# NTSB CHI02FA288: Bell 206L-1, N400SL, Doland, SD, September 10, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 9, 2002, 21:52 local (Sep 10, 2002, 02:52 UTC) - Place: Doland, SD - Coordinates: 44.853889, -98.040275 - Nearby events: https://openairdocs.org/map.md?lat=44.8539&lon=-98.0403&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report February 24, 2005 - Report: Approved by Office Director - Parties: Rolls-Royce Corporation, Omniflight Helicopters, Incorporated, Bell Helicopter, Federal Aviation Administration - Rapid City FSDO - NTSB case key (mKey): 55742 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI02FA288 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/55742/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=55742 - Page: https://openairdocs.org/ntsb/CHI02FA288 ## Probable cause Pilot spatial disorientation while flying in dark night conditions, resulting in a loss of aircraft control; and the company's inadequate remedial actions after identifying the pilot's night flying deficiency over areas without lighted references. A factor to the accident was the dark night conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, cruise - spatial disorientation, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - light condition - dark night (contributing factor) - remedial action - inadequate, company/operator management (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The helicopter was destroyed when it impacted terrain during an emergency medical service flight. The accident occurred during a dark night, in a sparsely populated area with no lighted ground references. Marginal visual flight rules conditions prevailed along the route of flight. The pilot had a documented history of having difficulty flying at night without lighted ground references. The company base and safety managers reported the pilot's night flying deficiency to the company chief pilot. The chief pilot subsequently evaluated the pilot during a night flight. After the evaluation flight, the chief pilot decided to increase the pilot's nighttime weather minimums for a period of 25 night hours as he gained night experience. The accident flight occurred on the pilot's fourth night mission after being evaluated by the chief pilot. Inspection of the helicopter wreckage did not reveal any evidence of a pre-impact malfunction. A review of the helicopter's daily usage logs indicated that there were no unresolved maintenance discrepancies. The pilot who flew the helicopter prior to the accident flight did not report any malfunctions. ## Factual narrative HISTORY OF FLIGHT On September 9, 2002, at 2152 central daylight time (cdt), a Bell 206L-1 helicopter, N400SL, piloted by a commercial pilot, was destroyed during a collision with terrain about 3.6 nautical miles (nm) southeast of Doland, South Dakota. Night marginal visual meteorological conditions (MVFR) prevailed at the time of the accident. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135 while on a company flight plan. The pilot, flight nurse, flight paramedic, and patient were fatally injured. The flight departed from Avera St. Luke's Hospital (SD54), Aberdeen, South Dakota, at 2131 and was en route to Heart Hospital of South Dakota Heliport (2SD6), Sioux Falls, South Dakota. The helicopter was operated by Omniflight Incorporated, an on-demand air ambulance service. According to company personnel, the flight from SD54 to 2SD6 was considered a routine flight and the accident pilot was familiar with the route. The route was normally flown direct from SD54, navigated by pilotage and augmented with a global positioning system (GPS) receiver. When flying GPS direct, the helicopter passes over Doland. According to company dispatch records, the helicopter departed SD54 and proceeded directly toward 2SD6. At 2149:49 (hhmm:ss), the company dispatcher asked the pilot for a position report. The pilot replied that there were four individuals on-board the helicopter, that the helicopter had two hours of fuel remaining, and that the estimated time en route (ETE) was 58 minutes. The dispatcher confirmed the pilot's transmission, including the 58 minute ETE. The pilot's position report placed the helicopter near Doland, according to company pilots familiar with the route. At 2151:11, the pilot relayed the crew identification numbers to the dispatcher. At 2151:16, the dispatcher repeated the crew identification numbers and the pilot replied, "affirmative." There were no additional transmissions received from the accident helicopter. Several Doland area residents witnessed the accident helicopter flying over the town around 2150. The witnesses reported that the helicopter was flying southeast over the town approximately 300 - 500 feet above ground level (agl). One witness reported that the helicopter "seemed to be running fine." Another witness reported that the helicopter was "a little slower...than normal." One of the witnesses reported that "the sky was overcast, but the clouds were breaking up as [he] noticed stars becoming visible. It had rained earlier in the evening, but at least by [2130 cdt] it was not raining." Another witness reported that "the clouds were starting to break up [and] it was clearing in the west but clouds were present in the east." DAMAGE TO AIRCRAFT The helicopter was destroyed by impact forces with terrain. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot, age 39, held a commercial pilot certificate with rotorcraft/helicopter, airplane single engine land (SEL), and helicopter/airplane instrument ratings. The pilot also held a certified flight instructor (CFI) certificate with rotorcraft/helicopter, SEL, and helicopter/airplane instrument ratings. The pilot's last FAA medical examination was completed on February 4, 2002, when he was issued a second-class medical certificate with the limitation "shall wear corrective lenses." The pilot was a Japanese citizen working in the United States as a registered permanent resident. According to the pilot's flight records, he had accumulated 2,670.3 hours of flight experience, with 2,572.2 hours in helicopters and 98.1 hours in SEL airplanes. The pilot had logged 2,338.4 hours as pilot-in-command (PIC), of which 2,062.0 hours were as a helicopter flight instructor. The pilot had 140.5 hours of night experience, with 129.2 hours in helicopters and 11.3 hours in airplanes. He had logged 91.0 hours of night cross country flying, including 79.7 hours in helicopters. A review of the pilot's flight logbooks indicated a majority of his night experience was completed near major metropolitan areas while providing flight instruction. The pilot had 56.8 hours of instrument experience in both helicopters and airplanes. He had logged 10.2 hours in actual instrument conditions and 46.6 hours in simulated conditions. The pilot had 20.4 hours of instrument time in helicopters, all of which were in simulated conditions. A majority of the pilot's helicopter experience, 2,249.5 hours, was completed in the Robinson R-22. The pilot had also accumulated 321.2 hours in the Bell 206, 1.0 hour in the Aerospatiale AS-350 and 0.5 hours in a Bell 47. The pilot had flown 244.2 hours in helicopters during the past year, consisting of 130.2 hours in Bell 206 helicopters and 114.0 hours in Robinson R-22 helicopters. He flew 81.4 hours during the prior 6 months, 51.1 hours during the past 90 days, and 1.6 hours during the previous 30 days. The pilot did not fly during the 24 hours before the accident flight. The pilot worked 17 twelve-hour shifts during the previous 30 calendar days. The pilot reported for duty on September 9, 2002, at 1900, after being off-duty for 12 hours. - Flight Training History The pilot began his primary helicopter flight training on September 6, 1991, and obtained a private pilot certificate on December 13, 1991. He continued his flight training and obtained his commercial pilot certificate on March 16, 1992, and his CFI certificate on May 13, 1992. On August 25, 1992, the pilot began helicopter flight instruction in Japan and obtained a Japan Civil Aviation Bureau (JCAB) commercial helicopter license on March 3, 1993. On August 6, 1999, the pilot began airplane flight instruction in the United States and obtained a FAA private pilot rating for SEL airplanes on September 10, 1999. He then began instrument airplane flight instruction. On April 20, 2000, the pilot did not pass an airplane instrument practical exam and received a Notice of Disapproval of Application. According to FAA records, during the examination the pilot became disoriented while flying instrument approaches and the flight examiner had to take control of the airplane. The pilot also incorrectly selected the radial for a VOR approach and missed the airport by several miles. On two occasions during the flight the examiner had to explain air traffic control clearances to the pilot. After the checkride the pilot did not fly airplanes until February 2, 2001, when he resumed taking instrument instruction again. The pilot successfully obtained his airplane instrument rating on February 28, 2001. He continued to receive airplane flight instruction and obtained a commercial SEL airplane rating on March 23, 2001, and a CFI SEL airplane rating on April 3, 2001. On November 6, 2001, the pilot received a CFI instrument airplane rating. The pilot took two FAA practical examinations on November 19, 2001. The first practical exam was to add a helicopter instrument rating to his commercial certificate. The pilot satisfactorily passed the practical examination for the helicopter instrument rating. The second practical exam was to add a helicopter instrument rating to his flight instructor certificate. The pilot did not pass the practical exam and received a Notice of Disapproval of Application. According to FAA records, the pilot demonstrated unsatisfactory knowledge of ATC procedures and clearances. The pilot obtained his instrument helicopter instructor rating on December 04, 2001, after successfully completing the practical exam on the second attempt. - Aviation Employment History The pilot came to the United States to work as a helicopter flight instructor, in January 1994. He was initially employed by Puget Sound Helicopters, Renton, Washington. In May 1997, he began providing flight instruction for Kyodo Air Incorporated, Paso Robles, Califo ## Aircraft - Registration: [N400SL](https://openairdocs.org/deregistered/N400SL-2006-02-07), registration cancelled 2006-02-07, S/N 45235, built 1979 (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: 45235 - Airframe hours: 9749.7 - Engines: Allison 250-C28B 500 horsepower turbo shaft - Damage: Destroyed - Flight: Part 135 - Registered owner: Omniflight Helicopters, Incorporated - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, August 29, 2002, 18.2 hours before - Departed: SD54, Aberdeen, SD - Destination: 2SD6, Sioux Falls, SD - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: fatal; commercial, foreign, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane, helicopter; medical: class 2, valid medical--w/ waivers/lim; last flight review January 25, 2002; seat: right; toxicology performed; flight hours: 2,670 total, 321 in this make and model, 2,338 as pilot in command, 51 in the last 90 days, 2 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 10° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft overcast - Temperature: 55 °F, dew point 54 °F - Altimeter: 30.15 inHg - Observed at: HON, 30 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 20020909025909A](https://openairdocs.org/incident/20020909025909A), Sep 9, 2002: Bell 206L1, Doland, SD, Destroyed, 4 fatal. (-23) On September 10, 2002, at approximately 9:52 pm CDT, a Bell helicopter m/n BHT-206-L1, s/n 45235, N400SL, operated by omniflight helicopters inc., 135… ## Docket (35 files) The files NTSB released with the investigation on January 20, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=55742. 10.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 384 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406310&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Meteorology 5 - Factual Report of Group Chairman (item 2, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40169856&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Witness Statements (item 3, .PDF, 397 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406311&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Correspondence with Omniflight Base Safety Manager (item 4, .PDF, 238 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406312&FileExtension=.PDF&FileName=Correspondence%20with%20Omniflight%20Base%20Safety%20Manager-Redacted.PDF - Correspondence with Omniflight Base Manager (item 5, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406313&FileExtension=.PDF&FileName=Correspondence%20with%20Omniflight%20Base%20Manager-Redacted.PDF - E-mail Correspondence with Omniflight Chief Pilot (item 6, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406314&FileExtension=.PDF&FileName=E-mail%20Correspondence%20with%20Omniflight%20Chief%20Pilot-Redacted.PDF - Correspondence with Hospital Staff (item 7, .PDF, 277 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406315&FileExtension=.PDF&FileName=Correspondence%20with%20Hospital%20Staff-Redacted.PDF - Toxicological Report (item 8, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406316&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406317&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406318&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. Overhead View of Accident Site (Supplied By South Dakota Crime Lab) (item 11, .PDF, 401 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224257&FileExtension=.PDF&FileName=Photo%201.%20%20Overhead%20View%20of%20Accident%20Site%20(Supplied%20By%20South%20Dakota%20Crime%20Lab)-Master.PDF - Photo 2. Overhead View of Accident Site (Supplied By South Dakota Crime Lab) (item 12, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224258&FileExtension=.PDF&FileName=Photo%202.%20%20Overhead%20View%20of%20Accident%20Site%20(Supplied%20By%20South%20Dakota%20Crime%20Lab)-Master.PDF - Photo 3. Wreckage Site Overview (item 13, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224259&FileExtension=.PDF&FileName=Photo%203.%20%20Wreckage%20Site%20Overview-Master.PDF - Photo 4. Initial Impact Point (item 14, .PDF, 264 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224260&FileExtension=.PDF&FileName=Photo%204.%20%20Initial%20Impact%20Point-Master.PDF - Photo 5. Initial Impact Point (item 15, .PDF, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224261&FileExtension=.PDF&FileName=Photo%205.%20%20Initial%20Impact%20Point-Master.PDF - Photo 6. Aft Fuselage, Tailboom, & Tail Rotor (item 16, .PDF, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224262&FileExtension=.PDF&FileName=Photo%206.%20%20Aft%20Fuselage,%20Tailboom,%20%26%20Tail%20Rotor-Master.PDF - Photo 7. Tailboom & Tail Rotor (item 17, .PDF, 287 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224263&FileExtension=.PDF&FileName=Photo%207.%20%20Tailboom%20%26%20Tail%20Rotor-Master.PDF - Photo 8. Wreckage Layout Overview (item 18, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224274&FileExtension=.PDF&FileName=Photo%208.%20%20Wreckage%20Layout%20Overview-Master.PDF - Photo 9. Main Cabin - Left Side (item 19, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224275&FileExtension=.PDF&FileName=Photo%209.%20%20Main%20Cabin%20-%20Left%20Side-Master.PDF - Photo 10. Main Cabin - Right Side (item 20, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224276&FileExtension=.PDF&FileName=Photo%2010.%20%20Main%20Cabin%20-%20Right%20Side-Master.PDF - Photo 11. Tailboom, Driveshaft, & Tail Rotor - Right (item 21, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224277&FileExtension=.PDF&FileName=Photo%2011.%20%20Tailboom,%20Driveshaft,%20%26%20Tail%20Rotor%20-%20Right-Master.PDF - Photo 12. Tailrotor (item 22, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224278&FileExtension=.PDF&FileName=Photo%2012.%20%20Tailrotor-Master.PDF - Photo 13. Wreckage Overview - Aft View (item 23, .PDF, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224279&FileExtension=.PDF&FileName=Photo%2013.%20%20Wreckage%20Overview%20-%20Aft%20View-Master.PDF - Photo 14. Aft Fuselage, Tailboom, & Tail Rotor - Left (item 24, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224281&FileExtension=.PDF&FileName=Photo%2014.%20%20Aft%20Fuselage,%20Tailboom,%20%26%20Tail%20Rotor%20-%20Left-Master.PDF - Photo 15. Main Transmission, Mast, Rotor Head (item 25, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224283&FileExtension=.PDF&FileName=Photo%2015.%20%20Main%20Transmission,%20Mast,%20Rotor%20Head-Master.PDF - Photo 16. Main Rotor Blades (item 26, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224285&FileExtension=.PDF&FileName=Photo%2016.%20%20Main%20Rotor%20Blades-Master.PDF - Photo 17. Flight Control System Layout (item 27, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224286&FileExtension=.PDF&FileName=Photo%2017.%20%20Flight%20Control%20System%20Layout-Master.PDF - Photo 18. Landing Skid Tubes and Cross Tubes (item 28, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224287&FileExtension=.PDF&FileName=Photo%2018.%20%20Landing%20Skid%20Tubes%20and%20Cross%20Tubes-Master.PDF - Photo 19. Engine Overview (item 29, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224289&FileExtension=.PDF&FileName=Photo%2019.%20%20Engine%20Overview-Master.PDF - Photo 20. Engine Overview (item 30, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224291&FileExtension=.PDF&FileName=Photo%2020.%20%20Engine%20Overview-Master.PDF - Photo 21. Spur Gearshaft Fracture Overview (item 31, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224293&FileExtension=.PDF&FileName=Photo%2021.%20%20Spur%20Gearshaft%20Fracture%20Overview-Master.PDF - Photo 22. Spur Gearshaft Fracture (item 32, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224294&FileExtension=.PDF&FileName=Photo%2022.%20%20Spur%20Gearshaft%20Fracture-Master.PDF - Photo 23. Spur Gearshaft Fracture (item 33, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224297&FileExtension=.PDF&FileName=Photo%2023.%20%20Spur%20Gearshaft%20Fracture-Master.PDF - Photo 24. Compressor Impeller and Front Support (item 34, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224298&FileExtension=.PDF&FileName=Photo%2024.%20%20Compressor%20Impeller%20and%20Front%20Support-Master.PDF - Photo 25. Compressor Impeller (item 35, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224299&FileExtension=.PDF&FileName=Photo%2025.%20%20Compressor%20Impeller-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.