Source: http://www.helicoptercrashes.com/2005
Timestamp: 2013-05-20 06:51:34
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Aerospatiale SA315B Helicopter Crash
On September 2, 2005, approximately 1240 mountain daylight time, an Aerospatiale SA315B, single-engine helicopter, N220SH, operated by Skydance Northwestern, Inc., Minden, Nevada, was substantially damaged when it impacted terrain following a loss of control during an external load operation approximately 11 miles southwest of the Duchesne Municipal Airport (U69), Duchesne, Utah. The airline transport pilot, sole occupant of the helicopter, was not injured. Visual meteorological conditions prevailed at the time of the accident. The flight was being conducted under Title 14 CFR Part 133 without a flight plan. The flight departed a remote landing zone near Duchesne, Utah, approximately 1200. According to the pilot, he was attempting to lift a 1,500 pound drill rig that was attached to the end of a 75-foot long line at a terrain elevation of approximately 7,000 feet msl. As the drill was being lifted off the ground, the helicopter “suddenly [and] violently accelerated (pitched) down [and] left.” The pilot attempted to correct the uncommanded movement by applying right aft cyclic; however, the helicopter began a “rapid spin to the left.” A ground witness observed the helicopter complete 3 or 4, 360-degree rotations. The pilot then closed the throttle to the flight idle position, and the left rotation stopped. The helicopter entered a descent toward the terrain with approximately 10 knots of forward airspeed. Approximately 30-40 feel above ground level (agl), the pilot pulled the “remaining” collective to slow the descent and rotor RPM. The helicopter’s main rotor blades contacted trees, and subsequently the helicopter came to rest on its right side. The pilot then shut off the fuel cut off, secured the electrical equipment, and exited the helicopter. During the accident sequence, the pilot did not jettison the external load. The pilot reported the wind conditions as “calm” and the temperature 71 degrees Fahrenheit at the time of the accident. Examination by an Federal Aviation Administration (FAA) inspector at the accident site revealed the tail rotor driveshaft was intact, no particles were found on the tail rotor and transmission magnetic chip detectors, and no damage was noted to the tail rotor blades.
The airframe was examined under the supervision of a FAA inspector at the operator’s headquarters in Minden, Nevada. Examination of the airframe revealed no anomalies with the main transmission, tail rotor drive, airframe fuel, and flight control systems. A fuel sample was obtained and tested with no evidence of contamination noted. In addition, the operator tested the fuel from the supplier at the time of the accident with no contamination or anomalies noted.
A review of the engine records revealed at the time of the accident, the airframe had accumulated 19,658.4 hours and the engine had accumulated 3,216.5 total hours and 318.6 hours since overhaul. On August 31, 2005, the helicopter underwent a 100-hour inspection, at a total airframe time of 19,637.4 hours. On November 29, 2005, at the facilities of Heli-Support, Inc., Fort Collins, Colorado, under the supervision of the NTSB investigator-in-charge, the Turbomeca Artouste III B1 engine (serial number 1818) was examined and functionally tested. A borescope examination of the engine revealed deposits in and on all fuel injector wheel holes. The deposit material and source of the material was not determined. The injector wheel contamination was not removed prior to the functionally test of the engine. Upon completion of the visual and borescope examination, the engine was functionally tested in accordance approved manufacturer’s test procedures in a dynamometer equipped test cell. The functional test of the engine met or exceeded manufacturer’s specifications, and no anomalies were noted with the engine.
The fuel pump and speed governor were removed from the engine and functionally tested. Flows were within serviceable limits for repair functional test. No anomalies were noted with the fuel pump and speed governor.
After the functional test of the engine, the engine was reborescoped. The borescope examination revealed deposits to a lesser degree, in and on the injector wheel holes.
Reconsidering Air Ambulance Usage
Air Ambulance:“Medical helicopters and their flight crews are of tremendous importance to the nation, especially rural Americans,” says one expert.
MARBLE FALLS, Texas — The helicopter pad behind the firehouse in this town of 5,000 people is hardly thought about on weekends when fireworks, boat races and music festivals overwhelm the streets and nearby Colorado River.
“Medical helicopters and their flight crews are of tremendous importance to the nation, especially rural Americans,” says one expert.
AP file But make no mistake about it: The air ambulance in Marble Falls has long been considered an important part of life — and the saving of it. When the town’s population swells to 25,000 on Saturday nights as visitors flock toward the mesquite barbecue or the famous pie at the Blue Bonnet Cafe, a pilot, flight nurse and a paramedic stand by the helicopter, just in case.
“Just because they are sitting there doesn’t necessarily always make them the best resource,” says Loren Stagner, assistant operations manager for Marble Falls Area emergency medical services (EMS). “Their initial concept was phenomenal, but the execution has failed.” Most still agree that Marble Falls needs an air ambulance service. There are times, in rare emergencies, when patients need to get to a hospital by air. In cases where time contributes to loss of life or limb, the hour-long drive to Austin is too much time to waste. The chopper can make the trip in 20 minutes. But the challenge now faced by Marble Falls’ emergency medical services — and others across the nation — is determining how to use helicopters in a way that reduces the risk to patients.
A USA TODAY investigation found that federal air safety regulators have failed to keep pace with the rapidly growing industry. As a result, patients and crew members have died in crashes that could have been prevented. More patients have died in helicopter ambulance crashes in the past five years than in the 10 previous years combined. Over the past five years, helicopter ambulance crashes have killed 60 people, including seven patients and two mothers of sick infants.
The nation has never relied more on air ambulance helicopters. As rural emergency rooms close and specialty care becomes more centralized in big cities, moving patients in from rural areas fast has become more important in emergency medicine.
Helicopters are the only rapid way that 28% of the nation’s population can get to a top trauma center within 60 minutes, according to a study published in the June issue of the Journal of the American Medical Association. “Medical helicopters and their flight crews are of tremendous importance to the nation, especially rural Americans,” says the study’s lead author, Charles Branas, an assistant professor of epidemiology at the University of Pennsylvania School of Medicine.
So while emergency medical services officials don’t want to limit access to helicopters, they are concerned about the crashes and they want to protect their patients. Applying safety standards is particularly important, industry officials say, because no two air ambulance operations are exactly alike.
Two distinct approaches for providing the service have emerged. The long-standing approach is to base a helicopter at a specialty hospital — a trauma, cardiac or burn center — and send hospital specialists to patients to bring them back to the hospital. These operations tend to use expensive helicopters with top-notch navigational instruments and safety gear, as well as highly experienced pilots.
Because these helicopters are more expensive to own and operate, and because the pilots and medical personnel are paid well, these operations typically lose money on each flight. They stay afloat through financial support from the hospital, which makes money by maintaining a steady flow of incoming patients.
The more recent approach, which continues to grow across the nation, is to base a helicopter in a rural area so that it is closer to the prospective patients. Because these operators stand alone in a community with little or no financial support, each helicopter must earn a profit to stay in the area.
These operators use helicopters that are less expensive to own and operate and lack the more sophisticated safety features of the typical hospital-based helicopter, such as calibrated navigational instruments that help pilots fly in poor visibility. Both their pilots and their medical crews tend to be less experienced than those at a traditional hospital-based operation.
“We’ve grown so fast in this industry that we’ve outpaced our ability to have that level of personnel on a consistent basis,” says Christine Zalar, a former flight nurse and an industry consultant with Fitch & Associates. “We’ve also placed aircraft in areas where those kinds of people don’t exist. You are working in an area that makes great sense because patients need to be moved but your talent pool in that area is a little more stretched.”
Today there are hybrids of both types of operations — with hospitals deploying helicopters in rural areas and freestanding aviation companies operating helicopters at hospitals.
But for the most part, the differences are still significant, says Bob Bass, Maryland’s EMS medical director, who is part of a nationwide effort by the air ambulance industry, health regulators and emergency physicians to help state officials craft air ambulance rules. “The larger carriers are trying to run a quality program and pay their pilots and pay their mechanics and run safely, and they are feeling they are being undercut by these other programs doing it on the cheap,” he says. Reducing the Number of Flights
Meanwhile, across the EMS field, there is a sense of urgency as emergency workers try to apply more logic to airlifts.
Marble Falls has never had any concern about its helicopter crew’s safety, but the accidents across the nation have paramedics here scrutinizing the performance of the many helicopters in the area and finding ways to reduce the number of times patients have to be loaded onto helicopters.
Waving off a chopper in a small town like Marble Falls means making a tough and complicated decision — fast.
After the helicopter set up its base in town, anytime an ambulance responded to find a victim near death, the medics called for the chopper. Many patients benefited, but others were flown just because things looked bad, and the paramedics lacked the training and experience to make more precise decisions.
“A lot of our newer paramedics, especially, they really weren’t sure,” Stagner says. “And it was just easier to err on the side of the patient and fly them.”
For example, he says, the medics were “flying everything that resembled a stroke” to Austin. But some of those patients did not meet the criteria for stroke center care, “so we were kind of wasting the resources.”
By teaching the medics to be more precise, the city raised the quality of care to match, and sometimes exceed, the care delivered by the local flight crew.
Marble Falls crews flew 189 patients the first 12 months after the local chopper base opened. In the past nine months, they flew 78. In nearby Austin, the governor’s trauma advisory council — doctors, paramedics, hospital administrators and air ambulance employees — is working to lasso an air ambulance industry that has grown fast and largely unregulated. In just a few years, the number of air ambulance transports in Texas has nearly tripled, from 4,144 in 2002 to 11,694 last year.
Texas health officials are drafting rules that would require, as some other states have, that all air ambulances in the state meet the same safety benchmarks. But there is some confusion about whether the state or the Federal Aviation Administration should play the leading role in industry safety oversight. Some air ambulance companies have resisted similar attempts in other states to impose the standards, which cover everything from mechanics’ tools to managers’ role in aviation safety. Some of those who opposed the state oversight cited the Airline Deregulation Act, which in the 1980s gave the federal government authority over aviation companies.
“The Federal Aviation Administration has said they don’t regulate medicine,” Bass says. “But there is a big gray zone about what is medical and what is aviation. The safety issues raise some additional concerns about what should be the state role.”
Accreditation Has Its Benefits
State emergency medical directors are working to identify the boundaries of federal aviation rules and medical oversight. Meanwhile, says Tom Judge, president of the Association of Air Medical Services, “this really speaks to the need for national accreditation and national standards so the public has some idea what it is that they are purchasing.”
If the rules are implemented in Texas, as they have been in Utah, the state would require all of the 54 helicopter ambulances that operate in the state to be accredited by the non-profit Commission on Accreditation of Medical Transport Systems (CAMTS). New Mexico is also working to require accreditation. Other states, including West Virginia and Oklahoma, have written state rules based on the detailed standards that must be met for CAMTS accreditation. Such accreditation — which involves in-depth inspections by a team of industry experts to analyze a health care team’s principles, practices and culture — is widely viewed as a vital patient safety tool. “We believe in an outside review of quality,” Judge says. “We don’t believe it is enough to just say ‘we’re great,’ but to have somebody come in and test it.” A scientific study is now underway to try to determine accreditation’s impact on air ambulance safety. Proving a link between accreditation and improved safety may be difficult, Judge says, but the accreditation process itself has benefits.
“To me, the bigger part of accreditation is that when the accreditation people leave, you could see a palpable change in the program,” he says. “That is where the real benefit for safety and quality of care comes in.”
Training Helped Him Survive
Flight nurse Jonathan Godfrey is not waiting for studies to determine whether accreditation saves lives. He is traveling to air ambulance bases telling flight crews that it does.
Federal air safety investigators have not determined what caused the crash, which occurred as the helicopter flew over a bridge near Ronald Reagan Washington National Airport. Investigators are trying to figure out whether wake turbulence from a jet landing at the airport might have contributed to the crash. Godfrey, paramedic Nicole Kielar, 29, and pilot Joseph E. Schaefer III, 56, had just dropped a patient off at Washington Hospital Center and were returning to their base. Kielar and Schaefer died in the crash.
Whatever the cause, Godfrey attributes his survival to the detailed training he got from a company officer with years of military experience. Godfrey was required to demonstrate his safety skills before being allowed to fly, as required by accreditation.
It paid off, he says, when he found himself strapped to his seat beneath the 39-degree river with a broken back, chest and arm.
“I did not do the normal reaction, which is to gasp when you hit cold water,” he says. “I kept the sense of mind not to inhale.”
He tried to unbuckle his seatbelt but his right arm didn’t work. “I didn’t know the bone was sticking out of my flight suit,” he says.
“I freaked out a couple of more seconds and then decided to do what my training had told me and that was to get my bearings of where I was and where everything else was,” he says. “I reached with my left hand, twisted the belt and came up to the surface.”
Godfrey says when he saw news reports about earlier helicopter crashes, he considered each a fluke. Now he sees a pattern.
“I don’t think complacency had anything to do with our crash, but the industry as a whole had become complacent,” he says.
Now, he says, “I think the attention to detail has gone up and the complacency has been suppressed a little bit. I think that little bit makes enough of a difference. It keeps us out of trouble.”
SOURCE: Robert Davis USA Today
Surge in Helicopter Crashes Scars Air Ambulance Industry
By Alan Levin and Robert Davis, USA TODAY
The helicopter flight to take heart patient Jerry Leonard from one Indiana hospital to another should have been routine.
But on the night of the trip, April 20, 2004, the pilot on the Air Evac Lifeteam air ambulance apparently forgot to adjust the helicopter’s altimeter, federal records show. When he slammed the helicopter carrying Leonard into a hillside near Boonville, Ind., the cockpit gauge showed he was 310 feet off the ground.
“Boy, I screwed up,” pilot Richard Larock told an emergency worker who responded to the crash.
Larock and two medical workers survived, but Leonard — 63 years old and strapped to a gurney — was flung from the helicopter, the stretcher strap forced against his throat. “It took 10 minutes for him to strangle to death,” says his son, Keith Leonard.
The flight that was supposed to help save Leonard’s life killed him instead.
A deadly trend of pilot errors, industry carelessness and poor government oversight has driven the number of air ambulance crashes to record levels. (Related story: Inexperience proves fatal)
Since 2000, 60 people have died in 84 crashes — more than double the number of crashes during the previous five years. During that period, more than 10% of the U.S. air ambulance helicopter fleet crashed. If commercial airlines lost the same proportion of large passenger jets as air ambulance companies lost helicopters, 90 airliners would crash each year.
Despite the surge in the number of crashes, however, air ambulance companies and the federal agency that oversees them failed time and again to take steps that might have averted tragedy and saved lives, a USA TODAY investigation shows.
The newspaper reviewed hundreds of pages of documents and interviewed dozens of pilots, aviation experts, federal officials, and executives with the companies that operate the flights. Because government statistics on air ambulance crashes are sparse, USA TODAY also created its own database of 275 accidents since 1978.
Unlike passengers on commercial jets, the people being transported by air ambulances — many critically ill or injured in accidents far from hospitals — had no choice but to make the flights.
The crashes that killed them often involved egregious errors by pilots and crew. In one case, a helicopter carrying an 11-day-old child and her mother slammed into the side of a mountain at night. In other crashes, pilots flew into thick fog even after other air ambulance pilots had refused to fly.
“This isn’t search and rescue,” says Jamie Lebovitz, the lawyer representing the Leonard family. “This is transport and kill.”
Accident reports by the National Transportation Safety Board read like a horrifying guide for how not to fly.
Among the crashes:
On March 10, 2000, a pilot charged with taking a sick infant to a Texas hospital lifted off in fog so thick that an ambulance driver and others on the ground quickly lost sight of the helicopter. The pilot’s employer, Temsco Helicopters Inc., forbade flying in such conditions, which require instruments to navigate, according to the NTSB. The pilot had only one hour of instrument experience. The helicopter crashed less than a mile away, killing all four people aboard.
On Aug. 26, 2002, medical workers on a Rocky Mountain Helicopters mission fled a burning helicopter after a crash landing without evacuating the patient — a baby with respiratory problems. The pilot had landed on a highway in Bradenton, Fla., after the helicopter’s engine caught fire. The pilot and three medical crewmembers fled. The pilot told investigators that he saw the baby after returning to fight the fire, and he rescued the child.
On July 13, 2004, a Med-Trans Corp. helicopter flew to a highway accident in Newberry, S.C., after three other helicopter companies turned the job down because mist and fog blanketed the area. Seconds after taking off with the patient, the helicopter struck nearby trees and crashed. All four people aboard died.
On Aug. 21, 2004, an Access Air Ambulance flight carrying an 11-day-old infant and her mother to a Reno hospital slammed into a mountainside in a remote area of northern Nevada. The pilot was following a well-traveled route over a mountain range on a moonless night but didn’t climb high enough. All five people aboard died.
On Oct. 20, 2004, a helicopter left Santa Rosa Beach, Fla., to pick up a patient at a hospital in De Funiak Springs, Fla., even though a nearby weather station reported low visibility, according to preliminary findings by the NTSB. The company, Metro Aviation Inc., was not certified to fly in such conditions. After only two minutes, the pilot radioed that he was attempting to return because of bad weather. The helicopter crashed into a bay, killing the pilot and two medical workers.
The newspaper’s investigation found that:
• Industry safeguards are so lax that pilots have repeatedly caused accidents by knowingly flying into bad weather, failing to check weather conditions or otherwise violating federal or company regulations. In at least 17 cases since 1995, pilots crashed after flouting fundamental flight rules. (Related story: Pilots pressure themselves to fly)
• Despite at least nine crashes since 2003 in which a disoriented pilot flew into the ground, federal regulations exempt helicopters from some of the most basic safety standards and equipment required for commercial airlines, including devices that warn pilots when they get too close to the ground.
• Government inspections of air ambulance operations, a process critical to holding companies accountable for safety, are haphazard and inadequate. A draft report by a Federal Aviation Administration task force that studied the crashes last year concluded that inspections are “hit-or-miss” and that some accidents were “partly attributable” to poorly trained inspectors. In three fatal crashes last year, FAA inspectors had never visited helicopter bases to check pilot credentials, maintenance records and other documentation, steps crucial to ensuring safe flight.
Some medical studies also question the need for many air ambulance flights. A 2002 study in The Journal of Trauma found that helicopters were used “excessively” for patients who weren’t severely injured, and often didn’t get patients to the hospital faster than ground ambulances.
One possible explanation for the alleged overuse: profit. Air ambulance firms receive roughly $7,500 per flight from insurance companies or Medicare.
But industry leaders cite other studies to show that thousands of lives are saved each year by speedy flights to hospitals — far more than are lost in crashes. A study this year in the Air Medical Journal found that states with better air ambulance coverage tended to have lower highway fatality rates. “We do this because there are benefits,” says Tom Judge, president of the Association of Air Medical Services, the industry’s trade group.
Pilots sometimes find themselves in particularly trying situations. Despite darkness or bad weather, they may be summoned to accident scenes. They aren’t supposed to take off in poor conditions, but their decision whether to fly could mean life or death.
“I don’t know anybody in this industry who isn’t dedicated to safety and dedicated to what we do,” says Ron Fergie, president of the National EMS Pilots Association.
FAA and industry officials say they are moving to improve safety. Among the steps: encouraging companies to buy night-vision goggles, which allow pilots to see hazards in the dark, when the majority of crashes occur.
The FAA also has worked with companies to develop procedures to help pilots decide whether to stay on the ground in dangerous conditions. The agency pledges to review safety standards at every air ambulance company this summer. And industry trade groups say many companies are improving training without waiting for mandates by the FAA.
“We take this very seriously,” says Jim Ballough, who oversees the FAA’s safety effort. “The public will see change.”
But in the face of industry concerns about cost, many of the most promising safety enhancements have not been required. Flight regulations have not been rewritten. The FAA hasn’t followed key safety recommendations it received from its own task force last December. And though safety reviews of companies are planned, Ballough concedes the agency still lacks a system to ensure that all air ambulance bases — especially those located far from their companies’ headquarters — are inspected.
In interviews, the FAA offered no explanation for why it failed to act earlier or devote more resources to monitoring the air ambulance industry. But the upswing in crashes occurred as the agency faced growing pressure to tighten oversight of large airlines after the crashes of a ValuJet flight in Florida in 1996 and an Alaska Airlines jet in California in 2000.
The failure to act, by the industry and the government, is “almost criminal,” says Vernon Albert, a former air ambulance company flight director who is now a safety consultant. “Someone needs to be uncomfortable,” Albert says, “and not the guy riding in the back of the helicopter.”
When Jerry Leonard was killed as a result of the Boonville, Ind., crash last year, “it was just like somebody driving a knife through your heart,” Keith Leonard says.
The Leonard family had driven to Deaconess Hospital in Evansville, Ind., to meet Leonard, who was having heart problems. He was being airlifted there from a hospital in Huntingburg, Ind., 40 miles away. Leonard never arrived.
The family “believed that this air ambulance, with a pilot and paramedic and nurse, were going to provide him with state-of-the art care and deliver him safely to a hospital,” says Lebovitz, the family’s lawyer. “And the company violated that trust. They breached that trust.”
Air Evac declined to comment on the accident, but spokeswoman Julie Heavrin says the company has taken several actions to improve safety, including buying a helicopter flight simulator for training.
Across the industry, however, mistakes by pilots remain the cause of the overwhelming majority of crashes. The newspaper’s analysis of almost 30 years worth of accidents shows that 82% of fatal crashes were caused by human error — almost all by pilots.
In 2000, the air ambulance trade group called on the FAA to push companies to emulate the type of training used by airlines to minimize mistakes. Known at airlines as “Crew Resource Management,” the training teaches pilots to listen to concerns from other crewmembers and to monitor themselves for factors such as fatigue and tension.
In July 2000, an industry committee suggested language for such a training program and sent it to Jane Garvey, the FAA’s administrator at the time, says J. Heffernan, an air ambulance company official who headed the effort.
“We don’t know what happened after that,” Heffernan says.
Some companies went ahead with the training program, but it was never endorsed or addressed by the FAA. Agency spokeswoman Alison Duquette says the FAA found no record that it even received the industry’s recommendations.
No one can say for sure whether the industry’s suggested safety program would have prevented air ambulance crashes if it had been instituted industrywide. But similar programs at airlines are credited with reducing accident rates.
Today, about five years and dozens of crashes after the industry first proposed the safety program, the FAA is preparing to formally endorse it.
A proposal within the FAA to gather more data on how many hours air ambulance firms fly also went nowhere. As a consequence, tracking the accident rate — that is, how often air ambulances crash compared with the number of flight hours — remains impossible.
The collection of more and better data about accidents is the basis for taking steps to improve safety, says Michael Barr, lead instructor for the University of Southern California’s aviation safety program. “If the government wants to make any kind of rule changes, they have to base that on hard data,” Barr says. “They need to show that there is a need and make it a factual presentation, not an emotional one.”
In a statement in response to the newspaper’s questions, the FAA says it doesn’t need to track the hours of air ambulance flights. “We know the causes for these accidents and know what intervention strategies are needed,” the statement says.
The air ambulance industry has stopped waiting for the FAA to act. It now has begun gathering that flight information itself.
‘Safety layers don’t exist’
Pilot Craig Bingham knew the weather was bad on Jan. 10, 2003. Fog had reduced visibility to one-sixteenth of a mile in parts of Salt Lake City. A pilot from another air ambulance firm had even called to warn him against flying, federal records show.
But Bingham took off anyway, hoping to rescue a motorist injured on the highway.
The veteran pilot apparently became disoriented in the fog and crashed into a field, federal records show. The accident killed Bingham and a paramedic. A flight nurse was severely injured.
The unique mission of the air ambulance industry has contributed to the difficulty of preventing crashes.
Unlike charter or airline flights that go into airports, air ambulances land on hospital roofs or, worse, by the sides of rural roads at night. And instead of delivering anonymous airline passengers, air ambulance pilots are charged with helping save lives. That mission can prompt pilots to press on in conditions when others might turn back.
“Most of the accidents will say ‘pilot error.’ It’s not so simple, really,” says Eileen Frazer, executive director of the Commission on Accreditation of Medical Transport Systems, a non-profit group that conducts safety audits of air ambulance firms. “There are all sorts of extenuating circumstances.”
Airlines and safety regulators have conducted a decades-long battle against pilot mistakes by improving training, oversight and technology. The combination has led to the safest period in commercial aviation history.
But almost none of those improvements have been applied to the air ambulance industry:
• About two-thirds of fatal air ambulance crashes occur in poor visibility, the newspaper’s analysis shows. Even so, pilots are not required to have special training about what to do when they encounter fog, snow or darkness.
• Air ambulance pilots need not obtain a weather report for their destination if they are not carrying a patient. Similarly, FAA rules that restrict how many hours pilots may work do not apply to flights without a patient.
• Helicopters are exempt from the federal rules that require data recorders on most planes that carry people for hire. The lack of these recorders in air ambulance helicopters makes it more difficult to determine what caused accidents — and to prevent future crashes.
Patrick Veillette, a former emergency medical pilot who has written several studies of air ambulance accidents, says the lack of emphasis on safety regulations, equipment and training is “setting the pilots up.”
Veillette now flies a business jet. He says the contrast between that type of flying and the air ambulance world is stark. In a jet, air traffic controllers guide him away from hazardous conditions. His cockpit is equipped with the latest safety devices, including one that sounds an alarm if he strays too near to the ground. A company dispatcher won’t allow him to take off unless conditions are safe.
For the air ambulance industry, “these multiple safety layers don’t exist,” he says.
Inspections ‘hit or miss’
No one was seriously hurt on Aug. 31, 2002, when an Air Methods Inc. helicopter clipped a parking garage as it tried to take off at Miami Children’s Hospital.
But an investigation of the accident revealed the lack of oversight that occurs at many air ambulance bases, particularly those far from company headquarters.
The FAA had never inspected the helicopter operation because it was new, the National Transportation Safety Board found. Construction at the hospital had rendered the heliport dangerous, but the hospital had never told state and federal officials of the changes.
And even though flying into the hospital was tricky, Air Methods had not provided the pilots any special training, the copilot told NTSB investigators. The copilot, who wasn’t named in the NTSB’s accident report, said company managers told him they knew it was “tight in there, but to deal with it since they needed the work.”
Air Methods CEO Aaron Todd says the company would “never accept a contract” that it could not perform safely.
Regardless, the case illustrates how FAA inspectors have been unable to keep up with the dramatic growth in the air ambulance industry. Air ambulance companies have expanded rapidly since the late 1990s as firms began competing in urban areas and demand for air ambulance services surged in rural areas where hospitals had shut down.
The industry’s trade group estimates that, since 2000, the number of air ambulance helicopters has climbed 50%, from 500 to about 750. The average number of crashes climbed even faster, from about five per year during the early and mid 1990s to more than 15 per year since 2000 — a 200% increase.
After investigating three of the worst air ambulance crashes last year, two involving Med-Trans Corp. helicopters, the NTSB found that FAA inspectors had never visited each of their local operations.
The NTSB is investigating pilot decisions in all three accidents, says Jeff Guzzetti, who oversees the NTSB’s air ambulance crash investigations. Eleven people died in the crashes, including two patients and the mother of one patient.
In one case, a Med-Trans crew flew to a roadside accident in South Carolina on July 13, 2004, after three other crews declined the mission because of bad weather. In another crash, a preliminary NTSB investigation shows that a pilot flew into a storm near Peyote, Texas, on March 21, 2004, after failing to check the weather, Guzzetti says.
Med-Trans spokesman Reid Vogel calls the company’s crews “highly skilled” and committed to safety.
A rapidly growing company based in Bismarck, N.D., Med-Trans has 12 helicopter bases around the country. But the only FAA inspectors assigned to monitor the firm were based in Arizona, near one of the company’s bases.
“The safety board investigators are interested in the adequacy of FAA oversight of air ambulance companies, especially ones which conduct operations all over the country, but have one FAA office responsible for oversight,” says Guzzetti. The NTSB plans to release a study of the industry later this year.
Linda Goodrich, vice president of the Professional Airways Systems Specialists, the union that represents inspectors, says staff reductions and budget cuts have made it increasingly difficult to inspect air ambulance operations.
Limited number of inspectors
The number of employees whom the FAA classifies as inspectors is expected to fall from 3,600 to about 3,400 this year, the FAA says. And hundreds of those workers are assigned to FAA’s Washington headquarters or are managers who do no inspections. FAA requests to add inspectors were turned down by the Bush administration. As a result, the agency focuses its resources on its biggest mission: inspecting large airlines.
The air ambulance industry, Goodrich says, “is at the bottom of the food chain.”
In fact, the draft report by the FAA task force examining the crashes concluded last December that the agency’s efforts to inspect some air ambulance operations were “a hit-or-miss proposition.”
The FAA’s Ballough says his department is trying to order more inspections of air ambulance firms. But at a time when the FAA’s aviation oversight budget has been cut by $25 million, or 5%, the agency can’t afford to devote too many inspectors to this relatively small corner of the aviation industry.
“It’s an issue of resources,” he says.
The FAA task force also concluded that several fixes could improve safety. Its draft report called for mandating improved pilot training for handling poor visibility, tightening air ambulance rules to make them more consistent with those for small airlines, and making weather limitations more strict. All of the recommendations could be put in place quickly, without the lengthy process of writing new regulations, the report says.
But the FAA and the industry have stuck to voluntary enhancements, avoiding mandates that change rules and require better equipment.
Ballough says some rule changes will come, but he says the FAA must proceed cautiously to ensure it chooses the right solutions. The industry also wants to move slowly. In a letter to FAA officials in January, the industry trade group said that imposing costly new safety rules might put some operators out of business.
The industry, says safety consultant Albert, “is accepting a higher accident ratio than the other areas of the aviation industry. And I say it very bluntly: If they weren’t accepting it, they’d be doing something about it, be it the FAA, the industry, the pilots or whatever.”
Richard Healing, an NTSB member, says air ambulance operators need to be especially vigilant about safety because accident victims and hospital patients usually have no choice whether to fly.
“My goal is to see that the helicopter community gets the same level of safety everybody else gets,” Healing says. “It’s clear that has not been the case in the past.”
For Keith Leonard and others who lost loved ones in accidents, the damage cannot be undone.
“To this day, every time I hear a helicopter I tense up,” Leonard says. “Just the sound of it takes me back to that night.”
Contributing: Marie Skelton and Paul Overberg
Aerial Spraying Helicopter Crashes
Vegetation Eradication Helicopter Crash
On April 20, 2005, about 0745 eastern daylight time, a Bell 206B, N2285B, registered to and operated by Heliworks, Inc., rolled over while lifting off from the Everglades near Coral Springs, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 135 local, other work use flight from Fort Lauderdale Executive Airport, Fort Lauderdale, Florida. The helicopter was substantially damaged and the commercial-rated pilot and two passengers were not injured. One passenger sustained serious injuries. The flight originated about 0700, from the Fort Lauderdale Executive Airport.
The pilot verbally stated that after takeoff, the flight proceeded approximately 15 miles west to Sawgrass Park where he landed and picked up three workers. He completed a load manifest and computed the weight and balance. He then proceeded to a site for vegetation eradication, and after landing, the workers got out, sprayed, then returned. He then departed again to another site where one of the workers got out, sprayed, and returned to the helicopter. He lifted up straight and the right side “popped up fast.” He lowered collective and applied right cyclic to correct the roll which had no affect; the helicopter rolled onto its left side. He further reported he did not perceive a problem with the helicopter or flight controls.
Examination of pictures provided by the operator revealed the helicopter was resting on its left side partially submerged. The tailboom was fractured but in close proximity to the wreckage and damage was noted to the bottom of the fuselage just aft of the aft crosstube. One of the main rotor blades was visible. According to FAA personnel, during recovery, the helicopter was dropped from a height of approximately 20-30 feet.
National Transportation Safety Board examination of the helicopter following recovery revealed the main rotor mast was fractured just below the static stop contact zone; the fracture surface circumferentially exhibited 45-degree shear lips. Both main rotor blades were fractured; 45 degree shear lips were noted on the fracture surfaces of both blades. One of the two main rotor blades was fractured approximately 152.5 inches from the centerline of the attach bolt; blue colored paint was noted on the leading edge of the blade. The other blade was fractured approximately 148 inches from the centerline of the attach bolt; blue colored paint was noted on the upper surface of the blade. The tailboom was separated at approximately boom station 63. One section of tailrotor drive shaft was displaced due to aft displacement of the 2nd tailrotor drive shaft bearing.
Examination of the left rear seat revealed the seatback cushion was not in-place, and the shoulder harness was connected to the lapbelt, but the male and female ends of the lapbelt were not connected. Examination of the right rear seat revealed the shoulder harness was connected to the lapbelt but the male and female ends of the lapbelt were not connected.
Examination of the collective flight control system revealed control tube assembly continuity from the cockpit to the lever assembly; a fracture was noted to the bellcrank P/N 206-001-568-001, near the area where the tube assembly connects. No evidence of preimpact failure or malfunction was noted on the fracture surface of the bellcrank assembly. Examination of the cyclic flight control system revealed control tube assembly continuity from the cockpit to each bellcrank assembly.
Each control tube assembly was fractured between the bellcrank assembly and the inner ring assembly. Both fractured control tubes were bent and exhibited “D” shaped deformation in the area of the fracture surface. One pitch link assembly was fractured between the attach point on the outer ring assembly and the attach point near the main rotor blade. The other pitch link assembly remained connected to the attach point near the main rotor blade, but the other end was not connected to the outer ring assembly. The end of the pitch link that was separated from the outer ring assembly still had the securing hardware and bearing connected to the end of the link. Examination of the outer ring assembly revealed one of the pitch link assembly attach point fitting was fractured; no evidence of preimpact failure or malfunction was noted to the fracture surface. The left and right cyclic, and the collective servo actuators were removed from the airplane for further examination at the helicopter manufacturer’s facility with FAA oversight.
Bench testing of the left cyclic servo actuator (S/N 6608) revealed the relief valve pressure “cracked” at 810 psig (specification is 825 to 895 psig test port pressure). The relief valve closed at 570 psig (specification is that it must close within 120 psig of the cracking pressure). During the “Manual Operation Test”, the manual force to move the cylinder was 44 pounds (specification is 26 pounds or less). All other sections of the test procedure were within normal limits. Testing of a sample of fluid revealed the particle count was greater than specified for all channels. Bench testing of the right cyclic servo actuator (S/N 2310) revealed with respect to the “Servo Valve Leakage Test”, the leakage amount was 50cc/minute (specification is 20 cc/minute). All other sections of the test procedure were within limits. Testing of a sample of fluid revealed the particle count was greater than specified for all but one of the five channels.
Bench testing of the collective servo actuator (S/N 6576), revealed that with respect to the “Manual Operation Test”, the unit did not move when a force of 40 pounds was applied (specification is 26 pounds or less). A force of 600 psi (normal 206B system pressure) was applied to the pressure port with the return port open and the cylinder would cycle. A “thick black material” was noted extruding from each end of the barrel. Further testing of the collective servo actuator with respect to the “Un-Boosted Force Test” revealed the peak force to cause movement of the piston ranged from 134 to 92 pounds in the retract direction and 88 to 121 pounds in the extend direction. The servo was then disassembled which revealed a localized area of “…fresh burnishing” of one side of the inboard gland bore. The piston rod was checked for straightness using “V-blocks” and a dial indicator and the total dial indicator run-out was .0065 inch.
The helicopter minus the retained components was released to David E. Gourgues, Regional Manager for CTC Services Aviation (LAD) Inc., on November 10, 2005. All NTSB retained components were also released to David Gourgues, on March 29, 2006.
Bell OH-58C Helicopter Crash
Crash Blamed on N1 Tachometer Generator Failure
On April 7, 2005, approximately 1815 mountain daylight time, a Bell OH-58C, N198PD, operated by the City of Colorado Springs Police Department, was substantially damaged during a forced landing 10 miles north of Colorado Springs, Colorado. Visual meteorological conditions prevailed at the time of the accident. The local public use flight was being operated under the provisions of Title 14 CFR Part 91 without a flight plan. The commercial certificated pilot and two passengers reported no injuries. The local flight originated approximately 1800.
According to the accident report submitted by the pilot, he was orbiting over a college campus when the “engine out light illuminated” in the cockpit. This light was followed by an “audible engine out alarm” and the “N1 gauge dropped.” The pilot elected to perform a precautionary landing west of Interstate 25 on Air Force Academy property. The pilot stated that the terrain sloped uphill and the helicopter stopped “abruptly” and rock back and forth. Approximately 30 inches aft from the boom attach point, the boom buckled, leaving a wrinkle approximately 9 inches in length and approximately 2 inches at its deepest point.
A postaccident examination revealed that the N1 tachometer generator had failed. Further examination revealed that the N1 tachometer generator wire was not connected to the cannon plug and frayed. Examination of the helicopter’s remaining systems revealed no anomalies.
According to the pilot, he was orbiting over a campus when the “engine out light illuminated in the cockpit,” followed by an “audible engine out alarm” and the “N1 gauge dropped.” The pilot elected to perform a precautionary landing to a field. The pilot stated that the terrain sloped uphill and the helicopter stopped “abruptly” and rock back and forth. A postaccident examination revealed that the N1 Tachometer Generator had failed. Further examination revealed that the N1 tachometer generator wire was not connected to the cannon plug and frayed.
The National Transportation Safety Board determines the probable cause(s) of this accident was the failure of the N1 tachometer generator which resulted in a precautionary landing. Other contributing factors include the frayed wire and the unsuitable terrain for a precautionary landing.
U.S. Forest Service Fire Helicopter Crash
National Forest Service Helicopter Crashes in East Texas
On March 10, 2005, approximately 1354 central standard time, a Bell 206B-3 helicopter, N85BH, sustained substantial damage when it impacted heavily wooded terrain in the Sabine National Forest near Shelbyville, Texas. The airline transport rated pilot and two United Stated Department of Agriculture (USDA) Forest Service (USFS) crewmembers sustained fatal injuries. Visual meteorological conditions prevailed, and the flight/mission was being monitored and conducted in accordance with USFS aviation policies for public use aircraft in fire management operations. The flight departed at 1347 from a field helicopter pad (H1), located approximately 7 miles southeast of the accident site.
On the morning of the accident, the helicopter was assigned to support a prescribed fire within heavily wooded terrain with 100-120 foot high trees near Shelbyville, TX. The prescribed fire was supported by the application of aerial ignition spheres utilizing a cabin mounted plastic sphere dispenser (PSD) machine. According to USFS operating procedures, PSD missions are typically flown at 50-300 feet above the top of vegetation at airspeeds from 20-40 knots. The helicopter was based at Angelina County Airport, Lufkin, Texas. Approximately 0928, after a mission brief, the helicopter, with pilot and two USFS personnel on board, and the re-fueling truck re-positioned to H1 (coordinates North 31 degrees 42.110 minutes West 93 degrees 52.540 minutes) and were met by support equipment and personnel from the Sabine National Forest to conduct a prescribed fire mission.
Approximately 1234 an initial recon of the burn area began, followed by approximately 11 minutes of aerial ignition work on the same flight. Approximately 1300 the PSD machine experienced a sphere jam, and the helicopter returned to H1 to resolve the problem. The helicopter shut down at H1 while the PSD machine problem was resolved. The helicopter then departed H1 at 1347 to resume the mission. According to USFS records from ground personnel on the burn, at 1352, the mission ignition specialist onboard the aircraft reported by radio that the helicopter was commencing firing operations. At 1354, a radio distress call was heard by 7 personnel on the burn. According to USFS personnel, the voice making the distress call appeared to be that of the ignition specialist, not the pilot. The call was, “Mayday, Mayday, Mayday, we are going down.” No further communications were heard from the helicopter.
At 1417, the helicopter wreckage was found at coordinates North 31 degrees 45.425 minutes West 94 degrees 00.244 minutes. Immediate rescue operations commenced. One USFS employee initially survived the crash and was being transported by ambulance to a local hospital. The passenger died during transport due to extensive injuries sustained in the crash.
A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held an airline transport pilot certificate with ratings for airplane single engine land, airplane multiengine land, and rotorcraft-helicopter, and a certified flight instructor certificate with ratings for single and multiengine land, rotorcraft-helicopter, and airplane and rotorcraft instrument. He was also an FAA certificated advanced and instrument ground instructor. His most recent FAA first class limited medical certificate was issued on September 7, 2004, with the limitation, “must have available glasses for near vision” At this time, he reported a total of 3,000 flight hours.
The pilot’s personal logbook was obtained. During a review of the logbook, several discrepancies were noted. Rotorcraft time appears to be consistent from the time rotorcraft time is first logged through the page ending February 20, 2004, at which time the pilots logbook shows a total rotorcraft time of 286.1 hours. On the page ending March 2, 2004, in the amount forwarded column, rotorcraft time increases to 1286.1. The page total is 27.3, which was added to time from the previous page for a total time of 1323.4 hours. This was an unaccounted 1,000-hour increase in rotorcraft time from the previous page. The extra 1,000 hours were added to and subtracted from cumulative flight time throughout the remainder of the logbook entries. The last entry in the logbook reflects the pilot’s total time in all aircraft to be 2,187.8 hours, 384.4 of that in rotorcraft, and 115.9 hours in make and model.
The 1980-model Bell 206B-3 helicopter was a single pilot, five place, single engine, light helicopter with a two-blade semi rigid main rotor, and a tail rotor that provided directional control. The helicopter was owned by Brainerd Helicopter Service, Inc, and operated by the United States Forest Service. A review of the aircraft logbooks revealed that the last annual inspection was performed on April 26, 2004, at a tachometer time of 309.27 hours. The tachometer read 2,837.4 at the scene of the accident. The aircraft total time was determined to be 4,565 flight hours at the time of the accident.
The helicopter was equipped with a Rolls Royce 250-C20B engine, serial number (S/N) CAE-840516. Historical records for the engine began on April 12, 1991, with 463.1 hours total time. The engine was converted to a Model 250-C20B (same serial number) on March 15, 1993, with a total time of 907.3 hours. Records continued with periodic inspections (100, 300, 600 and Annual) through February 22, 1999. The February 22, 1999, entry indicated that engine, S/N CAE-270208, was removed due to metal on the upper and lower chip detector plugs. There were no previous indications that engine S/N CAE-270208 had been installed. The total time prior to this entry was reflected as 2,653.2 hours on January 1, 1999, and according to the records, should have been for engine S/N CAE-840516. This total time was carried forward to the questionable entry on February 22, 1999, and subsequently crossed out and replaced with an engine total time of 2,296.2. The airframe log showed an entry for engine, S/N CAE 840516 being installed on February 22, 1999, but did not show engine S/N CAE 270208. The entry appeared to be inserted between two previously entered items on a single line and overlapped the A&P mechanics number from the previous entry. History of engine S/N CAE 840516 could not be determined from the records presented.
Historical records shows the last entry for engine S/N CAE 840516 was on 16 December 2004. Total time was recorded as 4,142.7 hours. The airframe total time was recorded as 4,499.5 hours total time. The daily log indicated a total time of 4,175.6 hours for the engine and 4,563.1 hours for the airframe. The serial number on the component card (FF357738) differed from the serial number on the Canadian Authorized release Certificate (FF37596) for the Bleed Valve.
The automated weather observing system at the A.L. Mangham Junior Regional Airport, near Nacogdoches, Texas, located approximately 30 miles southwest of the accident site, reported wind from 250 degrees at 5 knots, 10 statute miles visibility, a clear sky, temperature 22 degrees Celsius
The ignition specialist (FS crewmember in left front seat) was communicating with ground personnel on a U.S. Forest Service Tach channel at the time of the accident. He reported that he was resuming fire operations at 1352. At 1354, the ignition specialist made a “Mayday” call on the frequency. There were no further communications from the aircraft.
The helicopter came to rest on its right side in a heavily wooded area on a heading of 135 degrees at coordinates North 31:45.425 West 94:00.244. The initial point of impact was identified as the tops of 50-foot trees located around the wreckage. Global positioning system (GPS) elevation at the accident site was 386 feet msl.
Fuselage – The right skid was fractured just forward of the forward mounting saddle, and the fuselage floor was fractured aft of the forward cross tube. Impact damage was observed on the right rear portion of the fuselage. Approximately 15 pounds of personal gear was found in the aft baggage compartment. Front right and left doors were not installed. The nose of the helicopter exhibited light crushing and all of the Plexiglas chin bubble was broken out. The right forward door post was bent inward and upward. Damage to the left side of the fuselage was unremarkable. No fuel found in the tank; however, an odor consistent with that of jet fuel was present at the accident site. The fuel boost pump access panels were removed, and the rear boost pump valve locking bar was found loose (approximately 0.065 in.). The forward boost pump valve locking bar was found slightly loose (0.035 in). The fuel quantity indicating float access panel was removed, and the forward fuel quantity indicator lead (“C” post) was found in a loose condition.
Cockpit – All circuit breakers were in and the battery and generator switches were found in the “ON” position. The Hobbs meter indicated a time of 2,837.4 hours. The directional gyro/attitude indicator switch was “ON”. The altimeter was set to a barometric pressure setting of 30.09 inches of Mercury. The directional gyro indicated a 210 degree heading. The artificial horizon displayed a nose-up right-bank attitude. The fuel valve switch was “ON”. The right seat pan was crushed downward approximately two inches. Located at the forward most point of the wreckage debris were two Interstate DCS-33 12-volt batteries, which were reportedly removed from the helicopter battery compartment during rescue operations.
Controls – Control continuity to all flight controls was established. The collective control lever exhibited overload fracture outboard of the collective attachment control collar. Movement at the collective hydraulic actuator bell crank resulted in corresponding movement at the collective attachment control collar, and pre-impact control continuity was confirmed from the collective up to the main rotor system. The cyclic control stick exhibited an overload fracture at the base of the stick forward of the attachment collar. Movement of the control tubes resulted in the movement from the attachment collar up to the hydraulic actuator. A visual inspection confirmed control continuity from the hydraulic actuator to the main rotor pitch change horns. The anti-torque control tube was fractured at the tail rotor control pedal bellcrank. Removal of the broom closet panel revealed that movement of the tail rotor control tube was prevented due to crushing of the surrounding structure. Movement of control tube above the crushing resulted in corresponding movement of the control tube forward of the fracture at the tailboom. The tailboom section of the anti-torque control tube was separated from the tailboom during the impact sequence, and each end exhibited overload fracture. Movement of the control tube at the forward end of the tail rotor resulted in a corresponding pitch change in the tail rotor blades, confirming pre-impact control continuity in the anti-torque pedal system.
Transmission and Main Rotor System – The transmission remained attached to the airframe and the main transmission pylon mounts remained in place and attached to main transmission. The transmission displaced in an aft, downward direction, forcing the K-flex coupling into the isolation mount cover. The forward attachment of the main driveshaft was separated at the K-flex coupling and had multiple overload fractures of the K-flex. Scoring of the roof panel adjacent to the fractured K-flex was observed, and was consistent with circumferential flailing of the drive shaft, indicative that the drive was rotating at impact. There was no notable damage to the main rotor control system, up to the rotating swashplate. One of the two pitch change control tubes, extending from the rotating swashplate to the pitch-change horn, displayed an overload fracture approximately mid-length. One rotor blade, which reportedly came to rest forward of the main wreckage, exhibited trailing edge impact damage that was consistent with the diameter of trees in the immediate vicinity of the impact. The blade fractured just outboard of the doublers. The other blade exhibited trailing edge impact, and chord wise damage. The blade also exhibited chord wise scoring throughout the length of the blade. Both blades displayed damage consistent with a high pitch, slow turning rotor at impact.
Tail Rotor – The tailboom fractured just forward of the tail rotor gear box mounting pad. As a result, the tail rotor control tube fractured in overload as described above. Additionally, the tail rotor drive shaft decoupled from the tail rotor gear box and the aft portion of the tailboom, along with the tail rotor gear box assembly was located approximately 15 feet from the main wreckage. The tail rotor assembly remained intact, though the tail rotor blades displayed both impact and fire damage. The tail rotor pitch change assembly moved freely by hand and resulted in corresponding pitch change of the tail rotor blades. As the tail rotor blades were rotated by hand, the gear box rotated freely without any identifiable grinding or binding. The chord wise accordion bending of the tail rotor blades was consistent with low, or no, power at impact. The forward end of the tail rotor drive shaft exhibited torsional shearing. Deformation of spacers was progressively more identifiable forward of the torsional separation in the tail rotor drive. All hanger bearings rotated freely with no evidence of heat distress. The aft end spline of the tail rotor drive shaft was found decoupled. The torsional shearing of the tail rotor drive shaft was consistent with sudden stoppage forward of the drive shaft fracture point.
Engine – The left side of the engine compartment appeared normal. The left side engine mounts were intact. The Pc pneumatic air line was intact to the PT Governor “T” fitting. All pneumatic system B-nuts were at least finger tight. The PT Governor pointer indicated a high power application. The linkage was intact in the engine compartment, but was separated on the hydraulic deck and at the collective itself. The right side engine compartment door was uniformly crushed into the right side of the engine. The right side engine mounts were bent. The horizontal fire shield was crushed inward from the right side. The right side compressor air discharge tube was crushed from a right side impact. The forward end was partially separated from the compressor scroll. The right side of the outer combustion case was partially crushed from impact. There were no noted separated pneumatic tubes. Some tubes were crushed and deformed from impact damage. All pneumatic system B-nuts were at least finger tight. The 4th stage power turbine wheel would not rotate with attempts at hand rotation.
PSD Machine – The PSD machine was found inside the aircraft still strapped in its installed position. Some slight denting damage was found on the hopper and the plastic lid was broken off from the hopper at the hinges. Plastic spheres had been ejected from the hopper and were strewn within the cabin and outside the cabin around the aircraft. Several nylon fabric bags containing additional plastic spheres were still securely attached to their tether and intact. In each of the two slipper blocks on the same side as the PSD machine controls, slipper blocks 1 and 2, a partially burned plastic sphere was found. That is, one plastic sphere in slipper block 1 and one plastic sphere in slipper block two. The other two slipper blocks, 3 and 4, were empty. Black ash residue was found on the outside of the lower portion of the feed chutes above blocks 1 and 2. The inside feeder control lever was in the up position. This lever in the up position allows the plastic spheres to feed into the two inner slipper blocks; slipper blocks 2 and 3. The outside feeder control lever was in the down position. In the down position, plastic spheres are restricted from entering blocks 1 and 4. The power control toggle switch was found in the on position. The speed control switch was found in the slow position. It is unknown whether the emergency water was used. The power cord from the machine to the hopper was disconnected. The main power cord from the machine to the helicopter was disconnected at the cannon plug. It is unknown whether these plugs where disconnected on prior to impact, during impact, or by the rescue personnel first to arrive at the accident site.
An autopsy was performed on the pilot Dr. Brown, Forensic Pathologist, Jefferson County, Texas. Toxicological tests will be conducted at the FAA’s Civil Aeromedical Institute (CAMI), Oklahoma City, Oklahoma.
The wreckage was recovered to Air Salvage of Dallas, Lancaster, Texas, on March 12, 2005, for further examinations. On March 16, 2005, representatives from the NTSB, USFS, Bell Helicopter, and Rolls-Royce Engines convened at Air Salvage of Dallas to examine the wreckage.
Airframe – When the airframe fuel filter was removed a small amount of retained debris was noted and the filter was clean. External power was applied to the helicopter to check gauges, warning horns, enunciator lights, and fuel boost pumps. When power was applied; the fuel gauge reading was +100 gallons, enunciator lights illuminated for the Fuel Pump, Tail Rotor Chip, Rotor Low, and Engine-Out. The low-rotor warning horn was audible. When power was applied to the airframe fuel boost pumps, no audible indication of pump operation was noted. The pumps were then removed and bench tested. They appeared to be operating, and pressure and volume were not verified.
Engine – The fuel flow control, which should be set on the “low” setting, was set to an intermediate position (an etched setting between “low” and “high”). Fuel from the fire shield to the fuel nozzle could not be verified due to premature removal of the fuel line. Both chip detectors were removed, and a slight amount of fuzz was found on one of the chip detectors. The tach generators were removed. N1 rotated freely and smoothly with continuity to N1 drive train. The engine fuel filter was removed and was found clean and full with clear and bright fuel. The oil filter was removed from the accessory gearbox and the oil was normal in color with no burning indications. The bleed valve was found in an open position and closed fully when actuated by hand and returned to an open position when released. The fuel nozzle was removed and its screen was intact and free of debris.
The engine was shipped to Aeromaritime in Mesa, Arizona, for disassembly and further examination on April 7, 2005. After the shipping container was opened a component inventory and part numbers were verified. Pneumatic system leak checks were conducted and a slight leak was found at the PC line filter. The right side shoulder of outer combustion case (OCC) was cut away, and the combustion liner and case appeared normal. The right side compressor air discharge tube, all pneumatic lines, oil lines, fuel lines, and attachments were removed and inspected. After removal of the power turbine governor and fuel control, the drive shaft and splines were found intact. The first stage nozzle shield was intact and first stage nozzle appeared normal. The first stage wheel appeared normal with no visible damage to blades. The second stage wheel appeared normal with no visible damage to blades. The gas producer rotor rotated free and smooth by hand. Turbine shafting (pinion gear coupling, turbine to compressor coupling, power turbine inner and outer shafts) were intact when removed. The power turbine rotor could not be rotated by hand due to impact damage. The power turbine rotor was then removed from the exhaust collector, after which, the power turbine was then able to rotated by hand. Rotational scoring on the fourth stage nozzle was noted corresponding to the tip path planes of the third and fourth stage wheels. A drive spline was inserted into the N1 drive train of the accessory gear box, manually turned, and fuel pump pumped fuel from outlet. No anomalies were noted on the N1 side of the accessory gear box. Both the accessory gear box and compressor rotated free and smooth by hand and there was no noted damage. In summary, no conditions were found that would have precluded the engine from normal operation. The fuel control and power turbine governor were packaged and sent to Honeywell, South Bend, Indiana for bench testing.
Functional testing of the fuel control unit did not reveal conditions that would have precluded normal operation. Functional testing of the power turbine governor found out of limits repeatability on the initial test run. The repeatability improved on each subsequent test run and after the fourth test run was within test specifications. Disassembly of the unit disclosed wear material (Teflon) on the spool valve assembly where it interfaces with the Teflon tube. Signs of vibration were evident on the spool bearing and flyweights. No other test points and part inspections revealed anomalies.
Aerial Ignition Information as provided by the USFS:
Prescribed fire is a method of reducing the build-up of live and/or dead organic material in managed forest or range environments. This reduction in biomass has general short and long term benefits in that it may reduce the risk of uncontrolled wildfires, remove or prevent the establishment of undesired plant species, improve the health of established desired trees and plants, and improve wildlife habitat. Prescribed burning operations are performed in a variety of manners including hand ignition and aerial ignition which involves the application of burning material, generally fuel of some nature, to designated areas under specified and desirable meteorological and fuel conditions.
During aerial application of fuel, there are two primary methods of fire application: helitorch and Premo Mark III Aerial Ignition System. A helitorch utilizes gelled gasoline and is pumped from a barrel suspended beneath the helicopter. The Premo Mark III Aerial Ignition Device utilizes a small polystyrene ball, 32 mm in diameter, known more commonly as a plastic sphere, containing approximately 3.0 grams of Potassium Permanganate (KMnO) 99% reagent: an oxidizer used in a crystallized/powder form. When the KMnO comes in contact with Ethylene Glycol (anti-freeze), a combustive exothermic reaction occurs.
The Premo Mark III Aerial Ignition Device, often times referred to as a PSD (plastic sphere dispenser) machine or Ping-Pong ball machine, achieves the chemical reaction by physically injecting the plastic sphere with the ethylene glycol. The combustive reaction takes approximately 15 to 30 seconds to occur. During that time, prior to combustion, the machine ejects the ball, or essentially drops it. The PSD machine requires 24 volts DC power to operate.
For prescribed fire operations, the PSD machine is secured in the cabin of a helicopter. A nylon web strap runs from one side of the machine out the left side of the aircraft under the belly of the helicopter and then back into the aircraft right side attaching to the opposite side of the PSD machine. Normal configuration requires the removal of the right aft door (on Bell Helicopters) allowing the machine to extend over the door sill to drop the plastic spheres to the ground. The PSD machine comprises a hopper which holds approximately 450 plastic spheres; 4 chutes which funnel the plastic spheres to the slipper blocks; 4 needles which inject the plastic spheres with the ethylene glycol in a timed sequential order in each of the slipper blocks; two feed control levers; a 9 liter ethylene glycol tank; a 3.2 liter emergency water tank; a 2 amp drive motor; and a 2 amp glycol pump. Total weight of machine wet is approximately 98.0 lbs.
The feed control levers allow for the use of either 2 chutes or 4 chutes thus managing the quantity of balls injected and dropped from the machine. The PSD machine also has a slow and high speed controlling the rate at which balls are fed into the slipper blocks. During normal operations, spacing of the balls is achieved by a combination of the speed setting of the PSD machine, number of chutes used (1, 2 or 4 (using one chute requires the installation of a spacing kit which blocks off one of the chutes)), and helicopter airspeed. Normal PSD operations require helicopter flight below 500 ft. AGL and less than 50 mph. Optimum airspeed for application is 25-35 mph. Hovering out of ground effect (HOGE) often occurs. Application of the plastic spheres is generally performed in strips with the intent of allowing the fire to spread in a ‘backing’ manner.
It is not uncommon for a plastic sphere to become jammed or lodged in the PSD machine during operation. A jammed ball, if left unattended, could potentially ignite in the machine and then spread fire to the other plastic spheres in the machine and hopper. Operators are trained to respond at the first sign of a jam or smoke. Water can be injected into the slipper blocks from the water reservoir with a push of a button. Additional water is carried on board as a back up. With the first sign of smoke the pilot is alerted and on agreement with the operator will seek a landing sight to remove the PSD machine if necessary. If necessary, the PSD machine can be cut free from its restraining strap and dropped from the helicopter. However, development of a fire is rather slow and the resolution of any smoke or fire related problem is generally accomplished with the application of water.
Fueling History of the Accident Helicopter:
On March 6, 2005, Helicopter N85BH fueled at Angelina Co. Airport from the airports fuel truck. At approximately 0900 the helicopter took on 71 gallons of Jet-A fuel. The fuel serviceman stated that he thought that it was a “topped-off”. If that was the case, the helicopter would have had approximately 91 gallons on board before the first flight that morning. During the course of the day, the helicopter logged 4.3 flight hours. It was fueled two additional times from its own service truck for a total of 56.4 gallons, according to the fuel logs. The fuel burn rate for a 206B-3 is specified in the contract at 27 gallons per hour. 4.3 flight hours at 27 gallons per hour equals 116.1 gallons of fuel consumed during the day. The starting fuel quantity was approximately 91 gallons, plus the two fuelings equaling 56.4 gallons for a total of 147.4 gallons. Total gallons pumped, 147.4 gallons, minus the fuel consumed, 116.1 gallons, the result is 31.3 gallons remaining in the fuel tank at days end. The next fueling was on March 9, 2005. A total of 15 gallons was pumped bringing the on board total fuel to approximately 46.1 gallons. The fuel was dispensed from one of Angelina County Airport fuel trucks. On March 10, 2005, the helicopter flew from Angelina Co. Airport to H1 near the project area. Flight time from Angelina Co. Airport to H1 was approximately 30 minutes, consuming approximately 13.5 gallons. Fuel on board after flight would have been an estimated 32.6 gallons. At H1, before initiating the prescribed fire mission, N85BH took on 10 gallons of fuel from its service truck bringing the total to approximately 42.6 gallons. N85BH then flew a partial fuel cycle lasting approximately 46 minutes performing aerial ignition. Fuel consumed would have been approximately 20.7 gallons leaving 21.9 gallons on board. N85BH then took on an additional 20 gallons of fuel bringing the total on board fuel to approximately 41.9 gallons. N85BH then departed H1at 1347 after fueling returned to the burn area to resume ignition operations. N85BH was reported down 11 minutes later, at 1358. Fuel consumed during that 11 minutes would have been approximately 5 gallons. Usable fuel on board at the time of accident should have been approximately 36.9 gallons.
The helicopter wreckage and components were released to the owner after examinations were completed.
Air Evac Medical Helicopter Crashes
Arkansas Medical Helicopter Crashes Near Conway
On February 21, 2005, at 1339 central standard time, a single-engine Bell 206-L1 helicopter, N5734M, operated by Air Evac Lifeteam was substantially damaged during a hard landing following a loss of control while hovering out of ground effect near Gentry, Arkansas. The commercial pilot, the flight nurse, and the paramedic were seriously injured and the patient was fatally injured. The helicopter was registered to Air Evac Leasing Corporation, of West Plains, Missouri, d/b/a Air Evac Lifeteam, and was destined for Springdale, Arkansas. No flight plan was filed and visual meteorological conditions prevailed for the air medical transport flight conducted under 14 Code of Federal Regulations Part 135.
According to Arkansas State Police reports, the patient was involved in a single motor vehicle, rollover traffic accident. A dispatcher with Bentonville Fire and Ambulance, Bentonville, Arkansas, dispatched ground units to the accident scene and contacted Air Evac Lifeteam. She told the Air Evac Lifeteam dispatcher that she had no details of the patient’s injuries but the situation was “bad.” The dispatcher requested helicopter support and provided global positioning system (GPS) coordinates of the accident site.
A review of Air Evac Lifeteam’s radio transmissions revealed that at 1231, the Claremore, Oklahoma, based crew was dispatched to the accident site because the Springdale, Arkansas, crew were responding to another call. At 1239, the helicopter departed Claremore Regional Airport, and one minute later a crewmember reported there were three people on board and their estimated time en route was 20-30 minutes. While en route, the pilot contacted dispatch and informed them that they were unable to locate the motor vehicle accident and requested an update of the accident site’s GPS coordinates. The dispatcher contacted Bentonville Fire and Ambulance and learned that there were no changes to the GPS coordinates. The pilot and crew continued to search for the vehicle accident site.
Meanwhile, the patient had been transported via ambulance approximately one-half mile south of where the vehicle accident occurred to a designated landing zone, which was the front lawn of a private residence.
About 1327, a helicopter crewmember contacted dispatch and reported that they had located the site and were landing at the designated landing zone.
An Arkansas State Trooper, who had escorted the ambulance, reported that he observed the helicopter circle over the accident site, and then execute an approach to the north and land. The patient was then transferred over to the flight crew and loaded on to the helicopter. The Trooper observed the helicopter as it departed. He said he heard the helicopter’s engine achieve full power and then it began a vertical climb to approximately 100 feet, when it began to spin. The helicopter continued to spin, before it got “silent’ and dropped to the ground in a field adjacent to the landing zone.
Several emergency medical service (EMS) personnel also observed the helicopter as it departed. Each reported similar accounts of how the helicopter started to spin shortly after it departed, and subsequently land in the field.
A witness, who owned the property where the helicopter had landed, was in her backyard when she observed the helicopter depart. She said the helicopter was initially parked in her front yard facing the north. As it departed, the helicopter ascended and then began to slowly spin to the right as it maneuvered over her house and toward an open field adjacent to her home. She said the helicopter began to spin faster, and after it made several rotations it “dropped” and landed upright in the field. The witness could not recall how high the helicopter was above the ground when it started to spin, but she felt that it was too low. She also stated that she did not hear any unusual noises from the helicopter during its short flight.
The pilot was interviewed in the hospital the day after the accident. He stated that during his recon of the landing zone, he could not find any indicators that would assist him with determining wind direction; however, when he had reviewed the weather that morning the winds were reported out of the north between 330 and 030 degrees and were “brisk”, about 10-15 knots. The pilot was also able to identify and verify all obstacles reported by his crew in the vicinity of the designated landing zone.
After the patient was boarded, the pilot said that he pointed the nose of the helicopter on a heading of 360 degrees, then lifted the helicopter to a hover, and noted that the engine torque was near 100 percent. While still in a hover, the pilot maneuvered the helicopter to the right and stopped when he was within 20-25 feet of the property owner’s home. He did this so he could avoid the approximately 60-foot-high power lines that ran diagonally in front of the helicopter from southwest to northeast. There was also a set of power lines that ran north/south behind the property owner’s home. Both sets of power lines converged at the same wooden utility pole, which was located north of the home.
The pilot stated that when he departed, he began a vertical ascent but was trying not to increase the collective above the available torque. He added that he was concerned about clearing the power lines and losing effectiveness of the tail rotor. When the helicopter reached an altitude that was slightly below the power lines, it began an uncommanded turn to the right. The pilot had full left torque pedal applied at the time, and said that he attempted to gain forward airspeed, and also used the cyclic to follow the nose of the aircraft in an attempt to fly out of the turn. The pilot was unable to gain airspeed, and the helicopter began to spin to the right and descend. The pilot stated that his only option was to initiate an autoration, so he lowered the collective and placed the throttle in the idle position, which slowed the spinning. When the helicopter was approximately 10-20 feet above the ground, the pilot placed the collective to the full-up position to cushion the landing; however, there was not sufficient main rotor rpm to stop the high rate of descent. After the impact, the pilot said the engine was still running so he secured the helicopter, which included turning off the fuel valve and battery switch.
The helicopter was equipped with an In-Flight Position System (IPS), which tracked the helicopter’s movement as soon as its skids broke ground. A review of IPS data revealed that the helicopter departed Claremore Regional Airport at 1239, and landed at the designated landing zone near the accident site at 1327, a 48-minute flight. It then departed at 1335 with the patient onboard, and landed in a field four minutes later at 1339, the time of the accident. In addition, a review of the helicopter’s complete flight from Claremore to the accident site revealed that the helicopter did not proceed directly to the accident site, which was approximately 50 miles east of Claremore, Oklahoma. Instead, it flew on a northeasterly, then easterly course, toward the Gravette Medical Center Hospital, Gravette, Arkansas. After the helicopter passed the hospital, it made a right 180-degree turn and proceeded to fly westbound for several miles before it made a left turn and headed south toward the accident site.
According to the pilot, he set the accident site coordinates in one of the onboard GPS receivers prior to the flight. He said that after departure, he pushed the “direct” button on the receiver and then proceeded directly to the accident site. However, he was not aware that there was an IPS system installed on the helicopter and that his entire flight had been recorded. When asked why he flew the non-direct route that was recorded by the IPS, he stated that he did not recall that part of the flight, but did recall that the crew was more familiar with the area than he was, and that they “did have to maneuver and search for the accident site and they made a lot of corrections during the flight. If one of the crew members thought the coordinates were over there, then they would fly over there.”
The pilot denied that he may have programmed the GPS receiver incorrectly, and said that he would normally check his data.
The accident occurred during the hours of daylight approximately 36 degrees, 19 minutes north latitude, and 94 degrees, 34 minutes west longitude.
The pilot held a commercial certificate for rotorcraft-helicopter, instrument helicopter, and airplane single-engine land. He was also a certificated airframe and power plant mechanic. The pilot reported a total of 3,500 hours of total flight time, of which approximately 3,438 hours were in helicopters with 15 hours were in the make and model. His last second-class FAA medical certificate was issued on December 13, 2004.
During an interview, the pilot said that he had recently flown (within two weeks of the accident) Blackhawk helicopters for the United Stated Army, and had recently worked for a major airline as an avionics technician. Due to recent furloughs, and having friends who were EMS pilots, he applied to Air Evac Leasing Corporation and was hired as a pilot.
According to the operator, the pilot was hired on January 10, 2005, and completed the New-Hire Training program on January 20, 2005. All of his training was completed in a Bell 206-L1 helicopter, which totaled 11.1 hours.
Air Evac Leasing Corporation had completely refurbished the helicopter (S/N: 45449) at their facility in West Plains, Missouri. The helicopter had undergone an annual inspection on January 25, 2005, at an airframe total time of 23,121.8 hours. Since that time, the helicopter had accrued a total of 22.9 hours.
A review of the flight load manifest revealed that the airplane was under its maximum gross weight and within the allowable center of gravity limits at the time of the accident.
Weather reported at Smith Airport (SLG), near Siloam Springs, Arkansas, approximately 10 miles southeast of the accident site, at 1335, included wind from 050 degrees at 7 knots, visibility 10 statute miles, clear skies, temperature 61 degrees Fahrenheit, dewpoint 46 degrees Fahrenheit, and a barometric pressure setting of 30.01 inches of Mercury.
One of Air Evac Lifeteam’s pilots, who responded to the helicopter accident scene, reported that the wind in the surrounding area most of that day were from 030 to 050 degrees at 10 knots or less. He said the wind at the accident site were about the same, “as best [as he] could tell.”
The helicopter came to rest upright in a grass field on a heading of 172 degrees, approximately 100 yards southeast from where it had departed at an elevation of approximately 1,000 feet mean sea level (msl).
Both skids were spread their maximum distance, and the fuselage of the helicopter was resting flat on the ground. The aft skid cross-tube had pushed upward into the lower fuselage of the aircraft and ruptured the fuel cell. According to the Arkansas State Trooper, a significant amount of jet fuel surrounded the helicopter shortly after the accident.
The main rotor system including both blades, the tail boom, and tail rotor were relatively intact.
The engine, transmission, and tail rotor drive shaft panels were removed. The tail rotor #1 drive shaft (forward short shaft) was torsionally sheared and had separated into two sections. These pieces were found resting on the engine deck beneath the engine. Examination of the fractured ends revealed the steel drive shaft was twisted at the fracture points, indicative of the engine operating at the time of impact.
The engine fuel-filter canister contained a clear-colored liquid, that emitted an odor consistent with jet fuel, and it was absent of debris and water. The upper and lower transmission chip detectors were absent of debris or metal particles.
No pre impact mechanical anomalies were found with either the engine or the airframe.
SURVIVAL FACTORS INFORMATION
The pilot occupied the front right seat. His seat base was crushed and the frame exhibited a V-shaped deformation. His 4-point seatbelt/inertia reel shoulder harness assembly was found unlatched and both shoulder harnesses were displaced over the sides of the seatback. All seatbelt/shoulder harness attachment points were secure and the seatbelt functioned normally when tested. His injuries included compressed vertebrae, and a large cut over his right eye.
The flight nurse sat in the right aft seat. Her seat frame exhibited some deformation and cracking near the base. Her 4-point seatbelt/inertia reel shoulder harness assembly was found unlatched, and both shoulder harness straps were draped over her seatback. All seatbelt/shoulder harness attachment points were secure and the seatbelt functioned normally when tested. Her injuries included fractured vertebrae, a broken right knee and a bilateral fracture of both heel bones.
The paramedic sat in the left aft seat. His seat frame exhibited some deformation and cracking near the base. His seatbelt assembly was found unlatched, and both shoulder harness straps were rolled up and neatly placed above his seatback. The two female brackets were found placed between the firewall and interior lining. All seatbelt/shoulder harness attachment points were secure and the seatbelt functioned normally when tested. His injuries included several broken teeth, a severely fractured left orbital bone, right tibia/fibula fractures, pelvic fractures, torn ligaments in his right ankle, L4-L5 fractured vertebrae, and right shoulder injury. The paramedic was the only occupant wearing a helmet. The helmet was cracked on its left side and exhibited some blood splatter. Air Evac Leasing Corporation does not require flight crews to wear helmets, nor does the FAA require them.
The patient was loaded into the airplane on a backboard and strapped down to an aluminum litter, which was located on the left side of the helicopter. According to the paramedic, the patient’s feet were loaded toward the front of the helicopter, and his head was facing aft toward the rear of the aircraft. In this configuration, the patient’s head would have been slightly situated between the paramedic’s knees. Examination of the litter revealed that is was partially displaced from its mounting brackets, and the base of the litter had partially separated from its frame. The base was riveted to the frame, and several of the rivets had sheared. The base was also deformed.
In a telephone conversation, the Benton County Coroner stated that the patient sustained facial injuries, including a cracked skull, crushed trachea (had filled with blood), and flattened facial features, from the helicopter accident. She had interviewed EMS personnel who responded to the vehicle accident site, and they reported that the patient’s injuries were visible bleeding from an ear, and that he was combative, but no facial injuries. He may also have sustained a broken hip and abrasions to his arms and body. The Coroner also reported that she had retained recorded data from the patient’s heart monitor, which indicated that the patient was stable when he was placed in the helicopter. At the time of the accident, the patient’s vital signs spiked and then “dramatically” dropped off. EMS personnel, who witnessed the accident, immediately started CPR on him and attempted to place a trachea tube down his throat, but it was filled with blood. EMS personnel also reported that the patient had a heart rate of six beats per minutes, and they were unable to revive him. The coroner’s report suspected that the patient’s primary cause of death was a skull fracture and the secondary cause of death was a suspected fractured trachea.
After the helicopter accident, an employee of the Bentonville Fire and Ambulance contacted Air Evac Leasing Corporation and reported the accident. He requested that two more helicopters be sent to the scene to transport the surviving occupants to area hospitals.
According to the Survival Factors Specialist’s Factual Report, Air Evac Leasing Corporation policies OP-0280 and OP-0281, issued March 1, 2004, provided guidance for the crews pertaining to the use of seat restraints, “to provide for safe operations during all phases of the Air Evac Lifeteam Flight Program’s pre-flight, flight, and landing procedures.” OP-0280 stated that crews were to check the functionality of all safety belts and shoulder harnesses at the start of each shift. Additionally, the medical crew was to have “seat belts/shoulder harnesses on for take-off and landing (NO EXCEPTIONS).” OP-0281 stated “all flight crew/team members must wear seat belts continuously during the flight…if critical patient care necessitates removal of the seat belts, the pilot will be notified.” It also stated “the use of shoulder harnesses is highly recommended during the flight and is required during take-off and landing.”
Air Evac Leasing Corporation flight operations bulletin #004-2004, dated March 4, 2004, described Air Evac Lifeteam’s medical crewmember aircraft orientation and safety training programs. It stated that “Air Evac Lifeteam will conduct an aircraft orientation and operational safety training for all medical crewmembers upon hiring and continue monthly at the base of assignment throughout the calendar year.” The training manual contained 17 individual text lessons and all were to be completed in a 12-month cycle. Lesson #17 (scheduled for each April) was titled, “Passenger Briefing When Appropriate,” and contained the following statement: “Use of seat belts… is mandatory and the seat belt and shoulder harness must be worn at all times. The only exception to the seatbelt and/or shoulder harness rule for a crewmember is if the seatbelt or shoulder harness interferes with the performance of necessary duties. To have seat belt or shoulder harness released, it must be because of a medical emergency and not for convenience.”
The pilot, flight nurse and paramedic stated that they were familiar with the operator’s mandatory requirement that they had to wear their restraints during take off and landing. All three stated that they were wearing their available restraints (seatbelt and shoulder harness) at the time of the accident.
According to the pilot, neither medical flight crew had requested to take their seatbelt or shoulder harness off prior to or during the take off sequence. Everything was normal and neither crewmember had informed him of a problem with the patient. However, prior to departure he could not recall if the paramedic and flight nurse stated that they had given the normal “ready to go” verbal announcement. In addition, he did not visually confirm that they were wearing their restraints, since there “was no reason to question them.”
According to the operator, all of their aircraft that they had refurbished in the past five years, including the accident helicopter, had four-point, single inertia reel restraint systems installed at all seating stations.
Both aft restraints (inertia reels and lap belts) from the accident helicopter were removed and sent to the manufacturer for post-accident inspection and testing under the supervision of a Safety Board investigator. At the time of the testing, none of the webbings or components exhibited any scuffing, fraying, broken fibers, tears or deformation. Both inertia reels passed calibration testing.
According to a witness, who was standing approximately 100 yards from the helicopter when it impacted the ground, he said that he immediately ran to the helicopter and arrived within 30 seconds of the accident. When he arrived, he observed the pilot still “strapped” into his seat, and the flight nurse was lying outside of the helicopter on the ground. He thought that she may have been ejected from the helicopter but was not certain; however, all of the doors on the right side of the aircraft were open or missing. The witness eventually walked around to the left side of the helicopter and observed the paramedic standing on the ground, “propped” up against the doorframe near his seat.
Another witness, who was also standing about 100 yards away from where the helicopter came to rest, also responded immediately after it impacted the ground. According to the witness, the flight nurse was lying on the ground outside her door and he was “definitely” sure that, “she was ejected upon impact. I saw it.” He described her door as “bowing out” and opening on impact, which allowed her to be thrown free from the helicopter. The pilot remained restrained in his seat. The flight paramedic was also outside the helicopter, when he was instructed to move away from the helicopter due to the large amount of fuel leaking from the helicopter.
On October 31, 1983, Bell Helicopter published an Operations Safety Notice regarding loss of tail rotor effectiveness in the Model 206B and similar airframes. Bell Helicopter describes the phenomenon of loss of tail rotor effectiveness as “Unanticipated Right Yaw.” According to the Safety Notice: “When maneuvering between hover and 30 mph:
Be aware that a tail wind will reduce relative wind speed if a down wind translation
occurs. If loss of translational lift occurs it can result in a high power demand and an
additional anti-torque requirement. Be alert during hover (especially OGE) and high power demand situations. Be alert during hover in winds of about 8-12 knots (especially OGE) since there are no strong indications to the pilot, to the possibility of a reduction of translational lift. This reduction results in an unexpected high power demand and increased anti-torque requirements. Be aware that if a considerable amount of left pedal is being maintained, that a sufficient amount of left pedal may not be available to counteract an unanticipated right yaw. Be alert to changing aircraft flight and wind conditions such as experienced when flying along ridgelines and around buildings. Observe the relative wind conditions set out in the attached chart.”
A relative wind chart published by the manufacturer (and found in the accident helicopter) depicts a helicopter facing 360 degrees over a compass rose. One shaded area of the chart depicts winds from between 050 degrees and 210 degrees. According to a note on the chart: “Tail rotor control and/or engine temperature (TOT) may preclude operation in AREA B of the Hover Ceiling Charts when the relative wind is in the Critical Wind Azimuth Area.”
According to FAA Advisory Circular (AC) 90-95, “Any maneuver which requires the pilot to operate in a high power, low airspeed environment with a left crosswind or tailwind creates an environment where unanticipated right yaw may occur.” The AC also advised of greater susceptibility for loss of tail rotor effectiveness (LTE) in right turns and the phenomena may occur in varying degrees in all single main rotor helicopters at airspeeds less than 30 knots.
According to the manufacturer, if a sudden unanticipated right yaw occurs, the following recovery technique should be performed:
1. Pedal – Full left; simultaneously, cyclic – forward to increase speed.
2. As recovery is effected, adjust controls for normal forward flight.
CAUTION Collective pitch reduction will aid in arresting the yaw rate, but may cause an excessive rate of descent. The subsequent large rapid increase in collective to prevent ground contact may further increase the yaw rate and decrease rotor rpm. The decision to reduce collective must be based on the pilot’s assessment of the altitude available for recovery.
3. If the spin cannot be stopped and ground contact is imminent, an autorotation may be the best course of action. Maintain full left pedal until the spin stops, then adjust to maintain heading.
The helicopter wreckage was released to an representative of the owner’s insurance company on June 6, 2006
Air Medical Helicopter Crash in Maryland
Eurocopter LifeNet Helicopter Crashes Killing Two
On January 10, 2005, about 2311 eastern standard time, [1] a Eurocopter Deutschland GmbH EC-135 P2 helicopter, N136LN, operated by LifeNet, Inc., as Life Evac 2, crashed into the Potomac River during low-altitude cruise flight near Oxon Hill, Maryland. The certificated commercial pilot and the flight paramedic were killed, and the flight nurse received serious injuries. The helicopter was destroyed. The positioning flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91 and visual flight rules (VFR) with a company flight plan filed. Night visual meteorological conditions prevailed at the time of the accident.
The flight originated at the Washington Hospital Center Helipad (DC08), Washington, D.C., about 2304, and was en route to Stafford Regional Airport (RMN), Stafford, Virginia. Global positioning system (GPS) data for the flight [2] showed that the helicopter proceeded toward the Federal Aviation Administration’s (FAA) published helicopter route 1. [3] According to FAA air traffic control (ATC) transcripts, the pilot contacted the local controller at Ronald Reagan Washington National Airport (DCA), Washington, D.C., at 2305:47 and stated, “washington tower life evac two . . . sir we’re at uh medstar like to go out to uh r f k route one then to route four south.” The local controller responded, “life evac two (unintelligible) bravo airspace altimeter three zero two five.” The pilot responded, “roger understand cleared as requested.”
Examination of FAA ATC radar data showed that the helicopter intercepted a segment of published helicopter route 1, followed it southwest to intercept helicopter route 4, and then flew southbound along the Potomac River toward Woodrow Wilson Bridge. As the helicopter flew over the river toward Woodrow Wilson Bridge, its Mode C transponder reported that its altitude varied from 0 to 100 feet. [4] When the helicopter was about 0.5 nautical mile (nm) north of the bridge, its reported Mode C altitude was 200 feet.
At 2311:20, the pilot reported to the local controller, “life evac two is at the Woodrow Wilson [Bridge],” and the controller responded, “life evac two washington tower traffic on a ten mile final is a seven [sic] an airbus.” [5] At 2311:30, the pilot responded, “roger we have him in sight and will be out of his way,” and the controller stated, “life evac two maintain visual separation from traffic.” ATC radar data showed that, at the time of the pilot’s response, the helicopter was about 0.25 nm north of the Woodrow Wilson Bridge at an altitude of about 200 feet. The pilot made no further radio communications.
According to the flight nurse, who was seated in the helicopter’s left front copilot’s seat, the pilot maneuvered the helicopter to cross the bridge midspan. The flight nurse stated that the helicopter appeared to be at the same or higher altitude than the lights he saw on some construction cranes near the Woodrow Wilson Bridge. He stated that he “called the lights” on both sides of the river to the pilot and that the pilot acknowledged him. According to a Maryland Department of State Police report, the flight nurse also stated that there was a “commercial airplane coming into [DCA], and the pilot . . . made a change in his flightpath and started to descend.” [6]
According to ATC radar data, at 2311:39, the helicopter had crossed over the Woodrow Wilson Bridge and was just south of the bridge with a ground track of about 180 degrees and an altitude of about 200 feet. Four seconds later, the helicopter had a ground track of about 190 degrees and an altitude of about 100 feet. The helicopter’s last recorded position at 2311:48 showed a ground track of about 200 degrees and an altitude of about 0 feet. According to ATC radar data, at the time of the helicopter’s last radar return, the northbound Airbus that the local controller previously mentioned was about 2.2 nm south of the helicopter’s position at an altitude of about 1,700 feet.
According to the flight nurse, after the helicopter flew over the southern half of the Woodrow Wilson Bridge, the next thing he recalled was being submerged in water with his seatbelt on and his helmet off. He stated that the helicopter’s master caution lights and panel segment lights did not illuminate and that he did not hear any audio alarms sound before the crash. He stated that the pilot did not execute any evasive maneuvers or communicate any difficulties, either verbally or nonverbally.
According to witnesses in vehicles on the Woodrow Wilson Bridge, the helicopter crossed over the bridge before it descended and then impacted the water. None of the witnesses reported seeing the helicopter impact any objects before its descent. The wreckage was located in the Potomac River about 0.5 nm south of the Woodrow Wilson Bridge.
At 2314:46 (about 3 minutes after the helicopter crashed), the DCA local controller stated, “life evac two frequency change approved.” The controller received no reply and made no further attempts to contact the flight. The Maryland State Police later notified the controller of the crash.
The pilot, age 56, was hired by LifeNet in June 2004. He held a commercial pilot certificate with ratings for airplane single- and multi-engine land, rotorcraft helicopter, and instrument helicopter. His most recent FAA second-class airman medical certificate was issued on May 28, 2004. On his application for the medical certificate, he reported 1,500 hours total civilian flight experience, 30 hours of which were accumulated in the previous 6 months. [7] A review of company records showed that, in the 90 days, 30 days, and 24 hours before the accident, the pilot flew 42 hours, 12 hours, and 1 hour, respectively, and performed a total of 71 night landings.
According to LifeNet’s training records, during the pilot’s first few weeks of employment, the company provided 12 hours of basic indoctrination training, as well as 20 hours of initial ground training and 7.8 hours of flight training in the Messchersmitt Bolkal Blohm BK-117 helicopter. The training records indicated that the pilot completed the initial pilot-testing requirements of 14 CFR 135.293 and the pilot-in-command flight check required by 14 CFR 135.299 on July 8, 2004, in the BK-117. The company subsequently provided the pilot 18 hours of transition ground training and 5.8 hours of transition flight training for the EC-135, and the pilot completed the initial testing and flight-check requirements in the EC-135 on October 3, 2004.
During his employment with LifeNet, the pilot accumulated 51.5 flight hours in the BK-117 and 40.8 flight hours in the EC-135. According to LifeNet’s assistant chief pilot, when the pilot applied for employment, he reported that he had been retired since 1997 but that he was current for Part 135 operations and had passed Part 135 flight checks in a Bell 206 helicopter in February 2004 and in a BK-117 in April 2004. The assistant chief pilot stated that, according to the pilot’s interview and resume, he had been a military pilot in the U.S. Army from 1968 to 1971 and had accumulated about 2,400 military flight hours in helicopters, including about 350 hours of night flying and about 70 hours of instrument flying. From 1971 to his retirement in 1997, the pilot worked for a corporation in both nonflying and flying positions. During his 26-year corporate employment, the pilot accumulated 400 hours total flight experience in Agusta 109 and Sikorsky S76 helicopters and about 300 total civilian flight hours in fixed-wing airplanes.
The resume that the pilot submitted to LifeNet did not list his most recent employer, which was another Part 135 helicopter operator that had terminated his employment after about 2 weeks. According to the chief pilot for that company, the accident pilot was hired on April 12, 2004, but the company terminated his employment on April 28, 2004, because the pilot was unable to adequately perform complex tasks in the helicopter or fly a “complete mission” involving several tasks in a series. [8] During his training with this operator, the pilot accumulated about 7 hours of flight time in a BK-117.
Two medical crewmembers who flew with the pilot the night before the accident on the same route as the accident flight and on other previous flights stated that the pilot flew the helicopter in a manner equivalent to other pilots in the company.
The helicopter was manufactured in 2004 and was equipped with two Pratt & Whitney Canada PW206B-series turboshaft engines. The helicopter was configured with a front right pilot seat, a front left copilot’s seat, an aft-facing passenger seat in the left aft cabin, and an area for one medical patient in the aft cabin. Each seat was equipped with lap belt and shoulder harness restraints.
The helicopter was maintained in accordance with an FAA-approved aircraft inspection program. According to maintenance records, the most recent 50-hour inspection was performed on December 17, 2004. The most recent 100-hour inspection was performed on November 23, 2004, at an airframe total time of 94.5 hours. At the time of the accident, the helicopter had accumulated 166.6 total hours.
The maintenance logbook recovered from the helicopter included an entry dated January 10, 2005, for an inoperative radar altimeter. [9] The maintenance log also contained a “Record of Minimum Equipment List (MEL) Items and Deferred Maintenance” section that included an entry stating that the inoperative radar altimeter could be deferred for maintenance until January 20, 2005. [10]
According to the DCA automated surface observing system, located about 3.5 nm north of the accident site, the reported conditions at 2251 were winds calm, visibility 10 statute miles, broken clouds at 13,000 feet and 20,000 feet, temperature 45 degrees Fahrenheit (F), dew point 36 degrees F, and altimeter setting 30.25 inches of mercury.
According to recorded astronomical data, at the time and location of the accident, a new moon was below the horizon and provided no illumination.
The helicopter was recovered from about 5 feet of water in the Potomac River. Wreckage was scattered along a north-south oriented debris path. The wreckage was recovered, and examination indicated no evidence of a collision with a bird or other object, fatigue fractures, or other anomalies.
The main fuselage section was separated into the lower cockpit area and upper cockpit area. The lower cockpit area included the flight-crew floorboard section, antitorque pedals, the forward skid frame, and fragments of the fuel tank. The upper cockpit area included the flight-control tubes, the center electrical and flight-control structure, the upper flight-control deck, engines, the main transmission, and the rotor head.
The cyclic, collective, and antitorque control systems were damaged, and portions of some push-pull tubes were separated and not recovered. Continuity could not be established because of the separations; however, the separated surfaces showed fracture features consistent with impact-related overload.
The main rotor mast was in place and intact in the main transmission. The root ends of the four main rotor blades remained attached to the main rotor hub on the mast. Three of the four pitch-change links were connected to their two attach points, and the other pitch-change link was fractured in the middle. The fracture surfaces were consistent with compression-bending overload.
Portions of all four main rotor-blade tips were recovered. Each main rotor blade had overload fractures and chordwise scoring on the lower blade skin between 6 to 12 inches from the blade hub. Each blade also showed fractures along the blade span, consistent with impact damage. The main transmission remained attached to the center section of the upper airframe structure, and all four mounting points were intact. The main transmission turned freely, no chips were found on the detectors, and the transmission appeared intact and functional.
The tail boom was separated at the aft fuselage frame. The tail section included the complete fenestron assembly [11] with the tail rotor gearbox and tail rotor. The tail rotor driveshaft was displaced forward about 1.5 inches. The aft portion of the driveshaft, which was carbon composite, was found fractured, torsionally cracked, and deformed. All tail rotor blades remained complete and attached to the hub. The fenestron shroud around the tail rotor showed a rotational scrape at the 5 o’clock position. The width of the scrape corresponded with the tail rotor-blade width.
Both engines showed little damage, and the gas generator (N1 compressor and turbine) and power turbine (N2 turbine) for each engine rotated freely. Nonvolatile memory data extracted from the electronic engine control units for each engine revealed no evidence of preimpact faults.
The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on specimens from the pilot, and no drugs or alcohol were detected in the pilot’s blood or urine.
The State of Maryland, Office of the Chief Medical Examiner, performed autopsies on the pilot and the flight paramedic. The medical examiner determined that the pilot’s cause of death was “multiple injuries.” The flight paramedic’s cause of death was listed as “drowning complicated by hypothermia”; [12] the paramedic was found still belted into the left aft cabin seat.
According to the flight nurse, after the crash, he was submerged in water but was able to remove his seat restraints, exit the helicopter, and remain near the helicopter’s partially submerged tail section until a rescue boat arrived. He was taken to a hospital and treated for a broken arm and burns.
Several of the witnesses who saw the helicopter impact the water telephoned 911 to report the crash. According to the DCA tower’s daily record of operation, the DCA controller received a call about 2326 from a Maryland State Police helicopter crew advising that they were inbound to investigate reports of a downed aircraft near the Woodrow Wilson Bridge. According to an incident report from the City of Alexandria (Virginia) Fire Department, Station 201, the station was notified about the downed aircraft at 2330:18 and dispatched the first of nine emergency medical service apparatuses about 2331:12; the first boat was dispatched at 2333:09.
LifeNet’s Part 135 certificate was issued in 1995. LifeNet is headquartered in Chesterfield, Missouri, and has 89 aircraft based at various locations across the country. LifeNet’s fleet includes various AS-350, BK-117, and EC-135 series helicopters, various models of Bell helicopters, Eurocopter BO-105 helicopters, McDonnell Douglas MDHS-MD-900 helicopters, and Beech BE-100 and BE-200 twin-engine turboprop airplanes. LifeNet employs pilots and medical personnel.
A National Transportation Safety Board performance engineer completed a performance study using the last 30 seconds of the flight’s Mode C radar data and the location of the crash site to estimate the helicopter’s bank angle and flightpath descent angle at impact, as well as the time of the crash. The study estimated that the helicopter’s flightpath angle was about -3 degrees, its bank angle was about 12 degrees right, and it impacted the water about 3.5 seconds after the last radar return. [13]
The study also used primary and Mode C radar data to examine the helicopter’s proximity to other aircraft and to evaluate any possible encounter with wake turbulence or a bird flock. [14] Review of the Mode C radar data showed that a 70-passenger Canadair Regional Jet 700 (CRJ-700) passed northbound over Woodrow Wilson Bridge about 1 minute 45 seconds before the helicopter passed over the bridge. According to the data, the helicopter passed 900 feet directly beneath the flightpath of the CRJ-700. On the basis of the radar data, weather information, and information obtained through consultation with an FAA wake turbulence specialist, the study concluded that the time frame was sufficient to expect that the jet’s wake would be completely decayed before it could reach the helicopter and that, even if the wake had not decayed at all, its descent rate would not have been sufficient for it to have reached the helicopter.
Review of the primary radar data showed that an area of primary returns, which could possibly represent a bird flock, occurred north of the bridge about 1 nm north of the point where the helicopter began its descent and about 30 seconds before the beginning of descent. The data showed that the helicopter’s flightpath continued undisturbed beyond the location of the primary returns, which is not consistent with a sudden or catastrophic collision with a bird flock. No evidence of bird remains was observed in the area surrounding the accident site.
Construction Crane Information
During interviews, the flight nurse stated that, although he did not remember the helicopter striking anything, he thought that it must have struck an unlighted construction crane. Safety Board investigators used the recorded ATC radar data and data from the operator’s GPS to examine sites along the Potomac River. The helicopter’s projected ground track along the data points toward the accident site was at least 300 feet laterally from the nearest construction crane, and no additional obstacles were observed along the track. Examination of the five construction cranes closest to the flightpath showed no evidence of an aircraft strike or structural damage, and all of the cranes had the required lighting on top of their respective boom. Also, a Maryland Department of Transportation traffic surveillance camera located on the east side of the Potomac River at Woodrow Wilson Bridge captured video that showed, at the time of the accident, an aircraft overflew the bridge, passing above and beyond the construction cranes, then began to descend.
Comparison of Accident Flight with Previous Flight on the Same Route
The pilot had flown the route from DC08 to RMN the night before the accident. A review of the operator’s GPS data revealed that the previous flight’s ground track and altitudes were nearly identical to those of the accident flight while north of Woodrow Wilson Bridge and up to the point of crossing the bridge midspan at an altitude of about 200 feet. According to the data, after the helicopter crossed the bridge on the previous night’s flight, it continued southbound on a steady ground-track heading and at an altitude of about 200 feet until it was at least 3 nm south of the bridge, then it climbed. The data showed that the accident flight also crossed the bridge midspan at an altitude of about 200 feet; however, its heading then deviated to the right while it descended into the water.
Night Flying and Featureless Terrain Considerations
Several professional helicopter pilots who routinely fly along the Potomac River in the vicinity of the Woodrow Wilson Bridge were interviewed regarding their observations of physical lighting and the natural horizon of the shoreline. All of the pilots reported that the river widens south of the bridge and that the area becomes “very dark” because the parks and natural bird habitats there limit the physical lighting on the shoreline.
One helicopter pilot reported the following in a written statement: “Flying at night from North to South over the Woodrow Wilson Bridge is very similar to going into actual instrument conditions. A pilot [flying] low-level North of the bridge is typically flying VFR due to the intense amount of ground lights available along the river. Once the pilot crosses the bridge he is now flying into a black void. At this point an instrument scan must be established to maintain altitude. Because of the close proximity to water . . . a radar altimeter is necessary to ensure altitude awareness.”
According to the FAA Aeronautical Information Manual (AIM), [15] chapter 8-1-5, Illusions in Flight, Featureless Terrain Illusion, “An absence of ground features, as when landing over water, darkened areas, and terrain made featureless by snow, can create the illusion that the aircraft is at a higher altitude than it actually is.”
The FAA Airplane Flying Handbook [16] chapter 10, states the following about night flying: “Night flying requires that pilots be aware of, and operate within, their abilities and limitations. . . . Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.”
Air Defense Identification Zone and Flight Restricted Zone Communication Requirements
After September 11, 2001, an Air Defense Identification Zone (ADIZ) was established for the Washington, D.C., area, which includes the DCA class B airspace. According to the National Security Flight Advisory, pilots are required to maintain two-way radio communications with a controller while in the ADIZ. The Washington, D.C., Metropolitan Area Flight Restricted Zone (FRZ), which includes an area within the ADIZ transitioned by the accident flight, also requires the pilot to maintain two-way radio communications with a controller.
Pilots of flights that enter the ADIZ/FRZ typically maintain two-way radio communications with a controller and do not change from the assigned radio frequency until instructed to do so by a controller. [17] Pilots who violate the provisions of the ADIZ/FRZ could be subject to criminal charges and/or FAA administrative action, including civil penalties and suspension or revocation of airman certificates, or military interception.
[1] Unless otherwise indicated, all times are eastern standard time, based on a 24-hour clock.
[2] The helicopter was equipped with an Outerlink GPS tracking system, which enabled communications specialists at LifeCom in Omaha, Nebraska, to track the location of each flight and provide flight requests and flight-following services to the pilots. The GPS data recorded by the operator included ground track and altitude information and were consistent with the ATC radar data for the accident flight.
[3] The FAA’s National Aeronautical Charting Office (NACO) publishes helicopter route charts that depict aeronautical information for helicopter pilots, including helicopter route charts that depict routes, heliport locations, navigational aids, geographical features, landmarks, and obstructions. According to the NACO Baltimore-Washington Helicopter Route Chart current at the time of the accident, a section of helicopter route 1 followed the Anacostia River, passed near Robert F. Kennedy Memorial Stadium, and intersected with route 4 at the Potomac River. Helicopter route 4 ran north-south along the Potomac River and crossed the Woodrow Wilson Bridge. According to the chart, the route’s maximum altitude restriction north of the bridge was 200 feet and south of the bridge was 300 feet.
[4] A Mode C transponder transmits the helicopter’s identification and altitude information in response to interrogation signals received from ground-based radar equipment. Mode C information, if available, provides the helicopter’s altitude above mean sea level (msl) in 100-foot increments. All altitudes in this report were derived from transmitted Mode C altitudes. The elevation of the river in the vicinity of the accident site is about 10 feet above msl.
[5] At the time that the controller notified the helicopter pilot of the Airbus, the Airbus was south of the helicopter’s position and was about to turn and fly northbound for the final approach to DCA. The controller also advised the Airbus flight crew to expect that, once they were on the final approach, the southbound helicopter would be at their 12 o’clock position and 2 miles away. A member of the Airbus crew stated to the controller that the helicopter was in sight.
[6] According to the police report, this interview took place about 10 hours after the accident at the hospital where the flight nurse was receiving treatment.
[7] On the medical application, the pilot listed as his employer the name of a Part 135 helicopter operator that had terminated his employment 1 month earlier.
[8] In accordance with the Pilot Records Improvement Act of 1996, which was enacted to ensure that an operator adequately investigates a pilot’s background before hiring him or her, LifeNet requested records from the previous employer listed on the pilot’s resume. Because the pilot did not disclose to LifeNet his most recent employer, LifeNet was unaware of the employment termination.
[9] A radar altimeter is also known as a radio altimeter. The radar altimeter in the accident helicopter, when functional, provided a digital readout of altitude in feet above terrain, a low/high warning (visual amber indicator), and an indicator on the pilot’s multifunction display.
[10] According to the FAA, certain aircraft equipment may be inoperative without compromising an acceptable level of safety if the operator adheres to the conditions and limitations stated in the operator’s FAA-approved MEL. The FAA’s master MEL for the EC-135-series helicopter, on which the operator’s MEL is based, states that the helicopter may be dispatched with an inoperative radar altimeter, provided that the radar altimeter is repaired within 10 calendar days, excluding the day that the malfunction was recorded in the aircraft maintenance records. According to LifeNet’s director of operations, when the radar altimeter was functional, generally, the pilots of twin-engine helicopters would set the altitude preselect/alerter to the landing decision point (LDP) altitude. The LDP is the last point in the approach and landing path at which a balked landing can be accomplished with a failed or failing critical engine and with the engine failure recognized by the pilot.
[11] A fenestron is a type of helicopter tail rotor system in which the tail rotor assembly consists of a series of rotating blades shrouded within the vertical tail structure.
[12] The report also stated that the flight paramedic sustained a pelvic injury that, “although not fatal, may have contributed to death by restricting . . . mobility.”
[13] The study assumed that the helicopter followed a constant descent rate and angle from the location of the last radar return to the location of the wreckage and considered a Mode C uncertainty range of plus or minus 50 feet.
[14] The flight nurse reported that he observed a white bird fly up from the lower left of the helicopter before the accident. Two medical crewmembers who had flown with the accident pilot on the night before the accident reported observing a large flock of white birds flying up from the water near the Woodrow Wilson Bridge.
[15] U.S. Department of Transportation, Federal Aviation Administration, “Aeronautical Information Manual: Official Guide to Basic Flight Information and ATC Procedures,” (Washington, DC: FAA, 2006).
[16] U.S. Department of Transportation, Federal Aviation Administration, “Airplane Flying Handbook,” FAA-H-8083-3A (Washington, DC: FAA, 2004).
[17] The rules for operating within an ADIZ are outlined in 14 CFR Part 99 and include requirements for a functioning two-way radio and transponder, as well as certain procedural, position-reporting, and flight-planning requirements. The rules for operating within class B airspace are outlined in 14 CFR 91.131 and include two-way radio and transponder requirements.
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