Whittier, AK, USA
N141LG
Eurocopter Deutschland BK117C1
The commercial helicopter pilot was on a visual flight rules (VFR) 14 Code of Federal Regulations Part 135 EMS (emergency medical service) patient transfer flight from a remote medical clinic in Alaska to a hospital in Anchorage when it collided with the ocean during instrument meteorological conditions. The flight entailed flying over and near ocean waters and mountainous terrain during dusk and night conditions without lighted ground references (such as buildings and street lights) due to the uninhabited topography. With the pilot and patient were a paramedic and a nurse. While crossing over a portion of ocean approaching rising terrain, the helicopter likely encountered low ceilings and snow squalls. With the pilot unable to discern either the shore or the ocean, it is probable he flew the helicopter under control into the ocean. Pieces of the helicopter and the body of the nurse were recovered several days after the accident. The rest of the helicopter and its occupants are presumed to have sunk in the ocean. There were no distress calls received from the pilot, and no history of any significant mechanical issues with the helicopter. The accident flight was the pilot's first flight from this clinic, and this was his first winter season flying in Alaska. He had expressed his concern to a mechanic prior to the flight about flying over the accident route and water at night, and also told the nurse to bring his night vision goggles (NVGs) to assist him in seeing terrain. The pilot also had NVGs. It is unknown what weather information the pilot had when he elected to accept the flight. He had access to a company computer, and he and other company pilots routinely did their preflight weather planning using it. There is no record that he received any preflight weather briefing from the FAA, nor contacted them for weather information prior to his departure from the clinic, or sought weather updates while en route. It was night VFR when the pilot departed the clinic, but the weather had deteriorated near the accident site in close proximity to his departure time. The nearest reporting station was about 5 miles from the accident site. About 23 minutes before the accident, it was reporting instrument meteorological conditions with snow and low ceilings. Aerial search efforts had to be delayed due to the poor weather. Neither the operator nor the hospital provided en route weather updates, or primary dispatch services. The hospital's procedure was to call the assigned EMS pilot to request a flight, and the pilot made the decision to either accept or reject the flight. Company procedures required that the pilot complete a risk assessment form prior to taking a flight. There was no risk assessment form found for the accident flight, and company management could not locate other risk assessment forms for previous EMS flights. An exemplar risk assessment form was completed by the NTSB investigator-in-charge using information that the pilot could reasonably expect to have known prior to accepting the flight. That information equated to a "Moderate" risk level, and required company management's concurrence to authorize the flight. Company management was not notified. The pilot was required to phone the hospital communications center at 10-minute intervals via satellite phone while en route, and when he did not call at the required time, a search was initiated. The operator's main base was in Anchorage, and the EMS facility was in another Alaska town. The operator had not been assigned a principal operations inspector (POI) to oversee their operations until about 2 months prior to the accident. The POI had not inspected or visited the remote EMS location. Prior to the POI's assignment, the operator did not have a POI assigned for the preceding 22 months, but instead relied on various points of contact (POC) within the local FAA Flight Standards District Office to provide oversight. Investigation disclosed no evidence that any POC had visited the EMS facility. The operator also did not adhere to the proper procedures in training the accident pilot in the use of the NVGs. These discrepancies were not discovered by the FAA until after the accident. NTSB/SIR-06/01 recommended that the FAA require EMS operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. With a formalized dispatch and flight following process, it is probable the helicopter would have been turned around/canceled prior to entering instrument meteorological conditions (IMC), or due to the noncritical nature of the patient, the patient could have waited until an airplane was available that was capable of flying in IMC.
HISTORY OF FLIGHT On December 3, 2007, about 1718 Alaska standard time, a Eurocopter BK117C1 helicopter, N141LG, is presumed to have sustained substantial damage during impact with ocean waters, about 3 miles east of Whittier, Alaska. The helicopter was operated by Evergreen Alaska Helicopters, Inc., under contract to Providence Hospital, Anchorage, Alaska, under their Lifeguard Program, as a visual flight rules (VFR) patient transport flight under 14 CFR Part 135. Of the four persons aboard, the commercial pilot, paramedic, nurse, and patient, only the body of the nurse was recovered. The remaining three were not located, and are presumed to have also died. Instrument meteorological conditions prevailed in the area of the accident, and company VFR flight following procedures were in effect. The accident flight departed Cordova, Alaska, about 1640. The helicopter was based in Soldotna, Alaska, and flew to Cordova to pickup the patient about 1340. After boarding the patient, the helicopter departed for Anchorage about 1640. During the flight from Cordova to Anchorage, the pilot communicated with the hospital's communications center at 10-minute intervals via satellite telephone. During the communications he gave the helicopter's position and estimated time of arrival in Anchorage. The helicopter was reported missing when the pilot failed to make a required position report, and attempts to communicate with him failed. On the evening of December 3, the Alaska Rescue Coordination Center (ARCC) initiated a search for the missing helicopter. Initially, search efforts were restricted to watercraft due to weather in the search area. The following day both aircraft and watercraft carried on the search, as well as ground searchers on land. On December 8, the body of the nurse and some wreckage were found floating in Passage Canal near Whittier. On December 10, the active search for the helicopter and its three missing occupants was terminated. The flight from Cordova to Anchorage required flying over/near the ocean waters of Prince William Sound. Prince William Sound is an isolated area with no roads, few small towns/villages, and essentially no land or water-based lights. For patient transfers from Cordova to Anchorage, Providence hospital routinely used airplanes operating under instrument flight rules as the preferred transportation method. The use of the helicopter was the last option. Helicopter flights operate under visual flight rules only. The VFR flight in a helicopter from Cordova to Anchorage typically would follow the north and east boundary of Prince William Sound to avoid extended flight over water. The accident flight departed Cordova about 1640, and official sunset was 1548. Federal Air Regulation Part 135.205(a) states: No person may operate a helicopter under VFR unless that person has visual surface reference, or at night, visual surface light reference, sufficient to safely control the helicopter. DAMAGE TO AIRCRAFT To date, the only pieces of helicopter wreckage recovered are fragmented pieces of the main rotor blades, and the aft left cabin door. Two flight helmets belonging to the flight nurse and the pilot were found floating in the surf. Night vision goggles were attached to the helmets via lanyards. The NVG switches were found in the "ON" position. PERSONNEL INFORMATION No personal flight records for the pilot were discovered for examination, and the following information was taken from operator and FAA records. The pilot held a commercial pilot's certificate, with ratings for airplane single-engine land, helicopter, and instrument helicopter. An FAA second class medical certificate was issued to the pilot on January 29, 2007, with the limitation that he must wear corrective lenses. The pilot was hired by Evergreen Helicopters on April 16, 2007. At the time of the accident he had about 2,678 hours of flying experience. Of those hours, about 2,398 were in helicopters, and about 120 hours were in the same make and model as the accident helicopter. The pilot had 65 hours of night flying experience, 78 hours of simulated instrument flight, and 18 hours of actual instrument flight time. He accumulated about 70 hours of Alaska time working for another operator during the summer in Southeast Alaska, and 109 hours with the current operator for a total of 179 hours of Alaska time. He had not previously flown during the winter months in Alaska. For night vision goggle (NVG) training he had flown three flights for 5.0 hours total flight time. The flights included inadvertent IMC procedures, and unusual attitude recovery. The NVG training was begun on August 20, and completed on August 22, 2007. According to the FAA, the pilot did not complete the NVG training as prescribed by the vendor/trainer, which according to the trainer, required five separate flights for a total of at least 5 hours of flight time, and therefore the pilot was not qualified to use NVG. The FAA had not assigned a Principal Operations Inspector (POI) to the operator at the time of the NVG training, and did not cancel the pilot's NVG usage, as the discrepancy was not discovered until after the accident. According to the operator, they understood that the pilot required 5 hours of NVG flight, not specifically five flights, and therefore they believed the pilot was trained to qualification. Route training was provided to the pilot during his local area familiarization flights, however Cordova was not included in that familiarization training. No evidence was discovered showing that the pilot had ever flown to or from Cordova. The pilot completed and passed a Federal Air Regulation Part 135.293/299 Airman Competency Check ride on May 8, 2007, given by a company check airman. The check ride included instrument navigation and communications procedures, use of the auto pilot, inadvertent IMC procedures, and unusual attitude recovery. The accident pilot held an instrument rotorcraft certificate, but was not required to be IFR current. According to the check pilot, the accident pilot was a capable pilot, and current in all of his required pilot tasks and training. The pilot's weather training consisted of completing the operator's interactive computer module, which was completed on May 5, 2007. The operator's pilot training manual contains a section titled, "Special Subjects Training - For Additional Pilot Authorizations." Additional training subjects include underwater evacuation and ditching; however, the training was not required for the EMS helicopter position and was not provided to the accident pilot or crew. The medical flight crews received formal training from the operator, in the operation of some helicopter systems, principally communications, patient care relative to flight, airspace surveillance, NVG usage, and emergency procedures. Essentially, medical flight crewmembers who had flown with the accident pilot, felt he was conscientious, professional, and a good pilot. One crewmember said on one occasion, he and the pilot got into severe turbulence, and after the flight the pilot was visibly shaken, as was he. Another crewmember said he was concerned about the number of days in a row the pilots worked 12 hour shifts, and wrote a letter to his supervisor because he was concerned that the accident pilot was making mistakes due to fatigue. The letter was forwarded to the operator, and the pilots were give additional days off. OPERATOR INFORMATION Evergreen International is a multinational aviation company supporting hundreds of aircraft worldwide. At the time of the accident, Evergreen Alaska Helicopters, Inc., a subsidiary of Evergreen International, supported numerous helicopter operations throughout Alaska, including two dedicated EMS helicopters, both of which were contracted to Lifeguard, Providence Hospital. The accident helicopter was stationed at Providence Hospital, Soldotna, Alaska, and designated for day/night VFR operations only. At the time of the accident, operational control of flight operations was specified in the company's FAA-approved Operations Specifications. The specifications stated in part, "...operational control is named management personnel to include Chief Pilot, Director of Maintenance, Chief Inspector, and Director of Operations." Under paragraph 7(a), the operations specification stated in part, "...prior to the certificate holder conducting any flight operation under Part 135, the certificate holder must provide information to the designated pilot in command that indicates which flight or series of flights will be conducted under Part 135, that indicates which Part 91 flights will be conducted by the certificate holder, and that the certificate holder is accountable and responsible for the safe operations of these flights or series of flights." According to the operator, all flights for Providence Hospital were conducted under Part 135. According to the company operations manual Chapter 10, page 4, Pilot in Command: "The Director of Operations and the Pilot in Command are jointly responsible for the initiating, continuation, diversion, and termination of a flight in compliance with Regulations and Evergreen's Operations Specifications." The crew for the helicopter at Soldotna was a single pilot, and usually two medical crewmembers. The pilot has numerous tools to conduct flight operations, including computer access to weather data, and company operations specifications and procedures. Pilots received an annual Part 135 check ride, and annual safety training. The company did make a helicopter and fuel available for pilots who wanted to stay instrument current. The instrument training/currency was voluntary. No evidence was presented showing that the accident pilot was instrument current. At the time of the accident, the company operations manual stated that when inadvertent IFR was encountered, the pilot’s primary responsibility was to maintain attitude control (level the helicopter), heading control (turn to avoid known obstacles), add climb power, and attain climb airspeed. The pilot should then climb to the area’s minimum safe altitude, make no turns greater than a standard rate turn, and contact ATC/FSS. Aviation Flight Risk Evaluation Program The operator had a flight risk evaluation program with an associated form to be completed by the pilot and filed at the main office in Anchorage. There was no continuity among the pilots interviewed as to when and how the form was filled out. Some pilots filled the form out as a daily risk evaluation, while others filled it out for each flight. The remaining Soldotna-based pilot said he left the completed forms with other paperwork destined for the main office, but did not know what became of them. The chief pilot at the main office was not able to locate the completed forms, and no form for the accident flight was presented. The risk evaluation program used a point system divided among categories, such as administrative, equipment, crew, weather, and environment. Selected elements are given a point value, and the total point value is assigned a risk factor, such as low, caution, medium, and high, etc. There is a required action associated with each risk factor. For instance, low requires pilot concurrence, caution requires the pilot to take steps to lower/reduce the risk, and medium requires management concurrence with the pilot to initiate the flight. Using the operator's form, and the conditions present for the accident flight that the pilot knew, or should have known at the time of evaluation prior to the flight, the point value reached the medium risk level. A medium risk level flight required concurrence from operator management to proceed. The pilot did not contact his management for concurrence. Weather Minimums The pilot was operating in Class G airspace, and the Part 135 VFR visibility requirements for night cross-country flight during Helicopter Emergency Medical Services (HEMS) flights in Class G airspace using NVG were 1,000 feet and 3 miles. At the time of the accident, these minimums were included in the company operations specifications. AIRCRAFT INFORMATION The helicopter was a 2003 model year, Eurocopter GMBH BK117C1, twin-engine turbine helicopter. According to the operator's records, at the time of the accident the helicopter had about 11,021 hours of flight time. It was maintained under an Approved Airworthiness Inspection Program (AAIP), and the last inspection was completed November 19, 2007. The helicopter was equipped for instrument flight. An examination of the airframe and engine log books revealed no known mechanical anomalies. The helicopter was configured as an air ambulance. Among other equipment, it contained communications equipment, seating for the medical crew, stretchers for patients, medical monitors, medical equipment, and on-board oxygen. The helicopter was certified for day/night VFR flight by one pilot. It had standard instrumentation for instrument flight, and was certified for single-pilot instrument operations. The helicopter was not equipped with emergency pop-out floats, and none were required by the FAR. METEOROLOGICAL INFORMATION VFR conditions prevailed along the route of flight from Soldotna to Cordova, and at the time of departure from Cordova, but instrument flight rules (IFR) conditions developed in Whittier after the helicopter departed Cordova. FAA weather cameras at Whittier/Portage Pass, pointed south toward Prince William Sound, showed rapidly deteriorating weather in the area of Whittier, and Portage Pass, just before sunset at 1548 Alaska standard time. After sunset the weather cameras were unusable. The weather reporting stations along/near the route of flight from Cordova to Anchorage, principally Whittier and Portage were automated stations. Automated stations can be accessed via computer, by telephone, or aircraft radio. When accessed by telephone or aircraft radio they provide current weather conditions being sensed at the time of the contact. In addition, the FAA maintained a series of weather cameras in select areas accessible through the Internet and Flight Service Stations. Telephone and computer records showed that the pilot used the telephone to contact the automated reporting sites, as well as Internet resources to gather information about the weather conditions along the route of flight prior to leaving Soldotna. He did not contact an FAA flight service station for a complete weather briefing. No records were discovered showing that the pilot accessed any weather sites after departing Soldotna. The closest weather reporting station to the accident site was the automated weather station at Whittier, about 5 miles west of the suspected accident location. The 1655 AST observation, about 23 minutes prior to the estimated time of the accident, reported 1 mile visibility in light snow and mist, ceiling obscured, vertical visibility 300 feet, wind from 120 degrees at 6 knots, temperature and dew point 22 degrees F, altimeter setting 29.46 inches of HG. Another helicopter transited the Whittier/Portage Pass portion of the route about 2 hours prior to the accident helicopter. The pilot of that helicopter described weather conditions as waves of snow squalls and near zero visibility. He said during daylight hours he was able to see snow squalls ahead and behind, and had to land his helicopter several time to wait out the squalls. No pilot reports appropriate to the area and time of the accident were found. COMMUNICATIONS The EMS dispatch center is located at Providence Hospital, and staffed by hospital employees. There were no employees of the helicopter operator involved in the dispatch operation. The dispatchers processed requests for transportation, but did not make any decisions relative to the transport. Dispatchers are given a list of aircraft available for transport from each facility. The list has an order of preference i.e. first choice, second choice, etc. Dispatchers do not make decisions on the appropriateness of particular aircraft based on distance, weather, time of day, or criticality of the patient. Once a third choice aircraft is dispatched, in this instance the helicopter, no further st
The pilot's decision to continue VFR flight into night instrument meteorological conditions. Contributing to the accident were the operator's failure to adhere to an FAA-approved and mandated safety risk management program, the FAA's failure to provide sufficient oversight of the operator to ensure they were in compliance with the risk management program, the pilot's lack of experience in night winter operations in Alaska, and the operator's lack of an EMS dispatch and flight following system.
Source: NTSB Aviation Accident Database
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