and uselessly distracting requirement, and needs to be
 stricken immediately. Think of it, it's the best of both worlds: controllers aren't
 distracted by shout line clutter on MKC's end, and controllers aren't required to
 make what they know are stupid shout line calls on MCI's end, and the
 management folks get to "err on the side of safety" over and over again. What
 could be better? Seriously, you guys should have them try this out for 30 days.
 We'll see just how committed they are to "safety."

Synopsis
 MKC Controller voiced concern regarding the Conflict Alert (CA/CA) and it's viability,
 noting distractions caused by constant unnecessary alerts.
ACN: 968512

Time / Day
 Date : 201109
 Local Time Of Day : 1201-1800

Place
 Locale Reference.ATC Facility : ZHU.ARTCC
 State Reference : TX
 Altitude.MSL.Single Value : 4000

Aircraft : 1
 Reference : X
 ATC / Advisory.Center : ZHU
 Aircraft Operator : Corporate
 Make Model Name : S-76/S-76 Mark II
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Flight Phase : Cruise
 Airspace.Class E : ZHU

Aircraft : 2
 Reference : Y
 ATC / Advisory.Center : ZHU
 Aircraft Operator : Corporate
 Make Model Name : S-76/S-76 Mark II
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Flight Phase : Takeoff
 Airspace.Class E : ZHU

Person
 Reference : 1
 Location Of Person.Facility : ZHU.ARTCC
 Reporter Organization : Government
 Function.Air Traffic Control : Instructor
 Function.Air Traffic Control : Enroute
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 968512
 Human Factors : Communication Breakdown
 Human Factors : Confusion
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : Flight Crew

Events
 Anomaly.ATC Issue : All Types
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings
 Primary Problem : Procedure

Narrative: 1
 As the on job training instructor I heard trainee issue Helicopter XXX clearance to
 HUM maintain FL050 and code with the read back garbled and broken due to
 frequency problems. Due to traffic that was off route and trying to get corrected for
 weather reconnaissance, (block FL050B060), I suggested FL040. When trainee
 issued FL040 to Helicopter XXX, I heard a different voice advise stand by. Then, I
 heard Helicopter XXY departing. Apparently we had both Helicopterr XXX and
 Helicopter XXY answering the clearance and SIMILAR CALLSIGNS FILED FROM
 SIMILAR RIGS AT SIMILAR COORDINATES. However, coordinates were stated in
 the clearance and they are not the same coordinates. The end result, Helicopter
 XXX was outbound VFR/065 and Helicopter XXY was inbound at FL040. This could
 have ended in an accident if both helicopters had been at their rig and departed at
 the same time. Recommendation, PLEASE GET THE GULF OF MEXICO GOOD
 FREQUENCIES WITH GOOD COVERAGE AND GET HELICOPTERS TO USE NON
 SIMILAR CALLSIGNS, ESPECIALLY IN THE SAME AREA, SAME COORDINATE AND
 SAME RIG BLOCK AREAS!

Synopsis
 ZHU Controller reported an unsafe condition involving helicopter operations in the
 Gulf Of Mexico suggesting improved radio coverage and the elimination of similar
 callsigns.
ACN: 968463

Time / Day
 Date : 201109
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 700

Environment
 Flight Conditions : Marginal
 Weather Elements / Visibility : Rain
 Weather Elements / Visibility.Visibility : 8
 Light : Daylight
 Ceiling.Single Value : 1400

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Corporate
 Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission : Photo Shoot
 Flight Phase : Cruise
 Route In Use : Direct
 Airspace.Class B : ZZZ

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Government
 Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission : Traffic Watch
 Flight Phase : Cruise
 Route In Use.Other
 Airspace.Class B : ZZZ

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Corporate
 Function.Flight Crew : Single Pilot
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Commercial
 Qualification.Flight Crew : Rotorcraft
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Instrument
 Experience.Flight Crew.Total : 4180
 Experience.Flight Crew.Last 90 Days : 94
 Experience.Flight Crew.Type : 2011
 ASRS Report Number.Accession Number : 968463
 Human Factors : Confusion
 Human Factors : Distraction
 Human Factors : Situational Awareness
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party2 : Flight Crew
 Communication Breakdown.Party2 : ATC

Events
 Anomaly.Airspace Violation : All Types
 Anomaly.Conflict : Airborne Conflict
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 200
 Miss Distance.Vertical : 500
 Were Passengers Involved In Event : N
 When Detected : In-flight
 Result.Flight Crew : Exited Penetrated Airspace

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Airspace Structure
 Primary Problem : Ambiguous

Narrative: 1
 I was the pilot of a news gathering helicopter dispatched to gather video of a store
 robbery where a police officer had been shot and two suspects were on the run. I
 contacted a nearby airport's Tower and advised that I was en-route to a scene on
 the eastern edge of their airspace. The Controller advised me the State Police had
 requested that the Tower keep the airspace clear of traffic. I asked the Tower if
 there were any TFRs in effect and he said no. I said that I would check with my
 News Desk to see how they wish to proceed and I'd get back to him. I told my
 Photographer to call "The Desk" while I called the closest FSS to double check TFRs.
 Before I had the opportunity to call the Tower back the Controller advised me to
 remain clear of their Class "D" airspace. I acknowledged and changed my course,
 departing the Class "D". I overheard the State Police helicopter say there was a guy
 on the ground with a "long gun". At this point in the flight I was class "G" airspace
 hovering south of a nearby golf course. I had the State Police helicopter in sight
 circling the scene and was maintaining visual separation. The Controller then
 advised me that the State Police wanted me to depart the area. I again queried the
 Controller about any TFRs, but the Controller again instructed me to depart the
 area to the south. I complied with their request while I made another radio call to
 the FSS and requested information regarding TFRs in my immediate area. The
 Briefer replied that there were no published TFR's at the time but advised there
 were not any flight restrictions in an area to the north. The Controller cleared me to
 fly north but advised the State Police helicopter that I was en-route to his location.
 I arrived at the north side of the area and came to a hover less that 1 NM from the
 actual scene at 700 FT AGL. I had the State Police helicopter in sight and was
 maintaining visual separation. I observed the Police helicopter in an orbit at 1,100-
 1,200 AGL when he passed in front of me and almost directly above me. The State
 Police helicopter pilot advised me that he was passing over me and that I MUST
 DEPART THE AREA IMMEDIATELY. At no point did I feel that the Police helicopter
 was dangerously close to me and no evasive action was taken. Right after the
 officer instructed me to leave ATC also instructed me to leave because a TFR was
 about to go into effect. I complied with the instructions. As I flew southeast I
 queried the Controller about the TFR dimensions and FDC NOTAM number and he
 replied that they were waiting on a fax. I flew in a large circle around the City then
 headed northeast. Upon departing the Class "B" I contacted Approach and queried
 the Controller about the TFR, its number and dimensions. He told me that there
 was indeed a TFR and to "Stay out of there" to which I replied affirmative. Upon
 landing the ATC advised me of the FDC NOTAM number, the location of the TFR, its
 dimensions and effective times. This incident comes only three weeks after a
 similar situation (shooting) that took place within the Class "B". No TFR was issued;
 however, ATC again instructed me that I must remain clear of the airspace for
 police activity. After this flight I called the Tower and spoke with the Supervisor on
 duty. He informed me that he made a decision to have me move based on police
 information which in his opinion impacted the safety of the flight. The next day I
 called the Tower again and, luckily for me, I spoke with the previous Supervisor's
 Supervisor. I explained what had happened and asked him to reference the
 regulation which grants ATC the authority to have aircraft move due to a Law
 Enforcement request. He said that he would get back to me. He eventually did get
 back to me and said that he spoke with his superiors at the Tower, the local FSDO,
 the State Aeronautics Commission as well as the State Police and he informed me
 that everyone came to the agreement that ATC does not have the authority to have
 an aircraft move or depart the airspace due to a request from Law Enforcement.
 This leaves me somewhat confused. This Supervisor is telling me that they do not
 have the authority to have me move yet the local area Tower Controller is
 instructing me to remain clear of their airspace. As far as I know, The State Police
 have no authority over aircraft while in flight. I ultimately have a customer and
 employer to answer to and I am just trying to operate legally and as safely as
 possible. In order to prevent this sort of scenario in the future I feel that three
 things need to happen. 1. The local airport's ATC staff must be fully aware of their
 responsibility and limitations regarding Law Enforcement requests. 2. Electronic
 news gathering pilots must be fully briefed on how to deal with police requests. 3.
 The local Law Enforcement Agencies must communicate effectively with the news
 stations and electronic news gathering pilots and without delay, relay these
 potential perceived threats from the ground or in the air.

Synopsis
 The pilot of an "electronic news gathering" helicopter expressed concern that area
 law enforcement agencies were improperly demanding that their operations over
 criminal activities and associated police actions be restricted by ATC. The reporter
 contends that a TFR must first be activated before news agencies can be excluded
from the vicinity of any news worthy event, including those that put them
potentially in harm's way from criminal activites.
ACN: 968239

Time / Day
 Date : 201109
 Local Time Of Day : 1801-2400

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 0

Environment
 Flight Conditions : VMC
 Light : Night

Aircraft
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Air Taxi
 Make Model Name : MBB-BK 117 All Series
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Passenger
 Flight Phase : Parked

Component
 Aircraft Component : Tail Rotor
 Aircraft Reference : X
 Problem : Improperly Operated

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 ASRS Report Number.Accession Number : 968239
 Human Factors : Training / Qualification
 Human Factors : Distraction
 Human Factors : Situational Awareness

Events
 Anomaly.Aircraft Equipment Problem : Less Severe
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Flight Crew
 When Detected : Pre-flight
 Result.General : Flight Cancelled / Delayed
 Result.General : Maintenance Action
 Result.Flight Crew : Took Evasive Action

Assessments
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 I accepted a flight request. I had a nurse, RT, and a paramedic for the flight. The
 medical crew loaded up the isolette and bags in the aircraft while I took down our
 new sun shields from the windshields, front doors and sliding doors. It was after
 dark but the sunshades were still in the windows. I did a walk around but failed to
 see that the tail rotor blade was still tied down. While I was doing my walk around I
 was also telling the RT that I had put the case with the Nigh Vision Goggles (NVG)
 in her seat. I then got in the aircraft and started the check list. I started the
 number two engine first. As I was starting the engine, the RT asked me to help her
 with her NVG mount. I told her I was starting the engine but would help her in a
 minute. As the N1 approached 30% I noticed that the blades were not turning and
 I aborted the start. I realized that I must have missed the tail rotor tie down on my
 walk around. I got out and checked and sure enough, the tail rotor was still tied
 down. I then called the mechanic and canceled the flight. The N1 went to 31% and
 the TOT was about 650 degrees when I aborted the start. I am not trying to make
 excuses for what was an exceptionally poor walk around. I take full responsibility
 for failing to see the tie down. I let the distraction of removing the new window
 shades and talking with the med crew about something that could have waited until
 after I was done with my walk around, get the better of me. I need to do a better
 preflight walk around. I physically walked around the aircraft, right past the tie
 down and didn't see it.

Synopsis
 A BK-177 Pilot aborted an engine start after the number two engine N1 failed to
 rotate and the TOT rose abnormally because the tail rotor tie down was not
 removed.
ACN: 967135

Time / Day
 Date : 201108
 Local Time Of Day : 1201-1800

Place
 Altitude.AGL.Single Value : 3

Environment
 Flight Conditions : VMC
 Ceiling : CLR

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : None
 Mission : Passenger
 Flight Phase : Landing
 Route In Use : Direct
 Airspace.Class G : ZZZ

Component
 Aircraft Component : Tail Rotor Blade
 Aircraft Reference : X

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Qualification.Flight Crew : Multiengine
 Qualification.Flight Crew : Instrument
 Experience.Flight Crew.Total : 7040
 Experience.Flight Crew.Last 90 Days : 41
 Experience.Flight Crew.Type : 632
 ASRS Report Number.Accession Number : 967135
 Human Factors : Training / Qualification
 Human Factors : Situational Awareness

Events
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : Maintenance
 Anomaly.Deviation - Procedural : FAR
 Anomaly.Ground Event / Encounter : Ground Strike - Aircraft
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Company Policy
 Contributing Factors / Situations : Airport
 Primary Problem : Ambiguous

Narrative: 1
 I was called to pick up 3 passengers at the project site, as I made my final
 approach to the site and very close to the ground I had to make a cyclic aft
 adjustment to decelerate, as the nose came up I felt the stinger of the helicopter
 contact a FENCE. At this contact there was no yawing, and after there was no
 vibration of any kind, I had tail rotor command and no abnormal flight conditions, I
 got my passengers and flew them to their destination, where I shut down and
 inspected the tail rotor and stinger for damage, and found no evidence of any
 damage to either of the blades. The following morning I asked the mechanic to
 check the tail rotor for me to see if he could find anything wrong with it, and he
 told me that everything looked OK to him, at that point I decided to take the flight
 that was being requested as I did not see any visible damage and the mechanic did
 not see any visible damage either. As I was landing I got a call from the Chief Pilot
 and told me that the aircraft was grounded due to a tail rotor strike. I asked the
 Chief Pilot what was going to happen, he told me that he was going to gather all
 the information and would be in touch in the next couple of days after they review
 the information they had. I got a call from the Chief Pilot to tell me that my
 services where not needed anymore. That sure was a quick review of the facts. He
 told me that they had found a piece of wood in one of the rotor blades, but I was
 not allowed to see this. My being dismissed is not a problem as I would not want to
 work for some one with so little integrity and no idea of how to operate and support
 the operation. This is the background that led to this incident. Just prior to my
 check ride the Chief Pilot called me aside and told me that the contractor had
 changed the requirements of pilots PIC in type ( I was hired with a minimum of 500
 hours in type, I have 632 hours). The Chief Pilot told me that WE had to get my
 resume to reflect more than 1,000 hours in type or I would not be able to fly the
 contract (real nice after they had me quit my job to join this so called Helicopter
 company) so WE (he) forwarded a resume to the contractor that showed more than
 1,000 hours. When I got to the aircraft the dual controls had been removed but the
 holes where not covered and the stubs of the flight controls where exposed and
 they had been flying like that (un-airworthy) I asked the mechanic to please put
 the control covers on and he told me that they did not have any. I could not fly like
 that so I made some cardboard covers and covered them with duct tape, that had
 to be replaced every other flight as they kept coming off, but at least they would
 prevent any object from falling in and jamming the controls. The GPS in the aircraft
 had no power source so it would last only 3 hours, I asked and was told that a
 power source was going to be installed but they never did install it. I had to use my
 own Garmin 496 as it will last 8 + hours, and I have a spare battery. I should have
 grounded the aircraft the very first day for not having the covers. I agree with the
 contractor that I should have shut down and inspected the damage there, but the
 result would have been the same as I found no damage, instead of sitting there for
 god knows how long before I could even get a hold of someone. On the contractor
 side they should have those fences either removed or lowered to an acceptable
 level they are about 2 to 2 1/2 FT tall and the stakes protrude at least 3 FT and this
 is to high for a helicopter that has a low tail rotor and in some of these sites the
 helicopter barely fits inside the fences.

Synopsis
 Newly hired helicopter pilot reports tail stinger contact with a fence during landing.
 No abnormal handling or vibration is felt and the aircraft is flown, with passengers,
 to the next destination. Post flight inspection reveals no damage but the reporter is
 terminated two days later.
ACN: 967078

Time / Day
 Date : 201108

Place
 Altitude.AGL.Single Value : 0

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Mission : Ambulance
 Flight Phase : Parked

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 ASRS Report Number.Accession Number : 967078
 Human Factors : Communication Breakdown
 Human Factors : Confusion
 Human Factors : Training / Qualification
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party2 : Flight Attendant
 Analyst Callback : Completed

Events
 Anomaly.Aircraft Equipment Problem : Less Severe
 Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : FAR
 Detector.Person : Flight Crew
 Were Passengers Involved In Event : Y
 When Detected : Pre-flight
 Result.General : Work Refused

Assessments
 Contributing   Factors   /   Situations   :   Company Policy
 Contributing   Factors   /   Situations   :   Aircraft
 Contributing   Factors   /   Situations   :   Procedure
 Contributing   Factors   /   Situations   :   Incorrect / Not Installed / Unavailable Part
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 This is a safety awareness issue, not a report of an event that occurred, but rather
 one that was averted: On a flight assignment sometime last week, I noticed a new
 "device" being used by the "hospital employed", [our] company trained FAA
 medical aircrew members that I had not seen before. I was told "we just got it" the
 previous week. The equipment in question is the Ferno Oxy-Clip, and it is a device
 designed to carry portable oxygen bottles clipped to the handrails of various
 gurney/litter systems. We were on a hospital transfer assignment. After we landed,
 the medical crew departed to retrieve the patient from the hospital while I
 continued to shut down and postflight the aircraft. When the medical crew returned
 with the patient I noticed this new device clipped to the side rail with D sized
 oxygen bottle cradled in it that I had not seen before, nor was I aware they had it
 with them in their medical equipment baggage. After they loaded the patient and
 had situated their medical equipment the Medic asked the nurse if she was "OK" if
 he left the device attached to the handrail, as the flight was short? I had to
 intervene, as I had never seen one of these things before, and noticed that it was
 not TSO'd [Technical Service Order(ed)] for aviation use, nor part of the STC
 [Supplemental Type Certificate] for the litter system on the aircraft. I told the
 Medic that we'd have to remove it from the stretcher and secure the D bottle in the
 aircraft's approved bracket. The Medic complied with my order without debate. I've
 since labeled the device with a sticker that reads: NOT APPROVED FOR USE IN
 FLIGHT. There is no issue using the device on the ground, but it will have to be
 removed and stowed before we operate the aircraft. I mention this because I got
 the impression that they felt I was simply a cog in the wheels for their convenience
 and that since they have seen the equipment used elsewhere it was OK for them to
 use here. I notified my Base Lead to ensure I am not the only one telling the
 medical crew to not use this equipment for in-flight use. One of the big problems I
 see in this industry as a whole is that medical crewmembers often try to use
 equipment on aircraft that they have become accustomed to using in other non-
 aviation EMS jobs. Our company does not provide much training for medical
 aircrew members or pilots about what is and is not acceptable in aircraft. None of
 these regulations are clearly explained or defined in our GOM [General Operations
 Manual]. Pilots often find themselves dealing with such things for the first time
 when the medical crew arrives with the patient and they don't wish to "rock the
 boat", especially at Company Base locations where customer satisfaction becomes
 the primary focus. Pilots are simply not aware of the regulations because there is
 not much in the way of training by the air carrier. It should be part of the air
 carrier's medical crewmember training that they cannot simply procure and use
 equipment not approved first by the FAA.

Callback: 1
 The reporter advised that medical crews aboard his company aircraft can be either
 employees of the air carrier or, more often, employees of the hospital that
 contracts for their services. He believed that air carrier trained medical crews are
 "somewhat" more aware of the need for proper approval of devices used in flight
 but that company training for both flight and medical crews was still deficient in
 this area. Because only the flight crews are always employees of the air carrier the
 reporter believes it is essential that they be properly trained in identifying and
 insuring the use of only properly certified equipment while in flight.
Synopsis
 An EMS helicopter pilot addressed his concerns about the use of non certified
 medical equipment aboard EMS aircraft while in flight.
ACN: 965814

Time / Day
 Date : 201108

Place
 Locale Reference.Airport : ZZZZ.Airport
 State Reference : FO
 Altitude.AGL.Single Value : 0

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 7000
 Ceiling.Single Value : 10000

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : S-61A/B/L/N/R or SH-3 Sea King
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Passenger
 Flight Phase : Parked
 Maintenance Status.Records Complete : N
 Maintenance Status.Released For Service : Y
 Maintenance Status.Required / Correct Doc On Board : N
 Maintenance Status.Maintenance Type : Scheduled Maintenance
 Maintenance Status.Maintenance Items Involved : Installation
 Maintenance Status.Maintenance Items Involved : Inspection
 Maintenance Status.Maintenance Items Involved : Work Cards
 Maintenance Status.Maintenance Items Involved : Testing

Component : 1
 Aircraft Component : Compressor Stator/Vane
 Manufacturer : General Electric CT58140
 Aircraft Reference : X
 Problem : Malfunctioning

Component : 2
 Aircraft Component : Powerplant Fuel System
 Manufacturer : General Electric
 Aircraft Reference : X

Person : 1
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Rotorcraft
 Qualification.Flight Crew : Instrument
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Qualification.Flight Crew : Flight Instructor
 Experience.Flight Crew.Total : 6500
 Experience.Flight Crew.Last 90 Days : 200
 Experience.Flight Crew.Type : 2000
 ASRS Report Number.Accession Number : 965814
 Human Factors : Situational Awareness
 Human Factors : Confusion
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party1 : Maintenance
 Communication Breakdown.Party2 : Maintenance
 Analyst Callback : Attempted

Person : 2
 Reference : 2
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Captain
 Qualification.Flight Crew : Rotorcraft
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Experience.Flight Crew.Total : 8300
 Experience.Flight Crew.Last 90 Days : 200
 Experience.Flight Crew.Type : 6500
 ASRS Report Number.Accession Number : 965811
 Human Factors : Confusion
 Human Factors : Communication Breakdown
 Human Factors : Situational Awareness
 Communication Breakdown.Party1 : Maintenance
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party2 : Maintenance
 Analyst Callback : Attempted

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : Maintenance
 Detector.Person : Flight Crew
 Were Passengers Involved In Event : N
 When Detected : Pre-flight
 Result.General : Maintenance Action

Assessments
 Contributing Factors / Situations : Manuals
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Chart Or Publication
 Contributing Factors / Situations : Aircraft
 Primary Problem : Human Factors

Narrative: 1
 I was assigned a Sikorsky SK-61N helicopter for a passenger/cargo flight. I checked
 the logbook and noticed that four days earlier, Maintenance had replaced a control
 rod on the stator vanes. I asked Maintenance if an engine topping check (ETC) had
 been completed on the functional check flight; they informed me none was required.
 [Approximately seven days later], our company Check Airmen was assigned the
 same helicopter and he asked the same question; the Mechanic said "yes," a
 topping check was required. The pilots and mechanics got together and our Quality
 Control (QC) became involved. After researching in the manuals, we came to the
 conclusion that, yes, a topping check was required. We need to have better
 communications between the flight crew and Maintenance. Also, our mechanics
 need to have better training on "when" and "what" is required on a functional check
 flight.

Narrative: 2
 In a foreign country, on a Part 135 helicopter operation, using Sikorsky S61 aircraft,
 our Maintenance department changed a pitch link on the #1 engine stator gang
 assembly. Attention was not made to us to do a topping check the next day. We
 flew that aircraft over a week before we caught the error. The old pitch link was
 measured and replaced with a new one at the same dimensions and the
 Maintenance crew thought it was not necessary to do a topping check. They now
 realize it is important to get the engine topping check done after any change to the
 Fuel Control Unit (FCU).

Synopsis
 Two captains report about a Sikorsky S61N helicopter that had been flying for a
 week after a pitch link had been changed on the #1 engine stator gang assembly
 without a topping check being accomplished.
ACN: 965318

Time / Day
 Date : 201108
 Local Time Of Day : 0001-0600

Place
 Locale Reference.ATC Facility : CRQ.Tower
 State Reference : CA
 Altitude.AGL.Single Value : 0

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : CRQ
 Make Model Name : Robinson R22
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Phase : Takeoff
 Route In Use : None
 Airspace.Class D : CRQ

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : CRQ
 Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Phase : Landing
 Route In Use : None
 Airspace.Class D : CRQ

Person
 Reference : 1
 Location Of Person.Facility : CRQ.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Supervisor / CIC
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 965318
 Human Factors : Other / Unknown

Events
 Anomaly.Conflict : Ground Conflict, Critical
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors
Narrative: 1
 There was training on Local Control. I heard the Clearance Delivery Controller say,
 "You need to send that guy around." I turned around, looked at the runway, and
 saw an R22 departing Runway 24 airborne approximately at Taxiway A3, and a
 PA28, touching down around Taxiway A2. The aircraft appeared to be less than
 2,000 FT apart. I immediately offered to get the Local Control controllers off
 position, however the trainer said, "Well, it's already happened, let's keep training,"
 and advised of his intention to file a report. Another controller was going to be up
 to relieving the Local Controller. As Controller in Charge, I should have been paying
 closer attention to Local Control, especially while they were training.

Synopsis
 CRQ Controller witnessed a loss of separation event between an arrival and
 departure during a training session.
ACN: 963717

Time / Day
 Date : 201108
 Local Time Of Day : 1201-1800

Place
 Altitude.AGL.Single Value : 100

Environment
 Flight Conditions : VMC
 Light : Daylight

Aircraft
 Reference : X
 Aircraft Operator : FBO
 Make Model Name : Robinson R22
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Mission : Training
 Flight Phase : Cruise
 Route In Use : Direct
 Airspace.Class E : ZZZ

Component
 Aircraft Component : Main Rotor
 Aircraft Reference : X
 Problem : Improperly Operated

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : FBO
 Function.Flight Crew : Instructor
 Function.Flight Crew : Pilot Not Flying
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Commercial
 Experience.Flight Crew.Total : 1083.9
 Experience.Flight Crew.Last 90 Days : 240.1
 Experience.Flight Crew.Type : 878.3
 ASRS Report Number.Accession Number : 963717
 Human Factors : Human-Machine Interface
 Human Factors : Training / Qualification

Events
 Anomaly.Inflight Event / Encounter : Object
 Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.Flight Crew : Regained Aircraft Control

Assessments
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Aircraft
 Primary Problem : Human Factors

Narrative: 1
 My student and I had decided to stop practicing maneuvers yet still wanted to work
 towards his 100 PIC requirement for his commercial rating. We proceeded from our
 practice area towards an area of higher vegetation and higher altitude. When we
 reached the area, we performed a low orbit with a slow airspeed. During the
 maneuver, the student over controlled the aircraft during a wind shift and a
 descending turn, causing the Rotor RPM to decay. I took the controls and began the
 recovery. This ultimately led us into an area of residences and tall vegetation. After
 a long struggle I was able to regain RPM and maneuvered out of the area, but not
 without striking the rotor blades on vegetation. The damage to the rotors was
 within factory specifications, no persons or property was damaged.

Synopsis
 The Instructor Pilot failed to intervene in a timely manner when the pilot flying
 commercial student let the main rotor RPM drop excessively during low altitude
 orbit practice. The main rotor struck "vegetation" before the instructor was able to
 recover. No injuries or significant damage to the rotor system occurred.
ACN: 963041

Time / Day
 Date : 201107
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 0

Environment
 Light : Daylight

Aircraft
 Reference : X
 Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Mission : Ferry
 Flight Phase : Cruise
 Airspace.Class E : ZZZ

Component
 Aircraft Component : Fuselage Panel
 Aircraft Reference : X

Person
 Reference : 1
 Location Of Person : Hangar / Base
 Function.Maintenance : Technician
 ASRS Report Number.Accession Number : 963041
 Human Factors : Situational Awareness
 Human Factors : Training / Qualification
 Analyst Callback : Completed

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Deviation - Procedural : Maintenance
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.General : Maintenance Action
 Result.Flight Crew : Diverted
 Result.Flight Crew : Landed in Emergency Condition
 Result.Aircraft : Aircraft Damaged

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Manuals
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 After the 100 hour scheduled maintenance was complete, the aircraft was returned
 to service and the pilot took the aircraft to reposition it to its assigned base when
 the in flight incident occurred. The aft tail rotor drive shaft cowling dislodged itself
 from the aircraft and struck the Main blue blade and then contacted the tail rotors,
 the pilot landed. Then maintenance was notified. The Airworthiness Check that was
 performed on the aircraft during the 100 hour maintenance should be required to
 be done after maintenance so that any possible loose fasteners would be seen and
 dealt with prior to the aircraft returned to service.

Callback: 1
 The Reporter stated that he did a final walkaround with the pilot prior to flight and
 neither one of them noticed the fasteners loose. He stated that during flight the
 pilot felt some bumps and thought initially that he had encountered turbulence but
 when a flight control vibration developed he landed in an emergency condition
 where he found the main and tail rotor damage. He further suggested that a step
 be added to the scheduled maintenance procedure that requires all panels and
 access areas be reinspected to ensure this does not occur again.

Synopsis
 After the 100 hour scheduled maintenance service and while on a ferry flight to its
 base, a tail rotor drive shaft cowling came off striking the main and tail rotors of an
 AS350.
ACN: 962902

Time / Day
 Date : 201108
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Relative Position.Angle.Radial : 280
 Relative Position.Distance.Nautical Miles : 5
 Altitude.AGL.Single Value : 1000

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 30
 Work Environment Factor : Temperature - Extreme
 Light : Daylight
 Ceiling.Single Value : 10000

Aircraft
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Government
 Make Model Name : SA 330 Puma/332 Super Puma
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission : Ferry
 Flight Phase : Takeoff
 Route In Use : Direct
 Airspace.Class C : ZZZ

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Government
 Function.Flight Crew : Captain
 Function.Flight Crew : Instructor
 Function.Flight Crew : Pilot Not Flying
 Qualification.Flight Crew : Instrument
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Experience.Flight Crew.Total : 8000
 Experience.Flight Crew.Last 90 Days : 30
 Experience.Flight Crew.Type : 35
 ASRS Report Number.Accession Number : 962902
 Human Factors : Distraction
 Human Factors : Workload

Events
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Inflight Event / Encounter : Object
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.Aircraft : Aircraft Damaged

Assessments
 Contributing Factors / Situations : Weather
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Primary Problem : Ambiguous

Narrative: 1
 Upon departure from the airport I was repositioning my kneeboard from the door
 pocket to my knee. As I brought the kneeboard up and away from the door pocket
 it passed within a few inches of the open pilot door window. It was immediately
 sucked from my grasp and departed the aircraft. A person in the cabin witnessed
 the kneeboard strike the port side sponson and then [it] continued down and away
 from the ship. The sponson received minor damage. We normally fly with the rear
 doors closed on this ship. However, due to the extreme heat, we chose to fly with
 the doors open this day. In this configuration, there is a significant flow of air
 forward which contributed to the negative pressure in the cockpit.

Synopsis
 An AS332 pilot reported that after takeoff, he was putting his kneeboard on when it
 was sucked out by the slip stream of an open door which is normally closed but
 open for this flight because of the heat.
ACN: 962890

Time / Day
 Date : 201108
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Relative Position.Angle.Radial : 280
 Relative Position.Distance.Nautical Miles : 12
 Altitude.MSL.Single Value : 2000

Environment
 Flight Conditions : VMC
 Light : Daylight

Aircraft
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Corporate
 Make Model Name : S-76/S-76 Mark II
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission : Passenger
 Flight Phase : Cruise
 Route In Use : Direct
 Airspace.Class D : ZZZ

Component
 Aircraft Component : Turbine Engine
 Aircraft Reference : X
 Problem : Malfunctioning

Person : 1
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Corporate
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Not Flying
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Experience.Flight Crew.Total : 12300
 Experience.Flight Crew.Last 90 Days : 80
 Experience.Flight Crew.Type : 6150
 ASRS Report Number.Accession Number : 962890

Person : 2
 Reference : 2
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Corporate
 Function.Flight Crew : First Officer
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Qualification.Flight Crew : Instrument
 Experience.Flight Crew.Total : 6932
 Experience.Flight Crew.Last 90 Days : 75
 Experience.Flight Crew.Type : 1979
 ASRS Report Number.Accession Number : 963051

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Detector.Automation : Aircraft Other Automation
 Detector.Person : Flight Crew
 Were Passengers Involved In Event : N
 When Detected : In-flight
 Result.General : Declared Emergency
 Result.Flight Crew : Landed in Emergency Condition
 Result.Air Traffic Control : Provided Assistance

Assessments
 Contributing Factors / Situations : Aircraft
 Primary Problem : Aircraft

Narrative: 1
 During cruise flight the number two engine chip detector light illuminated. Crew
 performed emergency checklist, which advises landing as soon as practicable. We
 continued to our destination airport, declared an emergency and requested landing
 Runway 34. Tower cleared us for landing and activated their emergency response
 plan. We accomplished a single engine running landing, with number two engine in
 the idle position. Airport CFR vehicles followed us to ramp and obtained written
 report from the crew members.

Narrative: 2
 I advised the Captain that I was slowing to single engine airspeed and I reset the
 Master Caution light. The Captain initiated the Emergency Procedure backed up by
 the Emergency Procedure Checklist.

Synopsis
 An SK-76C helicopter flight crew followed appropriate emergency procedures and
 landed using single engine techniques following receipt of a chip detector warning
 in the number two engine.
ACN: 960711

Time / Day
 Date : 201107

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 0

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : EC135
 Operating Under FAR Part : Part 135
 Mission : Ambulance
 Flight Phase : Parked
 Maintenance Status.Maintenance Type : Scheduled Maintenance
 Maintenance Status.Maintenance Items Involved : Inspection
 Maintenance Status.Maintenance Items Involved : Work Cards

Person
 Reference : 1
 Location Of Person : Hangar / Base
 Reporter Organization : Air Taxi
 Function.Maintenance : Technician
 Qualification.Maintenance : Powerplant
 Qualification.Maintenance : Airframe
 ASRS Report Number.Accession Number : 960711
 Human Factors : Situational Awareness
 Analyst Callback : Completed

Events
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : Maintenance
 Detector.Person : Maintenance
 Were Passengers Involved In Event : N
 When Detected : Routine Inspection
 Result.General : Maintenance Action

Assessments
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 I am a Base Mechanic for an Air Taxi company. Was preforming a routine daily
 Check on a Eurocopter EC- 135T2 aircraft, when I discovered a 13mm wrench on
 the left-hand side of the Main Transmission Deck. I then notified the Director of
 Maintenance. He then directed me to file a report. Lack of tool control.

Callback: 1
 Reporter stated they were unable to determine who owned the 13mm wrench, or
 the Maintenance station the wrench could have come from. Most of the equipment
 on Eurocopter helicopters requires tooling sized in millimeters, not American
 Standard inches. He also noted that if there was a safe place to leave a wrench, the
 top of the Main Transmission Deck, where he found the wrench, wasn't less serious.

Synopsis
 A Base Mechanic reports finding a 13mm wrench on the left-hand side of the Main
 Transmission Deck of an EC135 Eurocopter during a daily Maintenance Check.
ACN: 959905

Time / Day
 Date : 201107
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : JNU.Airport
 State Reference : AK
 Altitude.MSL.Single Value : 1850

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 6
 Light : Daylight
 Ceiling.Single Value : 3000

Aircraft
 Reference : X
 ATC / Advisory.Tower : JNU
 Aircraft Operator : Air Taxi
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Passenger
 Flight Phase : Climb
 Airspace.Class D : JNU

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Instrument
 Qualification.Flight Crew : Rotorcraft
 Qualification.Flight Crew : Commercial
 Experience.Flight Crew.Total : 2000
 Experience.Flight Crew.Last 90 Days : 120
 Experience.Flight Crew.Type : 120
 ASRS Report Number.Accession Number : 959905
 Human Factors : Confusion
 Human Factors : Situational Awareness
 Human Factors : Time Pressure
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party2 : ATC

Events
 Anomaly.Conflict : NMAC
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 100
 Miss Distance.Vertical : 20
 When Detected : In-flight
 Result.Flight Crew : Took Evasive Action

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Primary Problem : Ambiguous

Narrative: 1
 Located on FBO's ramp area, [we] contacted the Control Tower and requested a
 Departure with an unrestricted climb with current ATIS information. Tower cleared
 me for the departure with the unrestricted climb. No mention of conflicting aircraft
 was mentioned by the Tower and no conflicting arrivals or departures were heard
 on the radio. Approximately 1 minute later, I noticed an airplane at a strange
 altitude and location. No mention of traffic was made by Control Tower and no
 radio call was heard from the airplane. I resumed visual scanning of the airspace
 and saw the airplane approximately 100 FT to the right and in front at the same
 altitude on a collision course. I quickly pulled aft cyclic and made a rapid climb over
 the airplane while the conflicting airplane passed approximately 20 FT under the
 helicopter. I then leveled out from the rapid climb and noted an altitude of 2,000 FT
 MSL with a current altimeter setting. As an estimation, the near miss occurred at
 approximately 1,800 to 1,900 FT MSL just north of the main taxiway parallel to the
 runway at approximately midfield. No radio transmissions were made by the Tower
 concerning the traffic and no radio calls by the airplane were heard. I believe the
 near miss occurred as a result of four factors. First, I did not hear any
 communication from the airplane traffic prior or during departure. Whether there
 was any communication at all is unknown. Second, the Tower did not caution about
 the conflict and issued an unrestricted climb to cause the conflict. Whether the
 Tower was aware of the conflict or whether the Tower was in communication with
 the traffic at all is unknown and the workload at the time may have not allowed the
 Tower to issue the flight advisory. Third, I failed to visually identify the conflict prior
 to the near miss, which could have created greater separation. Fourth, the airplane
 did not fly proper altitudes for the arrival that he/she was on, creating the near
 miss. One arrival has airplanes crossing midfield at 1,000 FT MSL, which I assume
 the airplane pilot was flying, the conflict would not have occurred, [because] at that
 altitude the airplane would have passed a safe distance under the helicopter flight.

Synopsis
 A helicopter pilot reported a near miss with an airplane at about 1,700 FT during a
 VFR departure in JNU airspace with no ATC traffic reports or communications from
 the other aircraft.
ACN: 959755

Time / Day
 Date : 201107
 Local Time Of Day : 0601-1200

Place
 Locale Reference.ATC Facility : ZZZ.ARTCC
 State Reference : US
 Altitude.AGL.Single Value : 200

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 20
 Light : Daylight

Aircraft : 1
 Reference : X
 ATC / Advisory.UNICOM : ZZZ
 Aircraft Operator : Government
 Make Model Name : Jet/Long Ranger/206
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission : Training
 Flight Phase : Takeoff
 Airspace.Class G : ZZZ

Aircraft : 2
 Reference : Y
 ATC / Advisory.UNICOM : ZZZ
 Aircraft Operator : Corporate
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 137
 Mission : Agriculture
 Flight Phase : Cruise
 Airspace.Class G : ZZZ

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Government
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Commercial
 Experience.Flight Crew.Total : 900
 Experience.Flight Crew.Last 90 Days : 62
 Experience.Flight Crew.Type : 250
 ASRS Report Number.Accession Number : 959755
 Human Factors : Situational Awareness

Events
 Anomaly.Conflict : NMAC
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 300
 Miss Distance.Vertical : 20
 When Detected : In-flight
 Result.Flight Crew : Took Evasive Action

Assessments
 Contributing Factors / Situations : Environment - Non Weather Related
 Primary Problem : Environment - Non Weather Related

Narrative: 1
 While on a routine training flight, our helicopter had a near miss with an
 agricultural spraying helicopter. We announced position and intentions (on air to air
 frequency 123.02) prior to lifting off on a west heading. At approximately 200 FT
 AGL I heard an aircraft on 123.02 say "I'm passing on your right, don't turn right."
 I looked over my right shoulder at about the 5 o'clock position at about 300 FT
 horizontal and 20 FT below was a beige jet ranger west bound at approximately
 150 FT AGL. I immediately altered course to the left and announced "I've got you
 on my right" on 123.02.

Synopsis
 A helicopter instructor pilot reported a near miss with an agricultural helicopter in a
 rural California area.
ACN: 959551

Time / Day
 Date : 201107
 Local Time Of Day : 1201-1800

Place
 Locale Reference.ATC Facility : ZDV.ARTCC
 State Reference : CO
 Altitude.MSL.Single Value : 7000

Aircraft
 Reference : X
 ATC / Advisory.Center : ZDV
 Aircraft Operator : Military
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : IFR
 Nav In Use.Localizer/Glideslope/ILS : Runway 30
 Flight Phase : Final Approach
 Airspace.Class E : GLD

Person
 Reference : 1
 Location Of Person.Facility : ZDV.ARTCC
 Reporter Organization : Government
 Function.Air Traffic Control : Enroute
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 959551
 Human Factors : Communication Breakdown
 Human Factors : Situational Awareness
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : Other
 Communication Breakdown.Party2 : ATC

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Primary Problem : Procedure

Narrative: 1
 The sector was at slightly above average traffic numbers, and above average
 complexity due to multiple approaches, VFR traffic, military refueling and break-ups
 and DEN departure traffic climbing above my low sector. I worked a jet into
 Goodland and he requested and commenced a Visual Approach. During his
 approach I accepted a hand off on a helicopter. The helicopter had a very hard to
 understand radio, but I believe that when the pilot checked on he said that he was
 also planning on the visual to GLD. He entered an area of poor RADAR coverage, I
 advised him that RADAR contact was lost and received a position report that I
 confirmed was within my airspace and also NAVAID limitations for Non-RADAR. I
 issued a pilot's discretion decent and asked the pilot if they had automated weather
 and NOTAMS for GLD. The pilot said that he did. When traffic allowed, I asked the
 pilot to report the field for the visual, and after two attempts due to a poor radio in
 the helicopter, the pilot told me he was requesting the ILS 30 Approach. I double
 checked the NOTAMS in ERIDS before issuing the clearance. I misread the last
 NOTAM. I believed that the NOTAM said that the runway approach lighting was OTS,
 when in fact the NOTAM said that the ILS was out of service. I issued a clearance
 for the aircraft to execute the ILS 30 Approach. I changed the aircraft to advisories
 and advised him to report his cancellation when able. At that point I was being
 relieved for a break, and during my position review the aircraft canceled IFR with
 the relieving controller. Workload during this even was coming down from the high,
 but at the time I felt like I was still a little behind, due to the radio problems, Non-
 RADAR situation, and other aircraft calling on my other frequency sites. I talked to
 a supervisor afterwards about a phraseology question related to the pilots request
 to change his requested approach to confirm that I had handled the situation
 correctly. The supervisor in talking about the situation realized that the Goodland
 ILS was out of service, via his briefing and confirmed that the aircraft landed safely.
 I believe that our NOTAM procedure could use work. Currently we have ERIDS set
 to display 'applicable' NOTAMS for the sector, but in the case of this sector (19)
 there are usually well over 100 outages posted. The major ones, equipment failures
 and the like sometimes can get buried, and when workload is high I believe that
 many controllers don't even check them for the airport they're issuing clearances in
 and out of. We have seen several instances of aircraft being cleared into airports
 that are closed because of these problems. Obviously it is ultimately the controller's
 responsibility, but I would like to see a better way to report major NOTAMS. Many
 times we'll have an airport with multiple NOTAMS, none of which are very
 important. A more complete position briefing would have helped, but obviously that
 would require the previous controller to have been aware of the outage which I
 don't believe he was. Often with a major outage we will mark a strip and post it in
 the posting area separate of the outage board. This helps, but only works if the
 controller realizes that he is affected by an outage.

Synopsis
 A ZDV Controller issued an ILS Approach when in fact the ILS was NOTAMed "Out
 of Service". The reporter noted the volume of NOTAMS listed in the ERIDS, and the
 lack of listing priority, as a contributing factor to the oversight.
ACN: 957774

Time / Day
 Date : 201106
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : EQY.Airport
 State Reference : NC
 Altitude.AGL.Single Value : 500

Environment
 Flight Conditions : VMC
 Light : Daylight

Aircraft : 1
 Reference : X
 ATC / Advisory.CTAF : EQY
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Mission : Traffic Watch
 Flight Phase.Other
 Route In Use : None
 Airspace.Class E : ZTL

Aircraft : 2
 Reference : Y
 ATC / Advisory.CTAF : EQY
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission : Traffic Watch
 Flight Phase.Other
 Route In Use : None
 Airspace.Class E : ZTL

Aircraft : 3
 Reference : Z
 ATC / Advisory.CTAF : EQY
 Make Model Name : Skyhawk 172/Cutlass 172
 Crew Size.Number Of Crew : 1
 Flight Phase : Initial Approach
 Route In Use : None
 Airspace.Class E : ZTL

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Corporate
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Qualification.Flight Crew : Instrument
 Experience.Flight Crew.Total : 10000
 Experience.Flight Crew.Last 90 Days : 100
 Experience.Flight Crew.Type : 9000
 ASRS Report Number.Accession Number : 957774
 Human Factors : Communication Breakdown
 Human Factors : Situational Awareness
 Human Factors : Distraction
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party2 : Flight Crew

Events
 Anomaly.Conflict : NMAC
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 0
 Miss Distance.Vertical : 100
 When Detected : In-flight
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 I was piloting a news helicopter. I was dispatched to fly to an area to provide aerial
 news coverage of a fatal auto accident. After I determined that the location was in
 the area of EQY, I radioed my position, altitude and intentions on CTAF several
 miles out. I was also in communication with another news helicopter on our
 common helicopter frequency as he was enroute to the same scene just a few miles
 behind me. I arrived at the accident location and established a slow right hand orbit
 at 1300 feet MSL. There were two other fixed wing aircraft in the area and I
 established visual contact with them and stated my position and intention. Five
 minutes later, I established visual contact with the other news helicopter as he
 arrived on the scene. He had also made all appropriate radio position calls enroute.
 I told the pilot of the other helicopter that both fixed wing aircraft in the area were
 no longer a factor as one had landed and the other had departed. He then
 established a right hand orbit on scene at 1700 MSL. Over the course of the next
 30 minutes, the two news helicopters maintained constant position and altitude in a
 slow right hand orbit while providing aerial video of the accident scene for our
 respective news stations. During this time, several aircraft were taking off and or
 landing at the nearby airport. As we knew that we were positioned near the pattern
 for the operational Runway 5, both pilots were diligent in announcing our position
 and communicating our intentions with each aircraft in the pattern. Visual and radio
 contact was made with each and every aircraft in the local area. I recall
 communicating with a Piper aircraft and a few other aircraft in the pattern,
 including a jet arriving and landing from a base leg. All aircraft in the area were
 operating safely and without incident; one aircraft even commented in response to
 the local radio calls that he "wished drivers on the highway were as courteous as
 the pilots were." Most aircraft in the pattern were turning inside of our position for
 the base leg to Runway 5 with no problem. Approximately a half hour after I
 arrived a third news helicopter arrived at the scene and joined in right hand orbits
 with the two other helicopters on scene. Fifteen minutes later that that aircraft left
 the area. A short while later a C172 was in the airport traffic area and the pilot
 commented that "the news helicopters needed to vacate the area" as he thought
 that they were interfering with the local pattern. He accomplished at least one
 complete pattern at EQY with the news helicopters in their established position. The
 Skyhawk made another comment that "whatever the news helicopters were
 covering was not important enough to be operating near the airport." He then
 asked how long the helicopters were going to be in area. I responded that we
 would be departing shortly. The Skyhawk then turned on the downwind leg and I
 reported our position and established visual contact. As the aircraft moved closer to
 our position, the other helicopter pilot made a radio call to me asking if I had the
 Skyhawk in sight. I responded that I did. I thought that the Skyhawk would be
 making a close pass to the outside of us and then turn on his base leg after passing.
 While maintaining visual contact with the aircraft and in a near hover I saw the
 Skyhawk turn directly toward us. The aircraft passed directly over us with vertical
 separation of no more than 50 to 100 feet. I called the other helicopter and asked if
 he had witnessed the event and he said that he had.

Synopsis
 A news helicopter pilot covering an auto accident near EQY reported an intentional
 near miss with a C172 whose pilot was irritated by the helicopter's presence.
ACN: 957763

Time / Day
 Date : 201107
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : CCR.Airport
 State Reference : CA
 Relative Position.Angle.Radial : 110
 Relative Position.Distance.Nautical Miles : 5
 Altitude.AGL.Single Value : 800

Environment
 Weather Elements / Visibility.Visibility : 10
 Light : Daylight
 Ceiling.Single Value : 9000
 RVR.Single Value : 5000

Aircraft
 Reference : X
 ATC / Advisory.Tower : CCR
 Aircraft Operator : Corporate
 Make Model Name : Robinson R44
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Mission : Personal
 Flight Phase : Cruise
 Route In Use : Visual Approach
 Airspace.Class D : CCR

Component
 Aircraft Component : Main Rotor Indication
 Aircraft Reference : X
 Problem : Malfunctioning

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Corporate
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Private
 Experience.Flight Crew.Total : 2100
 Experience.Flight Crew.Last 90 Days : 12
 Experience.Flight Crew.Type : 12
 ASRS Report Number.Accession Number : 957763
 Human Factors : Training / Qualification
 Human Factors : Confusion

Events
 Anomaly.Aircraft Equipment Problem : Less Severe
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.Flight Crew : Landed in Emergency Condition
 Result.Aircraft : Equipment Problem Dissipated

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Aircraft
 Primary Problem : Procedure

Narrative: 1
 I was in flight...when Main Rotor Chip Light went on. I then thought I was losing
 power and controls were very stiff and hard to control. I could not take my hands
 off the controls to call Tower. I decided to put the helicopter on a closed runway as
 I had not talked to Tower and wanted to avoid any traffic landing on active runways.
 Upon landing, I reset breaker on warning lights and the Chip Light did not come on.
 Then I realized I had turned of the hydraulic switch by mistake.

Synopsis
 R44 pilot observes a Main Rotor Chip Light and lands on a closed runway after
 experiencing very stiff controls.
ACN: 957608

Time / Day
 Date : 201106
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : BDU.Airport
 State Reference : CO
 Altitude.MSL.Single Value : 6800

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 15
 Light : Daylight

Aircraft : 1
 Reference : X
 ATC / Advisory.CTAF : BDU
 Aircraft Operator : Air Taxi
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : None
 Mission : Passenger
 Flight Phase : Cruise
 Route In Use : Direct
 Airspace.Class E : ZDV

Aircraft : 2
 Reference : Y
 ATC / Advisory.CTAF : BDU
 Aircraft Operator : Personal
 Make Model Name : Any Unknown or Unlisted Aircraft Manufacturer
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission.Other
 Flight Phase : Climb
 Airspace.Class E : ZDV

Aircraft : 3
 Reference : Z
 ATC / Advisory.CTAF : BDU
 Aircraft Operator : Personal
 Make Model Name : Sail Plane
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Mission : Personal
 Flight Phase : Cruise
 Route In Use : None
 Airspace.Class E : ZDV

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Experience.Flight Crew.Total : 5900
 Experience.Flight Crew.Last 90 Days : 30
 Experience.Flight Crew.Type : 450
 ASRS Report Number.Accession Number : 957608
 Human Factors : Communication Breakdown
 Human Factors : Confusion
 Human Factors : Situational Awareness
 Human Factors : Training / Qualification
 Human Factors : Workload
 Human Factors : Distraction
 Communication Breakdown.Party2 : Flight Crew

Events
 Anomaly.Conflict : NMAC
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 200
 Miss Distance.Vertical : 200
 When Detected : In-flight
 Result.Flight Crew : Became Reoriented

Assessments
 Contributing Factors / Situations   :   Airspace Structure
 Contributing Factors / Situations   :   Procedure
 Contributing Factors / Situations   :   Human Factors
 Contributing Factors / Situations   :   Environment - Non Weather Related
 Primary Problem : Ambiguous

Narrative: 1
 CTAF frequency was monitored and appropriate calls were made north northwest of
 [the airport] at approximately 10 NM, 5 NM, 2 NM, and when "overhead the
 numbers" of Runway 26. In addition to this being a nearly direct route to the
 destination, direct over flight of the airport was, in my mind, the safest route
 through the busy traffic area/corridor and nearby airports; the altitude being flown
 (6,800 FT MSL) was well above the traffic pattern. I heard several CTAF advisory
 calls made by airplanes in the vicinity: one was approaching from the east at about
 ten miles; one was entering a downwind for Runway 08; another had just landed
 and was taxiing for parking on the ramp. I was able to obtain a visual on the traffic
except for the aircraft arriving from the east; however, I did "see" all airborne
traffic on my Traffic Awareness System (TAS) display. At no time did I visually
observe or see any traffic on my TAS other than the participating aircraft making
calls on the CTAF frequency. As I neared the approach end of Runway 26, I made a
call of my position on the CTAF frequency with altitude. I was heading
approximately 165 degrees. Within five seconds, I observed a tow plane with glider
on tow pass below, left to right, and slightly ahead of my position on a westerly
heading. Maneuver was not required, but in any case would have been too late if it
had been necessary. At no time did I hear any called traffic indicating a tow plane
with glider in the vicinity of the airport. There was no indication of such close
proximity traffic on my TAS, and no "traffic alert" was issued by my TAS; I
concluded that no transponder was in use by the tow plane. I made a call on the
CTAF frequency and asked "if the tow plane was on the traffic advisory frequency."
No answer. I again made a call requesting a response from the tow plane. This time
I received an answer from the pilot of the glider on tow. I asked the glider pilot if
he had seen or heard my traffic calls; he said "no". I then asked UNICOM for tow
plane info and I stated that I would call the tow operator at the conclusion of my
flight (in about one hour). By this time I was approaching [airport] airspace and
had to switch up that frequency in order to request transit through that airspace.
After the glider on tow passed below and from left to right in front of us, I informed
my crew about the near miss. The crew member, who was seated in the left rear
forward facing seat, stated that she had seen "two shadows, very closely spaced,
on the ground off to our left", but she didn't say anything because she was trying
to "figure out" what they were. However, at no time did she actually see either the
tow plane or the glider on tow. Secondly, as I watched both aircraft slowly fly off to
my right, I noted that I most likely would have never seen the tow plane as it was
mostly off-white in color when viewed from above and it blended nicely with the
ground clutter in the area. However, the glider was a combination of highly visible
orange and yellow, which hopefully I would have seen had I been in a position to
do so; I could not have seen either aircraft since they were approaching us from
my blind side - below and left and climbing into us; my position in the cockpit was
the right seat. Post flight discussion with the glider pilot (tow pilot was unavailable
or would not take my call) revealed a 'this is our turf' attitude with regard to glider
operations at this airport. The glider pilot stated several times that "we are flying a
pattern approved by the FAA." This latter point seems to apparently be used by the
tow operators as a shield from irresponsible action(s) on their part. Further
discussion with the glider pilot proved insightful in regard to how tow operations
are conducted: 1. The only call made by tow pilots is a "glider on tow departing
Runway XX". No other calls are made while in the pattern, according to this glider
pilot. The reason stated by the glider pilot is that "this airport is too busy to make
standard traffic calls as it would clog the radio (CTAF frequency)."2. Tow operations
are conducted in a cavalier manner. 3. Most glider pilots operating at the airport do
not have radios and therefore cannot defuse a potential traffic conflict. Nor can
they announce position and/or intentions. I do not absolve myself from scrutiny in
the above event. "See and avoid" was the order of the day, but did not work for me
due to the previously stated fact that the other aircraft approached from my blind
side. This did show that a proper lookout doctrine/discipline, especially applied
when flying through such potentially busy airspace, might have caused my crew
member to call out anything "suspicious" when observed - this was my
responsibility to reiterate to my crew. Also, I was not aware that such specific
glider tow patterns were in place. I have personally briefed three pilots of this near
midair and the circumstances surrounding it. In this instance, I unintentionally
placed my aircraft, crew, and customer in exactly a location/flight path where the
 potential for a near midair was increased because it intersected with a published
 glider tow flight path/operation. All the pilots are acutely aware of the midair
 collision that occurred last year. The circumstances were very similar - a VFR
 aircraft transiting through the area collided with a tow plane (glider on tow).

Synopsis
 A helicopter pilot at 6,800 FT had a near miss over BDU with a NORDO tow aircraft
 and radio equipped glider under tow only to find out that an established FAA tow
 pattern is approved in which pilots make no calls once airborne.
ACN: 956485

Time / Day
 Date : 201106
 Local Time Of Day : 1801-2400

Place
 Locale Reference.Airport : SGR.Airport
 State Reference : TX
 Relative Position.Angle.Radial : 070
 Altitude.MSL.Single Value : 650

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 10
 Light : Daylight
 Ceiling.Single Value : 22000

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : SGR
 Aircraft Operator : Air Taxi
 Make Model Name : Bell Helicopter Textron Undifferentiated or Other Model
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 135
 Flight Plan : None
 Mission : Passenger
 Flight Phase : Cruise
 Route In Use : Direct
 Airspace.Class D : SGR

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : SGR
 Make Model Name : Cessna Aircraft Undifferentiated or Other Model
 Flight Phase : Initial Climb
 Airspace.Class D : SGR

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Commercial
 Qualification.Flight Crew : Instrument
 Experience.Flight Crew.Total : 2360
 Experience.Flight Crew.Last 90 Days : 64.18
 Experience.Flight Crew.Type : 640
 ASRS Report Number.Accession Number : 956485
 Human Factors : Communication Breakdown
 Human Factors : Other / Unknown
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : Flight Crew

Events
 Anomaly.Conflict : NMAC
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 200
 Miss Distance.Vertical : 200
 When Detected : In-flight
 Result.Flight Crew : Took Evasive Action

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Airspace Structure
 Primary Problem : Human Factors

Narrative: 1
 Lifted and called Tower for clearance through Delta airspace direct from position to
 my destination and was squawking pre-assigned code. [I] received clearance with
 an altimeter setting of 29.93 at altitude 650 MSL. Three minutes later was crossing
 extended end of departing Runway 17 just south of the Highway on a 070 degree
 heading, when I encountered a Cessna taking off Runway 17. I evaded aircraft by
 turning down and to the right as they flew over head about 200 FT above my
 aircraft. TCAS did not alert me to traffic and did not receive warning from Tower.
 [I] heard over the radio from other pilot that "he flew underneath me." I replied:
 "saw traffic evaded to the right." [I] flew through Delta airspace without any other
 occurrence.

Synopsis
 Helicopter pilot at 650 MSL experiences a NMAC with a Cessna departing Runway
 17. The reporter had received a clearance through the Class D and a squawk two
 minutes prior to the incident. Evasive action was taken by both aircraft.
ACN: 954870

Time / Day
 Date : 201106
 Local Time Of Day : 1201-1800

Place
 Altitude.AGL.Single Value : 300

Environment
 Flight Conditions : VMC
 Light : Daylight
 Ceiling : CLR

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : A109 All Series
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Ambulance
 Flight Phase : Initial Climb
 Route In Use : Direct
 Airspace.Class G : ZZZ

Component
 Aircraft Component : Engine Control
 Aircraft Reference : X
 Problem : Improperly Operated

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Qualification.Flight Crew : Rotorcraft
 Experience.Flight Crew.Total : 6000
 Experience.Flight Crew.Last 90 Days : 40
 Experience.Flight Crew.Type : 6000
 ASRS Report Number.Accession Number : 954870
 Human Factors : Fatigue
 Human Factors : Situational Awareness
 Human Factors : Time Pressure
 Human Factors : Confusion
Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.Flight Crew : Became Reoriented
 Result.Flight Crew : Took Evasive Action

Assessments
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 After lift off from a field site on a medical transport for the flight to the receiving
 hospital, I was configuring the aircraft for cruise flight to include landing gear,
 parking brake off, and rotor rpm. I was about to make the radio call to the flight
 dispatch when there was a change in engine noise. A quick check of instruments
 showed that an engine had gone into idle. I check the engine control switch and
 saw that it was in the idle position. I immediately returned it to flight. The engine
 power was restored and the mission was completed. This was the fifth flight of the
 12 hour shift and the second consecutive medical scene flight before returning to
 the base hospital. I do not recall how and when I moved the engine control switch.
 I reported this serious incident to the Chief Pilot, and notified the company Safety
 Officer.

Synopsis
 After takeoff on the fifth flight during a 12 hours shift, an Agusta 109E helicopter
 pilot inadvertently moved the Engine Control Switch to the Idle position. He caught
 the error quickly when the engine sound changed.
ACN: 952309

Time / Day
 Date : 201105
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Relative Position.Distance.Nautical Miles : 500
 Altitude.AGL.Single Value : 150

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 10
 Light : Daylight
 Ceiling.Single Value : 10000

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Corporate
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Mission : Test Flight
 Flight Phase : Final Approach
 Route In Use : Visual Approach
 Airspace.Class D : ZZZ

Aircraft : 2
 Reference : X
 ATC / Advisory.Tower : GTR
 Aircraft Operator : Military
 Make Model Name : Small Aircraft, Low Wing, 1 Eng, Retractable Gear
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Mission : Training
 Flight Phase : Final Approach
 Route In Use : Visual Approach
 Airspace.Class D : GTR

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Corporate
 Function.Flight Crew : Instructor
 Qualification.Flight Crew : Multiengine
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Qualification.Flight Crew : Instrument
 Qualification.Flight Crew : Flight Instructor
 Experience.Flight Crew.Total : 8500
 Experience.Flight Crew.Last 90 Days : 50
 Experience.Flight Crew.Type : 650
 ASRS Report Number.Accession Number : 952309
 Human Factors : Distraction
 Human Factors : Situational Awareness
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party2 : Flight Crew
 Communication Breakdown.Party2 : ATC

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Conflict : Airborne Conflict
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Inflight Event / Encounter : Other / Unknown
 Detector.Person : Flight Crew
 Detector.Person : Air Traffic Control
 Miss Distance.Horizontal : 300
 Miss Distance.Vertical : 50
 When Detected : In-flight
 Result.Air Traffic Control : Issued Advisory / Alert

Assessments
 Contributing Factors / Situations :   Procedure
 Contributing Factors / Situations :   Human Factors
 Contributing Factors / Situations :   Environment - Non Weather Related
 Contributing Factors / Situations :   Airspace Structure
 Primary Problem : Human Factors

Narrative: 1
 On this occasion I was pilot in command with copilot occupying the right seat and
 two passengers in the rear. We were returning from a 30 minute evaluation flight
 which would clear the aircraft for transfer to the new owner. The 30 minute flight
 was to culminate with a practice ILS 18 approach to ZZZ. This is our normal
 procedure to evaluate the functioning of aircraft instrument systems. The copilot
 was also conducting a practice approach since the ILS 18 approach has not been
 available during his tenure due to system down time. We requested a practice ILS
 approach and were advised of the usual VFR clearance stipulations and cautioned
 that the ILS was NOTAMed down. We acknowledged and were granted permission
 for a practice approach. We took an easterly heading and activated the ILS
 autopilot coupling. The system received the LOC and began a turn to intercept the
 inbound track. The Controller advised of traffic northwest of our position
 approximately 5 miles, and I asked if the traffic was also on approach. No answer
 was received; which is not unusual. As we approached the FAF and began our
 descent, I again queried Approach about the traffic's intentions with no response.
 As we crossed the FAF, I informed Control that we were switching to Tower and
 was cleared to Tower frequency. The approach continued normally until we were
 abeam [the OM], when the Tower screamed 'you can't do that, you can't shoot an
 approach here without contacting the Tower.' He was very excited and obviously
 hostile to me as the offender. I was scolded for making an approach with jet traffic
 behind me. Not knowing what he was referring to, I informed him that we had just
 been handed off by Approach and told to switch to Tower. I had in fact switched to
 Tower frequency at the FAF and contacted the Tower. During the Tower's lecture, I
 attempted to request a sidestep to land on Echo southbound at Hotel taxiway as is
 our normal routine, again there was confusion and the Tower was totally
 preoccupied with the well being of a training aircraft which I discovered was rapidly
 closing on my 6 o'clock position. As we approached the threshold of Runway 18, we
 were provided with a show of airmanship by a training aircraft that was impressive
 but reckless and irresponsible! The aircraft had closed to within 'a mile of my tail
 and sidestepped to Taxiway Echo south. He conducted a hi-speed pass in this
 position at approximately 50-100 FT AGL, and then proceeded to make an
 aggressive correction back to the runway centerline, using a 60 to 80 degree bank,
 again within a mile of my aircraft. The Tower again expressed his concern for the
 training aircraft's well being and was told by the pilot that he was 'frustrated.' The
 Tower assured him that that all was well and cleared him back to his base. Had we
 conducted our normal sidestep to land on Taxiway Echo southbound at Hotel, the
 result could have been a deadly midair! This childish stunt could have been deadly
 for 6 people. This incident (potential accident) was the result of three simple
 mistakes, either of which alone was a non event. But when coupled in the "rule of
 threes" they produced the ingredients of a potential accident. The events were as I
 saw them: 1) Approach Control failed to inform me that the reported traffic was on
 approach to ZZZ and then failed to answer my request for this information on two
 further occasions. 2) Approach failed to inform the Tower of both my approach and
 hand-off at the FAF. It appears he also failed to inform Tower of the trainer's
 approach. 3) The Tower 'lost his cool' and instead of issuing a simple 'go-around'
 order to either me or the training aircraft spent valuable time reprimanding me
 over the air; instead of a professional 'call me over the land line when you're on the
 ground.' The training aircraft pilot's errors are almost too numerous to enumerate,
 but they included: A.) When reported traffic is in close proximity under VFR, with
 no separation provided, it is prudent to go around if you don't have the traffic in
 sight, even if you are a 'jet' and the reported traffic is a 'lowly helicopter.' B.) The
 proper procedure for a go around is a pull-up and reentry to downwind, not a knife-
 edge-pass down the adjacent taxiway. C.) It is never acceptable to conduct a high
 speed, low level pass on an aircraft that is in the landing pattern.

Synopsis
 A helicopter pilot on a practice ILS reported traffic confliction with a training aircraft
 which overtook him and then overflew the airport in a show of frustration. There is
 no report of ATC guidance during this event.
ACN: 949343

Time / Day
 Date : 201105
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 0

Environment
 Light : Daylight

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : Eurocopter AS 350/355/EC130 - Astar/Twinstar/Ecureuil
 Operating Under FAR Part : Part 135
 Mission : Ambulance
 Flight Phase : Parked
 Maintenance Status.Released For Service : Y
 Maintenance Status.Maintenance Type : Unscheduled Maintenance
 Maintenance Status.Maintenance Items Involved : Testing
 Maintenance Status.Maintenance Items Involved : Repair
 Maintenance Status.Maintenance Items Involved : Inspection

Component : 1
 Aircraft Component : Cockpit/Cabin Communication
 Manufacturer : Eurocopter / Ecureuil
 Aircraft Reference : X
 Problem : Malfunctioning

Component : 2
 Aircraft Component : Interphone System
 Manufacturer : Eurocopter / Ecureuil
 Aircraft Reference : X
 Problem : Malfunctioning

Person
 Reference : 1
 Location Of Person : Hangar / Base
 Reporter Organization : Air Taxi
 Function.Maintenance : Lead Technician
 Qualification.Maintenance : Powerplant
 Qualification.Maintenance : Inspection Authority
 Qualification.Maintenance : Airframe
 Experience.Maintenance.Technician : 20
 ASRS Report Number.Accession Number : 949343
 Human Factors : Distraction
 Human Factors : Situational Awareness
 Human Factors : Time Pressure
 Human Factors : Troubleshooting
 Human Factors : Workload
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Maintenance
 Communication Breakdown.Party2 : Other
 Communication Breakdown.Party2 : Maintenance
 Analyst Callback : Completed

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : FAR
 Detector.Person : Flight Crew
 Were Passengers Involved In Event : Y
 When Detected : In-flight
 Result.General : Maintenance Action

Assessments
 Contributing Factors / Situations : MEL
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Company Policy
 Contributing Factors / Situations : Chart Or Publication
 Contributing Factors / Situations : Aircraft
 Contributing Factors / Situations : Procedure
 Primary Problem : Company Policy

Narrative: 1
 After putting a new aircraft into service we developed an intermittent Intercom
 Communication System (ICS) issue between the front [pilots] and back seats. The
 ICS was MEL'd on this date. Troubleshooting was accomplished two days later with
 the aircraft in-service. Problem could not be duplicated and MEL was removed. ICS
 failed again five days later and was again MEL'd. Aircraft was taken out of service
 to troubleshoot the aircraft. Forward ICS panel was replaced the following day, as
 well as rang-out [electrical] wiring with the assistance of company Avionics support.
 All wires rang out correctly and issue could not be duplicated during a ground run
 or flight check. MEL was again cleared. During troubleshooting on the same day, I
 was asked to defer the maintenance till the next day. I do realize we need to keep
 our aircraft in service as much as possible to keep our customer happy and keep
 generating revenue. I am being pressured to put off unscheduled maintenance to a
 later date. Not only is this just plain wrong, it puts my crew in an unsafe situation.
 I will NOT compromise the safety of my crew to schedule unforeseen/intermittent
 problems with the aircraft. I cannot resolve intermittent issues at a convenient
 time; I have no choice but to troubleshoot the system when it occurs. This system
 can only be MEL'd for three days and for good reason, it is a system that needs to
 function correctly to keep communication between the Pilot and Crew open and
 safety at its highest. The customer must understand that I am doing my best to
 provide a safe and fully functional aircraft and not dictate when I perform
 unscheduled maintenance. This will potentially and eventually cause an accident in
 the future if all maintenance has to be scheduled. I need support to be able to
 maintain my aircraft in the safest way I can and to not be pressured by the
 customer to defer maintenance. I have always done my best to keep my aircraft in
 service as much as possible and to be available at all times. My unscheduled 'Out of
 Service' time speaks for itself. I maintain my aircraft at the highest level possible
 and I will not compromise safety for anyone. My crews' lives depend on me doing
 my job the best I can. If I am being pressured to put maintenance off this is a
 safety of flight issue and needs to be resolved and soon.

Callback: 1
 The Reporter stated this was a new Eurocopter AS-350 helicopter with less than
 fifty hours of operation that developed an intermittent intercom problem that was
 difficult to duplicate on the ground. The two front seats (pilots) could not talk with
 the back seat Medic and Flight Nurse. The pilots could talk with each other and the
 Medic and Nurse could communicate with each other, but not front to back or back
 to front. Reporter stated the only way for the Medic or Nurse to communicate with
 the pilots would be for one of them (Medic or Nurse) to stretch their individual
 headset cord forward to the cockpit and plug into the co-pilot's radio com #2 jack
 which would then allow one of the back seats to communicate directly with the
 pilots. But, in that condition, the Medic and Nurse could not communicate with each
 other. Reporter stated his company installs their own interiors for their air
 ambulances. Because the problem was intermittent, troubleshooting was difficult.
 Finally the communication problem became a hard fault. He could not continue to
 defer the discrepancy again, even though he was heavily pressured to do so. That's
 when he took the helicopter out of service. Even though he and an Avionics
 Mechanic had previously "Rung-Out" the intercom electrical wiring without finding
 any problems, he (Reporter) went back and started checking for loose connections
 in the aircraft's belly at the same J-Box connections. There are hundreds of wires
 with terminal pins at the J-Box area, but since then, after he physically checked the
 security of those connections, the intercom communication problem has not
 returned. Reporter also stated that one of his concerns about continuing to defer
 the communication failure between the pilots and back seat occupants was the
 importance of all onboard to help the pilot be aware of traffic around the helicopter.
 During the time the back seat communication was deferred, a Nurse saw an aircraft
 approach the AS-350 from the aft side and was unable to notify the pilot who had
 not seen the aircraft.

Synopsis
 A Lead Mechanic reported a chronic intercom failure between the front seat pilots
 and the back seat Medic and Flight Nurse on a Eurocopter AS-350. He also noted
 the lack of support from his Management to perform proper troubleshooting and
 pressure to continue deferring the intercom discrepancy.
ACN: 948560

Time / Day
 Date : 201105
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 0

Environment
 Flight Conditions : VMC
 Light : Daylight
 Ceiling : CLR

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : MBB-BK 117 All Series
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : IFR
 Flight Phase : Parked

Component
 Aircraft Component : Yaw Control
 Aircraft Reference : X
 Problem : Failed

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 ASRS Report Number.Accession Number : 948560
 Human Factors : Training / Qualification
 Human Factors : Troubleshooting
 Human Factors : Distraction
 Human Factors : Situational Awareness

Events
 Anomaly.Aircraft Equipment Problem : Less Severe
 Detector.Person : Flight Crew
 When Detected : Pre-flight
 Result.General : Maintenance Action
 Result.General : Flight Cancelled / Delayed

Assessments
 Contributing Factors / Situations : Aircraft
 Primary Problem : Aircraft

Narrative: 1
 While conducting pre-start walk around noticed a dent centered in a single tail rotor
 paddle approximately halfway in distance between the root and end of the blade.
 Here is the sequence of events. I conducted a pre-flight of the aircraft in the
 morning upon reporting for my shift with no aircraft deficiencies noted. [I] received
 an inter-hospital flight request for a patient pick-up at hospital for transport to
 another hospital. Conducted pre-start walk around with no deficiencies noted and
 flew to the sending hospital. After shutdown, [I] conducted post-flight walk around
 with no deficiencies noted. Loaded patient, conducted pre-start walk around with
 no deficiencies noted and flew to receiving hospital. After shutdown at receiving
 hospital, conducted post-flight walk around with no deficiencies noted and serviced
 the helicopter. Conducted crew link up inside the hospital and moved back outside
 for departure back to base. During the execution of my pre-start walk around prior
 to returning to base, noted a shadow on one of the tail rotor paddles that "didn't
 look right." Upon close-up visual examination and moving the blades to just the
 right position in relation to the sun, noted a dent in the paddle that, when touched,
 felt to me as a delamination in the fiberglass outer shell from the inner foam core
 of the paddle itself. After grounding the aircraft, I contacted the base mechanic to
 initiate the logistical requirements of repairing the tail rotor and contacted our
 communications center to take us out of service. If something does not look right,
 feel right or smell right; stop, assess the situation, and determine a course of
 action. On this day, I personally looked at the tail rotor on five separate occasions
 and did not notice any deficiencies. During the execution of the sixth walk around
 of the day, the sun was at just the right angle to create a shadow that allowed me
 to discover what could have been a catastrophic flaw for the tail rotor. (Point of
 note, one hour later, it took three of us to find the dent again since the sun had
 moved enough to create a different lighting angle on the blade.)

Synopsis
 A BK117 pilot discovered a possible delamination in one of the tail rotor blades
 while conducting the sixth walk around of the day. The flaw was very difficult to
 detect until daylight at the correct angle revealed a shadow which, when examined,
 revealed the flaw.
ACN: 947974

Time / Day
 Date : 201105
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Relative Position.Angle.Radial : 180
 Relative Position.Distance.Nautical Miles : 15
 Altitude.AGL.Single Value : 500

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 10
 Light : Daylight
 Ceiling.Single Value : 12000

Aircraft : 1
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : MBB-BK 117 All Series
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Ambulance
 Flight Phase : Initial Approach
 Route In Use : Direct
 Airspace.Class G : ZZZ

Aircraft : 2
 Reference : Y
 Aircraft Operator : Government
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Mission : Utility
 Flight Phase : Cruise
 Airspace.Class G : ZZZ

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Instrument
 Qualification.Flight Crew : Commercial
 Qualification.Flight Crew : Flight Instructor
 Experience.Flight Crew.Total : 3090
 Experience.Flight Crew.Last 90 Days : 32
 Experience.Flight Crew.Type : 310
 ASRS Report Number.Accession Number : 947974

Events
 Anomaly.Conflict : NMAC
 Detector.Person : Other Person
 Miss Distance.Horizontal : 0
 Miss Distance.Vertical : 100
 When Detected : In-flight
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 We were heading east bound to a motor vehicle accident on the highway, all
 standard position calls made. Overhead the scene in a right hand turn at
 approximately 500 FT AGL heading roughly west to south east, I was looking and
 clearing to the right when the nurse in the rear called out that a helicopter had
 passed right beneath us by less than 100 FT heading south to north (from our right
 side). The nurse said he could see the aircraft was a [helicopter]. Even though I
 was looking in that direction I did not see the aircraft. Neither aircraft made any
 kind of avoiding climb descent or turn. The crew when they were on the ground
 questioned the local fire and police department and they said the aircraft was the
 county aircraft and that it had been in the local area just prior to our arrival. We
 think the pilot may have been 'rubber necking' the scene unaware of the possibility
 of EMS, news or police helicopters as it was fairly major event with multiple
 vehicles and EMS units on scene.

Synopsis
 EMS helicopter pilot reports NMAC with another helicopter apparently rubber
 necking an accident scene.
ACN: 946265

Time / Day
 Date : 201104
 Local Time Of Day : 1201-1800

Environment
 Flight Conditions : VMC
 Light : Daylight

Aircraft : 1
 Reference : X
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 2
 Mission : Ambulance
 Flight Phase : Cruise

Aircraft : 2
 Reference : Y
 Make Model Name : Bell Helicopter Textron Undifferentiated or Other Model
 Mission : Ambulance
 Flight Phase : Cruise

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 ASRS Report Number.Accession Number : 946265
 Human Factors : Other / Unknown

Events
 Anomaly.Conflict : Airborne Conflict
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 This report concerns an incident involving our helicopter and another passing too
 close to one another. I am reluctant to call this a near miss since we were never in
 any danger of colliding. However, we did pass too close for comfort! This happened
 while we were in level cruise flight at 5500 MSL enroute back to base. We had just
 completed a patient transport, having dropped off our patient at the Medical Center.
 We were on a southeasterly course back to base. I was actively scanning for
 aircraft, looking forward when someone announced on [the frequency], "Hello,
 there!" In that instant, an aircraft flashed by our left side, approximately one
 quarter mile away, on a parallel but opposite direction course, a few hundred feet
 below our altitude. The bright red and white Bell 407 immediately caught my
 attention as our competitor. The 407 was just barely visible to me above the lower
 edge of the windows out the left side of our aircraft. Shocked by the sudden
 encounter, I acknowledged the radio transmission by saying, "Nice paint job!" My
 impression was that the other pilot failed to see us, as well, until only a moment
 before our passing by. If he had seen us any earlier, I believe they would have
 turned away to increase separation and made some sort of position report to us. It
 was evident by their comment that they were also taken by surprise. We did not
 get a TCAS alert since we were outside a radar environment in this remote area. As
 I processed what happened, I tried to understand why I had failed to see the other
 aircraft in time to avoid this encounter. While I cannot excuse myself from
 responsibility, I identified several factors that made the other aircraft difficult to
 spot: 1. The nearly head on approach angle meant that there was very little change
 in relative position, of the other aircraft, in my field of view. The other aircraft was
 probably nearly stationary, from my vantage point, until the actual passing. 2. The
 closure rate was very fast: approximately 260 knots, allowing little time to see and
 avoid. 3. The other aircraft was lower, difficult to spot against the ground clutter.
 From my position, in the right seat, my view looking ahead, to the left and lower is
 partially blocked by the instrument panel. 4. Smoke from a large wildfire reduced
 visibility somewhat to approximately 10 miles. After landing, I discussed what
 happened with my crew. The medic was sitting on the left side of the aircraft [and]
 reports that she was actively scanning for aircraft but also failed to see the other
 aircraft until our passing. The nurse, was sitting behind me was scanning out the
 right side of the aircraft and did not see the aircraft on our left. We were not talking
 in the minute or so before the incident; there were no distractions from the task of
 scanning. I shared my observations about the contributing factors, as listed above,
 with my crew. We felt better after our discussion but we were all still a little
 unnerved by thoughts of what could have happened. For my part, I'm considering
 making periodic radio calls while enroute; position reports in the blind, similar to
 what we now do near landing zones. This might help to prevent a re occurrence of
 this problem during the non ATC enroute phase of flight.

Synopsis
 Medevac helicopter pilot reports airborne conflict with another opposite direction
 helicopter at 5500 feet.
ACN: 946202

Time / Day
 Date : 201104
 Local Time Of Day : 0001-0600

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 0

Environment
 Flight Conditions : VMC
 Light : Daylight

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Make Model Name : MBB-BK 117 All Series
 Crew Size.Number Of Crew : 1
 Mission : Ambulance
 Flight Phase : Cruise

Aircraft : 2
 Reference : Y
 Make Model Name : Cessna 150

Component
 Aircraft Component : DC Rectifier
 Aircraft Reference : X
 Problem : Malfunctioning

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 ASRS Report Number.Accession Number : 946202

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.Flight Crew : Diverted
 Result.Flight Crew : Landed As Precaution
 Result.Air Traffic Control : Provided Assistance
Assessments
 Contributing Factors / Situations : Airport
 Contributing Factors / Situations : Aircraft
 Primary Problem : Aircraft

Narrative: 1
 While enroute to pick up a passenger the T/R chip light illuminated. I tried to fuzz
 burn the chip but was unsuccessful. I elected to land at the nearest airport. About
 one hour prior to my flight a small Cessna ran off the runway closing the whole
 airport. When I contacted the Tower to see if I could land on the helipad area of the
 ramp the controller told me the whole airport was closed and I could only land if I
 was having an emergency. I told him that I didn't necessarily need to declare an
 emergency for a chip light but I didn't want to overfly a suitable landing area. The
 Controller then cleared me to land on the ramp. Once I landed I asked the Tower
 Controller if I needed to call him or fill out any paperwork and he stated that I did
 not have to do anything at all. I think this event was handled well by the controller.

Synopsis
 A BK-117 Pilot elected to land at the nearest suitable airport when a tail rotor chip
 light illuminated and would not fuzz burn off, only to learn the selected airport was
 closed due to an earlier runway excursion. The Local Controller opted to clear the
 helo for the landing at the helipad for safety of flight concerns.
ACN: 944804

Time / Day
 Date : 201104
 Local Time Of Day : 1801-2400

Place
 Locale Reference.Airport : LAX.Airport
 State Reference : CA
 Altitude.MSL.Single Value : 1500

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : LAX
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Flight Plan : VFR
 Flight Phase : Cruise
 Airspace.Class B : LAX

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : LAX
 Aircraft Operator : Air Carrier
 Make Model Name : MD-88
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 121
 Flight Phase : Initial Climb
 Airspace.Class B : LAX

Person : 1
 Reference : 1
 Location Of Person.Facility : LAX.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Traffic Management
 ASRS Report Number.Accession Number : 944804
 Human Factors : Situational Awareness

Person : 2
 Reference : 2
 Location Of Person.Facility : LAX.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 944817

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Conflict : Airborne Conflict
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Primary Problem : Procedure

Narrative: 1
 I was working helicopter position at LAX. A VFR helicopter on a previously approved
 photo mission was on an east to west photo shoot between the north (24L/R) and
 south (25L/R) runway complexes. I observed the helicopter west bound
 approaching the shore line at 1,500 FT. I instructed the helicopter to remain to the
 center of the north and south complexes for traffic departing the south complex. I
 observed the helicopter turn east toward the Tower and all of the departures off
 Runway 25R. A MD88 departing Runway 25R advised Local 1 that the helicopter
 was too close. I was providing visual separation between the helicopter and the
 MD88. Recommendation, do not approve photo missions.

Narrative: 2
 An MD88 was departing Runway 25R. There was a photo mission helicopter at
 1,500 FT MSL north of the departure end of the runway. I had both aircraft in sight.
 As I issued the frequency change to the MD88 to Departure Control, I issued him
 the traffic advisory. He responded that he was uncomfortable with the proximity of
 the helicopter and that he would be "filing" something. I gave him the Tower phone
 number and switched him to departure. Recommendation, do not allow photo
 missions in that area.

Synopsis
 LAX Controllers described a potential conflict event between an air carrier departure
 from the south complex and a helicopter on a photo mission between the runway
 complexes, both reporter's recommending no future photo missions.
ACN: 944481

Time / Day
 Date : 201104
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.MSL.Single Value : 400

Environment
 Weather Elements / Visibility : Thunderstorm
 Weather Elements / Visibility : Rain
 Weather Elements / Visibility : Turbulence
 Weather Elements / Visibility.Visibility : 5
 Ceiling.Single Value : 2000

Aircraft
 Reference : X
 ATC / Advisory.UNICOM : ZZZ
 Aircraft Operator : Personal
 Make Model Name : Robinson R44
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Mission : Personal
 Flight Phase : Landing
 Route In Use : Visual Approach
 Airspace.Class G : ZZZ

Component
 Aircraft Component : Airspeed Indicator
 Aircraft Reference : X
 Problem : Malfunctioning

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Personal
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Private
 Qualification.Flight Crew : Rotorcraft
 Experience.Flight Crew.Total : 130
 Experience.Flight Crew.Last 90 Days : 60
 ASRS Report Number.Accession Number : 944481
Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Inflight Event / Encounter : Weather / Turbulence
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.General : Maintenance Action
 Result.Flight Crew : Landed in Emergency Condition
 Result.Flight Crew : Diverted

Assessments
 Contributing Factors / Situations : Weather
 Contributing Factors / Situations : Aircraft
 Primary Problem : Aircraft

Narrative: 1
 I took off [after] briefing and checking METAR, NOAA, and TFR; isolated storms
 rising to northwest, to not affect my flight to southeast along the shore line until
 my destination. Eighty miles from departure I got on airspeed indicator stuck. I
 made a decision to turn back to the nearest airport, but all were near the
 thunderstorm. As soon as I was flying back I got moderate turbulence, so I decided
 to make a precautionary landing on a football field. Without an airspeed indicator
 and turbulence I [made my] approach to landing on the football field. I flew up
 twice to check the area and there were no people in the field or obstacles that
 could be a safety factor. As a precaution, as soon as I was on the ground safely, I
 called to mechanic for instruction or repair, and also I called the Inspector from FAA
 that I met one day before just to report that I landed there as a precaution. As
 instructed I just opened the dash checked wire, and check the pitot tube over the
 main mast. I was there for 1:40 hours until thunderstorm and rain finished over the
 area, as soon there everything done and working well, I took off and flew back to
 base.

Synopsis
 R44 pilot reports a precautionary off airport landing due to airspeed indicator failure
 and thunderstorms in the area.
ACN: 943861

Time / Day
 Date : 201104
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 0

Environment
 Light : Daylight

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : MBB-BK 117 All Series
 Operating Under FAR Part : Part 135
 Mission : Ambulance
 Flight Phase : Parked
 Maintenance Status.Records Complete : N
 Maintenance Status.Released For Service : Y
 Maintenance Status.Required / Correct Doc On Board : N
 Maintenance Status.Maintenance Type : Unscheduled Maintenance
 Maintenance Status.Maintenance Items Involved : Inspection
 Maintenance Status.Maintenance Items Involved : Installation
 Maintenance Status.Maintenance Items Involved : Repair
 Maintenance Status.Maintenance Items Involved : Work Cards

Component : 1
 Aircraft Component : Fuselage Skin
 Manufacturer : Eurocopter / Kawasaki
 Aircraft Reference : X

Component : 2
 Aircraft Component : Fuel Line, Fittings, & Connectors
 Manufacturer : Eurocopter
 Aircraft Reference : X
 Problem : Malfunctioning

Person : 1
 Reference : 1
 Location Of Person : Gate / Ramp / Line
 Reporter Organization : Air Taxi
 Function.Maintenance : Technician
 Qualification.Maintenance : Inspection Authority
 Qualification.Maintenance : Powerplant
 Qualification.Maintenance : Airframe
 ASRS Report Number.Accession Number : 943861
 Human Factors : Situational Awareness
 Human Factors : Training / Qualification
 Human Factors : Confusion
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Maintenance
 Communication Breakdown.Party1 : Other
 Communication Breakdown.Party2 : Maintenance
 Analyst Callback : Completed

Person : 2
 Reference : 2
 Location Of Person : Gate / Ramp / Line
 Reporter Organization : Air Taxi
 Function.Maintenance : Technician
 Qualification.Maintenance : Powerplant
 Qualification.Maintenance : Airframe
 ASRS Report Number.Accession Number : 943860
 Human Factors : Situational Awareness
 Human Factors : Training / Qualification
 Human Factors : Confusion
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Maintenance
 Communication Breakdown.Party1 : Other
 Communication Breakdown.Party2 : Maintenance
 Analyst Callback : Completed

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : FAR
 Detector.Person : Maintenance
 Were Passengers Involved In Event : N
 When Detected : Routine Inspection
 Result.General : Maintenance Action

Assessments
 Contributing Factors / Situations :   Procedure
 Contributing Factors / Situations :   Incorrect / Not Installed / Unavailable Part
 Contributing Factors / Situations :   Human Factors
 Contributing Factors / Situations :   Chart Or Publication
 Contributing Factors / Situations :   Aircraft
 Primary Problem : Human Factors

Narrative: 1
 This aircraft, [Eurocopter BK-117], has a hole in the belly between the fuel pumps.
 The hole was there when we got the aircraft from the Repair Station in ZZZ. There
 is tribal knowledge that many, if not all, BK-117s have these holes. The aircraft has
 most likely been operating with this hole for years and years. There is a clamp on
 the fuel transfer tube that can seep. The hole is for access to the clamp, as
 opposed to removal of the cabin floor, which would otherwise be needed for access.
 I was informed by Mechanic X that there was an issue with these holes. He told me
 that Eurocopter had issued a "No Technical Objection" (NTO), requiring a daily tap
 test and repair in 50 hours. A daily tap test requirement indicated to Mechanic X
 and me that this is a serious issue, so we took pictures of ours and sent to our
 Manager for evaluation right away. We took the aircraft out of service until we
 received guidance from Eurocopter. I do not recall ever seeing a BK-117 that did
 not have these holes. Our BK had this hole when it came from the Repair Station in
 ZZZ. Countless people, including [those] with far more experience than me had
 accepted this hole, so I did not believe that it was an improper repair until I heard
 from Mechanic X. Nevertheless, I had signed-off the aircraft with this condition. I
 would suggest a Service Bulletin (SB) from Eurocopter or possibly a Maintenance
 bulletin from our Company Operations. When I talked to the [Manufacturer]
 Technical Representative about our aircraft he said that there were many other
 aircraft having the same issue. The hole was known since October 2009. It was
 only identified as an issue April 2011.

Callback: 1
 Reporter stated there are two different holes in the lower fuselage belly skin that
 are discussed. One of the holes is a manufactured fuel drain hole about one-eighth
 of an inch (1/8 inches) in diameter that enlarges over time and eventually requires
 a sheet metal repair to reduce the opening. The other belly hole is an access hole
 that has appeared on many of their BK-117 helicopters, but is not a Eurocopter
 approved hole. The belly section of the BK-117 is only .012 inches thick metal skin
 with an inner bonded honeycomb layer; basically a composite skin, which can
 delaminate. Reporter stated the daily tap test is used to locate delamination around
 the unapproved holes until a permanent repair can be accomplished within 50
 hours. His company filed an FAA Form 337 for a major repair of the fuselage. When
 or how the unapproved access holes started appearing on the lower belly skin, no
 one seems to know. Some of the access holes looked like someone had taken a
 hatchet to the fuselage skin. Reporter stated that although the holes are "not
 approved" by the Manufacturer, they do provide easy access to the fuel tank
 transfer tube attaching clamps. The clamps apparently leak fuel, especially in the
 winter when outside temperature changes drastically when flying from warm
 weather in the southern states into frigid winter temperatures in the northern
 states. Since the access holes are "not approved," they all must be repaired. When
 the clamps leak fuel, mechanics will have to remove the cabin floor to gain access
 to tighten the transfer tube clamps. Reporter stated, the Manufacturer does not
 seem interested in issuing a Service Bulletin allowing the fuselage belly skin to be
 modified for access to the clamps.

Narrative: 2
 [I was] informed by another Mechanic that his aircraft had a hole in the belly that
 had been filled with a [body filler]. When we did our airworthiness check we looked
 and found a similar hole. It has been known that most [BK-117s] have holes like
 this. Did not believe it to be an issue until it was passed down from another
 Mechanic who had a similar hole. We then took action to fix the issue. Informed
 Eurocopter and they sent a "No Technical Objection" (NTO) for the inspection of the
 hole while a repair is being worked on. Suggest [we] have a complete drawing of
 the aircraft belly with all the holes in it.

Callback: 2
 Reporter stated the hole is located at the lower aft belly section of the BK-117
 fuselage just aft of the main fuel tank and forward of the auxiliary tank. Some of
 the BK-117s had holes that were over 1 inch in diameter, but should have been
 only 1/8 of an inch.

Synopsis
 Two mechanics report finding unapproved access holes in the lower belly section of
 the external fuselage skin of various Eurocopter BK-117 helicopters. The holes were
 used to access the fuel transfer tube attach clamps that tend to leak fuel when
 flying from warm weather to frigid winter weather states.
ACN: 942396

Time / Day
 Date : 201104
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.MSL.Single Value : 6000

Environment
 Flight Conditions : IMC
 Weather Elements / Visibility : Fog
 Ceiling.Single Value : 7200

Aircraft
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Make Model Name : Iroquois 205 (Huey)
 Crew Size.Number Of Crew : 1
 Flight Plan : VFR
 Flight Phase : Cruise
 Airspace.Class D : ZZZ

Person : 1
 Reference : 1
 Location Of Person.Facility : ZZZ.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 942396
 Human Factors : Communication Breakdown
 Human Factors : Situational Awareness
 Human Factors : Confusion
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : ATC

Person : 2
 Reference : 2
 Location Of Person.Facility : ZZZ.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Supervisor / CIC
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 942397

Person : 3
 Reference : 3
 Location Of Person.Facility : ZZZ.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Supervisor / CIC
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 942425

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : FAR
 Detector.Person : Air Traffic Control
 When Detected : In-flight
 Result.Air Traffic Control : Issued New Clearance

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Weather
 Primary Problem : Human Factors

Narrative: 1
 Did a VFR helicopter enter Class Delta airspace without a SVFR clearance? If yes, in
 this case, it is the fault of ATC, not the pilot. While on Local Control, TRACON called
 to request a VFR transition for a helicopter for which they were providing RADAR
 flight following. We work Local Control 1 combined with Local Control 2 over 95%
 of the time. When TRACON called, it was communicating with an IFR Twin Cessna
 on an ILS approach. Ground Control answered the TRACON shout line. Normally
 Local Control answers this line, but it is not mandated. Ground Control approved
 the transition, and then informed me that he had approved a VFR transition while
 pointing to it on the Local Control RADC RADAR. This did not concern me since the
 broken layer of clouds making the airspace IFR was only a few hundred feet thick
 with good VFR above the fog/clouds. The helicopter was indicating 6,000 FT MSL.
 Our field elevation is a little under 5,700 MSL. The cloud bases were 6,200-6,300
 MSL with tops (and top of fog) 6,600-6,800 MSL. When the helicopter entered the
 airspace without first climbing I started to call the helicopter. The helicopter
 answered after perhaps three calls. I advised the helicopter that "Delta airspace
 was IFR, say intentions". He wanted to continue northwest bound. I was so hoping
 he would advise me that TRACON has issued him a Special VFR clearance. I
 advised the helicopter that "VFR flight was not authorized, say intentions". He
 wanted to continue. I advised the helicopter again that "Delta airspace was below
 VFR minima and VFR flight was not authorized, say intentions". He responded,
 "Well I guess I'll land". After confirming that he had the airport in sight, cleared
 him to land on the runway, the closest controlled paved surface. Had the helicopter
 asked for SVFR I would have issued it. I believe low experience at both the
 TRACON and certainly with the Ground Controller contributed greatly to this
 situation. An experienced controller at TRACON would have transferred
 communication of the helicopter to our Tower frequency and let Tower deal with
 the situation. The TRACON called just as the IFR Twin Cessna got to the Outer
 Marker on the ILS. An experienced controller would not have initiated an inter-
 facility shout line call at the exact moment that they knew the ILS traffic would be
 calling Tower. I do not know if the TRACON Controller even understood we were
 IFR, and what ramifications that has. An experienced Ground Controller would have
 responded to the TRACON request with, "we are IFR, what are you asking for", or
 "did he request Special VFR", or something sensible. An experienced Ground
 Controller would have identified to the Local Controller that the transition was
 approved at 6,000 FT MSL; giving the Local Controller a chance to respond. An
 experienced Ground Controller would not have responded to the TRACON request
 with, "that'll work." It didn't work! I still do not know if TRACON issued an
 appropriate SVFR transition clearance, but I doubt it. The pilot of the helicopter
 gave no indication they had any familiarity with SVFR procedures. I will advise all
 my co-workers who are not Certified Professional Controllers not to answer the
 TRACON when I am working Local Control.

Synopsis
 Tower Controller described a confused SVFR event when both the ATC personnel
 and the pilot were apparently unfamiliar with SVFR requirements and conditions.
ACN: 941070

Time / Day
 Date : 201103
 Local Time Of Day : 0001-0600

Place
 Locale Reference.Airport : POC.Airport
 State Reference : CA
 Altitude.MSL.Single Value : 1300

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : POC
 Aircraft Operator : Government
 Make Model Name : Bell Helicopter 412
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 91
 Flight Plan : None
 Flight Phase : Initial Approach
 Route In Use.Other
 Airspace.Class D : POC

Aircraft : 2
 Reference : Y
 Aircraft Operator : Corporate
 Make Model Name : Citationjet (C525/C526) - CJ I / II / III / IV
 Operating Under FAR Part : Part 135
 Flight Plan : IFR
 Mission : Training
 Flight Phase : Landing
 Route In Use : Visual Approach

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Government
 Function.Flight Crew : Single Pilot
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Rotorcraft
 Qualification.Flight Crew : Multiengine
 Qualification.Flight Crew : Instrument
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Experience.Flight Crew.Total : 12000
 Experience.Flight Crew.Last 90 Days : 100
 Experience.Flight Crew.Type : 3000
 ASRS Report Number.Accession Number : 941070
 Human Factors : Other / Unknown
 Human Factors : Situational Awareness
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : Flight Crew

Events
 Anomaly.Conflict : NMAC
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 300
 Miss Distance.Vertical : 0
 When Detected : In-flight
 Result.Flight Crew : Took Evasive Action
 Result.Flight Crew : Requested ATC Assistance / Clarification
 Result.Air Traffic Control : Issued Advisory / Alert

Assessments
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 I contacted Tower approximately 6 NM northwest and requested an established VFR
 helicopter route arrival from the north. (The route involves descending to 1,600 FT
 MSL (500 FT AGL) in preparation for a mid-field crossing at the tower location on a
 heading perpendicular to the Runway Heading with a left turn inside of the fixed
 wing pattern and a termination to either the Runway The Local Controller was
 working several VFR aircraft in the traffic pattern at the time of the call. I reported
 that I had listened to the current ATIS information and continued inbound to the
 VFR reporting point north of the tower. While approximately 2 miles out from the
 airfield, I heard a Citation jet reporting inbound on the VOR-A procedure from the
 southwest. The pilot of the jet also requested a missed approach and a low
 approach over the runway. The Controller asked if the pilot was VFR or IFR and the
 pilot replied that he was IFR. The Controller advised the pilot that he would have to
 cancel IFR and proceed in VFR conditions. I did not hear the Controller issue my
 aircraft as traffic at any time to the Citation pilot. She did issue the traffic call out
 to me as I was approaching the Control Tower on the north side of the airport. I
 expected the Citation pilot to climb to the VFR pattern altitude after crossing the
 VOR on the south side of the airport in order to make a right traffic pattern for
 Runway 26. I could not see the jet upon the initial traffic call out and immediately
 notified the Tower that I did not have the jet in sight. Because the Controller did
 not respond to my call, I advised the Tower that I was turning east to avoid the jet.
 At the time of the turn I saw the Citation jet flying right at my position in the clean
 configuration. The aircraft made no heading correction to avoid me and was
 actually below my altitude (approximately 1,300 MSL) which is only 200-300 AGL. I
 hesitated several seconds again and requested clarification of my clearance to cross
 over the tower and used the words, "confirm that helicopter X is cleared to cross
 and cleared to land on the south parallel taxiway". The Controller replied
 "affirmative, cleared to land." At no time did I hear any restrictions issued to the
 Citation pilot nor did I hear any traffic issued to the Citation regarding my aircraft
 that was now going to land on a taxiway south of and parallel to the runway that
 the jet was going to overfly. As I turned final along the established noise
 abatement flight pattern for our aircraft, I was surprised to see the Citation jet
 make a high speed low level pass down the runway adjacent to me. His estimated
 altitude was less than 100 FT and he was in the "clean" configuration - gear up,
 flaps up. His speed was much faster than a "low approach" airspeed and the
 configuration was not what I expected for a VFR missed approach to a busy general
 aviation airport on a spring afternoon that hosts a high amount of student pilot
 activity. As he overflew the entire length of the runway at that low altitude, he
 commented that he was "doing it for the tower's benefit". I felt that the Controller
 was negligent in not instructing the jet pilot to avoid flying through the VFR traffic
 pattern at a low altitude and the Citation pilot was negligent for his impromptu "air
 show". There was no need for the pilot to descend below the pattern altitude once
 the IFR flight plan was canceled just prior to the MAP. In this situation, he was now
 VFR and needed to comply with the pattern altitude due to the VFR traffic in the
 pattern and a helicopter arrival from the north. It was too close for me and my
 crew.

Synopsis
 VFR helicopter pilot arriving perpendicular to the active runways reports NMAC with
 VFR CE525 on low missed approach.
ACN: 939468

Time / Day
 Date : 201103
 Local Time Of Day : 0001-0600

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 800

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 10
 Light : Daylight
 Ceiling.Single Value : 12000

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Air Taxi
 Make Model Name : Jet/Long Ranger/206
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Ambulance
 Flight Phase : Cruise
 Route In Use : Direct
 Airspace.Class D : ZZZ

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Military
 Make Model Name : T45 (or T2C) Goshawk
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 91
 Flight Plan : VFR
 Mission : Training
 Flight Phase : Initial Approach
 Route In Use : Vectors
 Airspace.Class D : ZZZ

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Taxi
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Experience.Flight Crew.Total : 9000
 Experience.Flight Crew.Last 90 Days : 75
 Experience.Flight Crew.Type : 1000
 ASRS Report Number.Accession Number : 939468

Events
 Anomaly.Conflict : NMAC
 Detector.Person : Flight Crew
 Miss Distance.Horizontal : 500
 Miss Distance.Vertical : 50
 When Detected : In-flight
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Airspace Structure
 Primary Problem : Ambiguous

Narrative: 1
 After departure from a hospital pad I contacted Tower for clearance through the
 airspace. Tower cleared me through the airspace at 800 FT or above and notified
 me of inbound traffic 8 miles out. I was less than 3 miles from the airfield at the
 time of receiving the clearance and continued my climb to 800 FT for a midfield
 crossing on a heading of 060. As I approached the north east side of the airfield a
 pair of T-45s in formation passed from left to right less than 500 FT in front of and
 100 FT above my aircraft. No alerts were given to me by Tower, [and] TCAS did not
 activate until the T-45s were already past me. I estimate the speed of the T-45s to
 have been in excess of 300 KTS.

Synopsis
 An EMS helicopter pilot reported an NMAC with two T-45s at low altitude and high
 speed over a Naval Air Station.
ACN: 936369

Time / Day
 Date : 201103
 Local Time Of Day : 1201-1800

Place
 Locale Reference.Airport : TOL.Airport
 State Reference : OH
 Altitude.AGL.Single Value : 0

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : TOL
 Make Model Name : EC135
 Crew Size.Number Of Crew : 1
 Flight Plan : VFR
 Flight Phase : Takeoff
 Airspace.Class C : TOL

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : TOL
 Aircraft Operator : Air Carrier
 Make Model Name : MD-83
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 121
 Flight Phase : Takeoff
 Airspace.Class C : TOL

Person
 Reference : 1
 Location Of Person.Facility : TOL.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 936369
 Human Factors : Situational Awareness
 Human Factors : Confusion

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Primary Problem : Procedure

Narrative: 1
 An MD83, was cleared for take off on Runway 25, about the time the MD83 was
 airborne a helicopter called the Tower for a VFR departure to the southwest, and
 reported the MD83 in sight. The developmental issued the departure frequency and
 a squawk code. The helicopter had difficulty hearing the code and required it be
 read back to him twice before he got it. By this time the helicopter had hover
 taxied to Taxiway Bravo, a parallel of Runway 25, and reported ready. The
 developmental cleared the helicopter for take off, without issuing a cautionary wake
 turbulence advisory, the helicopter, being ready, departed immediately prior to my
 being able to properly issue the wake turbulence advisory. Per the 7110.65 the
 ruling for this behind a large aircraft is very grey, on whether or not it's actually
 required or if there is a requisite delay. The time frame between the MD83
 departing and the helicopter departing wasn't known at the time, after looking into
 it we found that the time was outside of a three minute required delay.
 Recommendation, the 7110.65 is vague in this situation and doesn't prescribe a
 ruling for situations such as this for Large aircraft only heavy's. If it could be made
 clear whether it's allowed to depart from "parallels" at an "intersection" behind a
 larger aircraft, other than a heavy, would remove the grey area of understanding.

Synopsis
 TOL Controller providing OJT described a possible loss of separation event involving
 a helicopter taxiway departure along side of an Air Carrier departure, noting the
 required separation criteria is less than clear.
ACN: 936206

Time / Day
 Date : 201103
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : TEB.Airport
 State Reference : NJ
 Altitude.MSL.Single Value : 2100

Environment
 Weather Elements / Visibility : Windshear
 Weather Elements / Visibility : Rain
 Weather Elements / Visibility : Turbulence

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : TEB
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Flight Plan : IFR
 Nav In Use.Localizer/Glideslope/ILS : Runway 6
 Flight Phase : Final Approach
 Airspace.Class D : TEB

Aircraft : 2
 Reference : Y
 ATC / Advisory.TRACON : N90
 Aircraft Operator : Air Carrier
 Make Model Name : B757 Undifferentiated or Other Model
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 121
 Nav In Use.Localizer/Glideslope/ILS : Runway 13
 Flight Phase : Descent
 Airspace.Class B : LGA

Person
 Reference : 1
 Location Of Person.Facility : TEB.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 936206
 Human Factors : Other / Unknown

Events
 Anomaly.ATC Issue : All Types
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Primary Problem : Procedure

Narrative: 1
 A helicopter was on the ILS Runway 6 approach. The helicopter was on an IFR flight
 plan because of poor weather conditions i.e. heavy rain and wind gusts exceeding
 30kts etc. When the helicopter checked in I gave him the wind, cleared him to land,
 and issued him pilot reports of turbulence and wind shear on final. I noticed the
 helicopter was off course and appeared to be too high to make the approach. I
 asked him if he was able to rejoin the approach and he advised he was unable. I
 told him to execute the published missed approach, except maintain 2,000;
 normally the missed approach for ILS Runway 6 is climb to 1,000 then climbing left
 turn to 2,500 on R-335 to INT and hold. I told the helicopter to maintain 2,000
 because [another airport] was on the ILS Runway 13 approach which cuts right
 across our departure path at 3,000 descending. While I gave the helicopter these
 instructions, the CIC was coordinating alternate instructions with the Departure
 Controller to turn left heading 360 maintain 2,000, which I then issued to the
 helicopter. The helicopter did not maintain 2,000. His altitude indicated 2,100 and
 he continued to climb. I told him several times to maintain 2,000 and gave him the
 current altimeter. Every time I told the helicopter to maintain 2,000 he would just
 respond "we're doing it" or something like that. He became a conflict with traffic on
 the ILS approach, a B757 descending out of 3,000. I gave the helicopter a
 cautionary wake turbulence advisory and issued the traffic and told him to descend
 to 2,000, I think by this time his altitude indicated about 2,400. The helicopter and
 the B757 were on diverging courses. After the conflict was resolved and I observed
 the helicopter was descending I switched him to Departure. Recommendation, I
 think the missed approach procedure for the ILS Runway 6 approach should be
 reviewed. It may help if the aircraft are capped at 2,000 instead of 2,500 to help
 prevent any confusion regardless of what approach is in use. Also, in the past few
 months there has been some confusion among the controllers about this missed
 approach procedure. A few months ago the VOR was OTS for maintenance and we
 were given a briefing informing us that while the VOR was down, for a missed
 approach tell the aircraft, "fly the missed approach, EXCEPT maintain 2,000." The
 confusion is that some controllers are under the impression that we still need to
 issue the "EXCEPT maintain 2,000," and other controllers are under the impression
 that we were only supposed to do this while the VOR was OTS. My concern is that
 we are supposed to issue it for every ILS 6 missed approach and that someone
 may not thinking it was only during the VOR maintenance a few months ago. If in
 fact we are supposed to still be issuing "EXCEPT maintain 2,000" then I think the
 approach charts should be changed or updated.

Synopsis
 Controller described a possible conflict between traffic on the ILS Runway 6
 approach executing a missed approach and traffic on the ILS for another airport.
 Confusion exists regarding the altitude for the missed procedure.
ACN: 935710

Time / Day
 Date : 201103
 Local Time Of Day : 0001-0600

Place
 Locale Reference.ATC Facility : ZZZ.Tower
 State Reference : US
 Altitude.MSL.Single Value : 900

Aircraft
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Make Model Name : Robinson R44
 Operating Under FAR Part : Part 91
 Flight Plan : SVFR

Person
 Reference : 1
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 935710
 Human Factors : Situational Awareness

Events
 Anomaly.Deviation - Procedural : FAR
 Anomaly.Inflight Event / Encounter : VFR In IMC
 Detector.Person : Air Traffic Control
 Result.Flight Crew : Regained Aircraft Control

Assessments
 Contributing Factors / Situations   :   Weather
 Contributing Factors / Situations   :   Procedure
 Contributing Factors / Situations   :   Human Factors
 Contributing Factors / Situations   :   Aircraft
 Primary Problem : Weather

Narrative: 1
 The pilot entered the airspace on an SVFR flight from the West. The reported
 weather included an overcast at 600 feet and the time was approximately 30
 minutes past sunset. As the pilot approached from 2 miles West of the airport, he
 entered the cloud layer with Mode C eventually indicating an altitude of 900 feet.
 The Mode C readout was consistent with visual observations before and after the
 event. In response to ATC inquiry, the pilot eventually said he could not see the
 ground and was in the clouds, disoriented. When the aircraft descended below the
 ceiling, it appeared to be spinning or rotating for about 1 revolution before being
 stabilized and re-oriented toward the airport. The helicopter's descent was arrested
 about 200 feet AGL. The pilot then landed at the airport without incident. A pilot
 deviation was reported. Recommendation, ensure that pilots of helicopters maintain
 a safe airspeed in marginal conditions and a safe altitude below the clouds.
 Additional training in unusual attitude recovery or unintended helicopter flight into
 clouds may be appropriate.

Synopsis
 Tower Controller described a harrowing event when an inbound SVFR Helicopter
 became disorientated an entered a spinning descent for landing.
ACN: 935390

Time / Day
 Date : 201103
 Local Time Of Day : 0001-0600

Place
 Locale Reference.ATC Facility : DCA.Tower
 State Reference : DC

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : DCA
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Flight Plan : VFR
 Flight Phase : Cruise
 Route In Use : None
 Airspace.Class B : DCA

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : DCA
 Aircraft Operator : Air Carrier
 Make Model Name : A319
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 121
 Flight Plan : IFR
 Flight Phase : Final Approach
 Route In Use.STAR : RIVER VISUAL
 Airspace.Class B : DCA

Person
 Reference : 1
 Location Of Person.Facility : DCA.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Handoff / Assist
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 935390
 Human Factors : Communication Breakdown
 Human Factors : Situational Awareness
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : Flight Crew

Events
 Anomaly.Conflict : Airborne Conflict
 Anomaly.Deviation - Track / Heading : All Types
 Anomaly.Deviation - Procedural : Clearance
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Staffing
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Primary Problem : Procedure

Narrative: 1
 While working ALC in a south configuration working Local and Helicopters combined.
 A helicopter was operating VFR in Zone 1, while there were multiple jet arrivals on
 the River Visual Approach for Runway 19. The helicopter requested to Split the P's
 for a Pentagon Transition. The helicopter's transmission was garbled and at times
 unreadable. When we determined the position of the helicopter and figured out the
 desired route of flight the pilot proceeded but not as requested. The observed flight
 path took the helicopter from the Memorial Bridge to split the P's eastbound then it
 turned westbound split the P's again and proceeded via the Pentagon westbound.
 When the Helicopter turned Westbound, the RA was reported by the pilot. The A319
 landed with out problem, and the helicopter proceeded without incident.
 Recommendation, keep the Helicopter Position Open. Staff it at all times. Or, keep
 the Local and Helicopter Position combined and keep everyone in the facility current
 and proficient at the combined position.

Synopsis
 DCA Controller reported a TCAS RA event experienced by a River Visual arrival
 during operations utilizing combined Local and Helicopter positions, suggesting the
 an increase in the use of the Helicopter position.
ACN: 934278

Time / Day
 Date : 201102
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 0

Environment
 Light : Daylight

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : Jet/Long Ranger/206
 Operating Under FAR Part : Part 135
 Mission : Passenger
 Flight Phase : Parked
 Maintenance Status.Maintenance Deferred : N
 Maintenance Status.Released For Service : Y
 Maintenance Status.Maintenance Type : Unscheduled Maintenance
 Maintenance Status.Maintenance Items Involved : Inspection
 Maintenance Status.Maintenance Items Involved : Testing
 Maintenance Status.Maintenance Items Involved : Repair

Component : 1
 Aircraft Component : Engine Temperature Indication
 Manufacturer : Bell Helicopters
 Aircraft Reference : X

Component : 2
 Aircraft Component : Turbine Assembly
 Manufacturer : Allison / Rolls Royce
 Aircraft Reference : X

Person
 Reference : 1
 Location Of Person : Hangar / Base
 Reporter Organization : Air Carrier
 Function.Maintenance : Technician
 Qualification.Maintenance : Airframe
 Qualification.Maintenance : Powerplant
 Experience.Maintenance.Inspector : 10
 Experience.Maintenance.Lead Technician : 10
 ASRS Report Number.Accession Number : 934278
 Human Factors : Confusion
 Human Factors : Situational Awareness
 Human Factors : Troubleshooting
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : Maintenance
 Communication Breakdown.Party2 : Other
 Communication Breakdown.Party2 : Maintenance
 Analyst Callback : Completed

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Other Person
 Were Passengers Involved In Event : N
 When Detected : Routine Inspection
 Result.General : Maintenance Action

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Manuals
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Company Policy
 Contributing Factors / Situations : Chart Or Publication
 Contributing Factors / Situations : Aircraft
 Primary Problem : Company Policy

Narrative: 1
 I was working when the Shop Supervisor directed me to make a Start/Enrichment
 adjustment on a Bell 206-L4 helicopter. I was told that it wanted to start hot. After
 reviewing the appropriate Maintenance Manual (MM), I adjusted the Start
 /Enrichment per the applicable MM. While at the aircraft, I assisted the pilot who
 had the starting problem in resetting the Turbine Outlet Temperature (TOT)
 Overtemp light. After the Fuel Control Unit (FCU) adjustment was complete, I
 signed-off the Engineering report properly. Approximately one hour later, the pilot
 made another attempt to start but aborted due to low battery voltage. The battery
 was replaced with a Serviceable like item and subsequent start was uneventful.
 One day later, I was notified by the Chief Pilot that the government agency [we
 contract our helicopters with] submitted a Safety Report regarding the Bell 206-L4
 I had worked on the day before that had overtemped. I immediately called the pilot
 and he verified that the TOT exceeded 927C for no more than a second. The Chief
 Inspector and I confirmed that an overtemp condition had occurred on that start. A
 Hot Start Inspection was performed on the aircraft Indicating System and the
 Turbine section per applicable MMs, with no defects noted. The aircraft was ground
 run and flown. Aircraft was returned to service. The lack of communication between
 the pilot, Shop Supervisor and myself could have possibly caused the loss of
 aircraft and/or life.

Callback: 1
 Reporter stated a special key (tool) is required to reset (extinguish) the Turbine
 Outlet Temp (TOT) Overtemp light once the light has illuminated. He never thought
 to ask the pilot if the engine had in fact, overtemped, during his engine start-up.
 Since he was instructed by his Shop Supervisor to go over and reset the Overtemp
 light and adjust the Fuel Control Unit (FCU), he didn't realize there was an issue
 with an actual overtemp situation requiring a Hot Start Inspection, thinking there
 was a lower temperature turbine gauge installed. Reporter stated there are two
 different Turbine Temperature gauges, with different settings for illuminating the
 Turbine Overtemp light, that are interchangeable on the Bell 206-L1, L3 and L4
 helicopters per Bell. The Bell-L1 and L3 helicopter engines are Lycoming and the
 Overtemp light comes on at a lower 768C (degrees Centigrade) compared to the
 Allison/Rolls Royce engines that are standard on the B206-L4s, which run hotter
 with a 927C Overtemp light. Reporter stated there is nothing in the Bell
 Maintenance Manual or Rolls Royce Maintenance Manual (MM) informing Mechanics
 about the interchangeability of the TOT gauges. Mechanics and pilots have to look
 in the Airframe Manual and Flight Manual under 'Starting' and in the 'Turbine Outlet
 Temperature' section to determine what engine is installed and then use that
 information with a temperature table in the Flight Manual to know what the
 Overtemp setting should be. If a Bell 206-L1 or -L3 helicopter has an L4-type
 Turbine Temperature gauge installed, than pilots and mechanics must be aware the
 Turbine Temperature settings are different.

Synopsis
 Mechanic reports he was instructed by his Shop Supervisor to reset the Total Outlet
 Temperature (TOT) Overtemp light that had illuminated during an engine start on a
 Bell 206 L-4 helicopter with an Allison/Rolls Royce engine. He failed to ask the pilot
 if the engine had actually overtemped, which would require a Hot Start Inspection.
ACN: 933511

Time / Day
 Date : 201102
 Local Time Of Day : 0001-0600

Place
 Locale Reference.ATC Facility : DCA.Tower
 State Reference : DC
 Altitude.MSL.Single Value : 1200

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : DCA
 Aircraft Operator : Air Carrier
 Make Model Name : MD-80 Series (DC-9-80) Undifferentiated or Other Model
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 121
 Flight Plan : IFR
 Flight Phase : Initial Approach
 Route In Use : Visual Approach
 Airspace.Class B : DCA

Aircraft : 2
 Reference : Y
 ATC / Advisory.CTAF : ZZZ
 Make Model Name : Helicopter
 Flight Phase : Initial Climb
 Airspace.Class B : DCA

Person : 1
 Reference : 1
 Location Of Person.Facility : DCA.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Developmental
 ASRS Report Number.Accession Number : 933511
 Human Factors : Other / Unknown

Person : 2
 Reference : 2
 Location Of Person.Facility : DCA.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 933512

Events
 Anomaly.Conflict : Airborne Conflict
 Anomaly.Deviation - Altitude : Excursion From Assigned Altitude
 Anomaly.Deviation - Procedural : Published Material / Policy
 Detector.Person : Air Traffic Control
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Primary Problem : Procedure

Narrative: 1
 I was training on Local Control with Helicopter Control combined. A MD80 was
 descending on final approach for Runway 19 on about an 8 mile final when a VFR
 helicopter reported landing assured at Georgetown Hospital requesting frequency
 change, the hospital is located directly underneath the Runway 19 final 4 miles
 from the airport. At the time of reporting landing assured, the helicopter's Mode C
 indicated 400 descending. After seeing the beginning of descent into Georgetown
 Hospital, I approved the pilot to change frequency. As the MD80 approached a 4
 mile final, I observed the helicopter climbing and circling in the vicinity of
 Georgetown Hospital, at that time I issued traffic to the MD80 on the helicopter and
 attempted to establish contact to issue traffic, but could not establish
 communication. The pilot of the MD80 then notified me that he was responding to
 an RA due to the helicopter traffic. The MD80 climbed approximately 100-200 FT in
 response to the RA and then continued on the approach and landed after the RA
 was resolved. At the time of the RA, the MD80 indicated 1,200 FT and helicopter
 indicated 700 FT. Recommendation, I would recommend that if a helicopter reports
 landing assured and requests frequency change to advisory that the pilot
 understands that they are not allowed to climb above the last altitude observed by
 ATC without proper coordination. If the helicopter is required to circle for any
 reason in order to land at the heliport, they should be required to contact ATC
 immediately for approval.

Synopsis
 DCA Controller described a TCAS RA event involving an arrival to Runway 19 and a
 helicopter landing at Georgetown Hospital, the helicopter climbing unexpectedly
 after granting a frequency change.
ACN: 932794

Time / Day
 Date : 201102
 Local Time Of Day : 0601-1200

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Relative Position.Distance.Nautical Miles : 40
 Altitude.AGL.Single Value : 150

Environment
 Flight Conditions : VMC
 Weather Elements / Visibility.Visibility : 10
 Light : Daylight
 Ceiling : CLR

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : Jet/Long Ranger/206
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Passenger
 Flight Phase : Final Approach
 Airspace.Class G : ZZZ

Component
 Aircraft Component : DC Battery
 Aircraft Reference : X
 Problem : Malfunctioning

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Carrier
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Commercial
 Qualification.Flight Crew : Flight Instructor
 Qualification.Flight Crew : Multiengine
 Experience.Flight Crew.Total : 2323
 Experience.Flight Crew.Last 90 Days : 133
 Experience.Flight Crew.Type : 1051
 ASRS Report Number.Accession Number : 932794
 Human Factors : Training / Qualification
 Human Factors : Troubleshooting

Events
 Anomaly.Aircraft Equipment Problem : Critical
 Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor
 Anomaly.Deviation - Procedural : Published Material / Policy
 Anomaly.Deviation - Procedural : FAR
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Aircraft
 Primary Problem : Aircraft

Narrative: 1
 On approach to an offshore oil platform, I noticed smoke coming from the battery
 compartment in the nose of the aircraft. I proceeded to shut down after landing.
 Upon further inspection, I found that melting plastic was causing the smoke and
 removed it. I then continued my flight to our base onshore to have a Mechanic
 inspect and fix the problem. Upon inspection an aircraft Technician removed and
 replaced the battery relay. After review of FAR 91.7b and 135.65b, I realized my
 actions may have not been in accordance with these regulations.

Synopsis
 A Bell 206B3 battery overheated on approach and melted an adjacent plastic
 component causing smoke. The pilot removed the melted component and returned
 to base where a faulty battery was replaced but he later questioned his return
 flight's legality prior to maintenance.
ACN: 931477

Time / Day
 Date : 201102
 Local Time Of Day : 1801-2400

Environment
 Flight Conditions : VMC
 Light : Night

Aircraft
 Reference : X
 Aircraft Operator : Air Taxi
 Make Model Name : Helicopter
 Crew Size.Number Of Crew : 1
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Passenger
 Flight Phase : Landing
 Route In Use : Direct

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Reporter Organization : Air Taxi
 Function.Flight Crew : Single Pilot
 Function.Flight Crew : Pilot Flying
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 Experience.Flight Crew.Total : 8960
 Experience.Flight Crew.Last 90 Days : 60
 Experience.Flight Crew.Type : 250
 ASRS Report Number.Accession Number : 931477
 Human Factors : Communication Breakdown
 Human Factors : Situational Awareness
 Human Factors : Workload
 Human Factors : Confusion
 Communication Breakdown.Party1 : Flight Crew
 Communication Breakdown.Party2 : Other
 Analyst Callback : Completed

Events
 Anomaly.No Specific Anomaly Occurred : All Types
 Detector.Person : Flight Crew
 When Detected : In-flight
 When Detected : Taxi
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Environment - Non Weather Related
 Contributing Factors / Situations : Airport
 Primary Problem : Environment - Non Weather Related

Narrative: 1
 About a year ago I began flying helicopter EMS flights for a company that uses
 Night Vision Goggles (NVGs) during night flights. I had flown with NVGs in the
 military. During this year I have noticed that at civilian hospital helipads the green
 helipad perimeter lights are invisible when looking at the helipad through the NVGs.
 Many helicopter EMS companies are using NVGs. My company which has many EMS
 helicopters plans to have all their night helicopter flights flown using NVGs very
 soon. I suggest the FAA change the standard of helipad perimeter lights from green
 to a color of light that is compatible to NVG operations.

Callback: 1
 The Reporter stated that because NVGs produce a green visual environment so that
 green lights are not visible. Older helicopter cockpits have been modified to be NVG
 friendly and newer helicopters are coming from factory NVG friendly. The Reporter
 suggests almost any color except green. Blue, orange, white, yellow or red are
 acceptable. The FAA Safety Alert for Operators (SAFO) may need to be readdressed
 to include discussion of avoiding the green visual light range from about 490 NM to
 550 NM.

Synopsis
 An EMS helicopter pilot reported that some hospitals use green helipad perimeter
 lights which are not visible to pilots wearing night vision goggles. The FAA Safety
 Alert for Operators (SAFO) does not address avoiding the green 490-550
 nanometer visible light range.
ACN: 930446

Time / Day
 Date : 201101
 Local Time Of Day : 0001-0600

Place
 Locale Reference.Airport : ZZZ.Airport
 State Reference : US
 Altitude.AGL.Single Value : 500

Environment
 Flight Conditions : VMC
 Light : Night

Aircraft
 Reference : X
 ATC / Advisory.Tower : ZZZ
 Aircraft Operator : Government
 Make Model Name : S-76/S-76 Mark II
 Operating Under FAR Part : Part 135
 Flight Plan : VFR
 Mission : Passenger
 Flight Phase : Takeoff
 Airspace.Class B : ZZZ

Person
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Government
 Function.Flight Crew : Captain
 Function.Flight Crew : Pilot Flying
 Function.Flight Crew : Single Pilot
 Qualification.Flight Crew : Commercial
 Qualification.Flight Crew : Multiengine
 Qualification.Flight Crew : Rotorcraft
 Experience.Flight Crew.Total : 5963
 Experience.Flight Crew.Last 90 Days : 23
 Experience.Flight Crew.Type : 5400
 ASRS Report Number.Accession Number : 930446
 Human Factors : Distraction
 Human Factors : Physiological - Other
 Human Factors : Troubleshooting
 Human Factors : Confusion

Events
 Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor
 Detector.Person : Other Person
 Were Passengers Involved In Event : N
 When Detected : In-flight
 Result.Flight Crew : Diverted
 Result.Flight Crew : Requested ATC Assistance / Clarification
 Result.Flight Crew : Landed As Precaution

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Contributing Factors / Situations : Aircraft
 Primary Problem : Aircraft

Narrative: 1
 Prior to takeoff I had turned on the cabin heater due to the low outside air
 temperature. Upon applying power and lifting off the elevated heliport to the north,
 the Flight Medic in the cabin area stated she smelled something "funny." As I
 turned westbound she said, "I've got smoke in the back." I asked her to confirm
 that she had said smoke and she replied, "Yes and it is pretty thick." I was already
 in contact with ZZZ Tower as we were exiting the Class B airspace. I asked the
 Tower for permission to land at the FBO ramp area on the north side of runways
 XXL and R. I stated, "I have smoke in the cabin." The Tower responded that I was
 cleared to land abeam the ramp on the taxiway. She also asked if I needed
 assistance. I stated, "Not at this time." She asked me if I wanted the emergency
 equipment to roll and I replied again, "Not at this time." I complied with the
 immediate action items on the aircraft checklist which included opening the pilot's
 door window, turning off the environmental control unit (heater system), and
 closing the ECU vents. As soon as I did these items, the flight medic said the
 smoke cleared. Opening the pilot's vent window hastened the dissipation of the
 smoke and fumes. Upon landing and taxiing to the ramp, we opened the cabin and
 cockpit doors to further ventilate the cabin and cockpit area. I determined that the
 "smoke" was actually the residual water and cleaning solution which had been used
 earlier that day after a morning flight when the engines were rinsed due to flight in
 a salt water environment. The fluid had not evaporated and was trapped in the
 bleed air lines that are part of the heater system. When the heater was activated,
 the water and cleaning fluid vaporized, causing a fogging of the cabin that
 resembled smoke in the darkness of the rear cabin. At no time was there any
 actual smoke. I recognized the smell for what it was but was determined not to
 make any further diagnosis in the air. Once the smell and vapor cloud had cleared,
 I was confident that the problem had been with the heater system and that there
 was no danger of continued flight. We then departed and returned to our home
 base. My diagnosis was confirmed by maintenance personnel and the daytime duty
 pilot when they performed a ground check of the aircraft later that morning. They
 saw only some residual vapor and smelled a slight chemical odor from the heater
 vents. The Mechanic confirmed my evaluation of the chain of events and
 recommended running the aircraft engines after any engine rinse to ensure all
 residual fluid was eliminated from the bleed air lines to the heater.

Synopsis
 An S-76 helicopter pilot diverted to a nearby airport when air conditioning fumes
 misidentified as smoke filled the cabin shortly after takeoff from a nearby heliport.
ACN: 930339

Time / Day
 Date : 201101
 Local Time Of Day : ZZZ

Place
 Locale Reference.Airport : LAS.Airport
 State Reference : NV
 Altitude.MSL.Single Value : 2600

Environment
 Flight Conditions : VMC
 Light : Night

Aircraft : 1
 Reference : X
 ATC / Advisory.Tower : LAS
 Aircraft Operator : Air Carrier
 Make Model Name : Large Transport, Low Wing, 2 Turbojet Eng
 Crew Size.Number Of Crew : 2
 Operating Under FAR Part : Part 121
 Flight Plan : IFR
 Mission : Passenger
 Flight Phase : Takeoff
 Airspace.Class B : LAS

Aircraft : 2
 Reference : Y
 ATC / Advisory.Tower : LAS
 Make Model Name : Helicopter
 Flight Phase : Cruise
 Airspace.Class B : LAS

Person : 1
 Reference : 1
 Location Of Person.Aircraft : X
 Location In Aircraft : Flight Deck
 Reporter Organization : Air Carrier
 Function.Flight Crew : Captain
 Qualification.Flight Crew : Air Transport Pilot (ATP)
 ASRS Report Number.Accession Number : 930339
 Human Factors : Situational Awareness
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : Flight Crew

Person : 2
 Reference : 2
 Location Of Person.Facility : LAS.Tower
 Reporter Organization : Government
 Function.Air Traffic Control : Flight Data / Clearance Delivery
 Function.Air Traffic Control : Local
 Qualification.Air Traffic Control : Fully Certified
 ASRS Report Number.Accession Number : 930623
 Human Factors : Situational Awareness
 Human Factors : Workload
 Human Factors : Distraction
 Human Factors : Time Pressure
 Human Factors : Communication Breakdown
 Communication Breakdown.Party1 : ATC
 Communication Breakdown.Party2 : Flight Crew

Events
 Anomaly.Conflict : Airborne Conflict
 Anomaly.Deviation - Track / Heading : All Types
 Anomaly.Deviation - Procedural : Clearance
 Detector.Automation : Aircraft TA
 Detector.Person : Air Traffic Control
 Detector.Person : Flight Crew
 When Detected : In-flight
 Result.General : None Reported / Taken

Assessments
 Contributing Factors / Situations : Procedure
 Contributing Factors / Situations : Human Factors
 Primary Problem : Human Factors

Narrative: 1
 After takeoff from Runway 1R at LAS at about 500 FT AGL received a TCAS TA. The
 target indicated 200 FT below our altitude and was touching the aircraft symbol on
 the ND.

Narrative: 2
 I issued a restriction to a helicopter to remain west of the departure course to
 Runway 1R for departing traffic (an air carrier). I then cleared the jet for takeoff on
 Runway 1R. It was at or just after the top of the hour and I noticed the ATIS was
 due to be updated so I was updating the ATIS computer and didn't notice how close
 the helicopter was coming to the departure course of Runway 1. I finished what I
 was doing with the ATIS which only took a few seconds. I then observed the
 helicopter very close to the 1R departure course and the jet climbing on his
 departure. I observed the air carrier aircraft climbing above the altitude of the
 helicopter and switched the jet to Departure. I then asked if the helicopter if it was
 going to stay where he was and he replied no and requested to move to the west,
 which I approved. I should have paid more attention to the helicopter instead of
 updating the ATIS; even though I restricted the pilot to remain west of the
 departure course of Runway 1R. Typically the helicopter pilots here in Las Vegas
 are very good and comply with any restrictions quite well. In the future I think it
 would be more effective to make the restriction more complete by giving a mileage
 associated with the limitation. For example remain 1 mile west of the departure
 course of Runway 1 for departing traffic.

Synopsis
 An Air Carrier Captain and LAS Tower Controller report a departing helicopter
 approached the 1R departure path after the jet's takeoff causing a TCAS TA.

								
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