JUNEAU, AK, USA
N6007S
Eurocopter AS-350B-2
The certificated commercial helicopter pilot, with five passengers aboard, was attempting to return to the Juneau International Airport after completion of an ice field sightseeing tour flight. During a gradual descent, over a large, featureless, and snow-covered ice field, a localized snow shower momentarily reduced his forward visibility. The pilot reported he slowed the helicopter to about 70 knots and attempted to use a mountain range on the left side of the helicopter for visual reference. He said: 'The visibility got to a point where I was unable to discern any topographic features, only a dark shape on the horizon.' He added that 'flat light conditions' contributed to his inability to recognize any topographical features on the ice surface. The helicopter continued to descend, struck the snow-covered ice field, slid about 150 feet, and nosed over. The pilot reported that there were no preaccident mechanical anomalies with the helicopter. The helicopter was not equipped with a radar altimeter, and the pilot did not hold an instrument rating. The pilot received no emergency instrument training from the company, nor did the company require him to demonstrate the ability to maneuver the helicopter solely by reference to the installed flight instruments. FAA Order 8400.10 requires Principal Operations Inspectors, and approved company check airmen, to have pilots demonstrate their ability to control a helicopter solely by reference to flight instruments during 14 CFR 135.293 competency checks for VFR-only helicopter operations. The operator's FAA-approved training manual did not require training or competency checks of the pilot's ability to maneuver the helicopter solely by reference to flight instruments.
HISTORY OF FLIGHT On September 10, 1999, about 1204 Alaska daylight time, a Eurocopter AS-350B-2 helicopter, N6007S, was destroyed when it impacted the surface of the Juneau ice field, about 16 miles north of Juneau, Alaska, at 58.37.433 north latitude, and 134.33.620 west longitude. The helicopter was being operated as a visual flight rules (VFR) on-demand sightseeing flight under Title 14, CFR Part 135, when the accident occurred. The helicopter was operated by TEMSCO Helicopters, Inc., Ketchikan, Alaska. The certificated commercial pilot and four passengers aboard received minor injuries. The remaining passenger received serious injuries. Visual meteorological conditions prevailed at the time of departure, and company flight following procedures were in effect. The flight originated about 1104 from the Juneau International Airport, Juneau. During an interview with the National Transportation Safety Board investigator-in-charge on September 11, the pilot reported that he was attempting to return to the Juneau International Airport after completion of an ice field sightseeing tour flight. He said that during a gradual descent, over a large, featureless, and snow-covered ice field, a localized light snow shower momentarily reduced his forward visibility. He stated that he slowed the helicopter to about 70 knots and attempted to use a mountain range on the left side of the helicopter for visual reference. He said: "The visibility got to a point where I was unable to discern any topographic features, only a dark shape on the horizon." He added that "flat light conditions" contributed to his inability to recognize any topographical features on the ice surface. The helicopter continued to descend, struck the snow-covered ice field, slid about 150 feet, and nosed over. DAMAGE TO AIRCRAFT The helicopter was destroyed by impact forces. CREW INFORMATION The pilot held a commercial helicopter pilot certificate, and helicopter flight instructor certificate. He did not hold an instrument rating. The most recent second-class medical certificate was issued to the pilot on April 4, 1999, and contained the limitation the holder shall wear corrective lenses. According to the pilot/operator report (NTSB form 6120.1/2) submitted by the operator, the pilot's total flight time consisted of 2,400 hours, of which 1,190 were accrued in the accident helicopter make and model. In the past preceding 90 and 30 days prior to the accident, the report lists a total of 250 and 71 hours, respectively. The pilot was hired by the operator on April 15, 1998. He completed an initial 14 CFR 135.293/.299 check ride on April 29, 1998. On April 26, 1999, the pilot completed a recurrent check ride as per 14 CFR 135.293/.299. Both initial and recurrent check rides were accomplished in the accident helicopter make and model. The operator provided a copy of the accident pilot's part 135 competency/proficiency check, FAA form 8410-3, dated April 26, 1999. The portion of the form reserved for the flight check airman's comments/grading of the pilot's skills in operating the helicopter solely by reference to instruments, was lined through and not completed. AIRCRAFT INFORMATION The helicopter was an American Eurocopter AS-350B-2, equipped with a Turbomeca Arriel-1D1 turboshaft engine. The helicopter was outfitted with the manufacturer's high density seating configuration. This configuration accommodates 6 passengers and a pilot. The helicopter was maintained under the operator's Approved Aircraft Inspection Program (AAIP). This program contains inspections performed approximately every 100 hours. The helicopter and engine were manufactured in January 1990, and both had accumulated 752.3 hours in service at the time of the accident. 82.3 hours had elapsed since the most recent 100 hour inspection. A review of maintenance records revealed no evidence of preexisting anomalies at the time of the accident. All equipment required by 14 CFR Part 91.205, 207, 209, and 135.149, 159, and 161, were installed on all company helicopters. The company was authorized to operate the helicopter in day and night VFR conditions. 14 CFR Part 135.159, Equipment Requirements: Carrying Passengers Under VFR At Night, states, in part: "No person may operate an aircraft carrying passengers under VFR at night...unless it is equipped with- (a) A gyroscopic rate-of-turn indicator... (b) A slip skid indicator. (c) A gyroscopic bank-and-pitch indicator. (d) A gyroscopic direction indicator..." The accident helicopter was not equipped with a radar altimeter, nor was it required to be. METEOROLOGICAL INFORMATION The closest official weather observation station is Juneau, which is located about 16 nautical miles south of the accident site. On September 10, 1999, at 1155, an Aviation Routine Weather Report (METAR) was reporting, in part: Wind, 090 degrees at 9 knots; visibility, 10 statute miles; ceiling and clouds, 1,400 feet few, 4,900 feet scattered, 6,500 feet overcast; temperature, 53 degrees F; dew point, 48 degrees F; altimeter, 30.23 inHg. Remarks: Well defined ceiling in vicinity of mountains. An AIRMET for mountain obscuration in clouds and precipitation was issued for the pilot's planned tour flight. The National Transportation Safety Board investigator-in-charge interviewed three pilots that were in the area of at the time of the accident. All the pilots interviewed related that overcast conditions, localized snow showers, and very flat light conditions, made it difficult to discern the surface of the glacier. They added that the weather reports and forecasts from Juneau most often do not represent the actual weather conditions in the mountains, and over the ice field. COMMUNICATIONS About 1104 the operator's dispatch center recorded the accident helicopter's departure from the Juneau International Airport, with five passengers aboard. The accident pilot indicated that he would be conducting a "pilot's choice tour," and would return to the Juneau International Airport in about one hour and twenty minutes. The last radio transmission received from the accident helicopter was about 1148, reporting that he was landing on the East Branch of the ice field, a planned part of the tour. No further radio transmissions were received from the accident helicopter. No radar coverage is available in the area of the accident. WRECKAGE AND IMPACT INFORMATION The National Transportation Safety Board investigator-in-charge, two representatives from the FAA's Juneau Flight Standards District Office, and a representative from American Eurocopter Corporation, examined the helicopter wreckage at the accident site on September 14, 1999. In addition, two members from the Juneau Mountain Rescue Team accompanied the accident investigative team to the accident site to recover rescue equipment, and provide site safety while on the glacier. The accident site was located on the Juneau ice field, about 5,270 feet above sea level (msl). Deteriorating weather conditions limited the available time at the scene. The topographical features surrounding the accident site consisted of smooth, featureless, and freshly snow-covered glacial ice. There was a gradual downward slope in the direction of the accident helicopter's preaccident flight path. The helicopter collided with snow-covered glacial ice. A path of wreckage debris and ground scar from the first observed point of impact, to the wreckage point of rest, was on a magnetic heading of 228 degrees. (All heading/bearings noted in this report are oriented towards magnetic north.) The first observed portions of helicopter's wreckage noted along the 150 feet long wreckage path, were small pieces of fragmented composite material that matched the color scheme of the accident helicopter, a left side skid tube toe, and portions of windscreen plexiglas. The helicopter fuselage and passenger cabin was lying inverted at the end of the wreckage path, with the nose of the helicopter orientated on a 328 degrees magnetic heading. The tail boom assembly was completely severed just aft of the tail boom attach points. The severed tail boom assembly came to rest in a normal, upright position. The forward cabin and passenger compartment was bent, and buckled inward along the upper roof area. The entire nose section and instrument panel were torn and crushed in an aft direction. The forward cabin floor section was crushed and distorted inward, which invaded the front seat passenger's and pilot area. The engine was partially broken free of its aft mounts. The main rotor transmission assembly was separated from the transmission mounts. The transmission, main rotor mast, and main rotor hub assemblies, were located on the right side of the inverted helicopter. The emergency locator transmitter (ELT) was located in the right side baggage area. The ELT external antenna is located about mid-way on the tail boom assembly. The coaxial antenna wire between the ELT and the external antenna was found severed. No evidence of preimpact mechanical anomalies were found. SEARCH & RESCUE The accident helicopter was reported overdue about 1224. Attempts to contact the missing helicopter by radio were unsuccessful. About 1244, company dispatch personnel notified the local base manager that the accident helicopter was about 20 minutes overdue. The base manager and one observer departed the Juneau International Airport, in another company AS-350BA helicopter, to search for the overdue helicopter. The base manager proceeded along the accident helicopter's proposed route, and stated low clouds and "flat light conditions" prevented him from reaching the upper elevations of the ice field, the suspected location of the overdue helicopter. He added that no emergency locator transmitter (ELT) signal was received. At 1348, an additional company AS-350B-2, N6052C, departed the Juneau heliport with one helicopter rated pilot-passenger aboard, with the intentions of assisting in the search efforts. About 1358, the base manager returned to the Juneau heliport to obtain additional fuel, and notify company management personnel in Ketchikan of the situation. While at Juneau, the base manager contacted other local helicopter operators, and requested additional search assistance. At 1416, the base manager and the observer again departed for the search area to join the other company helicopter, N6052C. About 1445, the pilot of N6052C radioed the base manager that he had crashed on the ice while searching for the accident helicopter (N6007S). The base manager then relayed the message to the company dispatcher. (See ANC99LA140 for details) About 1450, an additional company AS350B-2 helicopter, N6099Y, reported to the dispatcher that he was inbound from Petersburg, Alaska, with one company employee aboard. He informed the dispatcher that he had been monitoring the radio communications between N6052C and the base manager's helicopter, and was aware of the search situation. The dispatcher then requested that N6099Y continue inbound to Juneau Airport, refuel, and join the other company helicopter involved in the search. The pilot reported to the dispatcher that he presently had sufficient fuel aboard, and that he would be proceeding directly to the search area. During the search, the pilot of N6099Y established radio communication with the pilot of N6052C, who provided vectors to their location. Weather conditions prevented the crew of N6099Y from reaching the site. The pilot of N6099Y elected to return to the Juneau Airport for fuel, and wait for the weather to improve. Once N6099Y was refueled, they immediately returned to the accident site of N6052C, and successfully recovered the pilot and passenger. They all elected to continue the search for N6007S. At 1616, the U.S. Coast Guard, Office of Search and Rescue, was notified by a Temsco Helicopters dispatcher that the company had an overdue helicopter. The dispatcher added that two TEMSCO Helicopters, along with various other operators, were assisting in the search efforts. About 1631, the pilot from a different company helicopter that was involved in the search, reported that he had sighted what he believed to be N6007S, the missing helicopter. He added that he was unable to get any closer than 2 miles due to low ceilings, and flat light conditions. This information was broadcast on the common advisory frequency of 122.75. During an interview with the National Transportation Safety Board investigator-in-charge on September 11, the pilot of N6099Y stated he was monitoring the advisory frequency, and determined that N6007S was just to the south of his location. He said that as he headed south he located N6007S about 2 miles away. He said that he slowed the helicopter to about 30 knots in an attempt to gain reference using a mountain range on the left of the helicopter, and the accident site of N6007S. He said that the helicopter struck the unseen snow-covered ice field, slid about 50 feet, nosed over, and rolled to the left. (See ANC99LA141 for details) Poor weather conditions prohibited airborne search and rescue personnel from reaching the accident sites of N6007S, and N6099Y. About 1915, a U.S. Coast Guard HH-60 helicopter was able to fly a 9 member mountain rescue team to the 4,350 feet msl level of the Juneau ice field. The rescue group was outfitted with tents, food, and medical supplies. After completing a two mile hike, search and rescue team members reached the two accident sites about 2300. The pilot and five passengers from N6007S, the pilot and three passengers from N6099Y, and the accompanying rescue personnel, remained at the two accident sites overnight. The following morning, a U.S. Coast Guard HH-60 helicopter evacuated all personnel from both accident sites. ADDITIONAL INFORMATION At the time of the accident, the company operated a fleet of twelve AS-350 helicopters from Juneau. All helicopters operated by TEMSCO Helicopters, Inc., were equipped with standard flight instruments including airspeed, vertical speed, barometric altimeters, and gyroscopic pitch-and-bank indicators. Radar altimeters are designed to depict the actual altitude above the surface over which an aircraft is flying. None of the helicopters were equipped with radar altimeters, nor were they required to be. The company director of operations, and two other company officers, functioned as FAA approved check airman. They perform the FAR 135.293/299 proficiency checks for company pilots. Each designee holds a flight instructor certificate in helicopters. Flight crewmember training is affected by several documents: Company Operations Manual, Company Training Manual, Operating Specifications, Federal Aviation Regulations (FARs), and FAA Orders. The FARs dictate that an air carrier operating under 14 CFR Part 135 will have an approved training program. This training program is to be reviewed and approved by the FAA Principal Operations Inspector (POI), who is required to follow FAA Order 8400.10 (Air Transportation Operations Inspector's Handbook). Any changes to the Training Manual must be approved by the POI prior to being implemented. FAA Order 8400.10 does not have the binding force of regulation for an air carrier. It is the guidance provided to FAA inspectors, and is considered the national policy guidelines for the Flight Standards Service of the FAA. These guidelines are passed to the air carriers by their incorporation into the Operating Specifications, and issuance or withdrawal of approvals for company training manuals. FAA Order 8400.10, Change 7, chapter 3, paragraph 539 states, in part: "PART 135 BASIC CHECKING MODULE. The flight test required to qualify a pilot for revenue service is termed a basic checking module... Operators must design the basic checking module of a Part 135 curriculum to satisfy the requirements of Part 135.293. FAR 135 does not specify the maneuvers (events) which must be accom
The pilot's continued flight into instrument meteorological conditions (IMC), and inadequate altitude/clearance. Factors associated with the accident were flat light and whiteout conditions, snow, and snow-covered terrain. An additional factor was the FAA's inadequate certification/approval of the operator's training manual, which did not require the operator to provide instrument training or instrument flight proficiency checks to its pilots.
Source: NTSB Aviation Accident Database
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