ANC99FA139

NTSB accident investigation · Eurocopter AS-350B-2 · Juneau, AK · September 10, 1999

Accident · Serious injuriesField investigationFinal report
Date
September 10, 1999, 12:04 local (20:04 UTC)
Place
Juneau, AK
Injuries
1 serious, 5 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N6007SEurocopter AS-350B-2
Weather
Instrument (IMC) · Day
Status
Completed · report August 10, 2000
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19990910046609A
Case key
47396

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 flight into instrument meteorological conditions (IMC), and inadequate altitude/clearance. Factors associated with the accident were flat light and whiteout conditions, snow, and snow-covered terrain. An additional factor was the FAA's inadequate certification/approval of the operator's training manual, which did not require the operator to provide instrument training or instrument flight proficiency checks to its pilots.

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 weatherDescent
Light condition - otherFactor
Weather condition - whiteoutFactor
Weather condition - snowFactor
Vfr flight into imc - continuedPilot in commandCause
In flight collision with terrain/waterDescent
Terrain condition - snow coveredFactor
Altitude/clearance - inadequatePilot in commandCause
Inadeq certification/approval,operation/operatorFaa(organization)Factor

Analysis

The certificated commercial helicopter pilot, with five passengers aboard, was attempting to return to the Juneau International Airport after completion of an ice field sightseeing tour flight. During a gradual descent, over a large, featureless, and snow-covered ice field, a localized snow shower momentarily reduced his forward visibility. The pilot reported he slowed the helicopter to about 70 knots and attempted to use a mountain range on the left side of the helicopter for visual reference. He said: 'The visibility got to a point where I was unable to discern any topographic features, only a dark shape on the horizon.' He added that 'flat light conditions' contributed to his inability to recognize any topographical features on the ice surface. The helicopter continued to descend, struck the snow-covered ice field, slid about 150 feet, and nosed over. The pilot reported that there were no preaccident mechanical anomalies with the helicopter. The helicopter was not equipped with a radar altimeter, and the pilot did not hold an instrument rating. The pilot received no emergency instrument training from the company, nor did the company require him to demonstrate the ability to maneuver the helicopter solely by reference to the installed flight instruments. FAA Order 8400.10 requires Principal Operations Inspectors, 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. The operator's FAA-approved training manual did not require training or competency checks of the pilot's ability to maneuver the helicopter solely by reference to flight instruments.

Factual narrative

History of flight

On September 10, 1999, about 1204 Alaska daylight time, a Eurocopter AS-350B-2 helicopter, N6007S, was destroyed when it impacted the surface of the Juneau ice field, about 16 miles north of Juneau, Alaska, at 58.37.433 north latitude, and 134.33.620 west longitude. The helicopter was being operated as a visual flight rules (VFR) on-demand sightseeing flight under Title 14, CFR Part 135, when the accident occurred. The helicopter was operated by TEMSCO Helicopters, Inc., Ketchikan, Alaska. The certificated commercial pilot and four passengers aboard received minor injuries. The remaining passenger received serious injuries. Visual meteorological conditions prevailed at the time of departure, and company flight following procedures were in effect. The flight originated about 1104 from the Juneau International Airport, Juneau.

During an interview with the National Transportation Safety Board investigator-in-charge on September 11, the pilot reported that he was attempting to return to the Juneau International Airport after completion of an ice field sightseeing tour flight. He said that during a gradual descent, over a large, featureless, and snow-covered ice field, a localized light snow shower momentarily reduced his forward visibility. He stated that he slowed the helicopter to about 70 knots and attempted to use a mountain range on the left side of the helicopter for visual reference. He said: "The visibility got to a point where I was unable to discern any topographic features, only a dark shape on the horizon." He added that "flat light conditions" contributed to his inability to recognize any topographical features on the ice surface. The helicopter continued to descend, struck the snow-covered ice field, slid about 150 feet, and nosed over.

Damage to aircraft

The helicopter was destroyed by impact forces.

Crew information

The pilot held a commercial helicopter pilot certificate, and helicopter flight instructor certificate. He did not hold an instrument rating. The most recent second-class medical certificate was issued to the pilot on April 4, 1999, and contained the limitation the holder shall wear corrective lenses.

According to the pilot/operator report (NTSB form 6120.1/2) submitted by the operator, the pilot's total flight time consisted of 2,400 hours, of which 1,190 were accrued in the accident helicopter make and model. In the past preceding 90 and 30 days prior to the accident, the report lists a total of 250 and 71 hours, respectively.

The pilot was hired by the operator on April 15, 1998. He completed an initial 14 CFR 135.293/.299 check ride on April 29, 1998. On April 26, 1999, the pilot completed a recurrent check ride as per 14 CFR 135.293/.299. Both initial and recurrent check rides were accomplished in the accident helicopter make and model.

The operator provided a copy of the accident pilot's part 135 competency/proficiency check, FAA form 8410-3, dated April 26, 1999. The portion of the form reserved for the flight check airman's comments/grading of the pilot's skills in operating the helicopter solely by reference to instruments, was lined through and not completed.

Aircraft information

The helicopter was an American Eurocopter AS-350B-2, equipped with a Turbomeca Arriel-1D1 turboshaft engine.

The helicopter was outfitted with the manufacturer's high density seating configuration. This configuration accommodates 6 passengers and a pilot.

The helicopter was maintained under the operator's Approved Aircraft Inspection Program (AAIP). This program contains inspections performed approximately every 100 hours. The helicopter and engine were manufactured in January 1990, and both had accumulated 752.3 hours in service at the time of the accident. 82.3 hours had elapsed since the most recent 100 hour inspection. A review of maintenance records revealed no evidence of preexisting anomalies at the time of the accident.

All equipment required by 14 CFR Part 91.205, 207, 209, and 135.149, 159, and 161, were installed on all company helicopters.

The company was authorized to operate the helicopter in day and night VFR conditions. 14 CFR Part 135.159, Equipment Requirements: Carrying Passengers Under VFR At Night, states, in part: "No person may operate an aircraft carrying passengers under VFR at night...unless it is equipped with- (a) A gyroscopic rate-of-turn indicator... (b) A slip skid indicator. (c) A gyroscopic bank-and-pitch indicator. (d) A gyroscopic direction indicator..."

The accident helicopter was not equipped with a radar altimeter, nor was it required to be.

Meteorological information

The closest official weather observation station is Juneau, which is located about 16 nautical miles south of the accident site. On September 10, 1999, at 1155, an Aviation Routine Weather Report (METAR) was reporting, in part: Wind, 090 degrees at 9 knots; visibility, 10 statute miles; ceiling and clouds, 1,400 feet few, 4,900 feet scattered, 6,500 feet overcast; temperature, 53 degrees F; dew point, 48 degrees F; altimeter, 30.23 inHg. Remarks: Well defined ceiling in vicinity of mountains.

An AIRMET for mountain obscuration in clouds and precipitation was issued for the pilot's planned tour flight.

The National Transportation Safety Board investigator-in-charge interviewed three pilots that were in the area of at the time of the accident. All the pilots interviewed related that overcast conditions, localized snow showers, and very flat light conditions, made it difficult to discern the surface of the glacier. They added that the weather reports and forecasts from Juneau most often do not represent the actual weather conditions in the mountains, and over the ice field.

Communications

About 1104 the operator's dispatch center recorded the accident helicopter's departure from the Juneau International Airport, with five passengers aboard. The accident pilot indicated that he would be conducting a "pilot's choice tour," and would return to the Juneau International Airport in about one hour and twenty minutes.

The last radio transmission received from the accident helicopter was about 1148, reporting that he was landing on the East Branch of the ice field, a planned part of the tour. No further radio transmissions were received from the accident helicopter.

No radar coverage is available in the area of the accident.

Wreckage and impact information

The National Transportation Safety Board investigator-in-charge, two representatives from the FAA's Juneau Flight Standards District Office, and a representative from American Eurocopter Corporation, examined the helicopter wreckage at the accident site on September 14, 1999. In addition, two members from the Juneau Mountain Rescue Team accompanied the accident investigative team to the accident site to recover rescue equipment, and provide site safety while on the glacier. The accident site was located on the Juneau ice field, about 5,270 feet above sea level (msl).

Deteriorating weather conditions limited the available time at the scene.

The topographical features surrounding the accident site consisted of smooth, featureless, and freshly snow-covered glacial ice. There was a gradual downward slope in the direction of the accident helicopter's preaccident flight path.

The helicopter collided with snow-covered glacial ice. A path of wreckage debris and ground scar from the first observed point of impact, to the wreckage point of rest, was on a magnetic heading of 228 degrees. (All heading/bearings noted in this report are oriented towards magnetic north.) The first observed portions of helicopter's wreckage noted along the 150 feet long wreckage path, were small pieces of fragmented composite material that matched the color scheme of the accident helicopter, a left

Aircraft

Registration
N6007S
Reported as
Eurocopter AS-350B-2
Category
Helicopter
Serial number
2433
Airframe hours
752
Engine
Turbomeca ARRIEL 1D1, 732 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 135
Registered owner
Temsco Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 17, 1999 · 82 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
27
Certificate
Commercial
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
2,400 total · 1,190 in this make and model · 2,300 as pilot in command · 250 in the last 90 days · 71 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
90° at 9 knots
Visibility
10 statute miles
Lowest ceiling
6,500 ft overcast
Temperature
54 °F, dew point 48 °F
Altimeter
30.00 inHg
Observed at
PAJ, 16 nm away

Docket · 15

The files NTSB released with the investigation on July 28, 2000, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.0 MB in all.

FAA reports on this event · 1

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