Enterprise, AL, USA
N911GF
EUROCOPTER AS 350 B2
After picking up a patient at a motor vehicle accident (MVA) site, the airline transport pilot of the helicopter air ambulance flight, which was operating under visual flight rules (VFR), departed in dark night instrument meteorological conditions (IMC) to transport the patient to a hospital; a flight nurse and paramedic were also on board. Witness statements, video, and photographs indicated that reduced visibility in fog and mist as well as very-light-to-light precipitation existed at the MVA site, and the nearest weather station, 4 miles away, was reporting a 300-ft ceiling and 3 miles visibility. Radar data indicated that, after takeoff, the helicopter entered a left turn and climbed to 1,000 ft above mean sea level (msl). The rate of turn then began to increase, and, after reaching a peak altitude of 1,100 ft msl, the helicopter began a rapid descent that continued to ground impact. According to the radar data, the flight lasted about 1 minute. A search was initiated when the pilot did not check in with the communications center as required, and the wreckage was located the next morning about 1/2 mile from the departure location. Examination of the accident site and wreckage revealed that the helicopter struck trees and terrain and was highly fragmented. Examination of the wreckage did not reveal evidence of any preimpact malfunctions or failures that would have precluded normal operation of the helicopter. Although the helicopter was not certificated for flight in IMC, it had sufficient instrumentation to operate in the event of an inadvertent encounter with IMC and was equipped with a helicopter terrain avoidance warning system, a night vision imaging system which included night vision goggles (NVGs), and an autopilot. The pilot had about 265 hours experience operating in IMC and had been trained in inadvertent IMC loss of control recovery, but he was not instrument current. Further, he had not been trained or qualified by the operator to fly in IMC. He was likely using NVGs during the flight as one of the first responders who helped load the patient into the helicopter saw the pilot wearing them. Based on the weather conditions, the flight path of the helicopter, and the lack of preimpact failures or anomalies, it is likely that the pilot experienced spatial disorientation after entering IMC and subsequently lost control of the helicopter. To accomplish operational control of its flights, the operator used an operational control center (OCC) that was staffed 24 hours a day by operational control coordinators. According to the operator, the pilot had the final authority and responsibility for decisions relating to safety of flight, and the operational control coordinators were responsible for confirming whether a flight or series of flights could be initiated, conducted, or terminated safely, in accordance with the authorizations, limitations, and procedures in their operations manual, and the applicable regulations. In the case of the accident flight, the operator's required VFR weather minimums were a 1,000-ft ceiling with a flight visibility of 3 miles. The operational control coordinators' role was accomplished by inputting flight data into software programs that would perform automated database queries for pilot currency and aircraft maintenance information and would provide weather information based upon route of flight. Both OCC personnel and pilots had the authority to terminate a flight at any time if required conditions were not met. There were two personnel on duty before and during the time of the accident at the operator's OCC, a trainee operational control coordinator and a senior operational control coordinator. About 1 hour before the helicopter accident, the OCC received notification of the request for the helicopter to respond to the MVA, and the coordinators used a software program called "OCC Helper" to query weather information. Although the coordinates for the location of the MVA provided to the OCC were correct, the format of the coordinates was not the correct format for OCC Helper. Therefore, the OCC Helper software only recognized the MVA site as being near the helicopter's base, which was reporting visual meteorological conditions, and did not show the IMC being reported at weather stations closer to the MVA site. The trainee reported that latitude and longitude format was a common problem with OCC Helper and, at times, required OCC personnel to reformat the latitude and longitude coordinates to get the coordinates to work in OCC Helper. On the night of the accident, the incorrectly formatted latitude and longitude for the MVA site were not corrected in OCC Helper until after the helicopter had departed its base en route to the MVA site. Given the IMC weather conditions being reported, which were below the required VFR weather minimums for the flight, the OCC coordinators should have provided the pilot with additional weather information after they had correctly input the coordinates of the MVA site into the OCC Helper software; however, they did not do so. The lack of monitoring of the flight by the OCC through direct human interaction due to overreliance on mission support software and other automated aids, and the incorrectly interpreted latitude and longitude information by both the software and the operational control coordinators resulted in a loss of operational control. Although the software formatting issues were known, there was no standard operating procedure to mitigate the problem. The pilot had access to internet-based weather information at the helicopter's base, but it is unknown what weather information the pilot reviewed before beginning the flight to the MVA. However, text messages between the pilot and a friend and between the flight nurse on the accident flight and the same friend indicated that the pilot was aware of the possibility of encountering IMC before he departed the base for the MVA site. Further, after landing at the MVA, the pilot would have been aware that the weather conditions at the site were below the company's VFR weather minimums. Given the weather conditions at the MVA site, the pilot should have canceled the flight or, at a minimum, contacted the OCC to obtain updated weather information and guidance. However, the pilot's fixation on completing the mission probably motivated him to depart on the accident flight in IMC, even though significantly less risky alternatives existed, such as canceling the flight and transporting the patient by ground ambulance.
HISTORY OF FLIGHT On March 26, 2016, about 0018 central daylight time, a Eurocopter AS350 B2, N911GF, impacted trees and terrain near Enterprise, Alabama. The airline transport pilot, flight nurse, flight paramedic, and patient being transported were fatally injured. The helicopter, which was registered to Haynes Life Flight LLC and operated by Metro Aviation, Inc., was substantially damaged. The flight was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135 as a helicopter air ambulance flight. Night instrument meteorological conditions (IMC) prevailed for the flight, which operated on a company visual flight rules (VFR) flight plan. The flight departed from a farm field near Goodman, Alabama, about 0017, and was destined for Baptist Medical Center Heliport (AL11), Montgomery, Alabama. According to the Coffee County Sheriff's Office, on March 25, 2016, about 2309, sheriff's deputies and the Enterprise Rescue Squad were dispatched to a motor vehicle accident (MVA) near Goodman, Alabama. A sheriff's deputy contacted Haynes Ambulance Communication Center (HCC) by cellular phone when he learned that the motor vehicle was overturned and that an unconscious victim was inside. According to communications records, HCC received the call from the deputy at 2319:10. The pilot of the helicopter, was notified at 2320:38. The helicopter, which was known as "Life Flight 2" and was based at the Troy Regional Medical Center, Troy, Alabama, departed Troy at 2326:57 and arrived at the landing zone (LZ) in a farm field adjacent to the MVA site at 2353:15. Witnesses stated that, after touchdown, the pilot remained in the helicopter with the engine running. The flight paramedic and flight nurse exited the helicopter and entered the Enterprise Rescue Squad ambulance to help prepare the patient for transport. Once the patient was ready for transport, the flight nurse, flight paramedic, and several other emergency responders rolled the gurney about 70 yards through a grassy area to the helicopter and loaded the patient on-board. One of the first responders later reported that he noticed that the pilot had something over his eyes "like sunglasses, but it was square looking." Once the patient had been loaded, the flight nurse and flight paramedic also boarded, and, at 0016:45, the helicopter lifted off and turned north toward AL11. Review of radar data provided by the United States Army from the approach control radar site at Cairns Army Airfield (OZR), Fort Rucker, Alabama, located about 13 nautical miles east of the accident site, indicated that, the helicopter was first identified on radar after takeoff at 0017:35. The helicopter was in a shallow left turn and climbing to 1,000 ft above mean sea level. At 0018:04, the rate of turn began to increase and continued to increase over the next 4 seconds when the helicopter reached a peak altitude of 1,100 ft. The helicopter remained at this altitude and continued the left turn until 0018:28 when the helicopter began a rapid descent. Five seconds later, radar indicated that helicopter had descended through 600 ft. Moments later, the helicopter descended below the floor of the radar coverage area, and radar contact was lost. According to the radar data, the flight lasted about 1 minute. According to HCC, the helicopter's on-board Skyconnect satellite tracking system updated every 3 minutes, and the pilot was supposed to contact them every 15 minutes. However, after the helicopter lifted off, HCC did not receive the pilot's normal 15-minute check-in, and, when they checked the satellite tracking system, it showed that it had not updated and that the helicopter was still at the LZ. HCC then began to notify authorities that they believed that the helicopter was down somewhere. About 0700, after an extensive search, search parties began to smell what they believed was jet fuel and eventually located the wreckage in a swampy, heavily wooded area. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA), Metro Aviation, and pilot records, the pilot held an airline transport pilot certificate with a helicopter rating and type ratings for the Agusta Westland AB-139 and AW-139. He also held a flight instructor certificate with ratings for helicopter and instrument helicopter. The pilot was hired as a flight instructor in June 2009 by Helicopters of America. He then became their lead flight instructor and worked for them until September 2009 when the company ceased operation. He was then hired by Cloud 9 Helicopters, where he became senior flight instructor. On April 14, 2011, he was hired by Petroleum Helicopters International (PHI). When hired by PHI, he had accrued 2,448 total hours of helicopter flight experience and had flown the R22, R44, H269, AS355, MD500, MD600, and A109. At PHI, he flew the AW139 as both a first officer (co-pilot) and a captain (pilot) in both visual flight rules (VFR) and instrument flight rules (IFR) operations. During his tenure at PHI, he accrued an additional 1,889.63 flight hours supporting oil and gas contracts until he left their employment on November 16, 2015. At the time of the accident, the pilot had been employed by Metro Aviation for about 6 months and had accumulated 90 hours of flight experience in the accident helicopter make and model since he was hired. His total flight experience was 5,301 hours of which 5,265 hours were as pilot in command, 474 hours were at night, and 265 hours were in actual instrument conditions. His flight experience during the 90 days before the accident was 47 hours, including 20 hours in the 30 days before the accident. Review of Metro Aviation/PHI training records indicated that he had received training in human factors and decision-making, night operations, night vision goggles (NVGs), and inadvertent entry into IMC. He did not meet currency requirements for flight in IMC at the time of the accident. AIRCRAFT INFORMATION The helicopter was manufactured in 1998. It was equipped with a three-blade main rotor system and a two-blade tail rotor system and was powered by a Turbomeca Arriel 1D1 engine rated at 641 shaft horsepower. The helicopter was equipped with skid-type landing gear, a night vision imaging system (NVIS), which consisted of NVGs and NVG-compatible lighting, a helicopter terrain avoidance warning system (HTAWS), and an autopilot. The helicopter was not certificated for flight in IMC. According to Metro Aviation, the helicopter was maintained under an FAA-approved aircraft inspection program. The helicopter's most recent inspection was completed on February 12, 2016. At the time of the accident, the helicopter had accrued 8,923.2 total hours of operation. METEOROLOGICAL INFORMATION Videos, Photographs, and Witness Information Witness statements indicated that fog, mist, and reduced visibility existed at the MVA site at the time of the helicopter's arrival. Witness statements, photographs, and videos also indicated that these conditions were still present when the helicopter lifted off about 23 minutes later. Review of witness videos and photographs of the accident flight revealed that, during the takeoff sequence, very light to light precipitation was falling in the field surrounding the helicopter. The precipitation was also visible in the helicopter's landing light beams directed forward from the helicopter. According to one witness, there was slight drizzle around the time of the takeoff, and, although there was no ground fog, there may have been fog above the trees. Another witness stated that there was a heavy mist, and the ceiling was "very low, maybe 100 foot." This witness also stated he could see the tops of the trees, and, by shining his flashlight up, he could easily tell that the fog started about two to three times as high as the nearest tree. Another witness stated that, at the time of the helicopter's departure, the fog was mixed with rain and was "kind of pretty thick." This witness also mentioned that the helicopter flew over the road, which was not far from the LZ, and the witness lost visual contact with the helicopter due to the fog. Surface Analysis Chart The National Weather Service (NWS) Surface Analysis Chart for 0100 depicted a stationary front that stretched from the northeastern Gulf of Mexico north-northeastward into southeastern Alabama and northeastward into western South Carolina. A low-pressure center was located in eastern Alabama. The station models around the accident site depicted air temperatures in the low to mid 60's degrees Fahrenheit (°F), with temperature-dew point spreads of 1°F or less, a southeast to east wind below 10 knots, cloudy skies, and fog. Areas near frontal boundaries with low temperature-dewpoint spreads at the surface are typically locations conducive to the formation of low clouds and fog, and, if enough moisture is available, precipitation can also be present. Surface Observations Enterprise Municipal Airport (EDN), located 4 miles east-northeast of the accident site, was the closest official weather station to the accident site and had an Automated Weather Observing System (AWOS). EDN weather at 0015 was reported as wind from 120° at 4 knots, 3 miles visibility, drizzle, an overcast ceiling at 300 ft above ground level (agl), temperature of 17°C, dew point temperature of 17°C, and an altimeter setting of 29.97 inches of mercury. EDN weather at 0035 was reported as wind from 120° at 4 knots, 3 miles visibility, drizzle, an overcast ceiling at 300 ft agl, temperature of 17°C, dew point temperature of 17°C, and an altimeter setting of 29.97 inches of mercury. Observations from other stations near the accident site also indicated low instrument flight rules (LIFR) conditions due to ceilings below 500 ft agl at the accident time. Satellite Data Visible and infrared images obtained from the Geostationary Operational Environmental Satellite number 13 indicated abundant cloud cover over the accident site at the time of the accident. The cloud tops near the accident site were moving from southwest to northeast. Based on the brightness temperatures above the accident site and the vertical temperature profile, the cloud-top heights over the accident site were about 16,000 ft at 0115. Radar Imagery Information The closest NWS Weather Surveillance Radar-1988, Doppler (WSR-88D) was located 28 nautical miles east-northeast of the accident site at an elevation of 434 ft, at Fort Rucker, Alabama. The WSR-88D base reflectivity images indicated very light precipitation between AL11 and the automobile accident site before 2320 on March 25. The very light to light precipitation continued to form, increase in area coverage, and move over the automobile accident site while the helicopter was en route and while the helicopter was on the ground loading the patient. The accident flight likely took off in drizzle or light rain conditions, and these precipitation conditions persisted through the accident time. Airmen's Meteorological Information Airmen's Meteorological Information (AIRMET) Sierra for IFR conditions due to mist was issued at 2145 on March 25 and was valid at the accident time. There was another AIRMET Sierra for IFR conditions due to mist and precipitation that was also valid just east of the accident site for portions of Georgia and northwestern Florida. These AIRMETs were valid at the time flight notification at 2321 on March 25 all the way through the accident flight time. Terminal Aerodrome Forecast (TAFs) OZR and Dothan Regional Airport (DHN), Dothan, Alabama, located XX miles and XX miles from the accident site, respectively, both had TAFs that forecast IFR or LIFR conditions at the accident time, and both OZR and DHN TAFs were issued well before the time the pilot was notified of the mission. National Weather Service Discussion The National Weather Service Office in Tallahassee, Florida, issued an Area Forecast Discussion (AFD) at 1929 on March 25 for the area surrounding the accident site. The aviation section of the AFD mentioned that IFR conditions would be present at all airports overnight with improving conditions by the daytime on March 26. Astronomical Data Moonrise occurred at 2103 on March 25. The phase of the moon was waning gibbous with 91% of the moon's visible disk illuminated. . For further details concerning meteorological information, refer to the Meteorology Report in the public docket for this accident investigation. WRECKAGE AND IMPACT INFORMATION Accident Site Examination Examination of the accident site revealed that the helicopter had struck trees about 1/2 mile north of the motor vehicle accident site. A debris path ran from south to north at a downward angle of about 45° through the trees and led to the helicopter. Airframe and Rotor System Examination The wreckage was heavily fragmented with only the aft fuselage being easily recognizable. The fuel tank was broken open, and the smell of jet fuel was present. The engine and transmission were separated from their mounts. The main wreckage was resting at the base of a large tree, and other 80-ft- to 100-ft-tall trees along the debris path exhibited impact damage and evidence of blade strikes. Examination of the main rotor blades (MRBs) indicated that the main rotor was under power during the accident sequence, and the blue and red MRBs were broken in mutual locations. The tail boom displayed a right horizontal bend mid-span; the right horizontal stabilizer and the tail rotor remained attached to the tail boom. Control continuity and rotation were confirmed from the tailrotor to the aft bulkhead. The left horizontal stabilizer was separated from its mounting location. The tail rotor pedals were separated from their mounting locations. Tail rotor pedal control continuity through the tail rotor flex ball cable was confirmed. Continuity was confirmed through the transmission, and all three main rotor actuators (left roll, right roll, and pitch) and the tail rotor actuator were identified along with their associated hardware. No abnormalities with hydraulic servo integrity were noted, and all push-pull tubes and mixing unit actuators were broken and exhibited signatures consistent with overload signatures. Main Rotor Actuators Examination The left roll actuator remained attached to the stationary star by its rod-end bearing, and the other two main rotor actuators were detached and torn from the stationary star and rod-end bearings. The right roll actuator adaptor casing showed an approximately 2.5-inch break from the threaded attachment fitting to the stationary star. All main rotor actuator servo input rods remained attached to the rotor mast casing and could be moved by hand in and out of each adaptor casing. All three servo input rods showed evidence of bending. All three main rotor accumulators were intact with the right roll and left roll accumulators showing slight dents on their outer surfaces. Pressure from each of the main rotor accumulators was released via its Schrader valve. At least 120 psi of pressure was released from each accumulator, indicating the accumulators were normally charged. Tail Rotor Actuator Examination The tail rotor actuator unit was still attached to the airframe, the servo accumulator, and the load compensator. The hydraulic input and return lines exhibited evidence of hydraulic fluid being present. The tail rotor accumulator was intact and released 50 psi of pressure via its Schrader valve, indicating the accumulator was normally charged. Attitude Indicator and Directional Gyro Examination The attitude indicator was disassembled and examined. The gyro showed rotational scoring on the inner and outer housings consistent with rotation at the time of impact. The directional gyro was also disassembled and examined. The gyro showed scoring on the inner and outer housings consistent with rotation at the time of impact. Fuel Filters Examination The helicopter was fitted with a standard engine fuel filter attached to the fuel control unit and an aftermarket airframe fuel filtering system. Both fuel filter housing units were clean and free of debris. Both filters also appeared to be clean and unobstructed. E
The pilot's decision to perform visual flight rules flight into night instrument meteorological conditions, which resulted in loss of control due to spatial disorientation. Contributing to the accident was the pilot's self-induced pressure to complete the mission despite the weather conditions and the operator's inadequate oversight of the flight by its operational control center.
Source: NTSB Aviation Accident Database
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