ANC98FA061

NTSB accident investigation · Aerospatiale AS-350-B2 · Juneau, AK · May 31, 1998

Accident · FatalField investigationFinal report
Date
May 30, 1998, 16:11 local (May 31, 1998, 00:11 UTC)
Place
Juneau, AK
Injuries
2 fatal, 1 serious, 5 uninjured
Phase of flight
Enroute
Aircraft
N187EHAerospatiale AS-350-B2N4948VCessna 172RG
Weather
Visual (VMC) · Day
Status
Completed · report September 28, 1999
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Case key
3093

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of both command pilots to maintain an adequate lookout to see and avoid each other's aircraft. Factors associated with the accident were the pilot's failure to follow published advisory procedures to monitor/issue position reports on the appropriate radio frequency, and his lack of familiarity with the geographic area.

The failure of both command pilots to maintain an adequate lookout to see and avoid each other's aircraft. Factors associated with the accident were the other pilot's failure to follow published advisory procedures to monitor/issue position reports on the appropriate radio frequency, and his lack of familiarity with the geographic area.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Midair collisionCruise
Visual lookout - inadequatePilot in commandCause
Visual lookout - inadequatePilot of other aircraftCause
Traffic advisory - not issuedPilot of other aircraftFactor
Procedures/directives - not followedPilot of other aircraftFactor
Lack of familiarity with geographic areaPilot of other aircraftFactor
Forced landingEmergency descent/landing
Midair collisionCruise
Visual lookout - inadequatePilot in commandCause
Visual lookout - inadequatePilot of other aircraftCause
Traffic advisory - not issuedPilot in commandFactor
Procedures/directives - not followedPilot in commandFactor
Lack of familiarity with geographic areaPilot in commandFactor
Loss of control - in flightCruise
Flight control,aileron - separation
Wing - loss,partial
Aircraft control - not possible
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The air tour helicopter was at 2,100 feet msl, and had just crossed a salt water channel when it collided with the airplane. The helicopter landed with substantial damage, and one injured passenger. The airplane was destroyed when it impacted water in the channel, and both pilot-rated occupants were fatally injured. An 18-inch portion of the airplane's right wing remained attached to the helicopter. None of the occupants of the helicopter saw the airplane prior to collision. The helicopter was on a standard tour route utilized by the company, and published in an FAA advisory pamphlet which the airplane occupants also had on board. The collision occurred at a location where the advised traffic route inbound to the Juneau airport crossed the helicopter's air tour route. The helicopter had completed crossing the channel, and was 100 feet above the upper limit of the recommended altitude for the crossing. The airplane was 100 feet above the lower limit of the recommended altitude for aircraft traveling west. This area has a high volume of VFR air tour, air taxi, and general aviation traffic. The area is uncontrolled, Class G, airspace, with no radar coverage. The helicopter pilot described the visibility as good. The helicopter pilot made traffic advisory radio transmissions on the common traffic advisory frequency (CTAF) for the area of the collision. This frequency was published in the Alaska Supplement, the FAA advisory pamphlet for the area, and the VFR sectional aeronautical chart. The airplane's radios were not tuned to this frequency. The helicopter was illuminated with pulsating landing lights, and high visibility strobes. The airplane was configured with high visibility strobe lights on the wing tips, and two, nose-mounted landing/taxi lights, and a red anti-collision beacon on the tail. The control switches for the anti-collision beacon was found 'ON.' The control switch for the strobe lights was found in the 'OFF' position. The position of the landing/taxi lights could not be determined. Neither pilot in the airplane had any record of flight experience in the Juneau area.

The air tour helicopter was at 2,100 feet msl, and had just crossed a salt water channel when it collided with the airplane. The helicopter landed with substantial damage, and one injured passenger. The airplane was destroyed when it impacted water in the channel, and both pilot-rated occupants were fatally injured. An 18-inch portion of the airplane's right wing remained attached to the helicopter. None of the occupants of the helicopter saw the airplane prior to collision. The helicopter was on a standard tour route utilized by the company, and published in an FAA advisory pamphlet which the airplane occupants also had on board. The collision occurred at a location where the advised traffic route inbound to the Juneau airport crossed the helicopter's air tour route. The helicopter had completed crossing the channel, and was 100 feet above the upper limit of the recommended altitude for the crossing. The airplane was 100 feet above the lower limit of the recommended altitude for aircraft traveling west. This area has a high volume of VFR air tour, air taxi, and general aviation traffic. The area is uncontrolled, Class G, airspace, with no radar coverage. The helicopter pilot described the visibility as good. The helicopter pilot made traffic advisory radio transmissions on the common traffic advisory frequency (CTAF) for the area of the collision. This frequency was published in the Alaska Supplement, the FAA advisory pamphlet for the area, and the VFR sectional aeronautical chart. The airplane's radios were not tuned to this frequency. The helicopter was illuminated with pulsating landing lights, and high visibility strobes. The airplane was configured with high visibility strobe lights on the wing tips, and two, nose-mounted landing/taxi lights, and a red anti-collision beacon on the tail. The control switches for the anti-collision beacon was found 'ON.' The control switch for the strobe lights was found in the 'OFF' position. The position of the landing/taxi lights could not be determined. Neither pilot in the airplane had any record of flight experience in the Juneau area.

Factual narrative

See narrative for ANC98FA061A

History of flight

On May 30, 1998, at 1611 Alaska daylight time, an Aerospatiale AS-350-B2 helicopter, N187EH, and a Cessna 172RG airplane, N4948V, collided in midair, approximately four miles southeast of downtown Juneau, Alaska. The helicopter sustained substantial damage to the right-side doors and fuselage. The commercial pilot and four passengers were not injured. The remaining helicopter passenger sustained serious injuries. The helicopter made an emergency landing at a mine site about 1/2 mile north of the collision point. The airplane impacted the water in the Gastineau Channel, about one mile west of the collision point, and was destroyed. The airplane's private pilot, seated in the left seat, and the commercial pilot/flight instructor, who was seated in the right-front seat, both sustained fatal injuries. Visual meteorological conditions prevailed at the time of the accident. A company flight plan was on file for the helicopter, and a VFR flight plan had been filed by the airplane pilot.

The helicopter flight was being conducted under 14 CFR Part 135 as an air tour flight, transporting cruise ship passengers to the Juneau ice fields. The helicopter was operated by ERA Aviation, Inc., of Anchorage, Alaska. The flight departed the ERA heliport, 10 miles west of the collision point, as the third ship in a flight of three. The first two helicopters departed at 1602 and 1603. The accident helicopter was delayed on the pad while the pilot adjusted a passenger's seat belt, and departed at 1606.

The airplane flight was conducted under 14 CFR Part 91 as a U.S. Government civil flight. The airplane was owned by Take Flight Alaska, Inc., of Anchorage, and was rented and operated by the Federal Aviation Administration, Alaskan Region, in Anchorage. The accident flight was the second flight of the day for the airplane occupants. The flight departed Sitka, Alaska, for Petersburg, Alaska, at 1343. Then departed Petersburg at 1525, for the Juneau International Airport, Juneau, Alaska. The airplane's pilot contacted the FAA Juneau Flight Service Station (AFSS) on 122.2 MHz at 1608, said that N4948V was 15 miles down Gastineau Channel, and closed the VFR flight plan. No other transmissions were received from the airplane.

The helicopter pilot stated to the NTSB investigator-in-charge (IIC) during an interview on May 31, that he had just crossed Gastineau Channel from Treadwell on a magnetic heading of about 040 degrees at 2,000 feet above sea level (msl), and was beginning a climb, when the helicopter was impacted from the right side. The pilot stated that the passenger's audio narration tape ended just as the helicopter crossed the channel, and he had just asked how his passengers were doing.

None of the helicopter occupants said they saw the airplane prior to the collision. The passenger seated in the right-rear seat told the IIC that he was looking 30 degrees to the right of the helicopter's nose at the moment of impact. He said "I saw a flash of something white and angular, to the right, which I thought was a large bird."

The helicopter pilot indicated that at the time of collision, the helicopter was thrown onto its left side, pitched about 70 to 80 degrees nose down, and his feet were knocked off the pedals. He said that he regained control of the helicopter, immediately began an emergency descent to land, and transmitted that "187 is going down" on 123.05 MHz, 118.7 MHz, and on the company FM radio frequency. The pilot related that he entered an autorotative descent, recognized that the helicopter was controllable, and completed a power-on landing.

After landing, he noted that the passenger seated in the right-rear seat was injured, and that there was debris, including a wingtip light, in the aft cabin. He told the NTSB IIC that it was at that point he realized his helicopter had collided with an airplane.

Witnesses on the ground heard a loud noise, looked up, then saw the airplane on a westerly heading, and the helicopter on a northerly heading, flying away from each other. The airplane was described as momentarily remaining level, appearing to lose a piece of wing, then spiraling vertically into the water.

An air taxi pilot told the IIC that as he was exiting the Gastineau Channel northeast bound up the Taku Inlet about 1605, he saw a white Cessna enter the Gastineau Channel westbound. He said he did not hear any transmissions from this airplane on 123.05 MHz.

Injuries to persons

The two occupants of the Cessna 172RG sustained fatal injuries. Both were attached to their seats by seatbelts and shoulder harnesses. The pilot was seated in the left pilot seat, and the pilot-rated passenger was in the right pilot seat.

The passenger seated in the right-rear seat of the helicopter sustained a closed fracture to his right lower leg. The remaining five occupants of the helicopter were not injured.

Damage to aircraft

The helicopter sustained substantial impact damage to the right side of the cabin and fuselage, damage to antennas mounted under the tail boom, and surface scratches to the lower vertical stabilizer and both tail rotor blades.

The airplane was destroyed by a combination of collision and water impact forces.

Personnel information

Helicopter

The pilot of the helicopter has a commercial helicopter pilot certificate, and a private pilot certificate for single-engine land airplanes. He holds instrument ratings in both helicopters and single-engine airplanes. In addition, he was rated as a flight instructor in helicopters. He had a first class medical certificate issued on July 18, 1997, with no limitations. The pilot is 75 inches tall, with a sitting height of 33 1/2 inches from the seat pan to his eyes.

The helicopter pilot was hired by the company on April 19, 1997, and originally assigned to the Anchorage, Alaska base. He was authorized to fly AS-350, BH-212, and BH-412 helicopters for the company. The helicopter pilot's last flight review was his annual 14 CFR Part 135.293 and 135.299 competency and line checks. These were performed by a company check airman on March 20, 1998, in an AS-350-B2 helicopter.

At the time of the accident, the helicopter pilot had accumulated about 2,350 total flight hours, 2,250 in helicopters, and 403 hours in the AS-350. In the 90 and 30 days prior to the accident, he had flown 35 and 23 hours, respectively. On the day of the accident, the pilot had flown 2.5 hours on four previous air tours in the accident helicopter. The accident flight was his fifth flight of the day. This was the second season that he flew tours for the company in the Juneau area. He had acquired 17 hours flying in the Juneau area this season, all within the previous 7 days.

The pilot told the NTSB IIC during an interview on June 10, that he normally sleeps five to six hours per night, from midnight until 0600. He said that the night prior to the accident he attended a concert, and slept his normal amount. On the day of the accident, he preflighted his helicopter, and then slept another hour before he began his flights. He also indicated his sleep patterns were normal the previous two nights.

Airplane

The pilot of the airplane held a private pilot certificate with privileges for single-engine land airplanes which was issued on April 19, 1977. In addition, he held a certificate as an FAA control tower operator. According to the pilot's personal flight logbook which was found in the airplane, he had accumulated 433 hours of flight experience at the time of the accident. The last entry in this logbook was the previous flight on May 30, 1998. The pilot's logbook indicated that he had flown 20 hours in the previous 90 days, all accumulated in the previous 30 days.

The pilot held a third class medical certificate issued on June 13, 1996, with the limitation that he have glasses available for near vision. His medical certificate, and Alaska driver's license,

Aircraft · 2

Registration
N187EH
Reported as
Aerospatiale AS-350-B2
Category
Helicopter
Serial number
2839
Airframe hours
1,577
Engine
Turbomeca ARRIEL-1D1, 732 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Registered owner
Era Aviation, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · May 27, 1998 · 20 hours before
Departed
AK
Flight plan
Company VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Registration
N4948V
Reported as
Cessna 172RG
Category
Airplane
Serial number
172RG0422
Airframe hours
9,467
Engine
Lycoming O-360-F1A6, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Part 91
Operator
Federal Aviation Administrat'N, doing business as Alaskan Region
Registered owner
Take Flight Alaska, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 27, 1998 · 68 hours before
Departed
PSG · Petersburg, AK
Destination
JNU · AK
Flight plan
VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N187EH
Age
34
Certificates
Commercial, Flight instructor, Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
2,350 total · 403 in this make and model · 2,250 as pilot in command · 35 in the last 90 days · 23 in the last 30 days · 4 in the last 24 hours
Role
Pilot, aircraft N4948V
Age
54
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
433 total · 127 in this make and model · 349 as pilot in command · 20 in the last 90 days · 20 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 14 knots
Visibility
10 statute miles
Lowest ceiling
4,500 ft broken
Temperature
63 °F, dew point 50 °F
Altimeter
30.00 inHg
Observed at
JNU, 10 nm away

Docket · 59

The files NTSB released with the investigation on June 2, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 18.6 MB in all.

Supplement C (N187EH)Item 1 · .PDF · 449 KBSupplement D (N187EH)Item 2 · .PDF · 550 KBSupplement G (N187EH)Item 3 · .PDF · 106 KBSupplement K (N187EH)Item 4 · .PDF · 455 KBSupplement S (N187EH)Item 5 · .PDF · 86 KBSupplement A (N4948V)Item 6 · .PDF · 258 KBSupplement B (N4948V)Item 7 · .PDF · 410 KBSupplement E (N4948V)Item 8 · .PDF · 122 KBSupplement K (N4948V) Seat 01Item 9 · .PDF · 462 KBSupplement K (N4948V) Seat 1AItem 10 · .PDF · 450 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (N187EH)Item 11 · .PDF · 465 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (N4948V)Item 12 · .PDF · 10 KBRecord of Interview with Pilot (N187EH)Item 13 · .PDF · 135 KBPilot's Statements (N187EH)Item 14 · .PDF · 146 KBInterview Between Pilot and FAA (N187EH)Item 15 · .PDF · 2.7 MBPassenger Interview (N187EH)Item 16 · .PDF · 65 KBPassenger Statement (N187EH)Item 17 · .PDF · 127 KBMaterials Laboratory Report (N187EH)Item 18 · .PDF · 131 KBStatements From Other Pilots in the Flight (2) (N187EH)Item 19 · .PDF · 294 KBMap of Published Company Tour (N187EH)Item 20 · .PDF · 1.2 MBDamage Diagram (N187EH)Item 21 · .PDF · 47 KBStructural Drawing (N4948V)Item 22 · .PDF · 570 KBWeather (N4948V)Item 23 · .PDF · 70 KBTranscript of Radio Communications (N4948V)Item 24 · .PDF · 294 KBCockpit Visibility Diagram (N187EH)Item 25 · .PDF · 48 KBCockpit Visibility Diagram (N4948V)Item 26 · .PDF · 90 KBLighting Conspicuity (N187EH)Item 27 · .PDF · 105 KBLighting Conspicuity (N4948V)Item 28 · .PDF · 265 KBCockpit Checklist (Lights) (N4948V)Item 29 · .PDF · 341 KBChecklist C-172RG (N4948V)Item 30 · .PDF · 120 KBPerformance Chart C-172RG (N4948V)Item 31 · .PDF · 111 KBPassenger SODA (N4948V)Item 32 · .PDF · 125 KBFAA ReportItem 33 · .PDF · 313 KBAlaska State Troopers ReportItem 34 · .PDF · 1.5 MBJuneau FAA Info Pamphlet ExcerptsItem 35 · .PDF · 1.4 MBJuneau Area Operators Letter of Agreement (excerpts)Item 36 · .PDF · 1.2 MBStatement of Party Representatives to NTSB InvestigationItem 37 · .PDF · 78 KBRelease of Aircraft WreckageItem 38 · .PDF · 149 KBToxicological ReportItem 39 · .PDF · 175 KBPhoto 1. AS-350, N187EH. Note aft skid crosstube has pieces of C-172RG wing.Item 40 · .PDF · 203 KBPhoto 2. N187EH. Note missing antennas and paint transfer on vertical stabilizer and tail cone.Item 41 · .PDF · 200 KBPhoto 3. Cabin of N187EH. Note right wing tip strobe, right wing station 208 rib, and dent in seat frame.Item 42 · .PDF · 187 KBPhoto 4. N187EH. Right side tail boom. Note missing antennas and paint transfer.Item 43 · .PDF · 156 KBPhoto 5. N187EH. Right side vertical stabilizer and tail rotor. Note paint transfer marks.Item 44 · .PDF · 163 KBPhoto 6. View looking northwest toward Juneau, AK, approaching Thane, AK, at 2,000 feet MSL. Approximate route of flight of AS-350 is depicted, scaled to show the 2,000 feet MSL level.Item 45 · .PDF · 142 KBPhoto 7. View approaching Douglas, AK, at 2,000 feet MSL in an AS-350 Helicopter. This is the approximate position that N187EH would have been approximately 2 minutes, 15 seconds prior to the collision. (no negative)Item 46 · .PDF · 132 KBPhoto 8. View abeam Treadwell, AK, at 2,000 feet MSL in as AS-350 helicopter. This is the approximate position that N187EH would have been approximately 1 minute, 00 seconds prior to the collision. (no negative)Item 47 · .PDF · 118 KBPhoto 9. View commencing turn to cross Gastineau Channel, at 2,000 feet MSL in an AS-350 helicopter. This is the approximate position that N187EH would have been approximately 0 minutes, 45 seconds prior to the collision.Item 48 · .PDF · 115 KBPhoto 10. View at mid-channel, at 2,000 feet MSL in an AS-350 helicopter. This is the approximate position that N187EH would have been approximately 0 minutes, 30 seconds prior to the collision. (no negative)Item 49 · .PDF · 118 KBPhoto 11. View looking southeast down Gastineau Channel taken by passenger's camera in N187EH, approximately 4 minutes prior to the collision. (no negative)Item 50 · .PDF · 324 KBPhoto 12. View of Gastineau Channel taken by passenger's camera in N187EH. (no negative)Item 51 · .PDF · 128 KBPhoto 13. Right wing damage of C-172RG, N4948V. (no negative)Item 52 · .PDF · 130 KBPhoto 14. N4948V right wing pieces retrieved from AS-350, N187EH.Item 53 · .PDF · 111 KBPhoto 15. N4948V right wing peices retrieved from AS-350, N187EH.Item 54 · .PDF · 93 KBPhoto 16. N4948V right wing pieces retrieved from AS-350, N187EH.Item 55 · .PDF · 70 KBPhoto 17. N4948V cockpit instrument panel showing position of the anti-collision beacon, and strobe light switches. (no negative)Item 56 · .PDF · 174 KBPhoto 18. N4948V cockpit instrument panel showing position of anti-collision beacon, and strobe light switches. (no negative)Item 57 · .PDF · 156 KBPhoto 19. N4948V view of wreckage at site looking west. (no negative)Item 58 · .PDF · 110 KBPhoto 20. N4948V view of wreckage at site looking east. (no negative)Item 59 · .PDF · 137 KB

FAA reports on this event · 2

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.