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The pilot, flight nurse, flight paramedic, and patient were not injured.
The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 air ambulance flight.
The pilot reported that he was approaching the rooftop heliport to land at the Regional One Health Medical Center.
While on a long final approach to the heliport, there was a left crosswind present and he had to reduce collective pitch control friction three times in order to move the collective as fast as he felt he needed to.
He brought the helicopter to a hover as he reached the heliport, then turned the helicopter to the right and landed.
After landing, he started the after-landing portion of the checklist, then turned the throttle twist grip on the collective from "FLY to "IDLE," believing that he had engaged the collective lock.
He then turned the horn mute switch to mute, grabbed the cyclic pitch control with his left hand, and reached for the clock start button with his right hand.
As he was reaching for the clock button, the collective "popped up," and the helicopter became airborne.
He immediately grabbed the cyclic with his right hand, the collective with his left hand, and twisted the twist grip to "FLY." The helicopter then landed hard, and the emergency locator transmitter (ELT) activated.
After exiting the helicopter, the flight nurse advised the pilot that there was damage to the sheet metal of the helicopter.
Security camera video also showed the incident sequence in its entirety.
The pitch of the rotor blades could be seen changing as the helicopter became airborne, and rotor coning was observed.
PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) and pilot records, the pilot held a commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter, and private privileges for airplane single-engine land.
The pilot attended an EC 130 pilot transition class at Airbus Helicopters from November 6 to November 10, 2017, and completed his 14 CFR Part 135 Airman Competency/Proficiency Check on January 17, 2018.
He reported that he had accrued 6,267 total hours of flight time, about 9 of which were in the incident helicopter make and model.
AIRCRAFT INFORMATION The single-rotor helicopter of conventional design was equipped with an automatically varying, three-bladed Starflex main rotor and an enclosed tail fan anti-torque device, known as a Fenestron.
The helicopter’s 802-shaft horsepower Turbomeca Arriel 2D turboshaft engine was equipped with a full authority digital engine control (FADEC) and a dual hydraulic system.
The helicopter was designed to be convertible from a dual-pilot configuration (for activities such as training), to a single-pilot configuration (for activities such as air ambulance).
AIRPORT INFORMATION The heliport was located on a roof of a building, about 85 feet above street level.
It was surrounded by obstacles except for a portion of the heliport that faced northeast.
The touchdown and liftoff area (TLOF) was marked with a red colored “H” centered inside a white cross.
The border of the TLOF was painted white.
It was equipped with a lighted windsock and yellow perimeter lights and measured 75 feet wide by 75 feet long.
FLIGHT RECORDERS The helicopter was equipped with an engine data recorder (EDR) that exclusively recorded data sent by the FADEC in a non-volatile memory component for maintenance purposes.
For both channels, engine parameters, logical words, and failure flags were recorded.
It also was equipped with an Appareo Vision 1000 unit, which recorded images, audio, and parametric data on a removable SD memory card.
In addition to the internally recorded data obtained from the Vision 1000, other parameters and observations were obtained by viewing the aircraft's cockpit instruments and security camera video.
Review of the onboard video depicted a series of events consistent with the pilot’s statement.
For a complete discussion of the onboard video, refer to Onboard Image Recorder factual report located in the public docket.
Review of EDR data indicated that, during the incident portion of the flight, the recorded transducer position for the collective showed the collective rising from an unlocked position with the helicopter’s engine transitioning from “Idle” to “Flight.” WRECKAGE AND IMPACT INFORMATION Examination of the helicopter revealed minor damage.
The skid type landing gear was spread out, and both landing gear cross tubes were deformed.
The forward belly panels were dented from contact with the forward landing gear cross tube, and the aft closeout panels were dented from contact with the aft landing gear cross tube.
On January 31, 2018, a Federal Aviation Administration (FAA) inspector traveled to Air Evac's Jackson, Tennessee, helicopter operations base to determine if the collective system had been properly balanced in accordance with the aircraft maintenance manual.
Two days before the incident, a mechanic at the base had removed the right seat flight controls and had configured the helicopter for single-pilot operation.
The collective was placed in the full-down position to attach a spring scale to the twist grip to measure the force required to pull it through its upward travel; however, once the mechanic removed his hand from the collective prior to attaching the spring scale; the collective immediately climbed unassisted to approximately the mid-travel position, indicating that the collective was improperly balanced for the single-pilot configuration.
It was determined that the spring force was much greater (approximately twice that required) than it should have been in the upward direction.
ADDITIONAL INFORMATION After the incident, as an additional risk mitigation factor, Air Evac EMS, Inc.
changed their abbreviated checklist for the EC130T2, so that the first item on the checklist after landing is to roll the twist grip to “IDLE” and then place and confirm the collective pitch is “Down/locked." A “NOTE” was also added to “Visually and verbally confirm collective is locked.”
The flight instructor and student pilot were parked with the airplane's engine running when the airplane began to move forward and to the right.
The instructor stated that upon noticing the forward movement, he applied the brakes.
He reported that the right rudder/brake pedal was positioned further forward than the left pedal, and upon application of brakes, the right turn increased before the airplane impacted another occupied airplane parked on the ramp, resulting in substantial damage to both.
The student pilot reported that he noticed the airplane's movement and tried to alert the instructor; however, the instructor appeared to be distracted.
Postaccident examination of the brake system revealed no anomalies that would have precluded normal operation.
It is likely that the airplane's nose wheel was initially displaced to the right, which resulted in the airplane's right turn.
The flight instructor's failure to maintain awareness while parked on the ramp with the engine operating, which resulted in impact with another parked airplane.
On February 3, 2016, about 1130 Pacific standard time, a Cessna 172S, N499DR, impacted a parked, occupied Cessna 172S, N1955L at the Gillespie Field Airport (SEE), San Diego/El Cajon, California.
Both airplanes were occupied with one certified flight instructor (CFI) and one student pilot; no one was injured.
N499DR sustained minor damage, and N1955L sustained substantial damage to the fuselage structure and rudder.
Both airplanes were registered to Sorbi Aviation Inc., and were operated by the California Flight Academy as 14 Code of Federal Regulations Part 91 instructional flights.
Visual meteorological conditions prevailed at the time of the accident and neither airplane had filed a flight plan.
Both airplanes were on the California Flight Academy parking ramp preparing for their local flights.
The CFI from N499DR reported that this was the student pilot's first flight lesson.
After completing a thorough preflight they hand towed the airplane out from its north facing parking spot and turned it towards the east.
They started the engine and it idled between 800-1000 RPM.
While listening to the airport's automatic terminal information service (ATIS) the airplane started to move with a right turning tendency.
The CFI stated he did not notice it at first, but when he did, he stepped on the brakes.
The airplane increased its right turn and struck a parked, occupied, airplane (N1955L).
In a later conversation, the CFI reported that when he attempted to stop the airplane he noticed that the right rudder pedal was slightly more forward than the left, but not by much.
In a written statement, the student pilot from N499DR reported that when the CFI was listening to the radio, the airplane started moving and turning into another airplane.
He stated "Hey you! Airplane is moving!" and he touched the CFI.
The CFI looked at him, then back at the radio, and he "did not do anything;" he appeared to be distracted.
The airplane continued its turn and impacted N1955L.
The CFI of N1955L reported that the student pilot and he were preparing for their flight with the engine off, when they suddenly felt a jolt and heard the sound of metal contacting metal.
They turned around and observed that N499DR had struck the aft fuselage of their airplane.
During a postaccident examination of N499DR's brake system by a Federal Aviation Administration airworthiness inspector, there were no visual defects or leaks.
He manipulated the brakes both dependently and independently with no anomalies noted.
The airplane was parked on the ramp with its engine not operating when another airplane taxied into it.
The other airplane, with a flight instructor and a student pilot onboard, was parked with the engine running when it began to move forward and to the right.
The instructor stated that upon noticing the forward movement, he applied the brakes.
He reported that the right rudder/brake pedal was positioned further forward than the left pedal, and upon application of brakes, the right turn increased before the airplane impacted the parked airplane, resulting in substantial damage to both.
The student pilot reported that he noticed the airplane's movement and tried to alert the instructor; however, the instructor appeared to be distracted.
Postaccident examination of the brake system revealed no anomalies that would have precluded normal operation.
It is likely that the airplane's nose wheel was initially displaced to the right, which resulted in the airplane's right turn when it began to move.
The failure of the flight instructor of the other airplane to maintain awareness while parked on the ramp with the engine operating, which resulted in impact with the parked airplane.
On February 3, 2016, about 1130 Pacific standard time, a Cessna 172S, N499DR, impacted a parked, occupied Cessna 172S, N1955L at the Gillespie Field Airport (SEE), San Diego/El Cajon, California.
Both airplanes were occupied with one certified flight instructor (CFI) and one student pilot; no one was injured.
N499DR sustained minor damage, and N1955L sustained substantial damage to the fuselage structure and rudder.
Both airplanes were registered to Sorbi Aviation Inc., and were operated by the California Flight Academy as 14 Code of Federal Regulations Part 91 instructional flights.
Visual meteorological conditions prevailed at the time of the accident and neither airplane had filed a flight plan.
Both airplanes were on the California Flight Academy parking ramp preparing for their local flights.
The CFI from N499DR reported that this was the student pilot's first flight lesson.
After completing a thorough preflight they hand towed the airplane out from its north facing parking spot and turned it towards the east.
They started the engine and it idled between 800-1000 RPM.
While listening to the airport's automatic terminal information service (ATIS) the airplane started to move with a right turning tendency.
The CFI stated he did not notice it at first, but when he did, he stepped on the brakes.
The airplane increased its right turn and struck a parked, occupied, airplane (N1955L).
In a later conversation, the CFI reported that when he attempted to stop the airplane he noticed that the right rudder pedal was slightly more forward than the left, but not by much.
In a written statement, the student pilot from N499DR reported that when the CFI was listening to the radio, the airplane started moving and turning into another airplane.
He stated "Hey you! Airplane is moving!" and he touched the CFI.
The CFI looked at him, then back at the radio, and he "did not do anything;" he appeared to be distracted.
The airplane continued its turn and impacted N1955L.
The CFI of N1955L reported that the student pilot and he were preparing for their flight with the engine off, when they suddenly felt a jolt and heard the sound of metal contacting metal.
They turned around and observed that N499DR had struck the aft fuselage of their airplane.
During a postaccident examination of N499DR's brake system by a Federal Aviation Administration airworthiness inspector, there were no visual defects or leaks.
He manipulated the brakes both dependently and independently with no anomalies noted.

On June 29, 2012, at 0705 UTC, a Hughes HU369D helicopter, German registration D-HLUX, owned and operated by Hahn Helicopters Flugdienste GmbH, was destroyed when it struck a powerline and subsequently impacted terrain near Lieser, Germany.
The pilot, the sole person on board, was fatally injured.
Visual meteorological conditions prevailed for the local aerial application flight.
This investigation is under the jurisdiction and control of the German government.

The pilot, flight nurse, flight paramedic, and patient were not injured.

The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 air ambulance flight.

The pilot reported that he was approaching the rooftop heliport to land at the Regional One Health Medical Center.

While on a long final approach to the heliport, there was a left crosswind present and he had to reduce collective pitch control friction three times in order to move the collective as fast as he felt he needed to.

He brought the helicopter to a hover as he reached the heliport, then turned the helicopter to the right and landed.

After landing, he started the after-landing portion of the checklist, then turned the throttle twist grip on the collective from "FLY to "IDLE," believing that he had engaged the collective lock.

He then turned the horn mute switch to mute, grabbed the cyclic pitch control with his left hand, and reached for the clock start button with his right hand.

As he was reaching for the clock button, the collective "popped up," and the helicopter became airborne.

He immediately grabbed the cyclic with his right hand, the collective with his left hand, and twisted the twist grip to "FLY." The helicopter then landed hard, and the emergency locator transmitter (ELT) activated.

After exiting the helicopter, the flight nurse advised the pilot that there was damage to the sheet metal of the helicopter.

Security camera video also showed the incident sequence in its entirety.

The pitch of the rotor blades could be seen changing as the helicopter became airborne, and rotor coning was observed.

PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) and pilot records, the pilot held a commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter, and private privileges for airplane single-engine land.

The pilot attended an EC 130 pilot transition class at Airbus Helicopters from November 6 to November 10, 2017, and completed his 14 CFR Part 135 Airman Competency/Proficiency Check on January 17, 2018.

He reported that he had accrued 6,267 total hours of flight time, about 9 of which were in the incident helicopter make and model.

AIRCRAFT INFORMATION The single-rotor helicopter of conventional design was equipped with an automatically varying, three-bladed Starflex main rotor and an enclosed tail fan anti-torque device, known as a Fenestron.

The helicopter’s 802-shaft horsepower Turbomeca Arriel 2D turboshaft engine was equipped with a full authority digital engine control (FADEC) and a dual hydraulic system.

The helicopter was designed to be convertible from a dual-pilot configuration (for activities such as training), to a single-pilot configuration (for activities such as air ambulance).

AIRPORT INFORMATION The heliport was located on a roof of a building, about 85 feet above street level.

It was surrounded by obstacles except for a portion of the heliport that faced northeast.

The touchdown and liftoff area (TLOF) was marked with a red colored “H” centered inside a white cross.

The border of the TLOF was painted white.

It was equipped with a lighted windsock and yellow perimeter lights and measured 75 feet wide by 75 feet long.

FLIGHT RECORDERS The helicopter was equipped with an engine data recorder (EDR) that exclusively recorded data sent by the FADEC in a non-volatile memory component for maintenance purposes.

For both channels, engine parameters, logical words, and failure flags were recorded.

It also was equipped with an Appareo Vision 1000 unit, which recorded images, audio, and parametric data on a removable SD memory card.

In addition to the internally recorded data obtained from the Vision 1000, other parameters and observations were obtained by viewing the aircraft's cockpit instruments and security camera video.

Review of the onboard video depicted a series of events consistent with the pilot’s statement.

For a complete discussion of the onboard video, refer to Onboard Image Recorder factual report located in the public docket.

Review of EDR data indicated that, during the incident portion of the flight, the recorded transducer position for the collective showed the collective rising from an unlocked position with the helicopter’s engine transitioning from “Idle” to “Flight.” WRECKAGE AND IMPACT INFORMATION Examination of the helicopter revealed minor damage.

The skid type landing gear was spread out, and both landing gear cross tubes were deformed.

The forward belly panels were dented from contact with the forward landing gear cross tube, and the aft closeout panels were dented from contact with the aft landing gear cross tube.

On January 31, 2018, a Federal Aviation Administration (FAA) inspector traveled to Air Evac's Jackson, Tennessee, helicopter operations base to determine if the collective system had been properly balanced in accordance with the aircraft maintenance manual.

Two days before the incident, a mechanic at the base had removed the right seat flight controls and had configured the helicopter for single-pilot operation.

The collective was placed in the full-down position to attach a spring scale to the twist grip to measure the force required to pull it through its upward travel; however, once the mechanic removed his hand from the collective prior to attaching the spring scale; the collective immediately climbed unassisted to approximately the mid-travel position, indicating that the collective was improperly balanced for the single-pilot configuration.

It was determined that the spring force was much greater (approximately twice that required) than it should have been in the upward direction.

ADDITIONAL INFORMATION After the incident, as an additional risk mitigation factor, Air Evac EMS, Inc.

changed their abbreviated checklist for the EC130T2, so that the first item on the checklist after landing is to roll the twist grip to “IDLE” and then place and confirm the collective pitch is “Down/locked." A “NOTE” was also added to “Visually and verbally confirm collective is locked.”

The flight instructor and student pilot were parked with the airplane's engine running when the airplane began to move forward and to the right.

The instructor stated that upon noticing the forward movement, he applied the brakes.

He reported that the right rudder/brake pedal was positioned further forward than the left pedal, and upon application of brakes, the right turn increased before the airplane impacted another occupied airplane parked on the ramp, resulting in substantial damage to both.

The student pilot reported that he noticed the airplane's movement and tried to alert the instructor; however, the instructor appeared to be distracted.

Postaccident examination of the brake system revealed no anomalies that would have precluded normal operation.

It is likely that the airplane's nose wheel was initially displaced to the right, which resulted in the airplane's right turn.

The flight instructor's failure to maintain awareness while parked on the ramp with the engine operating, which resulted in impact with another parked airplane.

On February 3, 2016, about 1130 Pacific standard time, a Cessna 172S, N499DR, impacted a parked, occupied Cessna 172S, N1955L at the Gillespie Field Airport (SEE), San Diego/El Cajon, California.

Both airplanes were occupied with one certified flight instructor (CFI) and one student pilot; no one was injured.

N499DR sustained minor damage, and N1955L sustained substantial damage to the fuselage structure and rudder.

Both airplanes were registered to Sorbi Aviation Inc., and were operated by the California Flight Academy as 14 Code of Federal Regulations Part 91 instructional flights.

Visual meteorological conditions prevailed at the time of the accident and neither airplane had filed a flight plan.

Both airplanes were on the California Flight Academy parking ramp preparing for their local flights.

The CFI from N499DR reported that this was the student pilot's first flight lesson.

After completing a thorough preflight they hand towed the airplane out from its north facing parking spot and turned it towards the east.

They started the engine and it idled between 800-1000 RPM.

While listening to the airport's automatic terminal information service (ATIS) the airplane started to move with a right turning tendency.

The CFI stated he did not notice it at first, but when he did, he stepped on the brakes.

The airplane increased its right turn and struck a parked, occupied, airplane (N1955L).

In a later conversation, the CFI reported that when he attempted to stop the airplane he noticed that the right rudder pedal was slightly more forward than the left, but not by much.

In a written statement, the student pilot from N499DR reported that when the CFI was listening to the radio, the airplane started moving and turning into another airplane.

He stated "Hey you! Airplane is moving!" and he touched the CFI.

The CFI looked at him, then back at the radio, and he "did not do anything;" he appeared to be distracted.

The airplane continued its turn and impacted N1955L.

The CFI of N1955L reported that the student pilot and he were preparing for their flight with the engine off, when they suddenly felt a jolt and heard the sound of metal contacting metal.

They turned around and observed that N499DR had struck the aft fuselage of their airplane.

During a postaccident examination of N499DR's brake system by a Federal Aviation Administration airworthiness inspector, there were no visual defects or leaks.

He manipulated the brakes both dependently and independently with no anomalies noted.

The airplane was parked on the ramp with its engine not operating when another airplane taxied into it.

The other airplane, with a flight instructor and a student pilot onboard, was parked with the engine running when it began to move forward and to the right.

The instructor stated that upon noticing the forward movement, he applied the brakes.

He reported that the right rudder/brake pedal was positioned further forward than the left pedal, and upon application of brakes, the right turn increased before the airplane impacted the parked airplane, resulting in substantial damage to both.

The student pilot reported that he noticed the airplane's movement and tried to alert the instructor; however, the instructor appeared to be distracted.

Postaccident examination of the brake system revealed no anomalies that would have precluded normal operation.

It is likely that the airplane's nose wheel was initially displaced to the right, which resulted in the airplane's right turn when it began to move.

The failure of the flight instructor of the other airplane to maintain awareness while parked on the ramp with the engine operating, which resulted in impact with the parked airplane.