# NTSB ATL00FA069: Eurocopter AS350B, N911AM, Sumner, GA, July 24, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 24, 2000, 02:30 local (06:30 UTC) - Place: Sumner, GA - Coordinates: 31.509088, -83.739593 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=31.5091&lon=-83.7396&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report December 4, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 49795 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL00FA069 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/49795/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=49795 - Page: https://openairdocs.org/ntsb/ATL00FA069 ## Probable cause The pilot experienced spatial disorientation, which resulted in a loss of control of the helicopter. Contributing factors was the dark night. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, cruise - object - tree(s) (contributing factor) - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - light condition - dark night (contributing factor) ## Analysis The flight was returning to the Worth County Baptist Hospital in Sylvester, Georgia. At approximately 0227, the pilot contacted the LifeFlight dispatcher and reported a Global Position System (GPS) location 7 miles west/northwest of Tifton, Georgia. No further communication was received from the pilot. Witnesses in the sparsely populated local area stated that it was a dark night and at about 0230 they heard the helicopter fly over their homes. They said the sky was clear of clouds and that the helicopter was low, maybe 400 to 500 feet above the ground. One witness stated that he watched the helicopter fly until out of site then heard a "pop sound" he said it sounded unusual and was not very loud. The flight failed to arrive at its final destination of Sylvester, Georgia. Examination of the wreckage found it localized in a heavily wooded area, with the skids buried in the ground with the trailing ends protruding upward at about a 70-degree angle. No pre-existing airframe or engine malfunctions were identified during the post crash examination. ## Factual narrative HISTORY OF FLIGHT On July 24, 2000, about 0230 eastern daylight time, a Eurocopter AS350B, N911AM, registered to and operated by Critical Care Medflight, was destroyed when it collided with trees and the ground during cruise flight 2 miles east of Sumner, Georgia. The commercial pilot, one flight nurse and one flight paramedic were fatally injured. Night visual meteorological conditions prevailed, and a company visual flight rules flight plan was filed for the repositioning flight being conducted under Title 14 CFR Part 91. The flight originated from Savannah, Georgia, at 0100, with an intended destination of Sylvester, Georgia. According to the operator, the purpose of the air medical flight operating as LifeFlight 3 was to transport a patient from Coffee County Hospital in Douglas, Georgia, to St. Joseph's Hospital in Savannah, Georgia. After dropping off the patient, the flight was returning to the Worth County Baptist Hospital in Sylvester. At approximately 0227, the pilot contacted the LifeFlight dispatcher and reported a Global Position System (GPS) location 7 miles west/northwest of Tifton, Georgia. No further communication was received from the pilot. Witnesses in the sparsely populated local area stated that at about 0230 they heard the helicopter fly over their homes. They said that it was a dark night, the sky was clear of clouds and that the helicopter was low, maybe 400 to 500 feet above the ground. One witness stated that he watched the helicopter fly until out of site then heard a "pop sound" he said it sounded unusual and was not very loud. He woke the next morning and found out about the accident and reported to the local police what he had observed. The flight failed to arrive at its final destination of Sylvester, Georgia. A search was initiated, and the helicopter was located at 0850, 2 miles east of Sumner, Georgia, by a pilot over flying the area. The helicopter collided with trees and came to rest in a swampy, wooded area adjacent to a cotton field. PERSONNEL INFORMATION The pilot held a commercial pilot certificate for helicopters and in single engine land airplanes, with airplane and helicopter instrument ratings. He also held a flight instructor certificate in helicopters, and an advanced instrument ground instructor certificate. In addition, he possessed a second-class airman medical certificate, dated July 23, 1999, with no waivers or limitations. According to company records, Critical Care Medflight hired the pilot on May 11, 2000. The pilot possessed a total of 2,500 hours, 2,280 of which were in helicopters. He had flown 40 hours in the previous 90 days, and 3 hours in the previous 24 hours. His last FAR 61.56 flight review was accomplished on May 5, 2000, in a Eurocopter AS350B. AIRCRAFT INFORMATION The 1980 Eurocopter, AS350B, N911AM, was configured as a medical flight for one pilot and three passengers. The single engine helicopter was owned and operated by C.C. Medflight, Incorporated in Wilmington, Delaware, and operated in Lawrenceville, Georgia. A review of the helicopters logbooks found that on June 7, 2000, the helicopter received an annual and 100 hour inspection with no major discrepancies noted. At the time of the accident the helicopter had accumulated 25 hours of flight time since that inspection. METEOROLOGICAL INFORMATION At 0230, weather conditions in Albany, Georgia, located 27 miles to the west, were reported as scattered clouds at 7,500 feet, visibility 7 statute miles, temperature 23 degrees C. (73 degrees F.), dew point 22 degrees C. (72 degrees F.), winds from 150 degrees at 4 knots, and an altimeter setting of 29.93 Hg. COMMUNICATIONS At approximately 0227, the pilot contacted the Life-Flight dispatcher and reported a Global Position System (GPS) location 7 miles west/northwest of Tifton, Georgia. No further communication was received from the pilot. WRECKAGE AND IMPACT INFORMATION The helicopter impacted the ground on a 330-degree heading. The cabin had separated toward the right side with the right hand forward cross tube mount sliding approximately half the distance from its normal position toward the skid. The forward ends of both skids were buried in the ground with the trailing ends of the skids protruding upward at approximately a 70-degree angle. Impact and the subsequent post-crash fire destroyed the cabin structure. The cockpit and right side of the cabin were thrown to the right of the impact site on a 040-degree heading over a distance of about 150 feet. Flight instruments were found separated from the instrument panel and destroyed. The pilots collective control was found and the stainless steel slide for the friction lock showed that the collective stick was at the maximum pitch setting. The engine, rotor head and mast, and main gearbox were located in a four-foot deep hole in the approximate correct orientation consistent to the nose of the aircraft as defined by the location of the skids. The tailboom was impaled by the left aft skid spring steel extension. The aft end of the tailboom, vertical fin, tail rotor gearbox, and right horizontal stabilizer were broken away from the tailboom, but located in the general vicinity of the above described wreckage. Examination of the main rotor shaft, head, and cyclic system remained virtually intact. The swashplate bearing appeared to be functional and could be rotated by hand. The anti-vibrator assembly was ejected from the shaft but remained approximately 10 to 12 inches forward of the rotor head; the attachment bolts were sheared and remained in the threads. The anti-vibrator assembly upper cowling was dented consistent with impact with a solid object. All main rotor blades were intact except that one blade was broken approximately half in length out in flap; there were no impact marks in the leading edge. One main rotor blade appeared to have a leading edge impact at the 1000-mm zone, but with low inertia or with something soft, as the blade remained intact except for trailing edge damage. All three starflex arms were broken in a 45-degree angle from inboard leading edge to outboard trailing edge. The frequency adapters, spherical thrust bearings, and sleeves were all intact except the yellow sleeves were stretched consistent with the impact at the frequency adapter. One pitch change link remained intact, but severely bent; the other two were broken and melted with the rod ends remaining at the attachment points in the blade horns and swashplate. Wood splinters were found in the anti-vibrator assembly and the yellow frequency adapter area. The tail rotor gearbox and rotor assembly appeared to be intact. Continuity was assured through the tail gearbox and rotor by rotating the gearbox by hand. The tail rotor pitch links remained intact with no apparent damage to the bearings or links. The tail rotor spider bearing was rotated by hand and appeared to function correctly. The tail rotor driveshaft evidenced no indication of rotation during the crash sequence. No pre-existing impact damage was identified during the examination. Examination of the engine found it deformed by impact with some parts missing either by the impact or post-crash fire. Missing parts included the bleed valve and start drain valve. The fuel control/governor was only attached by the fuel and airlines. The front case was broken with some of the gearing exposed. The input shaft was broken approximately 2/3 of the distance from the engine toward the main gearbox. After cutting away the case, the aft flex coupling for the input shaft was found to be in good condition. The inlet for the compressor was deformed with the compressor blades bent in two different directions. The tail pipe was severely deformed and was cut away to gain access. The power output coupling had scribe marks installed during assembly of the engine as a reference for over-torque/impact evidence. The marks were found to be misali ## Aircraft - Registration: [N911AM](https://openairdocs.org/deregistered/N911AM-2003-01-10), registration cancelled 2003-01-10, S/N 1319, built 1980 (OpenAirDocs) - Reported make and model: Eurocopter AS350B - Registry model: [S N I A S AS350D ASTAR](https://openairdocs.org/model/s-n-i-a-s-as350d-astar) (registry code 8680803) (OpenAirDocs) - Registry engine: [Lycoming LTS-101 600A series](https://openairdocs.org/engine/lycoming-lts-101-600a-series) (registry code 41562, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 1319 - Airframe hours: 4814 - Engines: Turbomeca ARRIEL 1B 517 horsepower turbo shaft - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: Critical Care Medflight, Inc., doing business as Lifeflight - Registered owner: C.C. Medflight, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 7, 2000, 25 hours before - Departed: SAV, SAVANNAH, GA - Destination: SYV, SYLVESTER, GA - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane, helicopter; medical: class 2, valid medical--no waivers/lim.; seat: right; toxicology performed; flight hours: 2,500 total, 1,800 as pilot in command, 40 in the last 90 days, 12 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 150° at 4 knots - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 163 °F, dew point 162 °F - Altimeter: 29.00 inHg - Observed at: ABY, 27 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 20000724023449A](https://openairdocs.org/incident/20000724023449A), Jul 24, 2000: Snias AS350D, Sylvester, GA, No damage, 3 fatal. (-23) On July 24, 2000, at about 0230 EDT, a Eurocopter AS350B, N911AM, returning to Sylvester, GA from a patient drop off in savannah, GA., was destroyed when… ## Docket (17 files) The files NTSB released with the investigation on November 15, 2001, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=49795. 4.4 MB in all. - Supplement G (item 1, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149886&FileExtension=.PDF&FileName=Supplement%20G-Master.PDF - Supplement S (item 2, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149887&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - ATC Pilot Weather Briefs (item 3, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393159&FileExtension=.PDF&FileName=ATC%20Pilot%20Weather%20Briefs-Redacted.PDF - Toxicological Report (item 4, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393160&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 5, .PDF, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393161&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393162&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393163&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Engine Teardown Report (item 8, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393164&FileExtension=.PDF&FileName=Engine%20Teardown%20Report-Redacted.PDF - Witness Statements (item 9, .PDF, 478 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393165&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Wreckage Diagram (item 10, .PDF, 403 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393166&FileExtension=.PDF&FileName=Wreckage%20Diagram-Redacted.PDF - Photo 1 - Aerial Photo 1 (item 11, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149896&FileExtension=.PDF&FileName=Photo%201%20-%20Aerial%20Photo%201-Master.PDF - Photo 2 - Aerial Photo 2 (item 12, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149897&FileExtension=.PDF&FileName=Photo%202%20-%20Aerial%20Photo%202-Master.PDF - Photo 3 - Flight Path Through Trees (item 13, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149898&FileExtension=.PDF&FileName=Photo%203%20-%20Flight%20Path%20Through%20Trees-Master.PDF - Photo 4 - Skids Stuck In-Ground at about a 70 Degree Nose Down Attitude (item 14, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149899&FileExtension=.PDF&FileName=Photo%204%20-%20Skids%20Stuck%20In-Ground%20at%20about%20a%2070%20Degree%20Nose%20Down%20Attitude-Master.PDF - Photo 5 - Cockpit Area (item 15, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149900&FileExtension=.PDF&FileName=Photo%205%20-%20Cockpit%20Area-Master.PDF - Photo 6 - Engine and Gearbox (item 16, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149901&FileExtension=.PDF&FileName=Photo%206%20-%20Engine%20and%20Gearbox-Master.PDF - Photo 7 - Damage to Tailrotor Assembly (item 17, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149902&FileExtension=.PDF&FileName=Photo%207%20-%20Damage%20to%20Tailrotor%20Assembly-Master.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.