# NTSB ANC17LA025: Airbus AS350, N207CH, Juneau, AK, May 23, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: May 22, 2017, 18:05 local (May 23, 2017, 02:05 UTC) - Place: Juneau, AK - Coordinates: 58.584167, -134.62277 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=58.5842&lon=-134.6228&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Minor injuries - Injuries: 4 minor, 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - Parties: Coastal Helicopters, Survey Point Holdings, FAA Juneau FSDO, Airbus Helicopters (Advisor), Turbomeca USA (Advisor), Bureau d'Enquetes et d'Analyses - NTSB case key (mKey): 95235 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC17LA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95235/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95235 - Page: https://openairdocs.org/ntsb/ANC17LA025 ## Probable cause The pilot's decision to depart into an area of degraded visual meteorological and flat light conditions, which resulted in a loss of visual references and subsequent controlled flight into terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Eurocopter France AS350B2, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=8680973), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Perception/orientation/illusion: situational awareness](https://openairdocs.org/ntsb-findings/02022035): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Eurocopter France AS350B2, 1 case](https://openairdocs.org/ntsb-findings/02022035/cases.md?model=8680973), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Eurocopter France AS350B2, 1 case](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=8680973), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Eurocopter France AS350B2, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=8680973), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Eurocopter France AS350B2, 2 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=8680973), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md) - [Personality/attitude: motivation/respond to pressure](https://openairdocs.org/ntsb-findings/02021025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Eurocopter France AS350B2, 1 case](https://openairdocs.org/ntsb-findings/02021025/cases.md?model=8680973), [All aircraft, 53 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Eurocopter France AS350B2, 2 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=8680973), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute: Loss of visual reference](https://openairdocs.org/ntsb-events/402); cases with it: [Eurocopter France AS350B2, 1 case](https://openairdocs.org/ntsb-events/402/sequence.md?model=8680973), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) - [Enroute: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Eurocopter France AS350B2, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=8680973), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis After another company pilot returned to base due to deteriorating weather conditions en route, the instrument-rated commercial helicopter pilot flew to a remote glacier to pick up passengers. Upon departing from the glacier, the pilot encountered deteriorating visibility and flat light conditions. She decided to turn back to the departure point and land to wait for conditions to improve; however, during the turn, the helicopter impacted the featureless, snow-covered terrain and came to rest inverted. The pilot reported no preimpact mechanical anomalies that would have precluded normal operation with the helicopter, and the accident is consistent with the pilot's failure to maintain clearance from terrain while operating in poor visibility and flat light conditions, which obscured features of the terrain and resulted in a loss of visual clues regarding the helicopter's distance from the ground. The operator assigned different weather minimums to each of its pilots depending on their experience level. The accident pilot was classified at the highest experience level and was permitted to fly in conditions as low as 1/2 mile visibility, cloud ceilings 300 ft above ground level (agl), and from remote sites with the potential for white out conditions. The estimated conditions reported from the landing site shortly before the accident included 1 1/2 miles visibility with fog and ceilings about 1,500 ft agl, though previous observations indicated that fog had begun developing about an hour before the accident occurred and that conditions had continued to deteriorate since that time. Though the reported weather conditions were above the minimums specified by the company's operations manual, it is possible that the pilot felt pressure to complete the flight given that she was classified as more experienced; it is also possible that the pilot and/or operator felt pressure to conduct the flight because there were no formal procedures in place in the event that passengers were required to remain on the glacier for an extended time due to a contingency such as weather conditions that prohibited flight. ## Factual narrative HISTORY OF FLIGHT On May 22, 2017, about 1805 Alaska daylight time, an Airbus AS350 B2 helicopter, N207CH, was substantially damaged when it collided with snow-covered mountainous terrain after departing a remote landing site on the Herbert Glacier, about 21 miles north of Juneau, Alaska. The commercial pilot and three passengers sustained minor injuries; three additional passengers were not injured. The helicopter was registered to and operated by Coastal Helicopters Inc. as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand air taxi flight. Degraded visual meteorological conditions were reported on the glacier at the time of the accident, and company flight following procedures were in effect for the flight, which originated from Juneau International Airport (JNU), Juneau, Alaska, at 1743. The purpose of the accident flight was to transport five cruise ship passengers who had completed a dogsledding shore excursion and one musher back to the operator's headquarters at JNU. The operator was contracted to provide helicopter transportation to and from the glacier where the dogsledding was conducted (known as "dog camp"). The accident passengers had been transported to the dog camp in the accident helicopter by another pilot. The pilot then returned to JNU, where he picked up another set of passengers to transport back to the glacier. The accident helicopter was one of a flight of two company helicopters that departed for the glacier. While en route, the pilot noted deteriorating weather conditions "moving up the glacier" that consisted of "swirling clouds." The pilot reported the conditions via radio to the operator's headquarters, then the pilots of both helicopters elected to return to JNU. Upon landing, the passengers disembarked, and the two pilots were replaced by other company pilots, who were permitted to fly in lower weather conditions; the two helicopters then departed empty to pick up the passengers on the glacier. The accident pilot stated that en route, the cloud ceilings and visibility were "really good," and she noted a "few clouds moving around" as she neared the glacier. After landing at the dog camp and boarding passengers, the other helicopter departed first, followed by the accident helicopter. The pilot reported that she took off and proceeded down the glacier; about 3/4 mile from the camp, she noted an area of fog along the intended route of flight and chose to return to the dog camp to wait for conditions to improve. She turned the helicopter toward a rocky area in order to maintain visual contact with the ground when, during the turn, the helicopter impacted snow-covered, featureless terrain and came to rest inverted. One passenger reported that he "could not see anything" as the helicopter departed "because of the thick fog." Another passenger described seeing "white everywhere" and stated that "you couldn't tell the sky from the ground." FLIGHT RECORDERS The helicopter did not carry, nor was required tocarry, a crashworthy flight data recorder. At the time of the accident, the operator did not have a formal flight data monitoring program in place, nor was it required to have one. SURVIVAL ASPECTS After the helicopter impacted terrain, the passenger seated in the far-right seat of the cabin was unable to activate the buckle of the 3-point restraint system to egress from the inverted helicopter. The pilot noticed that the passenger appeared to be disoriented. The pilot used a personal Leatherman multi-tool to cut through the belt material and release the passenger. The passenger then egressed from the helicopter without further incident. ## Aircraft - Registration: [N207CH](https://openairdocs.org/deregistered/N207CH-2019-05-23), registration cancelled 2019-05-23, S/N 2027, built 1987 (OpenAirDocs) - Reported make and model: AIRBUS AS350 (B2) - Registry model: [Eurocopter France AS350B2](https://openairdocs.org/model/eurocopter-france-as350b2) (registry code 8680973) (OpenAirDocs) - Registry engine: [Honeywell LTS101-700D-2](https://openairdocs.org/engine/honeywell-lts101-700d-2) (registry code 33825, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 2027 - Year built: 1987 - Airframe hours: 13838 - Engines: Turbomeca Arriel 1D1 732 horsepower turbo shaft - Damage: Substantial damage - Flight: Part 135 - Operator: Coastal Helicopters, Inc. - Registered owner: Coastal Helicopters, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 8, 2016 - Departed: JNU, JUNEAU, AK - Destination: JNU, JUNEAU, AK - Flight plan: Company VFR - Equipment: ADS-B, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: minor; commercial; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review November 3, 2016; seat: right; restraint: 4-point; flight hours: 3,930 total, 1,772 in this make and model, 3,870 as pilot in command, 128 in the last 90 days, 50 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 60° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: 6,500 ft overcast - Temperature: 54 °F, dew point 52 °F - Altimeter: 29.95 inHg - Observed at: PAJN, 14 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20170522005739A](https://openairdocs.org/incident/20170522005739A), May 22, 2017: Eurocopter France AS350B2, Juneau, AK, Destroyed. Aircraft departed dogsled camp following the right side down the glacier maintaining visual reference with the rock wall. Approximately 3/4 of a mile down the… ## Docket (16 files) The files NTSB released with the investigation on December 3, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95235. 21.3 MB in all. - Weather study (item 1, PDF, 30 pages, 10.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=5529753&FileExtension=pdf&FileName=ANC17LA025%20-%20Juneau,%20AK-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 9 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7002246&FileExtension=pdf&FileName=NTSB%20Form%206120_1_Redacted-Rel.pdf - Record of conversation (passenger) (item 3, PDF, 1 page, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7003431&FileExtension=pdf&FileName=Kristin%20Adam%20ROC-Rel.pdf - Statements (item 4, PDF, 9 pages, 436 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7001516&FileExtension=pdf&FileName=Statements_Redacted-Rel.pdf - Weight and balance information (item 5, PDF, 1 page, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7001732&FileExtension=pdf&FileName=Weight%20and%20Balance%20Sheet-Rel.pdf - Flight risk assessment forms (item 6, PDF, 2 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7000563&FileExtension=pdf&FileName=N207CH%20Flight%20Risk%20Assessment%20Forms-Rel.pdf - Coastal helicopters documents (item 7, PDF, 9 pages, 867 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7002782&FileExtension=pdf&FileName=Coastal%20Helicopters%20Documents-Rel.pdf - Coastal helicopters interview transcripts (item 8, PDF, 189 pages, 777 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7003298&FileExtension=pdf&FileName=Coastal%20Helicopters%20Interview%20Transcripts_Redacted-Rel.pdf - Coastal helicopters additional questions (item 9, PDF, 2 pages, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7002791&FileExtension=pdf&FileName=Coastal%20Helicopters%20Additional%20Questions_Redacted-Rel.pdf - N207CH accident ADS-B data (item 10, CSV, 919 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7003422&FileExtension=csv&FileName=N207CH%20Accident%20ADS-B%20Data-Rel.csv - N207CH accident satellite tracking system data (item 11, XLSX, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7002724&FileExtension=xlsx&FileName=N207CH%20Accident%20Satellite%20Tracking%20System%20Data-Rel.xlsx - Medallion foundation documents (item 12, PDF, 5 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7002255&FileExtension=pdf&FileName=Medallion%20Foundation%20Documents_Redacted-Rel.pdf - FAA interal cargo email (item 13, PDF, 1 page, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7016129&FileExtension=pdf&FileName=NTSB%20Request%2017-221%20FAA%20Answer_Redacted-Rel.pdf - Coastal helicopters Airbus as 350 passenger briefing card (item 14, PDF, 1 page, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7003307&FileExtension=pdf&FileName=Coastal%20Helicopters%20Airbus%20AS%20350%20Passenger%20Briefing%20Card-Rel.pdf - Bea letter (item 15, PDF, 1 page, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7002733&FileExtension=pdf&FileName=BEA%20Letter_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 16, PDF, 2 pages, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7000789&FileExtension=pdf&FileName=Coastal%20Helicopters%20NTSB%20Party%20Member%20Forms_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.