# NTSB CEN22LA122: Bell 206, N469AE, Eldorado, IL, February 12, 2022 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: February 11, 2022, 23:12 local (Feb 12, 2022, 05:12 UTC) - Place: Eldorado, IL - Coordinates: 37.817509, -88.441959 - Nearby events: https://openairdocs.org/map.md?lat=37.8175&lon=-88.4420&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: Serious injuries - Injuries: 1 serious, 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: Air Evac LifeTeam, Federal Aviation Administration - NTSB case key (mKey): 104650 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA122 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104650/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104650 - Page: https://openairdocs.org/ntsb/CEN22LA122 ## Probable cause Overheating of two lithium batteries in the paramedic’s flight suit pocket resulting in an explosion and fire that seriously injured the paramedic as the helicopter was about to take off. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Personnel issues](https://openairdocs.org/ntsb-findings/02050000): Personnel issues › Miscellaneous · Cabin crew (probable cause); cases with it: [Bell Helicopter Textron Canada 206L-4, 1 case](https://openairdocs.org/ntsb-findings/02050000/cases.md?model=1181455), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/02050000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Bell Helicopter Textron Canada 206L-4, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=1181455), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## Analysis The pilot reported that the helicopter was about to take off with a flight nurse, paramedic, and a patient onboard when she noticed a flash and flame reflection on the front left windscreen immediately followed by screams and the cabin filling with smoke. The pilot immediately reduced the throttle, pulled the fuel shutoff valve, and applied full rotor brake. The paramedic on board’s flight suit was on fire. The flight nurse on board managed to open the helicopter’s right-side door, unbuckle the paramedic, and pull her from the helicopter. The flight nurse extinguished the flames, called for additional help, and began cutting away the burned flight jacket and flight suit from the paramedic. In the paramedic’s left chest flight suit pocket were keys and a burnt lithium battery. The nurse reported that when she went to remove the battery to prevent further injury to the paramedic, the battery was extremely hot and smoking, and burned her hand. She threw the battery to the ground and continued to render care to the paramedic. Later two burnt lithium batteries lying on the ground next to the helicopter’s left skid were recovered. The pilot reported no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation. The operator’s parent company issued a safety alert to all of its air and ground ambulance companies warning of the dangers of improperly carrying or storing loose lithium and lithium-ion batteries used in personal electronic devices. ## Aircraft - Registration: [N469AE](https://openairdocs.org/aircraft/N469AE), registered now, S/N 52480, built 2015 (OpenAirDocs) - Reported make and model: BELL 206 (L4) - Registry model: [Bell Helicopter Textron Canada 206L-4](https://openairdocs.org/model/bell-helicopter-textron-canada-206l-4) (registry code 1181455) (OpenAirDocs) - Registry engine: [Rolls-Royce 250-C30P](https://openairdocs.org/engine/rolls-royce-250-c30p) (registry code 54013, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 52480 - Year built: 2016 - Airframe hours: 3363.6 - Engines: Rolls Royce 250-C30P 650 horsepower turbo shaft - Damage: Minor damage - Fire: On-Ground - Flight: Business, Part 135 - Operator: Air Evac Lifeteam - Registered owner: Air Evac Lifeteam - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, February 10, 2022 - Departed: El Dorado, IL - Flight plan: Company VFR - Equipment: Electronic flight bag or handheld device, Auto-pilot, ADS-B, Satellite tracking device, Onboard weather, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; commercial; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; seat: right; restraint: 4-point; flight hours: 2,710 total, 692 in this make and model - Other flight crew; seat: right - Other flight crew; seat: left ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 14 knots, gusting 20 - Visibility: 10 statute miles - Lowest ceiling: 3,500 ft broken - Temperature: 41 °F, dew point 32 °F - Altimeter: 30.07 inHg - Observed at: KHSB, 5 nm away - METAR: KHSB 120515Z AUTO 34014G20KT 10SM SCT019 BKN035 OVC041 05/00 A3007 RMK AO2 T00480002 ## 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 20220211000219A](https://openairdocs.org/incident/20220211000219A), Feb 11, 2022: Bell Helicopter Textron Canada 206L-4, Eldorado, IL, Minor damage. The haa crew was picking up a patient from a hospital. The flight medic carried her personal vap device lithium batteries in her pocket. After buckling in, the… ## Docket (5 files) The files NTSB released with the investigation on April 28, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104650. 3.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13432404&FileExtension=pdf&FileName=NTSB%20Form%206120.1_Redacted-Rel.pdf - Record of conversation (item 2, PDF, 1 page, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13536246&FileExtension=pdf&FileName=Record%20of%20Conversation-Rel.pdf - Statement of party representatives to NTSB investigation (item 3, PDF, 1 page, 883 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13536163&FileExtension=pdf&FileName=NTSB%20Signed%20Party%20Form%2003-17-2022%20(AE138)_Redacted-Rel.pdf - Photos (item 4, PDF, 8 pages, 395 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13771904&FileExtension=pdf&FileName=Photos,%20Eldorado,%20IL%20Batteries%20Explosion-Rel.pdf - Global medical response safety alert (item 5, PDF, 2 pages, 435 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13536072&FileExtension=pdf&FileName=02-16-22-safety-alert-batteries-Rel.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.