Venice, LA, USA
N211EL
Bell 206L1
According to an interview with the pilot, while en route to an unmanned offshore platform South Pass 38 in the Gulf of Mexico, the cloud ceilings were about 500 feet and the visibility was about 5 miles. However, as the helicopter neared the destination platform, the flight entered deteriorating weather. The pilot estimated that the cloud ceiling was about 300 feet and that the visibility was about 1 mile when he began circling to land on the platform. Although the weather conditions did not meet Air Logistics’ operating minimums, which required a 500 foot cloud ceiling and 3 miles of visibility, the pilot decided to continue to the destination platform, despite having the option to divert to another station. About 1 mile from the platform, as the pilot was maneuvering in an attempt to reduce the airspeed, the helicopter began an inadvertent descent and then entered an aerodynamic buffet that hindered the pilot’s ability to maintain straight and level flight. The buffet was most likely caused by the helicopter entering transverse flow effect (unequal lift vectors between the front and rear portions of the rotor disc) and by a reduction in lift vectors, which resulted from the tailwind that was present. After encountering the buffet, the pilot was unable to maintain control of the helicopter or to stop the helicopter’s descent before it impacted the water. The accident helicopter was equipped with externally mounted floats, which could have been deployed by actuating a trigger mounted on the cyclic. The helicopter was also equipped with two externally mounted liferafts that could have been deployed either by pulling an interior T-handle near the pilot’s left leg or by pulling one of the two externally mounted T-handles on the helicopter’s skid cross bar. According to a supplemental type certificate for the helicopter, a placard was only mounted near the interior T-handle. According to a pilot interview and a written statement obtained by Air Logistics, the pilot did not attempt to activate the helicopter’s flotation system or liferafts before water impact because he was preoccupied with recovering from the buffet. The accident pilot provided no indication why he did not deploy the external liferafts using the internal T-handle when the helicopter entered the water, even though he had received training on external liferaft deployments. Air Logistics’ training program and operating manual expected company pilots to deploy the floats before water impact but did not address pilot expectations in the event of water impact without floats deployed. Lacking additional guidance, the pilot reverted to his water survival training and immediately exited the helicopter. All of the occupants survived the impact, exited the helicopter, and inflated their lifejackets. The pilot was unable to reach the external liferaft T-handles on the skids and attempted to direct the passengers to deploy the liferafts. However, because the pilot had not conducted a passenger briefing (including instructions on how to deploy the liferaft system), the passengers did not know that liferafts were available externally and did not understand how to deploy the liferafts using the external T-handles before the helicopter sank. Under 14 CFR 135.117, the Federal Aviation Administration (FAA) requires pilots to ensure that, before flight, all passengers on flights involving extended overwater operations are orally briefed on ditching procedures and the use of required flotation equipment; however, the accident flight did not meet the 14 CFR 1.1 definition of an extended overwater operation because it was operating within 50 nautical miles of the shoreline. Per the Air Logistics flight operations manual (FOM), a passenger briefing was required that would have included the location of emergency equipment, such as seat belts, exits, lifejackets, and fire extinguishers. The FOM did not specify that liferaft locations were to be part of the briefing.[2] Regardless, no passenger safety briefing was provided before departure. Air Logistics passenger briefing cards, which were stowed in a pouch on the cabin sidewall for each passenger seat, provided directions on how to operate different emergency equipment; however, the briefing cards did not provide guidance on which equipment was installed on the helicopter. In addition, at the time of the accident, there were no placards to aid in recognition of the external liferaft activation handles. The passengers and the pilot attempted to swim to the platform, which was about 100 yards from the impact location, but were separated by high waves and were moved away from the platform by the current. About 1551, an Air Logistics radio operator mistakenly recorded the helicopter as “landed” in the company’s flight-following database. Because the helicopter was placed in the “landed” status, the flight-tracking program did not trigger any overdue notifications. About 34 minutes later (1 hour after the crash), the error was discovered by the Air Logistics base manager in Venice, Louisiana, because the pilot had not reported his status before sunset. As a result, the company diverted a field boat toward the offshore platform to search for the helicopter; however, the field boat was too far away to aid the survivors. The weather conditions precluded the launch of another helicopter to assist in the search. About 1 hour 15 minutes after the crash, the crewmembers of a shrimp trawler contacted the U.S. Coast Guard to report that they had retrieved two survivors and a deceased passenger from the water. The water temperature near the accident location was about 49 degrees Fahrenheit, and the passenger died of hypothermia secondary to asphyxia from drowning. A Coast Guard ship rescued the severely hypothermic pilot more than 4 hours after the estimated time of the crash. The pilot did not report engine power loss or control malfunction. The passengers did not report seeing any warning lights or hearing any aural warnings before the accident. An examination of the airframe and engine did not reveal any anomalies that would have precluded safe flight or the production of engine power. On October 20, 2008, the NTSB issued two recommendations pertaining to this accident. Safety Recommendation A-08-83 asked for the installation of a placard for each external T handle on turbine-powered helicopters with externally mounted liferafts that clearly identifies the location of and provides activation instructions for the handle. Safety Recommendation A 08-84 recommended that all operators of turbine-powered helicopters be required to include information about the location and activation of internal or external liferafts in pilot preflight safety briefings to passengers before each takeoff. Both recommendations are classified “Open—Response Received.” Safety Recommendation A-07-88, which the NTSB issued on October 19, 2007, also applies to this accident. In the recommendation, the NTSB asked the FAA to require that all offshore helicopter operators in the Gulf of Mexico provide their flight crews with beacon-equipped personal flotation devices; Safety Recommendation A-07-88 is currently classified “Open—Acceptable Response,” based on the FAA’s plan to consult with operators on the best ways to increase the chance of survival in a ditching and the issuance of an information for operators that describes recommendations to mitigate the risks and hazards for helicopters that may have to ditch in the Gulf. As a result of the accident, Air Logistics has initiated a program requiring that each pilot be provided a lifejacket equipped with a 406-megahertz emergency position indicating radio beacon that has full two-way voice capability and that is waterproof to 10 meters. This program requirement is consistent with the intent of the recommendation even without the FAA requiring it. Additionally, personal locator beacons (without two-way voice capability) have been installed in Air Logistics liferafts. Air Logistics also has started installing water-activated switches on the flotation system and liferafts for its Bell 407 helicopters; the switches are being installed during each helicopter’s next maintenance or inspection visit. Placards have also been placed on the underside of aircraft showing the mechanism for manual deployment of liferafts when the aircraft is upside down in the water. To standardize the briefing information given to passengers, the preflight briefing checklist, passenger briefing cards, and passenger briefing tapes have been revised to include information on the location and operation of liferafts. In addition, the company produced an initial and recurrent training video to include more detailed information on how to deploy the flotation system and liferafts installed on its helicopters, including footage of an actual deployment, and has revamped its aircraft type-specific briefing videos for passengers. The training and briefing videos are shown to all first-time passengers before they depart their shore base. Air Logistics also has a separate video specifically on raft and float deployment, which includes manual deployment from outside the aircraft; according to the company, this video usually runs continually in the waiting rooms at the shore base. Thus far, Air Logistics pilots and passengers have given positive feedback on the training and briefing videos. To address the problem of misreporting helicopter status, a senior company pilot now assists the radio operator with oversight of helicopters, and helicopter pilots are required to provide position reports every 30 minutes, regardless of whether their helicopter is airborne or has landed. The radio operator and the senior pilot monitor any pilot who requests a longer delay to eat lunch or take a restroom break, for example. Also, to eliminate inadvertent changes in helicopter status, an additional keystroke has been added to confirm that a helicopter has landed.
HISTORY OF FLIGHT On December 29, 2007, at 1535 central standard time, a Bell 206L1, N211EL, operated by Air Logistics LLC., impacted water during an approach to the offshore platform South Pass 38 in the Gulf of Mexico. One passenger was fatally injured, the commercial pilot sustained serious injuries, and two other passengers received minor injuries. The flight originated from offshore platform Chandeleur 63 at 1502 and was destined for South Pass 38, both in the Gulf of Mexico. Visual meteorological conditions prevailed and a company flight plan was filed for the Title 14 Code of Federal Regulations Part 135 on-demand air taxi. Interviews conducted with the pilot revealed that while en route to South Pass 38, weather was estimated to be approximately 500 feet and 5 miles visibility. When the pilot approached the platform, weather degraded to approximately 300 feet and 1 statute mile visibility. The pilot descended and elected to continue an approach to South Pass 38 despite violating company designated weather minimums of 500 feet and 3 miles visibility. At approximately 1 mile from the platform, the pilot maneuvered the helicopter "to the right and left" during the approach in an attempt to slow the helicopter. The pilot planned to circle to right of the platform and land into the wind. With a prevailing tail wind, the pilot slowed the helicopter through 20 to 25 knots and began descending. The pilot stated that he could not sense how fast the helicopter was descending and began feeling vibrations through the controls. Forward cyclic was applied and the pilot pulled the collective to add power and started a slight left turn to straighten the helicopter. The vibrations became stronger and the pilot was attempting to recover the helicopter when it impacted the water. No attempt was made to deploy the external skid-mounted floats. All personnel survived the impact and were able to egress the helicopter. The external-mounted life rafts were not deployed prior to the helicopter sinking. The survivors attempted to individually swim to the landing platform but were not successful. Fishing boats and the United States Coast Guard (USCG) rescued all the survivors. Two passengers were recovered after approximately two and one-half hours in the water. One passenger sustained fatal injuries from drowning and hypothermia. The pilot was recovered last having been in the water over four hours. PERSONNEL INFORMATION The pilot, age 49, held a commercial pilot license with helicopter land, helicopter instrument, airplane single-engine land, and airplane instrument ratings. In addition, the pilot held a flight instructor license with helicopter, helicopter instrument, airplane single-engine land, and airplane instrument ratings. A second-class airman medical certificate was issued on February 13, 2007 with no restrictions. The pilot began New Hire training on June 13, 2007. Helicopter Underwater Egress Training (HUET) and water survival training were both accomplished on June 21, 2007. On July 16, 2007, the pilot completed all of the operator's initial operating experience requirements and was permitted to conduct operations in the Gulf of Mexico. At the time of the accident the pilot reported having accumulated 2,877 total hours, 2,480 hours of rotorcraft time with 303 hours in the same make and model as the mishap helicopter. The pilot was scheduled on a seven days on then seven days off schedule. The accident flight occurred on day three of his rotation. According the company flight records, the day prior, December 28, was the first time that the pilot landed at and departed from South Pass 38. On this day the pilot also chose not to continue to another destination due to weather below company minimums. The pilot was involved in a previous accident on May 28, 2006, which involved a Robinson R-22 which was substantially damaged when the helicopter settled with power during a taxi demonstration. This accident was investigated by the NTSB under accident number NYC06CA125. The pilot informed Air Logistics of his previous accident during the hiring process. AIRCRAFT INFORMATION The 7-seat, single-engine helicopter, serial number 45251, was manufactured in 1979. The helicopter was equipped with skid-mounted Apical floats with two externally mounted life rafts. At the time of the accident, the airframe had accumulated approximately 23,767 hours. The helicopter was powered with a 500 horsepower Allison 250-C-28 turbo shaft engine, serial number CAE 860088. The engine had accumulated approximately 15,504 hours with 1,002 hours since major overhaul. The last inspection performed was an Approved Airworthiness Inspection Program (AAIP) conducted on December 19, 2007 at an airframe total time of 23,732.4 hours. The helicopter had flown 35 hours since this inspection. The Apical emergency floats with life raft system complied with Supplemental Type Certificate (STC) Number SR 01535 LA. The installed Apical system allowed for activation of the floatation systems through one pressure activated lever for the emergency floatation system located on the cyclic, one internal switch on the center console for the external life raft system, and two red handles located on both forward struts of the skids to activate the external life raft system. Placards are not required to assist in informing personnel how to deploy the life raft system when near the external handles. A graphical depiction of external float activation was provided on the company's passenger safety card. METEOROLOGICAL INFORMATION At 1500, an Air Logistics weather alert was issued informing pilots that showers continued to diminish but that ceiling and visibility remain "a concern." Ceilings of 600 feet were reported south of Fourchon and visibility as low as 4 statute miles in heavier downbursts. There is no record of the pilot obtaining this weather alert. The water temperature in the area of the accident was approximately 49 degrees Fahrenheit. COMMUNICATIONS The accident flight was conducting operations under flight following by Air Logistics. The system consists of tracking and monitoring using several programs with radio transmissions and telephone calls to communicate flight information. Flight following is located at Air Logistic headquarters and is staffed with six radio operators who are scheduled to work 0600-1800. Sky Connect utilizes 66 Iridium low-orbit satellites and on-board "Tracker-SOP" helicopter components to provide both communications and position reports. The system was configured to provide a position report every three minutes. At 1533:36 an automated report sent a position report along with the flight parameters of 65 knots groundspeed, altitude of 308 feet, heading 202 degrees. No report was made at 1536. Helicopter status is tracked by Air Logistics by utilizing Dataflyt's Flytwatch software. This software roughly works with a three step-process to place a helicopter in either "land" or "check" status. The first step requires the radio operator to select a helicopter to bring up position data. The second requires information to be entered in the appropriate block. The third step is to place the helicopter in either "land" or "check" status. Prior to the accident, placing the helicopter in "check" status would trigger an update request in two hours. In response to the accident, Air Logistics contacted the software vendor and changed the two-hour reminder to 30 minutes and incorporated an additional query screen to prevent controllers from "landing" the wrong helicopter. A written statement prepared by the radio operator was provided to the NTSB by Air Logistics. A radio operator was tracking N211EL as it flew to South Pass 38. When the pilot lifted off from Chandeleur 63, he estimated his landing time at South Pass 38 as 1550. At 1533 the pilot reported that he was within three nautical miles of South Pass 38. At 1551, the radio operator twice queried the pilot of N211EL whether or not the helicopter landed. Several seconds prior another helicopter reported landing. The radio operator recalled having 1EL's data on the screen but must have not completely pressed "ESC" on the keyboard to change helicopters and mistakenly "landed" the wrong helicopter. A review of the flight following database shows a land time of 1551 for helicopter N211EL. When the radio operator twice queried N211EL of landing status, no answer was given. Since the helicopter was placed into a "land" status, no overdue notifications were triggered by the computer Dataflyt program. Despite numerous requests, the radio operator refused to provide any further information. WRECKAGE AND IMPACT INFORMATION An underwater recovery was accomplished on January 4, 2008. The wreckage consisted of the main fuselage to include the forward and aft sections. The main rotor hub assembly was recovered still attached to the helicopter's transmission. Both main rotor blades exhibited overload fractures outboard of the doublers. The tail boom and tail rotor assembly were separated and were not located. SURVIVAL ASPECTS The helicopter impacted the water in a nose-down attitude with a left bank. All personnel successfully inflated their life vests. The helicopter was resting in the water at an angle that precluded the pilot from deploying the external life rafts. The pilot stated that he directed a passenger to deploy the life raft, but the passenger did not understand the pilot's directions. The helicopter remained afloat for approximately one minute before it sank beneath the waves. Since the survivors were approximately 100 yards from the landing platform, one passenger suggested that they should swim to the platform. The pilot agreed and all four attempted to swim to the platform. The high sea state separated the survivors and the current from the Mississippi Delta swept the survivors away from platform. The survivors estimated the wave heights to be 6 to 8 feet high. At 1551, the radio operator who was providing flight following for N211EL mistakenly recorded the helicopter as landed. At 1625, the Base Manager (BM) at Venice, Louisiana, called the landing platform attempting to locate the pilot and then called for information from flight following. At 1650, the BM and Director of Operations (DO) decided to move a field boat to locate the helicopter and pilot with a 90 minute en route time and a 1730 launch time of the night helicopter. At 1703 the night helicopter was alerted. Data available to the DO categorized the platform as being manned, so at 1725 the DO decided not to involve any external agencies and gave the night helicopter the authority to launch. However, due to poor weather, the night helicopter could not launch. At 1747, the operator attempted to reach the pilot by the pilot's personal cell phone and the telephones at South Pass 38. There is no record of whether contact was attempted via the helicopter's Iridium phone. At approximately 1750, one of the survivors spotted a shrimp trawler and yelled for assistance. The United States Coast Guard (USCG) received a MAYDAY call from a shrimp trawler informing the USCG of people found in the water. At 1820, the trawler transmitted the accident information. Air Logistics' Venice Base Manager was notified by a person at a local boat rental of the radio conversation between the trawler and the USCG. Air Logistics contacted the USCG and exchanged information. Both Air Logistics and the USCG launched helicopters but neither could arrive on scene due to bad en route weather. At 1900 a USCG boat arrived and began searching for the pilot. At 1948, the USCG reported finding the pilot. The pilot had been in the water over four hours. TESTS AND RESEARCH In his interview and written statement, the pilot did not report any loss of power or control malfunction. No warning lights or aural warnings were detected by the pilot or left seat passenger during the accident sequence. A surviving passenger who sat in the passenger compartment also reported no aural warnings prior to impact. An examination of the helicopter wreckage and engine was conducted by the NTSB and FAA with the assistance of technical representatives from the airframe and engine manufacturers. During the examination of the helicopter wreckage, flight control continuity was established excluding the tail boom assembly, which was not recovered. Damage sustained to the main rotor blades was consistent with the rotor system being driven with power at the time of impact. No pre-impact anomalies were discovered which would have precluded normal operation of the helicopter. The engine sustained corrosion damage due to salt water exposure. The main rotor drive shaft could not be rotated. All pneumatic, oil, and fuel lines were found secured. The fuel control pointer was noted in the "100%" position. No damage was noted to the impeller of the compressor section. The turbine section was examined and no visual damage was noted. No anomalies were discovered which would have precluded the normal operation of the engine.
The pilot’s decision to continue to the destination landing platform in weather conditions below the company’s weather minimums and his failure to maintain aircraft control during the approach. Contributing to the passenger fatality and the severity of the occupant injuries were the lack of a passenger briefing on how to deploy the liferaft, which was required by the company but not by the Federal Aviation Administration because this flight was not an extended overwater operation; the pilot’s failure to deploy the liferafts; and the company radio operator’s misreporting of the helicopter’s “landed” status, which delayed the rescue response.
Source: NTSB Aviation Accident Database
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