Green Cove Springs, FL, USA
N5016M
BELL 206B
The pilot, who was SK Jets’ president, owner, and director of operations, received a call from one of his company schedulers about 0335, notifying him about a trip for his largest customer to transport a doctor and a medical technician from Mayo Clinic Heliport, Jacksonville, Florida, to Shands Cair Heliport, Gainesville, Florida, to procure an organ for transplant. To prepare for this flight, the pilot reviewed aviation routine weather reports (METARs) and terminal area forecasts (TAFs) on the Internet; however, he did not obtain a standard weather briefing from a Federal Aviation Administration-approved source. At the time of his review of the METARs and TAFs, weather conditions near the departure heliport were visual meteorological conditions (VMC), with visibility of 10 miles and a broken cloud ceiling at 7,000 feet. Weather conditions were also VMC near Shands Cair Heliport, with visibility of 6 miles and a broken cloud ceiling at 1,600 feet. A TAF included a temporary condition during the estimated time of arrival near Shands Cair Heliport of instrument meteorological conditions (IMC) with visibility of 4 miles in mist and an overcast cloud ceiling at 400 feet. Just before the accident flight, the helicopter completed a short, uneventful repositioning flight from the operator’s home base at a nearby airport to Mayo Clinic Heliport. During that flight, although the helicopter initially climbed to about 1,000 feet above ground level (agl), it then flew between 700 and 900 feet agl, possibly due to a low cloud ceiling. About 0537, the helicopter picked up the doctor and medical technician at Mayo Clinic Heliport, departed, and proceeded southwest, flying a track slightly south and east of a direct course to Shands Cair Heliport. The pilot likely selected this route of flight so that he could navigate by landmarks and fly low in order to stay out of clouds. The pilot contacted an air traffic controller 4 minutes before the accident to ask about the status of restricted airspace, which he learned was inactive at the time. The transmissions were routine, and there was no evidence that the pilot or helicopter were experiencing any problems. During the en route portion of the 17 minute accident flight, the helicopter’s altitude varied between about 450 and 950 feet agl. The helicopter’s airspeed was about 100 to 110 knots. The last three radar returns were consistent with a right turn of about 45 degrees and a 300-foot descent, which placed the helicopter on a near-direct west course to Shands Cair Heliport at an altitude about 450 feet agl. The accident site was located about 1/2 mile south of the last radar return, with a southerly debris path, consistent with a significant change in course and left turn with a continued descent. The 320-foot-long straight debris field, with descending cuts into trees, was indicative of substantial forward speed at the time of impact. Examination of the wreckage revealed no evidence of any preimpact failures or malfunctions of the engine, drive train, main rotor, tail rotor, or structure of the helicopter. Additionally, there was no indication of an in-flight fire. The accident helicopter was not certified for instrument flight rules (IFR) flight and did not have an autopilot or radar altimeter. Further, the helicopter’s global positioning system did not have an optional modification that would have included a terrain and obstacle warning feature. The operator’s general operating manual (GOM) noted that unless otherwise approved by the director of operations or chief pilot, the weather minimums for visual flight rules (VFR) flight in a helicopter at night were a 1,000 foot cloud ceiling and 3-mile visibility. The GOM did not address whether the pilot, as director of operations, could approve himself to deviate from the night VFR minimums in a helicopter. All weather information suggests that there were areas of both VMC and IMC along the route of flight. The recorded weather near Mayo Clinic Heliport about 16 minutes after departure, when the helicopter was nearly halfway between Mayo Clinic Heliport and Shands Cair Heliport, included a broken cloud ceiling at 700 feet. Further, airmen’s meteorological information (AIRMET) Sierra was in effect at the time of the accident and indicated the potential for IFR conditions with mist and fog covering the route of flight and accident site. Although the pilot likely did not receive this AIRMET, the pilot did receive the information about the TAF indicating possible IMC. A former company helicopter pilot familiar with the flight route described the accident area as susceptible to fog due to swampy terrain and indicated that once fog develops (which would obscure the ground and surface features), the area was a “black hole” at altitudes of 200 to 400 feet agl, and a flight was effectively in IMC in these circumstances. During postaccident interviews, other company pilots stated that they would have accepted the trip based on weather reports presented but would have arranged a backup plan, such as ground transportation or transportation by fixed-wing aircraft, if the flight could not be completed. There was no evidence the pilot had arranged such a backup plan in the event that the trip could not be completed as scheduled due to the potential for IMC. (Although SK Jets used a flight risk analysis tool [FRAT] to assess risk of both helicopter and fixed-wing flights, a FRAT form was not recovered for the accident flight. However, had the FRAT form been filled out, it would have shown that the flight was low risk.) The pilot’s financial pressure as the owner of the company likely influenced his decision to continue flight into deteriorating weather conditions. The operator’s business had declined several years before the accident as a result of economic recession. The accident helicopter had been leased days before the accident. The operator’s only IFR certified helicopter, which was the largest customer’s preferred helicopter, had been down for maintenance for 4 months while the operator attempted to secure loans for engine maintenance. The pilot was scheduled to meet with this customer in the coming weeks to obtain clarification about the customer’s requirements. The pilot was also aware that his largest customer had begun identifying other aviation companies that might better fulfill its needs. Thus, the pilot would have been highly motivated to complete trips as requested so that he could demonstrate the reliability of his service. Additionally, due to the economic downturn, the pilot’s company had lost millions of dollars during the 3 years before the accident. Therefore, the pilot likely wanted to make the most of every revenue generating opportunity. Review of the pilot’s medical history revealed a 30-year history of hypertension and several other conditions, including insomnia, all of which were well controlled with medication. A postmortem analysis indicated that the levels of medication for insomnia that were in the pilot’s system at the time of the accident were below the therapeutic range and did not imply impairment. His routine conversation with a controller just minutes before the accident suggests that he was not incapacitated. Regarding the pilot’s work, rest, and sleep history, review of company records revealed that the pilot had not flown in the 7 days before the accident and had spent the previous 2 days with family, celebrating his anniversary and a holiday, indicating that he was not overworked during the days before the accident. The pilot experienced some circadian disruption during the 2 nights preceding the accident. Although he normally awoke about 0630, he awoke about 0800 the day before the accident and about 0330 the morning of the accident, and the accident occurred before his normal waking time. In addition, the pilot had experienced some sleep restriction for 2 nights preceding the accident. He obtained about 5 hours of sleep during each of those nights. However, according to the pilot’s wife, the pilot had been a 6 hour a night sleeper for the past 50 years and felt well rested on 6 hours of sleep. In addition, he supplemented his nighttime sleep with a 1- to 1 1/2-hour nap during the afternoon the day before the flight. Therefore, the reduction in his recent sleep, compared with his reported sleep need, was very small. Although the pilot likely experienced some fatigue on the morning of the accident because of circadian disruption and reduced sleep, the pilot’s reduction in total sleep was quite low compared to his reported sleep need, and the National Transportation Safety Board was unable to determine the extent to which fatigue might have affected the pilot’s preflight decision-making and performance during the accident flight.
HISTORY OF FLIGHT On December 26, 2011, about 0554 eastern standard time, a Bell 206B helicopter, N5016M, collided with terrain while maneuvering near Green Cove Springs, Florida. The airline transport pilot and two passengers were fatally injured. The helicopter was substantially damaged. The helicopter was registered to Abraham Holdings, LLC, and operated by SK Logistics, doing business as SK Jets, as a 14 Code of Federal Regulations (CFR) Part 135 on-demand air taxi flight. Night instrument meteorological conditions (IMC) prevailed along the flight route, and no flight plan was filed. The flight originated from Mayo Clinic Heliport (6FL1), Jacksonville, Florida, about 0537 and was destined for Shands Cair Heliport (63FL), Gainesville, Florida. Review of the pilot's portable electronic devices revealed that he received a call from a company scheduler about 0335 notifying him about the accident trip. About 0357, he reviewed weather reports for airports near the flight route on his computer. About 0423, he opened a card-activated entrance gate to the SK Jets hangars at Northeast Florida Regional Airport (SGJ), St. Augustine, Florida. According to Federal Aviation Administration (FAA) radar data, the helicopter conducted an uneventful repositioning flight from SGJ to 6FL1. It departed SGJ about 0517 and arrived at 6FL1 about 0530. Although the helicopter initially climbed to 1,000 feet above ground level (agl) during the repositioning flight, it then flew between 700 and 900 feet. After picking up the two passengers, the helicopter departed 6FL1 to the southwest, flying a track slightly south and east of a direct course to 63FL. The pilot contacted Jacksonville Approach about 0549 to inquire about the status of restricted airspace. About 0550, the controller replied that the restricted areas were inactive; the pilot acknowledged the transmission. No further communications were received from the pilot. During the enroute portion of the flight, the helicopter's altitude varied between approximately 450 and 950 feet agl. The helicopter's calibrated airspeed was about 100 to 110 knots. (For more information about the helicopter’s airspeed, see the National Transportation Safety Board’s [NTSB] Radar Study in the public docket for this accident.) The last three radar returns were consistent with a right turn of about 45 degrees and a 300-foot descent, which placed the helicopter on a near-direct course to 63FL about 450 feet agl. The last radar target was recorded at 0553:23, indicating a calibrated airspeed of 81 knots. The accident site was located about 1/2 mile south of the last radar return, with a southerly debris path. According to representatives of the Mayo Clinic Hospital, Jacksonville, Florida, the accident flight was contracted by the hospital to carry a doctor and a medical technician to Shands Hospital, Gainesville, Florida, for the purpose of procuring an organ for transplant. The flight was then to return to the Mayo Clinic Hospital with the procured organ. The flight did not arrive at Shands Hospital and was reported overdue by a Mayo Clinic Hospital representative; the hospital activated local search and rescue operations. The wreckage was located about 1000 in a remote wooded area by the Jacksonville Sheriff's Department Aviation Unit. PERSONNEL INFORMATION The pilot, age 68, was the founder, president, owner, and director of operations of SK Jets. He held an airline transport pilot certificate with ratings for airplane single engine and multiengine land. He also held a commercial pilot certificate and a flight instructor certificate, both with ratings for rotorcraft and instrument helicopter. Additionally, he held type ratings in the Learjet and Learjet 60. His most recent FAA first-class medical certificate was issued on October 5, 2011, with a restriction that he must wear corrective lenses. The pilot learned to fly at age 16 and later flew for the US Army, which included one-and-a-half tours of duty in Vietnam where he earned a Bronze Star, Purple Heart, and Distinguished Flying Cross with Three Oak Leaf Clusters. Review of company records revealed that the pilot had accumulated 11,343 total flight hours, 3,646 hours of which were in helicopters with 1,648 hours in the Bell 206. He had accrued a total of 3,288 hours of night experience and 3,259 hours of instrument experience. The pilot had flown 10.7 hours and 2.5 hours during the 90-day and 30-day periods preceding the accident, respectively, of which 3.1 hours and 1 hour were at night, respectively. None of the flight time during the 90 days preceding the accident was instrument time. The pilot had not flown during the 7-day period preceding the accident. The pilot was involved in a previous accident on December 22, 2007 (NTSB case number MIA08CA040). The accident pilot attempted the flight with three passengers onboard; however, a few minutes into the flight, he turned back and returned to the departure airport due to poor weather. (The ceiling was 400 feet, and the visibility was 2.5 miles.) While returning to the fuel pump area, the helicopter's tail rotor struck trees, resulting in substantial damage to the helicopter. There were conflicting reports about whether the collision happened during approach or taxi. According to current and former employees at SK Jets, a different helicopter pilot had turned down the flight due to the poor weather. Following that accident, the pilot successfully completed an FAA reexamination. Work/Rest/Sleep History According to the pilot's wife, he normally awoke about 0630 every day and went to sleep around 2330 or 0000, whether it was a workday or not. He had been a 6-hour-a-night sleeper for at least 50 years. On Friday, December 23, 2011, the pilot awoke about 0630 and went to the office about 0730. He came home early that day because it was his 50th wedding anniversary. He and his wife went to a nearby resort, arriving about 1500. They had a quiet evening at the resort, ate dinner, and stayed the night. The pilot's wife estimated that he might have fallen asleep about 2330. On Saturday, December 24, 2011, the pilot awoke about 0630, then went back to bed and slept an extra hour. He ate breakfast with his wife at the resort, and they ran an errand. They returned home and then visited the residence of a relative, where they ate lunch. They returned home again about 1620. The pilot engaged in routine activities and took a nap between 1800 and 1900. The pilot and his wife left the house about 2230 and attended midnight services at their church. On Sunday, December 25, 2011, the pilot and his wife returned home from church about 0115, and the pilot went to sleep about 0300. He awoke about 0800 and celebrated Christmas morning. The pilot went for a bike ride in the early afternoon and stopped by the office. He returned home and ate lunch about 1330. The pilot then told his wife he was going to take a nap (beginning about 1600) in case he had to fly that night because another SK Jets helicopter pilot was not going to be available. The pilot's wife was not sure how long he napped, perhaps 1 hour to 1 1/2 hours. After his nap, he got up and engaged in routine activities around the house. He ate dinner and went to sleep between 2230 and 2300 before being awakened by the telephone call about 0335. AIRCRAFT INFORMATION The five-seat, single-engine, two-bladed helicopter was manufactured in 1979 and maintained under an FAA-approved manufacturer's maintenance program. The helicopter's most recent inspection was a conformity inspection, completed on December 1, 2011. At the time of the inspection, the helicopter had accumulated 11,172.5 total hours of operation. The helicopter had flown about 3.5 hours since that inspection until the time of the accident. The helicopter was equipped with a Rolls Royce (Allison) model 250-C20B, 420-shaft horsepower turbine engine. Review of the maintenance records revealed that the engine was overhauled and installed on the helicopter in 2005 at 11,053.5 total engine hours. The engine had accumulated 167.1 hours since the overhaul until the time of the accident. The helicopter was not certified for instrument flight rules (IFR) flight and was not equipped with a radar altimeter or autopilot. The helicopter was equipped with a Garmin GNS 430 global positioning system receiver and a very high frequency omnidirectional range unit with localizer and glideslope indications. However, the Garmin GNS 430 unit installed on the helicopter only had modifications 1 through 5, which do not provide a terrain or obstacle warning function. An upgrade (modification 7) was available for the unit, which would have provided terrain/obstacle warning capabilities. Before the accident flight, the helicopter was fueled with 35 gallons of Jet A aviation fuel, which brought its total fuel load to approximately 58 gallons. METEOROLOGICAL INFORMATION There was no record of the pilot contacting flight service for the accident flight. However, the pilot's laptop computer was located at his residence, and its Internet browser was open to www.aviationweather.gov, with weather data displayed from the Aviation Digital Data Service (ADDS). The data included aviation routine weather reports (METARs) for SGJ; Craig Municipal Airport (CRG), Jacksonville, Florida; and Gainesville Regional Airport (GNV), Gainesville, Florida. The data also included terminal area forecasts (TAFs) for CRG and GNV. The ADDS service was not one of the weather sources approved in the SK Jets operations specifications; however, some company pilots stated during interviews that they used weather sources that were not approved in the general operations manual (GOM) or operations specifications as a supplement to the approved weather. (The GOM indicates to use an FAA-approved weather source.) Review of the laptop computer data revealed that the METAR for the initial departure airport, SGJ, about 0327 reported 10 miles visibility, scattered clouds at 1,700 feet, and a broken cloud ceiling at 7,000 feet. About 0509, about the time of initial departure, the recorded weather at SGJ included 10 miles visibility, a broken ceiling at 900 feet, and an overcast ceiling at 8,000 feet. CRG was located about 7 miles northwest of 6FL1. Review of the laptop computer data revealed that the METAR for CRG about 0353 reported 10 miles visibility and a broken ceiling at 7,000 feet. The recorded weather at CRG about 0553 was wind from 010 degrees at 6 knots, visibility 10 miles, overcast ceiling at 700 feet, temperature 14 degrees C, dew point 13 degrees C, and altimeter 30.22 inches Hg. The METAR for GNV, located about 5 miles northeast of the destination heliport, about 0353 reported 6 miles visibility, mist, and a broken cloud ceiling at 1,600 feet. The TAF at GNV for the accident flight’s estimated time of arrival at 63FL called for wind from 030 degrees at 6 knots, visibility better than 6 miles, and an overcast ceiling at 800 feet. The TAF also included a temporary condition during the estimated arrival time of IMC with visibility 4 miles, mist, and an overcast ceiling at 400 feet. Additionally, data downloaded from the pilot's cell phone revealed that he called the GNV automated surface observing system about 0419. The recorded weather at GNV about 0424 was wind calm, visibility 7 miles, broken ceiling at 1,400 feet, temperature 16 degrees C, dew point 14 degrees C, and altimeter 30.19 inches Hg. The recorded weather at GNV about 0553 was wind 020 degrees at 3 knots, visibility 7 miles, sky clear, temperature 16 degrees C, dew point 14 degrees C, and altimeter 30.21 inches Hg. The accident site was located about 12 miles northeast of Palatka Municipal Airport (28J), Palatka, Florida. The recorded weather at 28J about 0554 was wind 010 degrees at 3 knots, visibility 10 miles, few clouds at 3,800 feet, broken ceiling at 7,000 feet, temperature 15 degrees C, dew point 14 degrees C, and altimeter 30.21 inches Hg. The National Weather Service Surface Analysis Chart for 0700 depicted a stationary front to the south of the accident site, stretching from central Florida westward into the northern Gulf of Mexico. A cold front stretched from eastern Florida northeastward into the western Atlantic Ocean. The station models surrounding the accident site depicted temperatures from the low 50s to low 60s F, with temperature-dew point spreads of 3 degrees F or less, a north wind between 5 and 20 knots, and mostly cloudy skies. Station models along and south of the stationary and cold fronts had temperatures from the low to mid 60s F, with temperature-dew point spreads of 1 degree F or less, a north to northeast wind of 5 to 10 knots, cloudy skies, and fog. Infrared data from the Geostationary Operational Environmental Satellite number 13 was obtained from the National Climatic Data Center and processed with the NTSB’s Man computer Interactive Data Access System workstation. Satellite imagery surrounding the time of the accident, from 0200 through 0800 at approximately 15 minute intervals, were reviewed, and the closest images to the time of the accident depicted a layer of low clouds and stratus over the accident site about 0602. This layer of low clouds and stratus moved southward from 0602 through 0632, covering Keystone Airpark, Keystone Heights, Florida, and approaching GNV and 28J. At the time of the accident, airmen's meteorological information (AIRMET) Sierra was in effect for IFR conditions with mist and fog, which covered the flight route and accident site. AIRMET Sierra was issued about 0345 and valid until 1000. Review of US Naval Observatory Sun and Moon data for the date and location of the accident revealed that the beginning of civil twilight did not occur until 0654 and moonset occurred about 1849 the previous day. A former SK Jets helicopter pilot described the area near the accident site as susceptible to fog due to swampy terrain. He added that once fog developed, the area was a "black hole" at altitudes of 200 to 400 feet agl, and a flight in these circumstances was effectively in IMC. During postaccident interviews, other pilots from SK Jets stated that they would have accepted the trip based on weather reports presented but would have arranged a backup plan, such as ground transportation or fixed-wing transportation, if the flight could not be completed. There was no record of the accident pilot arranging any other transportation relating to the accident flight. Medical personnel reported that the transplant team had a maximum of 4 hours between cross-clamping the heart at the donor hospital and reprofusing it at the recipient hospital, which allowed for a maximum of about 2 1/2 hours for transportation. Additionally, shorter transportation times increased the odds of a successful operation, which made helicopter transportation the preferred method between the two hospitals. The SK Jets GOM, section V, page V-10, paragraph V.14, “VFR [visual flight rules] Helicopter Minimums,” stated, in part, "Unless otherwise approved by the Director of Operations or Chief Pilot, the following weather minimums will be used for VFR flight in the helicopter…Night – 1000 Foot Ceiling and 3 miles visibility." Further review of the GOM did not reveal any restrictions for the accident pilot, as director of operations, to approve himself to deviate from night VFR helicopter minimums. When the company manuals did not dictate limitations, operations were governed by 14 CFR Parts 91 and 135. Title 14 CFR 91.155 stated that no person may operate a helicopter under VFR in Class G airspace at an altitude of 1,200 feet or less above the surface at night unless the flight visibility was at least 3 miles. A helicopter may be operated clear of clouds if operated at a speed that allows the pilot adequate opportunity to see any air traffic or obstruction in time to avoid a collision. Section 135.205 stated that no person may operate a helicopter under VFR in Class G airspace at an altitude of 1,200 feet or less above the surface at night unless the visibility was at least 1 mile. Section 135.207 stated that no person may operate a helicopter under VFR unless that person has visual surface reference or, at night, visua
The pilot’s improper decision to continue visual flight into night instrument meteorological conditions, which resulted in controlled flight into terrain. Contributing to the pilot’s improper decision was his self-induced pressure to complete the trip.
Source: NTSB Aviation Accident Database
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