Sabine Pass, TX, USA
N180AL
BELL 206L-4
The air taxi flight was en route to an offshore drilling platform to drop off passengers. When the helicopter became overdue for its routine position report, the company attempted unsuccessfully to contact the pilot through several means, including radio and telephone. The company conducted an aerial search along the route of flight; however, the helicopter was not located. The company then notified the Coast Guard of the missing helicopter approximately an hour and forty minutes after it became overdue. The wreckage was located 2 miles offshore in 13 to 15 feet of water, along the helicopter's route of flight. An examination of the helicopter airframe, engine, and related systems revealed no anomalies. Damage was consistent with controlled flight into the water. A cold front had just passed through the area several hours prior to the accident. Visible satellite imagery around the time of the accident depicted mid- to high-level cloud layers in the vicinity of the accident location. Breaks in the upper cloud layers depicted low stratus-type clouds within 15 nautical miles of the accident location. AIRMETS for instrument meteorological conditions, turbulence, and icing were valid for the accident area and route of flight. Cloud bases were most likely below 1,000 feet above ground level and visibility was restricted due to mist and possible light snow. The air temperature was recorded at 34 degrees Fahrenheit and the water temperature was recorded at 64 degrees Fahrenheit. There was no record to indicate that the pilot had obtained a formal weather briefing from a recorded source. The pilot held a commercial certificate and an instrument rating; however, he was not approved for instrument flight under Part 135 and was not current. At the time of the accident the company did not have a formal risk assessment program and a formal evaluation of the flight risks was not performed for the accident flight. The pilot normally flew a helicopter in which the flight tracking system engaged when the master switch was turned on; however, the accident helicopter required the system to be activated by a separate switch in the cockpit. This variation was not in the checklist. According to company records, the pilot had been flying the accident helicopter for two or three days prior to the accident. During this time there was no track record for the helicopter, which is consistent with the pilot not activating the helicopter's flight tracking system. The pilot, whose personal flotation device was inflated and secured, suffered severe chest injuries complicated by asphyxia due to drowning. Two passengers were secured within their flotation devices; however, neither flotation device had been inflated. Two passengers were not wearing flotation devices when they were located; however, two personal flotation devices from the accident flight were recovered and showed signatures consistent with use. One had been partially inflated, and the second had been entirely inflated. The 4 passengers suffered asphyxia due to drowning with probable complication of cold water shock and hypothermia. The investigation was unable determine if the company's delay in notifying the Coast Guard contributed to the severity of injuries in the accident.
HISTORY OF FLIGHT On December 11, 2008, approximately 0730 central standard time, a Bell Helicopter 206L-4, N180AL, owned and operated by Rotorcraft Leasing Company L.L.C., was destroyed when it impacted water, six miles south of Sabine Pass, Texas, in the Gulf of Mexico. Instrument meteorological conditions prevailed at the time of the accident. The non-scheduled domestic passenger flight was being conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135, and was operating on a company flight plan. The commercial pilot and four passengers were fatally injured. The cross-country flight departed Sabine Pass at 0722 and was en route to, West Cameron 157, an offshore drilling platform in the Gulf of Mexico. According to officials with Rotorcraft Leasing Company L.L.C. (RLC) the pilot met his passengers, all employees of Island Operating Company, Inc., in Sabine Pass on the morning of the accident. Witnesses observed the pilot preflight and prepare the helicopter for the flight. At 0725, the pilot contacted RLC Communications Center and filed a flight plan from Sabine Pass to West Cameron 157. The pilot reported that he had four passengers and two hours of fuel on board, and expected to arrive at the destination at 0742. RLC’s Communications Center provided flight following services for the accident flight. Company policy required that a 15-minute position report be made for every flight. When the 15 minutes had elapsed (from the time the pilot filed his flight plan until his anticipated position report was due) the dispatcher immediately began to look for the helicopter. She attempted to contact the pilot at the destination platform, and the departure location with no success. The dispatch supervisor was notified of the missing helicopter within eight to 13 minutes of the missed report. Company helicopters in the area were launched in search of the missing helicopter with negative results. According to RLC records, the Coast Guard was notified of the missing helicopter between 0912 and 0913. According to the Coast Guard they were notified of the missing helicopter at 0917. Recovery vehicles were dispatched, and the helicopter wreckage was located approximately 1100 and recovered to Broussard, Louisiana, for further examination. PERSONNEL INFORMATION The pilot, age 43, held a commercial pilot certificate with helicopter and instrument ratings last issued on May 7, 2007. He was issued a second class airman medical certificate on May 20, 2008. The certificate contained the limitation “must wear corrective lenses while flying.” The pilot’s personal flight logbook was not located. According to the pilot’s resume he submitted to RLC in October of 2008, he had logged no less than 3,450 hours total time; 3,390 hours of which were logged in single engine helicopters, and 73 hours in simulated and actual instrument meteorological conditions. RLC flight records reflected the pilot had 220 hours of “offshore” flight experience. RLC hired the pilot on October 10, 2008. According to the company records, he received his initial training in October of 2008. Between the dates of October 13, 2008, and October 22, 2008, he had completed a total of 15.8 hours of flight training in the Bell 206 B and L3 models. The pilot’s airman competency and proficiency checks for CFR 135.293 (Initial and recurrent pilot testing), and 135.299 (Pilot in command: Line checks: Routes and Airports) were completed with a satisfactory rating in all tested areas on October 22, 2008. In addition to his flight training, the pilot successfully completed “Water Survival/Helicopter Underwater Egress Training” on October 20, 2008, at Acadiana Safety Association. According to the “RLC Pilot’s Monthly Summary” flight sheets, the pilot had flown 15.8 hours in October, 42.2 hours in November, and 19.1 hours in December. The pilot had logged no less than 77.1 hours in the Bell 206 while employed at RLC. During interviews with the director of operations, chief pilot, and safety officer, the pilot’s training, experience, and flight ability were discussed. It was elaborated that the pilot had good flight skills and demonstrated good situational control during flight. The pilot had not been involved in any previous events or activities that would have raised question as to his judgment or ability. AIRCRAFT INFORMATION The accident helicopter, a Bell 206-L4 (serial number 52104), was manufactured in 1994. It was registered with the Federal Aviation Administration (FAA) on a standard airworthiness certificate for normal operations. An Allison 250-C30P turbine engine rated at 650 shaft-horsepower powered the helicopter. The helicopter was registered to and operated by Rotorcraft Leasing Company, LLC., and was maintained under an approved inspection program. A review of the maintenance records indicated that the last inspection had been completed on November 30, 2008, at an airframe total time of 6,331.3 hours. The helicopter had flown 28.7 hours between the last inspection and the accident and had a total airframe time of 6,360 hours. METEOROLOGICAL INFORMATION The closest official weather observation station was Southeast Texas Regional Airport (KBPT), Beaumont/Port Arthur, Texas, located 21 nautical miles (nm) north of the accident site. The elevation of the weather observation station was 15 feet mean sea level (msl). The routine aviation weather report (METAR) for KBPT, issued at 0653, reported, winds, 300 degrees at 9 knots; visibility, 10 miles; sky condition, overcast 4,400; temperature 1 degrees Celsius (C); dew point, minus 1 degrees C; altimeter, and 30.01 inches of mercury (Hg). A special report was issued at the approximate time of the accident at 0736, which indicated winds at 300 degrees at 12 knots; visibility, 10 miles; ceiling broken at 1,200 feet, broken at 4,600 feet, and overcast at 12,000 feet; temperature, 1 degree C; dew point minus 1 degree C; and altimeter 30.03 inches of Hg. A review of the observations indicated that a strong cold front moved through during the previous evening producing instrument meteorological conditions with visibility restricted in light rain, mixed freezing precipitation that turned to light to moderate snow, which ended at 0612 with a dusting of snow reported. At the time of the accident, the low pressure system was located to the east in central Alabama with a cold front extending south-southwestward into the Gulf of Mexico, with northwest winds of 30 knots behind the front. The Aviation Weather Center in Kansas City, Missouri, issued the offshore area forecast at 0500 the day of the accident. The forecast for coastal waters, including the accident helicopter’s route of flight, predicted scattered to broken clouds at 1,000 feet, broken clouds at 2,500 feet, with clouds tops at 5,000 feet. The surface winds were forecast to be out of the northwest at 20 to 25 knots. Occasional broken clouds at 700 feet with visibility three to five miles in rain and mist were forecast. The National Weather Service also had a full series of Airman's Meteorological Information (AIRMET) current for the area. AIRMET Zulu for moderate icing conditions from the freezing level to 20,000 feet, AIRMET Tango for potential moderate turbulence below 12,000 feet, and AIRMET Sierra for instrument flight rules conditions with ceilings below 1,000 feet and/or visibility below three statute miles in precipitation and mist. Geostationary Operational Environmental Satellite (GOES) images taken at 0732 and 0745 depicted mid- to high-level clouds in the area of the accident. Breaks in the upper level clouds depicted low-level stratus-type clouds over the Gulf of Mexico in the vicinity of the accident location. A small band of stratocumulus was identified in the immediate vicinity of the accident site, consistent with that associated with more vertical development of clouds capable of producing snow showers. The Lake Charles (KLCH) WSR-88D weather radar did not detect any significant echoes over the accident site. The vertical azimuth display wind profile depicted winds from the north-northwest at 25 knots at 1,000 feet, increasing to 30 knots at 2,000 feet. Water temperature was recorded at 64 degrees Fahrenheit. According to RLC, other flights in the area had been grounded or delayed due to the passing weather. According to a pilot involved in the search and rescue efforts, he encountered northwest winds at 30 knots gusting to 35 knots, a temperature of 40 degrees Fahrenheit (F), visibility greater than 10 miles, and a ceiling of 700 feet overcast. This weather was encountered at the accident site. The pilot had not obtained a weather briefing through the FAA Flight Service Station or by utilizing a Direct User Access Terminal System (DUATS). The pilot was observed utilizing the computer prior to the accident to obtain weather information. WRECKAGE AND IMPACT INFORMATION The accident site was located two miles offshore in 13 to 15 feet of water. The wreckage was recovered and relocated to a secure hangar in Broussard, Louisiana, for further examination. MEDICAL AND PATHOLOGICAL INFORMATION The Southeast Texas Forensic Center, Inc., (Jefferson County Morgue) performed the autopsy on the pilot on December 12, 2008, as authorized by the Justice of the Peace, Precinct 8, Jefferson County, Texas. The autopsy revealed the cause of death as a “crushed chest complicated by asphyxia due to drowning.” The FAA’s Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy (CAMI Reference #200800281001). Results were negative for all tests conducted. The Southeast Texas Forensic Center, Inc., (Jefferson County Morgue) performed the autopsies on the four passengers, as authorized by the Justice of the Peace, Precinct 8, Jefferson County, Texas. The autopsies revealed the cause of death as a “asphyxia due to drowning with probable complication of cold water shock and hypothermia.” SURVIVAL ASPECTS According to RLC, each passenger that flies with their company is required to view a safety video, entitled “Helicopter Passenger Orientation,” prior to participating in charter activities. This video explains how to safely approach a running helicopter, how to fasten and unlatch a seatbelt, and how to wear and activate the personal flotation devices, amongst other safety topics. In addition, each helicopter was equipped with a passenger cabin safety card. This card depicts the same requirements in addition to requirements for deploying the flotation raft. RLC policy dictated that prior to each flight the pilot was to provide a safety briefing that included the location of survival equipment and the use of seat belts, and flotation equipment. Both the pilot and passengers were required to wear personal flotation devices during all phases of over water flight. Finally, most companies who employ RLC for charter purposes provide water survival and helicopter underwater egress training to their employees before they participate in over water operations. The swimming ability of the pilot and passengers was not determined. Seat belts The left front seatbelt assembly separated from the wreckage and was located in the water by the U.S. Coast Guard. The assembly included the right and left shoulder harness, headrest, inertial reel, buckle and right lap belt. The left lap belt remained attached to the door and door frame assembly. The buckle was latched together, securing the shoulder harness portion of the buckle. The right shoulder harness was twisted once. Slight deformation of the shoulder harness webbing was noted. The right front seatbelt assembly separated from the wreckage and was located in the water by the U.S. Coast Guard. The assembly included the right and left shoulder harness, headrest frame, inertial reel, buckle, and right and left lap belt. The buckle was latched together, securing the shoulder harness portion of the buckle. The right shoulder harness was twisted one full turn. A slight dent was noted on the male end of the lap belt. The shoulder harness buckles were deformed inward. Slight deformation of the seatbelt webbing was noted. The left aft-facing seatbelt was unlatched and included the male and female end of the lap belt. The male end of the buckle and shoulder harness remained attached to the door frame. The webbing from the male end of the lap belt was slightly torn. The belt placard was attached but was unreadable. The right aft-facing seatbelt was unlatched and included the seatbelt male and female end of the lap belt and shoulder harness. These remained attached to the fuselage structure. The male end of the lap belt buckle separated from the belt webbing and remained attached to the shoulder harness. Webbing material was frayed and torn within the cinch area of the male end of the buckle. The corresponding lap belt webbing was also frayed and torn. The aft left seatbelt was unlatched and included the male and female lap belt and shoulder harness. The male end of the lap belt buckle separated from the belt webbing and remained attached to the shoulder harness. The male buckle was bent down approximately 30 to 35 degrees. Slight deformation of the material was noted. The aft center seat belt assembly was buckled together securing a personal flotation device. No tearing or material deformation was noted. According to officials with RLC, the personal flotation device is secured in the seatbelt when no one is occupying that seat. The right aft seat belt assembly included the male and female lap belt with the shoulder harness. The assembly was unlatched. Personal Flotation Devices Four personal flotation devices (PFD) were recovered from the water and were arbitrarily labeled A, B, C, and D for identification purposes only. Each PFD was equipped with a whistle and compass, a bottle of sea dye, and an exposure blanket. Each inspection label indicated that the last inspections took place on November 24, 2008. PFD A was located within the aft cabin of the main wreckage. The PFD was found secured with the latched center seat belt as per company procedure. PFD B was partially inflated and entangled within the blue protection cover and activation pull tabs. No apparent tearing of the material was noted. Both CO2 bottles had been deployed. PFD C was partially inflated and entangled within the blue protection cover. The right CO2 bottle had been deployed. The left CO2 bottle was still secure. There was no apparent tearing of the material. The harness was not fastened. The very end of the harness material, containing a yellow flap, had been pulled through to the male end of the harness. PFD D was still contained within the blue protection cover. Neither the right nor left CO2 bottle had been deployed. There was no apparent tearing of the material. The harness was not fastened. Three additional PFD’s were recovered with the pilot and two of the passengers. They were provided to the Safety Board for further examination. The PFD’s were arbitrarily labeled E, F, and G for identification purposes. Each PFD was equipped with a whistle and compass, a bottle of sea dye, and an exposure blanket. Each inspection label indicated that the last inspections took place on November 24, 2008. PFD E was covered with a brownish-red substance, was wet, exuded a strong odor, and was not inflated. The exterior shell, the border of which was secured by a hook and loop fastener that was open along its entire length except for a small area on the top right, housed a yellow flotation bladder. There was no apparent tearing of the material. Neither the right nor the left CO2 inflation canisters had been activated (levers up and tucked into the cylinder housing). PFD F was wet and described as having a blue fabric front cover, a blue mesh back cover, and a yellow flotation bladder. The exterior shell, the border of which was secured by a hook and loop fastener which was open along its entire length. The bladder was fully deflated. The right CO2 inflation canister had been activated (lever down and free movement). The left CO2 canister had not been activate
The pilot’s failure to maintain clearance from the water. Contributing to the accident was the inadvertent encounter with instrument meteorological conditions.
Source: NTSB Aviation Accident Database
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