Agusta A109 accident near Salt Lake City, Utah, November 13, 2019
On November 13, 2019 at about 3:08 am local time, a 2011 Agusta A109 (helicopter), registered N271HC, was substantially damaged in an accident during enroute near Salt Lake City, Utah. It was an other work-use flight under charter and air-taxi rules (Part 135). No one was hurt; 3 people were on board or involved. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
The flight nurse’s inadvertent application of left anti-torque pedal during cruise flight, which resulted in a rapid yaw and pitch movement that caused the tail rotor blades to contact the tailboom.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- November 13, 2019 · about 3:08 am local time
- Place
- Salt Lake City, Utah · map
- Type
- Accident
- Injuries
- No one was hurt; 3 people were on board or involved.
- Weather
- visual conditions (good weather)
- Aircraft
- Agusta A109 SP, built 2011 · all A109s on the register
- Registration
- N271HC · registry record · serial 22250
- Damage
- Substantial damage
- Flight
- Other work-use flight · charter and air-taxi rules (Part 135)
The NTSB's narrative final · quoted from the NTSB record
The crew of the helicopter air ambulance flight departed to pick up a patient in night visual meteorological conditions. While en route to their destination, a flight nurse, who was seated in the left seat and communicating with ground personnel, inadvertently depressed the helicopter’s left anti-torque pedal instead of the foot-activated push-to-talk (PTT) switch to activate the microphone. The helicopter suddenly yawed left about 11°, which the pilot immediately countered and restored straight-and-level flight. The helicopter sustained damage to the tail rotor blades and empennage that was not discovered until several hours later when the accident crew was relieved. The damage to the blades and empennage was consistent with their making contact, and the flight data suggest this occurred during the first leg of the shift flight as the crew did not experience any other events that would have caused the degree of damage observed. Postaccident examination of the tail rotor gearbox and tail rotor blades did not reveal any anomalies. A performance analysis by the helicopter manufacturer showed that the amount of left pedal applied at the time of the pilot’s yaw recovery exceeded the parameters tested during certification. The flight nurse seated in the cockpit at the time of the accident normally sat in the rear cabin and was likely not as familiar with the location of the PTT, especially in nighttime lighting conditions.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- Inflight upset during enroute defining event
The NTSB's findings
- Personnel issues › Action/decision › Action › Incorrect action selection › Flight crew
Pilot
- Certificate: airline transport pilot
- Ratings: multi-engine land; single-engine land; single-engine sea; instrument: airplane; instrument: helicopter; rotorcraft: helicopter
- Flight time: 11,173 hours in all; 985 in this make and model; 41 in the last 90 days; 33 in the last 30 days; 10,443 as pilot in command
- Last flight review: August 30, 2019
- Medical certificate: Class 1 (without waivers/limitations)
- Seat: rgt
- Injury: no injuries
The aircraft
- Last inspection: type not recorded, October 25, 2019; 3,745 hours since
- Maximum gross weight: 7,000 lb
- Seats: 5
- Landing gear: retractable
- Engine 1: Pratt And Whitney PW207 (turboshaft); 3,653 hours total
- Engine 2: Pratt And Whitney PW207 (turboshaft); 3,589 hours total
- Operator: Ihc Health Services Inc
The flight
- Departed from: UT11 Murray UT at 2:52 am
- Destination: Spanish Fork UT
Weather at the time
- Light: daylight
- Visibility: 10 statute miles
- Sky: clear
- Temperature: 37°F (3°C), dew point 28°F (-2°C)
- Altimeter: 30.16 inHg
- Observation at 7:56 pm from KPVU, 5 miles away
Weather report (METAR): METAR KPVU 130256Z 00000KT 10SM CLR 03/M02 A3016 RMK AO2 SLP229 T00331017 58006=
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 3 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
14 documents, released by the NTSB on June 1, 2022. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.
| # | Document | What it is | |
|---|---|---|---|
| 1 | Aircraft Performance Study | PDF, 5 pages | View Download |
| 2 | Materials Laboratory Factual Report | PDF, 12 pages | View Download |
| 3 | Helicopter Specialist Report | PDF, 9 pages | View Download |
| 4 | Pilot/operator Aircraft Accident Report, NTSB Form 6120.1 | PDF, 9 pages | View Download |
| 5 | Record of Conversations | PDF, 7 pages | View Download |
| 6 | Email Correspondence with Operator | PDF, 10 pages | View Download |
| 7 | N271HC Schedule November 12 - 13 | PDF, 1 page | View Download |
| 8 | Excerpt from General Operations Manual | PDF, 13 pages | View Download |
| 9 | Adult Flight Nurse Operator Training Records | PDF, 7 pages | View Download |
| 10 | Accident Flight Operations Compliance Form | PDF, 1 page | View Download |
| 11 | Briefing Acronyms | PDF, 1 page | View Download |
| 12 | Statement of Party Representatives to NTSB Investigation | PDF, 1 page | View Download |
| 13 | Release of Aircraft Wreckage, NTSB Form 6120.15 | PDF, 2 pages | View Download |
| 14 | Accident Photographs | PDF, 5 pages | View Download |
The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.
