RA-25464
Mil MI-8MTV-1
The accident flight departed Port-au-Prince International Airport (MTPP) on a moonless night, as the second helicopter that was tasked in an attempted emergency medevac rescue of a severely injured woman on the far north coast of Haiti. At the time of departure, the latest weather report was 2 1/2 hours old. The most direct route to the medevac pickup site was over mountainous terrain. The CVR and wreckage evidence indicate that the flightcrew had abandoned its attempt to get to the pickup site and had turned south in the direction of base, when the helicopter impacted near the top of a mountain ridge. The helicopter, a Mil Mi-8MTV-1 (Mi-8) was properly certificated and maintained in accordance with applicable regulations. No evidence of pre-impact fire was found, nor was any indication of systems, mechanical, or structural failure. Radio-navigation capability was needed with at least one ground station in Haiti, to attempt the emergency mission in the ambient conditions into which the helicopter was flown. However, aircraft-to-station compatibility did not exist. The Mi-8 was equipped with non-directional beacon (NDB) navigation receivers that were not compatible with the VOR instrument landing system at MTPP. Cap Haitien Airport, near the intended medevac pickup site, maintained an NDB radio beacon, but was closed at the time of the accident. No flight plan was filed for the accident flight. FLIGHTCREW PERFORMANCE: The flightcrew was properly certificated and qualified in accordance with applicable regulations of the Russian Federation, and had there passed instrument flight checks. However, the flightcrew did not maintain instrument currency in Haiti. No International Charter Inc. of Oregon (ICI)/Vladivostok Air (V/A) flightcrew had flown a practice or actual instrument approach in Haiti, and the operator had no relationship with any radio-navigation facility in Haiti. Consequently, the flightcrew's navigation and approach-to-landing options in accordance with instrument flight rules (IFR) were non-existent. Also limited were final escape options. When, as indicated on the CVR, the flightcrew was attempting to visually navigate in the mountains in near total darkness and fog, there was no mention of climbing into the clouds to a level above the highest terrain and navigating to an instrument approach to a landing. When interviewed following the accident, the pilots in the first flightcrew on the emergency medevac mission mentioned the possibility of climbing into overcast conditions if they encountered conditions similar to those involved in the accident; when asked how they would descend from actual meteorological conditions (IMC), they mentioned the global positioning system (GPS). That option is tenuous, however, in a mountainous country that is part of the large island of Hispaniola. According to the CVR, the accident flightcrew made no mention of GPS. THE OPERATOR: The operator (ICI) is a U.S. company. Although possessing a commercial air taxi certificate in accordance with 14 Code of Federal Regulations Part 135, it had limited aircraft assets, and did not own, fly, or maintain helicopters. It contracted with V/A, a Russian Federation-based owner/operator, for the helicopters, as well as piloting, training, and maintenance duties. The operator's Russian flightcrews were well-qualified in accordance with Russian Civil Aviation Authority (CAA) regulations, however, they were at a linguistic disadvantage in contracting with an operator whose primary language is English and flying in a country whose national language is French. The fact that no radio-navigation compatibility was established between the Russian flightcrews and the Haitian or United Nations authorities in Haiti demonstrates that the contract with V/A was not adequately supported by the U.S. operator or the Haitian CAA. Either entity could have assisted the Russian flightcrews by establishing a safe IMC-compatible radio-navigation relationship, including filing IFR flight plans and facilitating the scheduling and flying of practice instrument approaches in Haiti. AIR TRAFFIC CONTROL, PORT-AU-PRINCE INTERNATIONAL AIRPORT: The meteorologist at MTPP did not give reports after 1700, on the day of the accident, and, according to the CAA, departed the tower following the 1700 weather report. A timely meteorological observation would have assisted the accident emergency medevac flightcrew in planning and decision-making. CAA HAITI AND UNTIED NATIONS MISSION: The Civil Aviation Administration, Haiti, governed the flight rules and oversaw the operations facilities and navigation aids in Haiti. The United Nations Mission in Haiti provided operational tasking to these flights. There was, however, no evidence that an authority came forward and volunteered to assist the Russian flightcrews regarding language, communications and navigation difficulties in the sometimes difficult transportation, logistic, and in this case, emergency medevac-tasked mission. FEDERAL AVIATION ADMINISTRATION: About the time of the accident, passengers departing Miami International Airport (MIA), Florida for MTPP were handed written cautions that the destination airport was not fully certified. There was no evidence found that the FAA had come to Haiti and assisted in upgrading communications and radio navigation facilities at the international airport or at regional airports. Upgraded communications and navigational support may have proved useful to both flightcrews on the day and later night of the attempted lifesaving mission.
NATIONAL TRANSPORTATION SAFETY BOARD AIRCRAFT ACCIDENT REPORT IMPACT WITH MOUNTAINOUS TERRAIN, AT NIGHT INTERNATIONAL CHARTER INC. OF OREGON, Mi-8MTV-1, RA-25464, 38 MILES NORTH OF PORT-AU-PRINCE, MARCH 14, 1999; IAD99RA036 1. FACTUAL INFORMATION 1.1 History of Flight On March 14, 1999, about 1945, a Mil Mi-8MTV-1, registration RA-25464, operated by International Charter Inc., of Oregon (ICI), impacted mountainous terrain, 15 miles west-southwest of Hinche, Haiti (Unless otherwise noted, all times are local, eastern standard time, est.). The flight had a dual mission of emergency medical evacuation (medevac) pickup, and the transport of maintenance and security personnel to assist a sister helicopter, RA-25463 (RA-63). All 13 persons on board RA-64 sustained fatal injuries. ICI, in contract with Vladivostok Air (V/A), provided two Mi-8 helicopters in Haiti, and flight and maintenance personnel. The operator was brought to Haiti by letter of agreement between the U.S. Embassy and the Haitian government, to replace CH-47 Chinook helicopters in a transport mission. ICI held FAA certificate number 17CA0811, effective January 8, 1998, and was certified to operate as an "air carrier and conduct common carriage operations," in accordance with 14 CFR Part 135 (ICI Operator's Certificate, Attachment 1). The Mi-8s were certified in Russia for flight and maintenance in accordance with Russian Civil Aviation Regulation no. 15.07.91r-17.07.91. RA-64 held Airworthiness Certificate no. DB-645, dated March 26, 1998, and was registered in Russia under Certificate of Registration no. 3231, dated April 20, 1998 RA-25464 (Certificates of Registration and Airworthiness, Russian Federation, Attachment 2). The flightcrew was comprised of two pilots and a flight engineer (Russian citizens). An ICI corporate officer, who was a U.S. citizen, served as the aviation officer, stationed in the cabin. The passengers consisted of three Russian maintenance personnel (to performance maintenance on RA-63) and six Argentine Gendarmeria security personnel, serving in the United Nations civil police mission to Haiti (MIPONUH). RA-64 was verbally tasked by the tasking officer of the UN mission to Haiti for the emergency medevac. Flight orders for a Canadian utility helicopter squadron, which ICI replaced, were on file at ICI base operations. A specific flight plan was not filed for the accident flight (The operator provided Attachment 3, regarding the flight plan. The attachment outlines a radio check with operations base to "Open my flight plan"). The ICI base radio operator stated that during the afternoon of March 14, he received a call from the tasking officer, who said that a written task order would follow by FAX. The mission was to fly an Mi-8 to Labadee, near Cap Haitien, about 85 miles north of the ICI facility at MTPP (MIPONUH AIR REQUEST, TASK/MISREP form, Attachment 4. The landing field at Labadee was a soccer field. There were no navigation aids at Labadee. The nearest airport was at Cap Haitien). The ICI on-call crew was notified and an ICI corporate officer took the position of in-cabin air officer. At 1735, RA-63 departed MTPP and at 1801 called base and reported landing assured at Labadee (ICI Radio Log, transcription and rewriting of transcription, 2 pages, Attachment 5). The chief air traffic controller at MTPP later stated that the tower operator staffed the tower until 2200 local. The 1700 and last recorded meteorological observation for MTPP was "visibility unlimited, few clouds broken at 3,000 feet, cumulonimbus, few clouds at 8,000 feet, and few clouds at 23,000 feet, temperature 29 degrees Celsius, dew point 22 degrees, QNH (barometric pressure) 1012.4, cumulonimbus north (Tower hourly weather log, Attachment 6. CAA, Haiti, stated that the meteorological observer departed the tower after the 1700 observation). The captain of RA-63 later stated that he flew to Labadee, flying northeast, and near the city of Hinche turned to the northwest, in order to take advantage of valleys and lower en route terrain. He stated that he noted clouds in the mountains but was not particularly concerned regarding weather for his return flight from Labadee. The medevac was a woman from Finland who had been struck by a boat and seriously injured. Upon RA-63 landing at a soccer field at Labadee, she was brought into the aircraft cabin. Prior to takeoff, the air officer, standing outside the helicopter, noted that the exhaust cowling for one of the engines was missing. The flight did not depart, and a call was made to ICI operations to state that the injured woman was still in need of transport and the aircraft was down in the landing zone for maintenance. According to the ICI base radio dispatcher, a company officer who had been in ICI operations throughout the afternoon, soon conferred in person at ICI with the MIPONUH tasking officer. Shortly thereafter, three V/A mechanics gathered with their tools to fly on board RA-64 to assist RA-63. Also, six Argentine Gendarmeria arrived to also fly on board RA-64, in order to provide overnight security for RA-63. A typed log, submitted by Port-au-Prince Tower, records that at "001520 [Zulu] RA464" initially contacted Tower for departure (Port-au-Prince "Pilot Controller Communications," Attachment 7. "001520" is 0015:20 Zulu/Greenwich Mean Time or 1915: local). RA-64 lifted-off with maintenance and security personnel on board. The ICI company officer was stationed in the cabin as the air officer. The ICI radio dispatcher recorded that at 1935 the flight radioed base that they were passing over Point November (five miles north of the ICI facility), outbound, and estimated landing at Labadee at 2000. The flight again contacted ICI base, about 4 minutes prior to impact (See CVR transcript, Attachment 8, two copies: complete in Russian and partial English translation). The RA-64 cockpit voice recorder (CVR) was recovered from the crash site and read-out at the Interstate Aviation Committee investigative laboratories in Moscow. The CVR conversation revealed that the flightcrew was aware that they were in mountainous terrain, attempting to maintain visual contact with the terrain, and turning and climbing prior to impact. ICI and V/A personnel stated that flightcrew were equipped-with and could have been wearing night vision goggles (NVGs. An investigator, early on-site, reports that he saw a "set of two rings" attached to the front of one of the flightcrew helmets. Flightcrew NVGs were not seen by other investigators or recovered from the wreckage.). As evidenced in the CVR transcript, the captain was at the controls, and immediately prior to impact, one flightcrew member stated, "Altitude 100 [meters radio altimeter], Altitude 70, Altitude." There was no moon that night (Quarters of the moon, by month, 1999; Attachment 9). A UN police advisory (CIVPOL) detachment at Gonaives, Haiti, submitted a log that stated that at 1940 they started a search, after receiving a radio transmission from RA-64 that said they were changing the itinerary because of bad weather conditions. The CIVPOL stated they later could not reestablish radio contact with the helicopter (This conversation is not on the CVR. The air officer in the cabin had a separate FM transmitter/receiver. The CIVPOL detachment at Gonaives did not contact ICI or other known agency, on the evening of March 14, regarding the radio conversation). About 2000, not having heard from RA-64, the ICI base dispatcher attempted to contact the flight by radio, without success. At 2035, the ICI air officer for RA-63 called by telephone to the base dispatcher. They agreed to keep trying to contact RA-64, but did not yet call the U.S. Coast Guard facility at MTPP (Statements of Josh Cotes and Lara Brekken, ICI employees, Attachment 10). At 2200, the ICI radioman called the company president in Oregon, and stated that he wished to call the USCG, which he did. At 2320, a USCG HH-60J Jayhawk departed north from MTPP, in a search attempt for RA-64 (Statements of HH-60J search and rescue pilots: RAF Flight Lt. Miller and USCG Lt. Bullock, Attachment 11. Additional witness statements, Attachment 12.). The route north was obscured by clouds and the HH-60J flew northeast towards the city of Hinche and the lower terrain in that vicinity. The USCG crew, wearing night vision goggles, found the mountainous areas obscured by clouds and were not able to search above 3,500 feet mean sea level (msl). After dawn, the USCG renewed the helicopter search for RA-64. Shortly after noon, March 15, a USCG HH-65 crew observed a crowd of people on a mountain slope, and then observed burned wreckage. The wreckage was found at an elevation of 4,200 feet msl, in a wreckage path approximately 90 meters in length, on an impact course of approximately 170 degrees. Examination found no evidence of any system problem with the aircraft prior to impact. A person who lived about five miles to the south of the accident site stated in interview that he observed the aircraft pass overhead with smoke coming down from the fuselage and then fire. There was no evidence of pre-impact fire found in wreckage examination. The turbine engines evidenced normal power at the time of impact. On-site examination was followed by instrument examination at the Interstate Aviation Committee Headquarters, Moscow. Wreckage examination evidenced that at the time of impact the helicopter was in a slight climb. Instrument examination revealed that the helicopter was in a 35 degree right bank at the time of impact. The impact was approximately 30 meters below the top of a ridge, beyond which mountain peaks and ridge lines gradually descended towards the south. The accident occurred at nighttime in instrument meteorological conditions (IMC), at 72 degrees 10 minutes West, 19 degrees 03 minutes North. (Coordinates 07.98246 by 21.08081) 1.2 Injuries to Persons Injuries Flightcrew Cabincrew Passengers Fatal 3 1 9 Other 0 0 0 Total 3 1 9 1.3 Damage to Aircraft The aircraft was destroyed at impact. 1.4 Other Property Damage The impact occurred in rural mountainous terrain. There was no private property damage. 1.5 Personnel Information 1.5.1 Captain The captain, age 49, was hired by V/A in 1973. He held a Russian Class One Pilot certificate. At the time of the accident, he had accumulated 11,800 total flying hours. He logged 10,800 hours in the Mi-8 helicopter, including 9,730 hours as captain, and 163 night flying hours. His medical certificate was issued on July 23, 1998, with no restrictions. He was certified in accordance with Russian civil air regulations to perform as a pilot under the following meteorological conditions: Day time: Visual Flight Rules (VFR), Special VFR: 150 meters cloud base, by 1,500 meters visibility, by wind speed of 25 meters per second. Night time: Special VFR: 450 meters cloud base, by 4,000 meters visibility, by 25 meters per second wind speed. Day time: Instrument Flight Rules (IFR): 150 meters cloud base, by 2,000 meters visibility, by 25 meters per second wind speed. The captain held a helicopter instructor pilot rating and was certified to pilot international flights. His last proficiency flight check in the Mi-8 was in Russia, February 3, 1999, under day/IFR, and night/special-VFR conditions. He also passed a proficiency check as a navigator, December 12, 1998. His most recent IFR approaches were in actual instrument meteorological conditions (IMC), 3-each: January 31, 1999, and during the February 3, 1999, proficiency flight check. He also received three hours of flight simulator instrument training February 2, 1999, as required within each 90-day period by Russian CAA regulations, and received three hours of supervised in-cockpit/on-the-ground emergency procedures review with the V/A chief pilot, during crew-rotation training in Haiti, February 8, 1999. All flight and simulator checks were passed and qualifications re-approved. 1.5.2 Copilot The copilot, age 39, was hired by V/A in 1978. He held a Russian Class Two Pilot certificate. At the time of the accident, he had accumulated 6,220 total flying hours. Since March 14, 1988, he logged 3,125 hours in the Mi-8 helicopter as copilot. His medical certificate was issued on October 13, 1998, with no restrictions. The copilot's most recent proficiency check in flying technique was on February 3, 1999. He also passed a proficiency check as a helicopter navigator on September 9, 1998. 1.5.3 Flight Engineer The flight engineer, age 40, was hired by V/A in 1977. He held a Russian Flight Engineer Class Two certificate. At the time of the accident, he had accumulated 4,570 total flying hours. He logged 2,050 hours in the Mil-8 helicopter as flight engineer. His medical certificate was issued on September 29, 1998, with no restrictions. His most recent flight engineer proficiency check was February 11, 1999, in Haiti. 1.5.4 Duty Period The captain of RA-63 stated that the accident flightcrew were on scheduled duty March 11 through March 13, 1999. The average crew rest (sleep) period was 9 hours and lasted from 2200 hours until 0700 hours. No other flights were flown by the accident flightcrew during the 3-day duty period, and they did not leave the ICI base operations and housing area at MTPP during the duty period. 1.6 Airplane Information Mi-8MTV-1, RA-25464, was manufactured at Mil Helicopter Company, Kazan Air Plant, Russia, February 28, 1991, as serial no. 95608. The helicopter was configured to carry a flightcrew of three (two pilots and a flight engineer) and 22 passengers. At the time of the accident, the airframe had accumulated 2,993 flight hours. It had a maximum gross weight of 13,000 kilograms (kg) (about 28,660 pounds), and maximum load capacity of 4,000 kg (about 8,818 pounds). It was capable of carrying 2,100 kg (about 4,630 pounds) of fuel, total, in two fuel cells. 1.6.1 Airplane Engines The helicopter was powered by two TV-3-117VM helicopter turbine engines, manufactured at the Zaporozie Air Plant, Ukraine. The left engine (no. 1), serial no. 7087881200002, was manufactured March 3, 1992. It had 1,194 total flight hours, 498 hours since overhaul on June 28, 1997, and 20 hours since last inspection, February 3, 1999. The right engine (no. 2), serial no. 7087882000012, was manufactured April 17, 1990. It had 1,994 total flight hours, 498 hours since overhaul, February 6, 1997, and 20 hours since last inspection, February 3, 1999. 1.7 Meteorological Information There were no recorded weather observations made by tower after 1700. The ICI radio dispatcher, in interview, stated that seeing no lights on at the tower, he thought it closed about the time of the departure of RA-64. The chief ATC controller stated that the tower was open until 2200. CAA, Haiti, stated that the meteorologist departed the tower after the last recorded weather observation, at 1700 (see Attachment 6). The nearest weather observation to the crash site was obtained by the USCG HH-60J search and rescue flightcrew, that departed MTPP at 2330, March 14, and reported that they were unable to search in the above 3,500 feet msl, because of cloud obscuration in the mountains (See Attachment 11). The barometric pressure at the accident site is unknown. The pressure provided to the accident flight by MTPP tower, recorded on the CVR at the time of takeoff was "1014" (millibars, or 30.03 inches of mercury). 1.8 Aids to Navigation MTPP Air Traffic Control (ATC) is scheduled-open daily until 2200. The Mi-8's did not practice instrument approaches and landings in Haiti, and communicated with MTPP to obtain takeoff and landing winds, temperatures, and barometric pressures. ICI base operations supplemented weather information by computer-downloading satellite data. MTPP was equipped with a very high frequency omni directional radio range / distance measuring equipment (VOR/DME) for international arrivals and departures. The airport did not have an ATC radar facility. The Mi-8s did not have V
The flightcrew's inability to maintain visual contact with mountainous terrain in night, instrument meteorological conditions. Contributing to the accident was a lack of preparation and support for difficult flight conditions, including lack of coordination between the U.S. operator, its Russian flightcrew and aircraft-owner partner, United Nations tasking authorities, and the Haitian civil aviation authority.
Source: NTSB Aviation Accident Database
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