ANC99FA073

NTSB accident investigation · Eurocopter AS-350BA · Juneau, AK · June 9, 1999

Accident · FatalField investigationFinal report
Date
June 9, 1999, 10:50 local (18:50 UTC)
Place
Juneau, AK
Injuries
7 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N6099SEurocopter AS-350BA
Weather
Visual (VMC) · Day
Status
Completed · report August 3, 2000
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Safety recommendations
Yes
FAA report
19990609006689A
Case key
46562

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 pilot's continued VFR flight into adverse weather, spatial disorientation, and failure to maintain aircraft control. Factors associated with the accident were pressure by the company to continue flights in marginal weather, and the "flat" lighting leading to whiteout conditions. Additional factors were the pilot's lack of instrument experience, lack of total experience, inadequate certification and approval of the operator by the FAA, and the FAA's inadequate surveillance of the emergency instrument procedures in use by the company.

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.

In flight encounter with weatherManeuvering
Light condition - otherFactor
Weather condition - whiteoutFactor
Flight into adverse weather - continuedPilot in commandCause
PressureCompany/operator managementFactor
Loss of control - in flightManeuvering
Aircraft control - not maintainedPilot in commandCause
Lack of total instrument timePilot in commandFactor
Spatial disorientationPilot in commandCause
Lack of total experiencePilot in commandFactor
Inadeq certification/approval,operation/operatorFaa(organization)Factor
Inadequate surveillance,inadequate procedureFaa(organization)Factor
In flight collision with terrain/waterManeuvering

Analysis

The air tour helicopter, with the pilot and six passengers, departed Juneau, Alaska, for a 50 minute flight over mountainous glaciers. About ten minutes after making a normal radio transmission, the helicopter was located by the pilot of a second company helicopter who was also conducting a tour. The accident helicopter impacted a nearly level, snow-covered glacier, and all occupants received fatal injuries. The leading edge of the impact crater was angled between 30 and 45 degrees below the horizon, and the face of the airspeed indicator gauge had a needle slap mark at 130 knots. The pilots of the only two helicopters near the accident site at the time of the accident, said the "flat light" made the featureless, snow-covered terrain difficult to discern from the indefinite, overcast ceiling. Photographs taken within one hour of the accident showed that the mountain pass the pilot was attempting to fly through was difficult to distinguish from the clouds, the glacier surface, and the surrounding snow-covered terrain. A postaccident inspection discovered no evidence of any preaccident mechanical anomalies. At the time of the accident, the pilot had accrued 7.9 hours in AS-350 helicopters, and a total of 37.5 hours in turbine helicopters, all with the accident company. This was the second day the pilot operated the AS-350 by himself. The pilot did not hold any instrument certificates, nor was he required to by the FAA. FAA Order 8400.10 requires Principal Operations Inspectors (POIs), and approved company check airmen, to have pilots demonstrate their ability to control a helicopter solely by reference to flight instruments during 14 CFR 135.293 competency checks for VFR-only helicopter operations. This requirement is not specified in 14 CFR Part 135. The FAA approved the company's training manual without this requirement being incorporated. The FAA did not ensure that the company check airman was aware of the checking requirements listed in FAA Order 8400.10. The pilot received no emergency instrument training from the company, nor did the company require him to demonstrate the ability to control the helicopter solely by reference to the installed flight instruments. The helicopter was required to, and did have, a gyroscopic pitch and bank indicator installed. The FAA's training minimums for new hire pilots is 16 hours of Indoctrination Training, and 16 hours of aircraft ground training. The FAA's national norm for these training programs are 24 hours each. POIs can approve the minimum hours based on the type and sophistication of the training methods. The approved training for the accident company was the minimum. The pilot's previous helicopter piloting experience (as a student, and as a flight instructor) was in Arizona and California. The pilot stated on his company resume that he had accrued 891 hours of helicopter flight experience at the time of his employment. The NTSB IIC, and the FAA, estimated the pilot actually had 612 helicopter flight hours when hired. The company had not received background checks for the pilot before the accident occurred, and was allowed by the Pilot Records Improvement Act to use a pilot for 90 days prior to receipt of background information. The pilot had expressed to a previous employer, and a previous instructor, that he was uncomfortable with company pressure to fly tours in bad weather.

Factual narrative

History of flight

On June 9, 1999, at 1050 Alaska daylight time, a skid/ski equipped Eurocopter AS-350BA helicopter, N6099S, was destroyed when it impacted the Herbert Glacier, about 3,400 feet above sea level (msl), approximately 20 miles north of Juneau, Alaska, at 58 degrees 34.958 minutes north latitude, 134 degrees 33.602 minutes west longtitude. The commercial certificated pilot and the six passengers on board were fatally injured. The helicopter was owned and operated by Coastal Helicopters, Inc., of Juneau, Alaska, under 14 CFR Part 135 as an on-demand air tour flight. The flight departed Juneau at 1008 for the Herbert Glacier. Visual meteorological conditions prevailed in Juneau at the time of the accident, and a company VFR flight plan was in effect.

The accident helicopter landed about the 1,000 feet msl level of the Herbert Glacier about 1025, as a routine part of the tour. The helicopter was near a second company helicopter which had also landed on the glacier. The accident flight took off again about 1035 to continue the tour. The pilot of the second company helicopter indicated he was about 5 minutes behind the accident helicopter, and did not have the accident flight in sight during the second half of the tour.

The pilot of the second company helicopter, and the pilot of a third helicopter (operated by a different company) who was on the Mendenhall Glacier side of the pass between the Herbert and Mendenhall glaciers, told the NTSB investigator-in-charge (IIC) that about 1045 they heard the accident pilot transmit "Coastal 99S is upper Herbert for the Mendenhall, right side." Both pilots said the radio transmission sounded normal. The pilot of the second helicopter, flying up the Herbert Glacier behind the accident helicopter, found the wreckage about 1055. Both pilots said the snow-covered glacier was featureless, the overcast ceiling was difficult to discern from the snow, and described the lighting as "flat." Both pilots said the overcast layer was a few hundred feet above the elevation of the 4,100 feet msl pass between the two glaciers, but neither could discern the exact ceiling.

Injuries to persons

All seven persons on board the helicopter were fatally injured. The State of Alaska Medical Examiner's report noted decelerative injuries to all occupants.

Damage to aircraft

The helicopter was destroyed by impact forces.

Personnel information

The pilot was a New Zealand citizen, legally working in the United States. He held no New Zealand airplane or helicopter certificates.

The pilot held a U.S. commercial helicopter pilot certificate issued on June 29, 1998. The pilot did not hold any U.S. ratings for airplanes. His helicopter flight instructor certificate was issued on September 19, 1998. He did not hold an instrument rating. All pilot rating examinations were administered by FAA Designated Pilot Examiners (DPE). There were no records indicating the pilot had received instrument training in the United States, or in New Zealand. His most recent U.S. second class medical certificate was issued on March 15, 1999, with no restrictions.

The New Zealand Civil Aviation Authority (CAA), and the New Zealand Transportation Accident Investigation Commission (TAIC), reviewed the pilot's New Zealand aviation, education, and medical records. This review found the following:

The pilot had been a part owner of two microlight aircraft in New Zealand. The other owner/partner estimated the pilot had accrued about 500 hours in microlights. During April 1996, the pilot completed a microlight check with a flight instructor. He was issued an Advanced Microlight pilot certification by the Recreational Aircraft Association of New Zealand (RAANZ), on October 27, 1997, for three-axis control (group B) aircraft. There is no CAA license required for microlight flying, but there is a legal requirement for pilots to hold a microlight certificate to fly microlight aircraft in New Zealand. The progression of certificates issued by the RAANZ is novice, intermediate, and advanced.

Interviews conducted by the FAA indicated the pilot had difficulty reading and writing English. Quantum Helicopters, Inc., in Chandler, Arizona, provided commercial helicopter flight training to the pilot. Quantum's chief pilot stated that the accident pilot began training for his helicopter flight instructor certificate, but the company terminated his training, citing a failure to meet the standards set forth in FAR 61.183: "To be eligible for a flight instructor certificate a person must - (b) Read, write, and converse fluently in English." The pilot then completed training for his flight instructor certificate with Group-3 Aviation, Inc., of Van Nuys, California, on September 18, 1998. He passed an examination for the certificate on September 19, 1998.

Interviews conducted by the FAA and NTSB IIC with other employers and flight schools did not indicate obvious language difficulties. The other persons interviewed consistently commented that upon review, none remembered the pilot performing detailed written work in person. Comments indicated that when given written work assignments, they were normally returned the following day, in good order. Group-3 Aviation commented that when the pilot arrived for training, he already had extensively prepared lesson plans with him, and generating new ones was not required.

The pilot was hired as a flight instructor by Aero Helicopters, Inc., in Scottsdale, Arizona, the same company which had provided his initial training for the private pilot certificate. He worked for Aero Helicopters, Inc., from September 20 to November 30, 1998. Between December 1, 1998 and May 8, 1999, the pilot worked as a flight instructor for Guidance Helicopters, Inc., in Prescott, Arizona.

The pilot was hired by Coastal Helicopters, Inc., on May 8, 1999. He was based and lived in Juneau. He completed initial ground training on May 11, 1999. On May 11, 1999, the pilot was administered a pilot-in-command, 14 CFR 135.293 and 135.299 proficiency and line check in a BHT-206 by the company president, who is also the director of operations, and FAA authorized company check airman. On June 7, the pilot successfully completed pilot-in-command checks in the AS-350.

The pilot had no turbine engine powered aircraft experience as a pilot prior to his employment at Coastal Helicopters, Inc. His previous helicopter piloting experience was in Robinson R-22, and Schweizer-300C helicopters. During his employment at Coastal Helicopters, Inc., he accrued a total of 37.5 hours of flight experience. He received a total of 5.7 hours of dual flight instruction in the BHT-206, and 5.7 hours of dual flight instruction in the AS-350. His total experience (including dual flight instruction) in the AS-350 at the time of the accident was 7.9 hours.

Flight and Duty Time

On the day of the accident, the pilot's estimated total helicopter experience was 650 hours. According to prior employer and flight school records compiled by the FAA, the pilot had accumulated 487 hours of verifiable flight experience in helicopters. An additional 125 hours of helicopter experience was estimated to have been accrued while employed by Aero Helicopters, Inc., from September 19 to November 30, 1999 (flight records are missing for this time period). The pilot's total estimated helicopter experience at the time of employment by Coastal Helicopters Inc., on May 5, 1999, was 612 hours.

In the 24 hours prior to the accident, the pilot had flown 2.2 hours. He completed his flights about 1700 on June 8, the day prior to the accident, and was off duty for 14 hours prior to reporting to work the morning of the accident.

The pilot flew each of the nine days prior to the accident. He had flown 13.8 hours in the previous 7 days, and 36.4 hours in the previous 30 days.

Helicopter Experience Claimed By The Pilot

Aircraft

Registration
N6099S
Reported as
Eurocopter AS-350BA
Category
Helicopter
Serial number
2810
Airframe hours
1,827
Engine
Turbomeca ARRIEL 1B, 641 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 135
Registered owner
Coastal Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 5, 1999 · 62 hours before
Departed
JNU · 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.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
29
Certificates
Commercial, Flight instructor
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
650 total · 8 in this make and model · 604 as pilot in command · 38 in the last 90 days · 36 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Lowest ceiling
800 ft overcast
Altimeter
30.00 inHg

Docket · 61

The files NTSB released with the investigation on June 14, 2000, on NTSB’s docket system: statements, records, photos and specialists’ reports. 76.8 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 1.2 MBSupplement CItem 2 · .PDF · 636 KBSupplement DItem 3 · .PDF · 782 KBSupplement SItem 4 · .PDF · 862 KBMaterials Laboratory Factual Report - 99-168Item 5 · .PDF · 1.0 MBMaterials Laboratory Factual Report - 99-191Item 6 · .PDF · 417 KBMaterials Laboratory Factual Report - 99-193Item 7 · .PDF · 322 KBNTSB InterviewsItem 8 · .PDF · 439 KBNTSB Interview with New Zealand InstructorItem 9 · .PDF · 360 KBWitness StatementItem 10 · .PDF · 243 KBFAA Interview with Company PilotItem 11 · .PDF · 1.0 MBFAA Interview with Pilot's FriendItem 12 · .PDF · 248 KBMap of Accident LocationItem 13 · .PDF · 6.4 MBWreckage DiagramsItem 14 · .PDF · 944 KBDamage Patterns Found on WreckageItem 15 · .PDF · 4.3 MBWeather ReportItem 16 · .PDF · 198 KBJuneau Weather During Each Flight of Accident PilotItem 17 · .PDF · 268 KBWeather for Each Training Day Pilot FlewItem 18 · .PDF · 707 KBWeather for Each Day Pilot Flew While Employed - Revenue FlightsItem 19 · .PDF · 2.4 MBTranscript of Radio CommunicationItem 20 · .PDF · 364 KBTransportation Safety Institute Composite Rotor Blade Impact AnalysisItem 21 · .PDF · 2.3 MBFAA Inspector StatementItem 22 · .PDF · 11.3 MBFAA ReportsItem 23 · .PDF · 1.5 MBFAA RecommendationsItem 24 · .PDF · 360 KBAlaska State Trooper's ReportItem 25 · .PDF · 3.3 MBCoastal Helicopters Written Comments to DRAFT ReportItem 26 · .PDF · 962 KBPilot Flight Time at Coastal Helicopters, Inc.Item 27 · .PDF · 819 KBCompany Radio and Operations LogItem 28 · .PDF · 292 KBFuel RecordsItem 29 · .PDF · 144 KBCompany Flight and Training RecordsItem 30 · .PDF · 403 KBPilot's ResumeItem 31 · .PDF · 399 KBNew-Hire Indoctrination Training MinimumsItem 32 · .PDF · 1.4 MBFAA Ops Handbook Aircraft Training Hour RequirementsItem 33 · .PDF · 4.3 MB8400.10 - Flight Training NormsItem 34 · .PDF · 880 KBChecking Module RequirementsItem 35 · .PDF · 4.1 MBFAA Requirements for IFR CompetenceItem 36 · .PDF · 270 KBFAA Policy on Ultralight Flight TimeItem 37 · .PDF · 4.7 MBTraining Program Outline - New HireItem 38 · .PDF · 1.5 MBTraining Program Outline - Weather TopicsItem 39 · .PDF · 103 KBTraining Program Transition Training ExcerptItem 40 · .PDF · 229 KBTraining Program Testing and Checking ModuleItem 41 · .PDF · 153 KBLesson Plans - Drafts - Training Manual ExcerptsItem 42 · .PDF · 3.3 MB14CFR135.63 - Record Keeping RequirementsItem 43 · .PDF · 1.5 MBPilot Records Improvement Act Amended 12/06/97Item 44 · .PDF · 7.1 MBStatement of Party Representatives to NTSB InvestigationItem 45 · .PDF · 230 KBRelease of Aircraft Wreckage, NTSB Forms 6120.15Item 46 · .PDF · 1.4 MBToxicological ReportItem 47 · .PDF · 180 KBPhoto 1. Overhead view of wreckage path.Item 48 · .PDF · 31 KBPhoto 2. Photo taken from one of the passenger's camera looking up the Herbert Glacier.Item 49 · .PDF · 38 KBPhoto 3. Photo taken looking down the Herbert Glacier about one hour after the accident.Item 50 · .PDF · 30 KBPhoto 4. Photo taken looking to the east about one hour after the accident. Arrow shows location of pass.Item 51 · .PDF · 29 KBPhoto 5. Photo taken looking to the east the day after the accident. Arrow shows location of pass. No Negative Provided.Item 52 · .PDF · 29 KBPhoto 6. Photo taken looking to the north about one hour after the accident.Item 53 · .PDF · 30 KBPhoto 7. Photo taken looking to the north the day after the accident. No Negative Provided.Item 54 · .PDF · 38 KBPhoto 8. Photo taken looking to the northeast about one hour after the accident. Arrow shows location of pass. No Negative Provided.Item 55 · .PDF · 30 KBPhoto 9. Photo taken looking to the northeast the day after the accident. No Negative Provided.Item 56 · .PDF · 35 KBPhoto 10. Note tail rotor 90 degree spar fracture and pitch change link deformation opposite normal rotation.Item 57 · .PDF · 42 KBPhoto 11. Note horizontal stabilizer damage in the same plane as, and same direction of travel as, tail rotor rotation.Item 58 · .PDF · 40 KBPhoto 12.View looking from top down at main rotor head star arm damage.Note delamination of red main rotor blade grip.Note star fracture on red and yellow star arms. No fracture on blue star arm. Direction of rotation is cloItem 59 · .PDF · 76 KBPhoto 13. Engine forward view. Note uniform compressor inlet damage. Note metal smearing damage in the aft direction to engine to main transmission output shaft spline coupling.Item 60 · .PDF · 71 KB
All 61 files on NTSB’s docket

FAA reports on this event · 1

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