ERA13LA022
2012-10-13 · West Chester, Pennsylvania, United States · None · 1 aircraft · Status: Completed
Airport OQN
Aircraft involved
Probable cause & findings
The pilot’s failure to see and avoid the preceding helicopter while maneuvering for landing. Contributing to the accident were the flight lead pilot’s inadequate preflight briefing and in-flight instruction to the formation pilots, which resulted in the loss of the formation flight's integrity and the pilots’ situational awareness within the flight.
Factual narrative
On October 13, 2012, about 0920 eastern daylight time, two helicopters in a flight of five, a Hughes 369A, N369SN (Chalk 3), and another Hughes 369A, N546 (Chalk 4), collided during hover-taxi while landing at Brandywine Airport (OQN), West Chester, Pennsylvania. The 3 occupants in Chalk 3 and the 2 occupants in Chalk 4 were not injured. Chalk 4 sustained substantial damage to all four main rotor blades and the tail pylon. Chalk 3 sustained substantial damage to the left landing skid. Both helicopters were operated under the provisions of 14 Code of Federal Regulations Part 91as personal flights. Visual meteorological conditions prevailed.The flight of helicopters, each designated "Chalk 1" through "Chalk 5," were enroute to an annual all-helicopter airshow. The pilots of Chalk 1, 3, and 4 provided written statements, and their statements were consistent throughout. They each said that "Flight Lead," Chalk 5 was flying in the trail aircraft position. According to their statements, the flight arrived in trail formation and overflew runway 09 at 1,200 feet and 60 knots. Chalk 1 stated he entered left traffic, and while on the left base leg for landing, Chalk 3 announced airplane traffic on final approach to Runway 09. Chalk 1 stated he turned left prior to the runway, and initiated a go-around on the north side of the runway. Flight lead, in the trail aircraft, then announced over the flight's internal radio frequency to, "Break left or land." According to Chalk 3, he then "initiated a steep approach" to land on runway 09, and while he maintained visual separation from Chalk 2, noticed the rotor disk of another helicopter immediately below and to the right of his just as contact between the two was made, which separated the left landing gear skid. Chalk 3 then egressed his passengers from a hover, and repositioned the helicopter back to LNS and sought the assistance air traffic control (ATC) and crash/fire/rescue services. The helicopter landed without further incident. According to Chalk 4, Chalk 1 announced a go-around, but Chalk 5 gave the command to break left or land. At that point, he had Chalks 1, 2, and 3 in sight. Chalk 4 then confirmed the airplane traffic was "no factor" and had initiated a go-around on the south side of the runway. When he looked back on the formation in front of him, he had only Chalk 2 in sight, and had lost visual contact with Chalks 1 and 3. Chalk 4 then performed a "normal" approach to a 5-foot hover over the runway centerline, began a hover-taxi to parking, and about 20 seconds later "felt" the contact with the other helicopter. He then landed the helicopter without further incident. The pilot of Chalk 4 held a private pilot certificate, with a rating for a rotorcraft-helicopter. He reported 586 total hours of flight experience, of which 253 hours were in the accident helicopter make and model. The pilot of Chalk 3 held a commercial pilot certificate, with a rating for a rotorcraft-helicopter. He reported 1,617 total hours of flight experience, 92 hours of which were in the accident helicopter make and model. Each of the accident helicopters had 100-hour inspections performed during the year prior to the accident, and each pilot reported there were no mechanical deficiencies with either helicopter that would have prevented normal operation. Examination of briefing slides provided to the group by the flight lead (Chalk 5) revealed that the aircraft position order briefed on the slides was not the order flown. There were no slides that provided guidance for loss of visual contact or an inadvertent encounter with instrument meteorological conditions. There was no slide that identified flight lead would fly from the trail position of the formation. The formation flight of helicopters, designated Chalk 1 through 5, was en route to an annual airshow. The lead helicopter (Chalk 1) was on the left base leg of the traffic pattern at the nontower-controlled destination airport when the Chalk 3 helicopter pilot identified and announced that an airplane was on final approach for the landing runway. The Chalk 1 helicopter pilot announced that he was conducting a go-around and turned the helicopter left, inside the landing runway, and proceeded upwind. About the same time, the flight lead pilot, who was traveling in the trail position (Chalk 5), instructed the other helicopter pilots to "break left or land." The flight lead pilot's ambiguous instruction resulted in the breakdown of the formation flight's integrity. Instead of a flight of five helicopters and one airplane attempting to avoid conflict in the traffic pattern, each of the six individual aircraft were immediately placed in a position in which the pilots had to avoid potential collisions with the other aircraft. The Chalk 4 pilot subsequently lost sight of the Chalk 3 helicopter as the pilots of both helicopters were maneuvering for landing. The Chalk 4 helicopter pilot then landed the helicopter and was hover-taxiing to park when the helicopter collided with the Chalk 3 helicopter as its pilot was maneuvering it to land on the runway. Before the flight, the flight lead pilot presented briefing slides to the group of pilots; however, the slides did not provide any procedures for a loss of visual contact while flying in formation. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
FAA avdata. C = Cause, F = Factor.
- C Personnel issues-Psychological-Attention/monitoring-Monitoring other aircraft-Pilot - C
- F Personnel issues-Task performance-Planning/preparation-Flight planning/navigation-Not specified - F
- C Personnel issues-Psychological-Attention/monitoring-Monitoring other aircraft-Pilot of other aircraft - C
- F Personnel issues-Task performance-Planning/preparation-Flight planning/navigation-Not specified - F
Verbatim from NTSB's published report. Source file
NTSB_2012_ERA13LA022.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
Matched on aircraft type or causal vocabulary (go-around). All research papers
- NASA NTRS 2025 · Conference Paper A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
- Flight Safety Foundation 2024 · FSF / AeroSafety World Go-Around Safety Forum Findings
Foundation Go-Around Safety Forum technical findings — examines why pilots fail to execute go-arounds when criteria are met (stabilized approach gate not met, energy state out of envelope, traffic con…
- Semantic Scholar 2022 · Article (Journal of Safety Research) Go-around accidents and general aviation safety.
INTRODUCTION Changes in General Aviation (GA) accident rates, specifically in the go-around phase, are examined by comparing the number of accidents, the proportion of fatal accidents, and the proport…
- Semantic Scholar 2021 · Article (Aerospace) Classification and Analysis of Go-Arounds in Commercial Aviation Using ADS-B Data
Go-arounds are a necessary aspect of commercial aviation and are conducted after a landing attempt has been aborted. It is necessary to conduct go-arounds in the safest possible manner, as go-arounds …
- NASA NTRS 2021 · Accepted Manuscript (Version with final changes) Go-Around Criteria Refinement for Transport Category Aircraft
Presently, airline pilots are trained to go around if, when lower than 500 ft above the ground, they are outside of a handful of parameters such as airspeed, position, and rate of descent.
- NASA NTRS 2019 · Conference Paper Validation of Proposed Go-Around Criteria Under Various Environmental Conditions
This paper evaluates the effects of environmental conditions on touchdown performance under varying approach states and validates proposed go-around criteria developed using data from a previously con…