Boonville, IN, USA
N137AE
Bell 206L-1
The helicopter collided with up sloping terrain during a night air medical flight. The accident occurred while transporting a patient from one hospital to another. Examination of the accident site and wreckage revealed the helicopter impacted the terrain in a level flight attitude. The accident site was at an abandoned strip mine located in a rural area. The area contained very few ground structures to provide reference lighting. During post accident interviews the pilot stated that he remembered picking up the patient and the next thing he remembered is the helicopter tumbling. The flight nurse and paramedic on board did not recall there being any indication of a problem prior to impact. The destination hospital is located inside the Class C airspace of the Evansville Regional Airport (EVV). The air traffic control facility at EVV closes at 2300. Between 2328 and 2339, the pilot made 12 attempts to establish contact with approach control as he approached the Class C airspace. There was a time zone change at EVV 16 days prior to the accident. Examination of the cockpit revealed the altimeter was set at 30.08 inches of mercury. The current altimeter setting was 29.77 inches of mercury. This resulted in the altimeter indicating about 310 feet higher then the actual altitude of the helicopter. The pilot who flew the helicopter prior to the accident flight reported the radar altimeter was operating erratically. This pilot and the mechanic who maintained the helicopter, both stated the accident pilot was informed of the problem. Bench testing of the radar altimeter failed to duplicate the reported erratic operation. The decision height (DH) bug on the radar altimeter was found set to 60 feet. Company policy is that the DH bug be set to 500 feet during visual night operations. Examination of the airframe, engine, and flight controls failed to reveal any mechanical failure/malfunction.
HISTORY OF FLIGHT On April 20, 2004, at 2343 central daylight time, a Bell 206L-1, N137AE, operated by Air Evac Life Team as Air Evac 17, collided with the terrain during a medivac flight. The patient was fatally injured. The pilot, paramedic, and nurse, were seriously injured. The helicopter was substantially damaged. The 14 CFR Part 135 flight was operating in visual meteorological conditions and was receiving company flight following at the time of the accident. The helicopter last departed the St. Joseph's Hospital Heliport (II47), in Huntingburg, Indiana, with an intended destination of Deaconess Hospital (16IN) in Evansville, Indiana. Air Evac 17 was based at the Davies County Airport (DCY), Washington, Indiana. At 2151, the crew was notified of a patient who needed to be transported from II47 to16IN. Air Evac 17 departed DCY about 2204 en route to II47. Air Evac 17 landed in II47 around 2223 and departed around 2325 en route to 16IN with the patient on board. The last radio contact that Air Evac dispatch had with the flight was at 2327 when Air Evac 17 reported they had departed II47 with 4 people and 450 pounds of fuel on board. The destination helipad, 16IN, is located within the Class C airspace surrounding the Evansville Regional Airport (EVV), Evansville, Indiana. The hours of operation of the air traffic control tower at EVV were between 0600 and 2300. The audio recording equipment was inadvertently left on after the tower closed. A recording of the approach frequency communications revealed the pilot of N137AE made 12 radio transmissions during the time period 2328 - 2339. The first four transmissions were attempts to contact the approach control. The fifth transmission was a partial transmission. This was followed by six more transmissions attempting to contact approach. The last transmission was partially unintelligible. Following the accident, the flight crew paramedic used a cellular phone and called dispatch to inform them that they had crashed. A recording of the call was made available to the NTSB. The beginning of the recording is time stamped 2344. The paramedic stated he did not know their location and the last location he was aware of was being 8 minutes from their destination. He stated they were in a field and he could see a flashing white light on a tower that was a couple miles away. During the cellular call, the paramedic stated he did not know what happened, but the helicopter was on its side. He later stated they just hit the ground. The paramedic informed the dispatcher that the pilot was trapped in the wreckage, the nurse was out of the wreckage by the tail of the helicopter, the patient was by the nose of the helicopter and that they were all injured. Despite his injuries which included a broken jaw, the paramedic continued talking with dispatch, the pilot, and the nurse. The paramedic asked the pilot what happened and the pilot responded that they lost altitude. During the time that the paramedic was on the cell phone with the dispatcher, other Air Evac employees were making telephone calls getting helicopters and local authorities out to search for N137AE. At 0055, the paramedic informed the dispatcher that he could see an aircraft light that was heading toward him. At 0112, the paramedic stated that he was able to see flashing lights on an emergency vehicle in the distance. The paramedic removed a blue pen light from the shoulder of the nurse and used the light to signal the helicopters that were flying overhead searching. At 0117, they were located by another Air Evac helicopter. One witness, who was at his residence located approximately 300 yards north of the accident site, reported that around 2330 he heard a helicopter fly overhead. He reported the helicopter sounded very loud and that the sound gradually faded away in the distance as if it was flying away. He stated that about a half hour later he heard another helicopter flying from west to east. He stated this one was not as loud as the first. He stated that shortly after hearing the second helicopter, he heard others in the area as if they were searching for something. He was not aware of the accident when he heard the helicopters. During an interview, the flight nurse stated he remembered being about 10 minutes away from 16IN and the next thing he remembered is being on the ground outside the helicopter. He stated he does not recall any problems prior to the helicopter impacting the ground. In a post-accident interview, the paramedic stated that he remembered picking up the patient in Huntingburg and caring for the patient during the flight. He stated the next thing he remembered is impacting the ground, getting out of the helicopter, and making the call to dispatch to get help. He stated that he does not remember the pilot indicating that there were any problems prior to impacting the ground. He stated that he recalled it being windy at the time of the accident. In a post-accident interview, the pilot stated he recalled picking up the patient in Huntingburg and the next thing he remembered is the helicopter tumbling on the ground. He stated he remembered being trapped inside the wreckage. The emergency medical technicians (EMT) who treated the pilot at the accident site reported that the pilot stated "Boy I screwed up." An EMT asked him what happened and the pilot reported, "I started making my turn and we started tumbling." PERSONNEL INFORMATION The pilot held a commercial pilot certificate with airplane single-engine land, helicopter, instrument airplane, and instrument helicopter ratings. The pilot held a second-class medical certificate dated January 23, 2004. The medical certificate contained the limitation: "Must wear corrective lenses." The pilot reported having a total of 3,846.7 hours of flight time of which 3,592.7 hours were in helicopters. The pilot reported he had a total of 649.6 hours of flight time in Bell 206L-1 helicopters. He reported he flew 63.7 hours in the last 90 days, 38.1 hours in the last 30 days, and 0.9 hours in the last 24 hours. All of this flight time was in a Bell 206L-1. The pilot's last biennial flight review was on January 20, 2004, in a Bell 206L-1 helicopter. The pilot completed his initial training with Air Evac in January 2001, and his Federal Aviation Regulation (FAR) 135 Airman Competency/Proficiency Check was satisfactorily completed on January 13, 2001. In February 2002, the pilot attended a Bell 206L-1 refresher course conducted by the Bell Helicopter Training Academy. The pilot satisfactorily completed this Ground and Flight Procedures Training Course. Records were not located to indicate the date that the pilot passed a FAR 135 Airman Competency/Proficiency Check in 2002. In January 2003, the pilot once again attended a Bell 206L-1 refresher course conducted by the Bell Helicopter Training Academy. The pilot was issued a completion certificate for the Ground portion of the training. Remarks in the training record state the pilot "... needs more flight training to achieve Bell minimum standards." There were no records located which indicated the pilot had received additional training. Records were not located to indicate the date that the pilot passed a FAR 135 Airman Competency/Proficiency Check in 2003. On January 9, 2004, the pilot failed his FAR 135 Airman Competency/Proficiency Check. Comments in the remarks section of Federal Aviation Administration Form 8410-3 stated, "Company Part 135 check ride unsat." Comments in the pilot's Flight Training Record dated January 9, 2004 state, "Unsat maneuvers - hydraulics, hovering autos, t/r malf were not complete. Knowledge of company ops, weak." Following this check ride, the pilot was placed in an Initial Training class for requalification. On January 20, 2004, the pilot passed a FAR 135 Airman Competency/Proficiency Check. During a post accident interview the pilot stated that Air Evac pilots usually work 7 days on duty followed by 7 days off duty. However, he stated that lately they have been working 8 days sometimes 9 days on duty. He stated that he usually worked the 2000 to 0800 shift. The pilot stated that the accident occurred on the 7th day of his shift. He stated that on April 18th he had little work to do, so he got plenty of rest. On the 19th he had one flight returning to DCY where he finished his paperwork around 0200 and he rested after that. He stated that he rested during the day on the 20th. He had dinner with crewmembers around 1800, and began his shift at 2000. AIRCRAFT INFORMATION The 1979 Bell 206L-1 (Long Ranger) was previously registered as N2758L. The helicopter was registered to Air Evac Leasing Corporation on October 29, 2003. The registration number was changed to N137AE on April 9, 2004. The helicopter was configured with one pilot seat, two aft-cabin forward facing seats, and one patient litter. The helicopter was equipped with an Allison 250-C28B engine, serial number CAE 860248, 500 horsepower turboshaft engine. The helicopter was equipped with a high skid type landing gear with float steps. The helicopter was maintained in accordance with an approved airworthiness inspection program. The program consisted of 4 phase inspections, one of which was accomplished every 25 hours of flight time. Phase 1 consisted of a basic overhaul inspection; Phase 2 was hydraulics; Phase 3 was an engine inspection; and Phase 4 was the rotor system. In addition to the phase inspections an annual inspection was accomplished as were daily inspections. The last annual inspection of the aircraft and engine was accomplished on March 26, 2004, at a total airframe time of 26,871.2 hours and an engine total time of 18,293.2 hours. The last phase inspection accomplished was a Phase 2 check, which was completed on April 18, 2004, at an aircraft total time of 26,909.0 hours and an engine total time of 18,331.0 hours. The last daily inspection was accomplished on the day of the accident at a total aircraft time of 26,910.1 hours and a total engine time of 18,332.1 hours. The pilot who flew the helicopter prior to the accident pilot reported, "... everything on the aircraft was functioning flawlessly and the aircraft performed as a new aircraft. There were no vibrations, no unusual flying tendencies, and the blades were flawlessly true and in balance. It flew very well. There was one minor problem with the radar altimeter that had caught my attention, it had a tendency to cycle from 2,500+' to 0' every once in a while, which caught my attention when it would pass through the place the bug was set and give a short burst alarm." This pilot stated that he informed the accident pilot of the problem and that they both checked the minimum equipment list (MEL) and determined that it was not required equipment for the flights. The mechanic who was assigned to maintain the helicopter stated that he was informed of the radar altimeter problem on April 18th. He stated he checked the system and did not find any obvious problems. He stated that he spoke with the company avionics specialist the following day and was told that it was probably an internal problem with the system and that it would need to be replaced. The mechanic stated that he completed the paperwork to order the replacement components and informed the accident pilot of the situation. He stated that he told the accident pilot that he could write up the problem if he so desired. The mechanic stated that the radar altimeter was a Category C item on the MEL and that the repair could be deffered for 10 days. He stated he was confident that the parts would arrive and the replacement would be completed within that time frame. There were no entries in the aircraft paperwork regarding the radar altimeter and it was not placarded as being inoperative. METEOROLOGICAL INFORMATION The weather observation station located at EVV recorded the weather at 2354 as being: wind 210 degrees at 12 knots, gusting to 17 knots; visibility 10 Statute miles (sm); a few clouds at 8,000 feetabove ground level (agl); temperature 21 degrees Celsius; dew point 12 degrees Celsius; altimeter 29.77 inches of mercury. The weather observation station located at the Huntingburg Airport (HNB) recorded the weather at 2135 as being: wind 190 degrees at 14 knots, gusting to 22 knots; visibility 10 sm; a broken cloud layer at 6,500 feet agl; temperature 23 degrees Celsius; dew point 9 degrees Celsius; altimeter 29.97 inches of mercury. The weather observation station, located at the Vincennes International Airport (LWV), Lawrenceville, Illinois, is located about 26 sm west of DCY. This is the closest weather reporting facility to the departure airport. The altimeter setting recorded at 2153 was 29.73 inches of mercury. An Indiana State Police helicopter pilot, who was sent out to search for N137AE, reported that the surface winds around 0115 were out of the southwest around 15 knots. He stated that when he was returning to EVV at the end of his flight, the winds at altitude were stronger then the surface winds. He reported that at an altitude of 1,500 feet mean sea level (msl), 1,000 feet agl his airspeed was indicating 110 miles per hour and that his ground speed was 70 knots (80 miles per hour). WRECKAGE AND IMPACT INFORMATION The accident site was on the property of an abandoned strip mine approximately one-half mile southwest of the intersection of Turpin Hill Road and Massey Road in Boonville, Indiana. The global positioning system (GPS) location of the main wreckage was 38 degrees 07.771 minutes north latitude, 087 degrees 19.281 minutes west longitude at an elevation of 486 feet msl. This location was approximately 2 sm outside of the Class C airspace at EVV. The wreckage path was 187 feet in length along a magnetic heading of 233 degrees on up-sloping terrain. The initial ground scars consisted of two parallel scars, which were approximately 3 inches wide and spaced about 7 feet apart. In the middle of these scars was a wider ground scar which contained the cutter from the wire strike protection system and the search light assembly. The cutter was buried in the ground. There was a strong smell of fuel present in this area. Just beyond this scar was a section of the forward crosstube. Approximately 19 feet to the right of the center ground scar were three parallel slash marks in the terrain. These marks ranged from 14 feet 7 inches to 3 feet 3 inches in length. The main wreckage was approximately 93 feet from the last of these slash marks. The helicopter came to rest on its right side. The fuselage was fractured just forward of the tail boom attach point. The lower forward portion of the fuselage and the nose sustained substantial impact damage. Both the forward and aft fuel cells were ruptured. The center post was intact and attached at the upper cockpit area. The lower portion of the center post was detached from the surrounding structure. The instrument panel was separated from the surrounding structure. The grass located behind the engine exhaust was burned. A melted plastic soda bottle that was located on the ground behind the exhaust. The tailboom remained attached to the aft portion of the fuselage. The vertical fin was separated from its mount and was found located next to the aft end of the tailboom. The horizontal stabilizer, although slightly damaged, remained attached to the tailboom. There was a 2-inch long slice in the leading edge of the left horizontal stabilizer. The landing skids, with the exception of a portion of the forward cross tube and a 7-foot long piece of the skid step, were located alongside the main wreckage. Both skid tubes, including the tips, were intact. Dirt was present on the bottom of the skids just aft of the tips. This was more prevalent on the right skid. The rear crosstube, although flattened, remained intact and attached to the skid tubes. The forward crosstube was flattened more then the rear tube. A section of the forward crosstube had separated and was found along the wreckage path. Both main rotor blades were attached to the hub. Although fractured, t
The pilot's inadequate planning/decision which resulted in his failure to maintain terrain clearance. Contributing factors were the pilot's inadequate preflight planning, his diverted attention, and the dark night conditions.
Source: NTSB Aviation Accident Database
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