# NTSB BFO94FA013: Bell 206L-1, N911ME, Portland, ME, November 20, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 19, 1993, 20:39 local (Nov 20, 1993, 01:39 UTC) - Place: Portland, ME - Location: 43.6332° N, 70.1853° W: Placed by OpenAirDocs: center of Portland, ME, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=43.6332&lon=-70.1853&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal, 1 serious - Status: Completed, report November 1, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 8833 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO94FA013 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8833/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=8833 - Page: https://openairdocs.org/ntsb/BFO94FA013 ## Probable cause THE PILOT'S CONTINUED VFR FLIGHT INTO INSTRUMENT METEOROLOGICAL CONDITIONS, AND HIS FAILURE TO ASSURE THAT ADEQUATE FUEL WAS AVAILABLE TO COMPLETE THE FLIGHT, RESULTING IN A LOSS OF ENGINE POWER DUE TO FUEL EXHAUSTION. FACTORS WHICH CONTRIBUTED TO THE ACCIDENT WERE: THE WEATHER, THE DARK NIGHT AND THE ROUGH SEA CONDITION. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - normal - preflight planning/preparation - inadequate, pilot in command (contributing factor) - vfr flight into imc - continued, pilot in command (cause) - weather condition - fog (contributing factor) - weather condition - rain (contributing factor) - weather condition - low ceiling (contributing factor) - Loss of engine power(total) - nonmechanical, approach - iaf to faf/outer marker (ifr) - weather condition - unfavorable wind (contributing factor) - fluid,fuel - exhaustion (cause) - fuel supply - not maintained, pilot in command (cause) - Forced landing, landing - flare/touchdown - light condition - dark night (contributing factor) - autorotation - performed, pilot in command - In flight collision with terrain/water, landing - flare/touchdown - terrain condition - water,rough (contributing factor) ## Analysis THE PILOT STATED THAT HE HAD DEPARTED PORTLAND EARLIER WITH 2 HR 45 MIN OF FUEL TO PICK UP THE PATIENT AT ELLSWORTH. HE STATED THAT HIS TOTAL CAPACITY WAS ABOUT 57O LBS, AND THE FUEL BURN FOR THE HELICOPTER WAS 200-220 LBS/HR. HE SAID THE 97 NM FLIGHT IS NORMALLY COMPLETED UNDER 1 HR, BUT TOOK 1 HR 10 MIN DUE TO WINDS. HE THEN DEPARTED ELLSWORTH WITH 310 LBS OF FUEL FOR THE RETURN FLIGHT. DURING THE RETURN FLIGHT TO PORTLAND HE ENCOUNTERED INSTRUMENT METEOROLOGICAL CONDITIONS AND A 'SUBSTANTTIAL HEAD WIND OF 40 TO 60 KNOTS.' WHILE BEING VECTORED INTO PORTLAND THE ENGINE QUIT AND THE HELICOPTER DITCHED IN THE OCEAN IN ROUGH SEAS 7 MI EAST OF THE AIRPORT. ACCORDING TO THE COMPANY OPERATIONS MANUAL FOR EMS PROCEDURES, IT STATES IN PART, 'THE MINIMUM ACCEPTABLE WEATHER IS IN VFR CONDITIONS...'. ## Factual narrative HISTORY OF FLIGHT On November 19, 1993, at 2039 eastern standard time, a Bell 206-L-1, N911ME, landed hard during a forced landing touchdown in the Atlantic Ocean seven miles east of Portland International Jetport, Portland, Maine. The helicopter was owned by Airmed Skycare Inc of Portland, and operated by Echo Helicopter Inc. of Portland, Maine. Instrument meteorological conditions prevailed at the accident site. The certificated commercial pilot received serious injuries, while two of the three passengers were fatally injured. The third passenger has not been recovered and is presumed to be fatally injured. The helicopter was submerged in 85 feet of water and was destroyed. The flight was conducted under part 14 CFR 135. The medical evacuation flight originated in Ellsworth, Maine. According to the pilot, he had departed Portland earlier to pick up a 70 year old burn victim at Ellsworth, Maine, and was returning when he encountered instrument meteorological conditions (IFR). He stated that he departed under visual flight rules (VFR) conditions; however, the weather deteriorated and he encountered a "substantial head wind of 40 to 60 knots" on his return flight. He stated that he obtained an instrument flight rules (IFR) clearance from Brunswick Approach Control. He was provided with vectors to runway 11, but during the approach the low fuel light illuminated. He stated that he requested a straight in approach to runway 29, and as he was turning onto the inbound course for the runway, the engine lost power. According to the pilot, when he departed Portland he had approximately 2 hours and 45 minutes of fuel on board. He stated that the flight to Ellsworth was 1 hour and 10 minutes. He said that the 97 mile trip is normally completed under an hour, but due to the winds the trip was longer. The pilot stated that he departed Ellsworth with 310 lbs of fuel on board for the flight. He stated that the helicopter's fuel consumption was about 200 to 220 lbs/hr. The pilot stated that when he first got an indication of low fuel, which is the low fuel light being illuminated, the light did not remain illuminated. The pilot reported that "the 20 minute low fuel light was only illuminated for 5 minutes so he estimated he had an additional 15 minutes of fuel remaining." According to Bell Helicopter Operations Safety Notice "It is possible for the fuel low warning to illuminate even though the fuel quantity gage indicates up to 215 lbs of fuel remaining." The Bell Flight Manual states, in part, that in the event of a low fuel caution light the fault and remedy advises "approximately 10 gallons of fuel remaining Plan landing." The engine lost power shortly thereafter and the pilot stated that he performed an autorotation using the helicopter's radar altimeter as he had no visual reference. During the autorotation, he reported that he deployed the floats attached to the skids. He said he decelerated the helicopter and tried to cushion the landing referring to the instruments. The helicopter landed hard in "rough water" with 6 foot waves and sank, inverted. Search efforts located two of the passengers four days later in the submerged, inverted helicopter. The accident occurred at night, about 43 degrees 40 minutes North latitude and 70 degrees 12 minutes West longitude. PERSONNEL INFORMATION At the time of the accident the pilot held a commercial pilot certificate for helicopter operations, and a commercial certificate with single and multi-engine land ratings for airplanes. The pilot reported his total flight time as 8221 hours including 3640 in type. The pilot completed his 14 CFR, Part 135 proficiency check ride on June 7, 1993. Details of the proficiency check are attached to this report. AIRCRAFT INFORMATION The 1980 year model Bell 206L-1 helicopter, serial no. 45553, was equipped with an Allison A250-C28 engine, serial no. 860368. The aircraft had over 2220 hours including 34 hours since the last Approved Aircraft Inspection Program (AAIP) on October 12, 1993. METEOROLOGICAL INFORMATION The 2141 hour surface weather observation for Portland International Jetport, about 7 miles west of the accident site was as follows: "Sky condition, 400 feet overcast; visibility, 2 miles in fog and rain; temperature, 50 degrees (F); dew point, 50 degrees (F); wind condition, 130 degrees at 13 knots gusting to 19 knots; and altimeter, 29.54 inches." WRECKAGE AND IMPACT INFORMATION The aircraft was recovered from the Casco Bay on November 26, 1993. The aircraft was submerged in about 85 feet of water. It was transported to Central Connecticut Aircraft Company, Plainsville, Connecticut, where it was examined on December 9, 1993. The skid of the aircraft was separated from the helicopter. During the recovery from the Bay, the tail boom and one of the main rotor blades were cut for removal, along with the tail rotor control tube at the point of tail boom breakage. One bolt was removed at the tail rotor drive shaft coupling in the same area. The recovery personnel stated that the main rotor blade was broken and the tail boom was still attached to the aircraft when it was removed from the water. They also stated that the control and drive for the tail rotor were intact and damaged. Control continuity of the drive train was confirmed by rotating the rotor in the direction of rotation. The rotor was unable to rotate backwards against the freewheeling unit due to engine gearbox deterioration from the salt water. The cyclic control was intact from the pilot's cyclic control stick to the main rotor. The collective pitch control was broken at the aft end resulting in a disconnect in the collective control at that point. The tail rotor control system continuity could not be determined due to deformation of the main fuselage. The link from the pilot's anti-torque pedals to the center console was fractured. Examination of the main rotor blades revealed one of the main blades was separated approximately three feet from the end of the blade root. The other blade revealed upward bending at the outboard end. Both pitch links and pitch horns were intact. One of the tail rotor blades was bent. There was evidence of red paint marks on the side of the blade matching airframe paint. There was no evidence of rotational damage. The plate at the lower end of the vertical fin and the horizontal stabilizer were twisted to the left. The STC'd fuel elbow was removed from the fuel tank filler port to gain visual access to the interior of the tank. There was no evidence of fuel in the main tank. The airframe around the main fuel tank was deformed. There was evidence of a puncture mark on the lower surface of the fuel bladder. The cover over the fuel lines was removed from the aft cabin floor to expose the fuel filters. The fuel lines and filters were removed from the aircraft. A 1/4 cup of a clear liquid was drained from each fuel line. The aircraft had two forward cell tanks. With the aircraft twisted to the left in a left side low position, the fuel quantity probe in the forward left cell was removed and the tank dip-sticked. There was approximately a half inch of clear liquid in the tank. The fuel vent line from the forward right cell was removed and that cell was dip-sticked. There was no evidence of liquid in this tank. The airframe fuel filter was removed and opened. The contents were emptied into a one lb coffee can. There was about 2/3 of the one lb container of clear liquid obtained. The filter was also examined and there was no evidence of any restriction. The engine was examined and appeared to be intact. The engine was transported to Allison Engines in Indianapolis, Indiana, where a teardown was done under the supervision of the FAA on March 18, 1994. The examination did not reveal any pre-existing deficiencies. Details of the examination are attached to this report ## Aircraft - Registration: [N911ME](https://openairdocs.org/deregistered/N911ME-2013-04-29), registration cancelled 2013-04-29, S/N 45553, built 1980 (OpenAirDocs) - Reported make and model: BELL 206L-1 - Registry model: [Bell Helicopter Textron 206L-1](https://openairdocs.org/model/bell-helicopter-textron-206l-1) (registry code 1182107) (OpenAirDocs) - Registry engine: [Allison 250-C28 series](https://openairdocs.org/engine/allison-250-c28-series) (registry code 03022, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 45553 - Airframe hours: 2220 - Engines: ALLISON A250-C28B 520 horsepower turbo shaft - Damage: Destroyed - Flight: Part 135 - Operator: Echo Helicopter Inc., doing business as Echo Helicopter Inc. - Registered owner: Airmed Skycare Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, October 12, 1993, 34 hours before - Departed: ELLSWORTH, ME - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; private, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 2, valid medical--w/ waivers/lim; seat: right; flight hours: 8,221 total, 3,640 in this make and model, 8,100 as pilot in command, 85 in the last 90 days, 21 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 130° at 13 knots, gusting 19 - Visibility: 2 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 50 °F, dew point 50 °F - Altimeter: 29.00 inHg - Observed at: PWM, 7 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 19931119043949A](https://openairdocs.org/incident/19931119043949A), Nov 19, 1993: Bell 206L1, Portland, ME, Destroyed, 3 fatal. Encountered strong headwind. Ran out of fuel on vectors to airport. Ditched ocean bay. Sank. Rain fog high waves. ## Docket (30 files) The files NTSB released with the investigation on October 10, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=8833. - Supplement A (item 1, .PDF, 198 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030496&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 309 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030498&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement G (item 3, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030497&FileExtension=.PDF&FileName=Supplement%20G-Master.PDF - Supplement K (item 4, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030499&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 5, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401533&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Redacted.PDF - Witness Statements (item 6, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401535&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 7, .PDF, 491 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030502&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Dispatch Log of Aircraft (item 8, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030503&FileExtension=.PDF&FileName=Dispatch%20Log%20of%20Aircraft-Master.PDF - Fuel Slips (item 9, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401536&FileExtension=.PDF&FileName=Fuel%20Slips-Redacted.PDF - Operations Specification for Echo Inc. (item 10, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401537&FileExtension=.PDF&FileName=Operations%20Specification%20for%20Echo%20Inc.-Redacted.PDF - Excerpts from Echo Inc. Operations Manual EMS Procedures (item 11, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030506&FileExtension=.PDF&FileName=Excerpts%20from%20Echo%20Inc.%20Operations%20Manual%20%20EMS%20Procedures-Master.PDF - Far 135.181 Performance Requirement for Single Engine Aircraft (item 12, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030507&FileExtension=.PDF&FileName=Far%20135.181%20Performance%20Requirement%20for%20Single%20Engine%20Aircraft-Master.PDF - Bell Helicopter Operations Safety Notice (item 13, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030508&FileExtension=.PDF&FileName=Bell%20Helicopter%20Operations%20Safety%20Notice-Master.PDF - Excerpt from Bell 206L Flight Manual (item 14, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030509&FileExtension=.PDF&FileName=Excerpt%20from%20Bell%20206L%20Flight%20Manual-Master.PDF - Airman Competency/Proficiency Check (item 15, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401538&FileExtension=.PDF&FileName=Airman%20Competency%2FProficiency%20Check-Redacted.PDF - Reconstruction of Fuel Burn (item 16, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030511&FileExtension=.PDF&FileName=Reconstruction%20of%20Fuel%20Burn-Master.PDF - U.S. Coast Guard Report (item 17, .PDF, 784 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030512&FileExtension=.PDF&FileName=U.S.%20Coast%20Guard%20Report-Master.PDF - Excerpts from Engine Examination Allison Engines (item 18, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401539&FileExtension=.PDF&FileName=Excerpts%20from%20Engine%20Examination%20Allison%20Engines-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 19, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401540&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 20, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401542&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. Right side view of aircraft. (item 21, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030516&FileExtension=.PDF&FileName=Photo%201.%20%20Right%20side%20view%20of%20aircraft.-Master.PDF - Photo 2. Rear view of aircraft. (item 22, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030517&FileExtension=.PDF&FileName=Photo%202.%20Rear%20view%20of%20aircraft.-Master.PDF - Photo 3. Left side of aircraft. (item 23, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030518&FileExtension=.PDF&FileName=Photo%203.%20%20Left%20side%20of%20aircraft.-Master.PDF - Photo 4. Rear section of aircraft. (item 24, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030519&FileExtension=.PDF&FileName=Photo%204.%20Rear%20section%20of%20aircraft.-Master.PDF - Photo 5. Forward section of aircraft. (item 25, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030520&FileExtension=.PDF&FileName=Photo%205.%20%20Forward%20section%20of%20aircraft.-Master.PDF - Photo 6. Right side view of aircraft. (item 26, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030521&FileExtension=.PDF&FileName=Photo%206.%20Right%20side%20view%20of%20aircraft.-Master.PDF - Photo 7. Separated skid with floats. (item 27, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030522&FileExtension=.PDF&FileName=Photo%207.%20Separated%20skid%20with%20floats.-Master.PDF - Photo 8. Separated skid. (item 28, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030523&FileExtension=.PDF&FileName=Photo%208.%20Separated%20skid.-Master.PDF - Photo 9. Side view of engine. (item 29, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030524&FileExtension=.PDF&FileName=Photo%209.%20Side%20view%20of%20engine.-Master.PDF - Photo 10. Forward fuel tanks and filter. (item 30, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40030525&FileExtension=.PDF&FileName=Photo%2010.%20Forward%20fuel%20tanks%20and%20filter.-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.