CHI04FA107

NTSB accident investigation · Bell 206L-1 · Boonville, IN · April 21, 2004

Accident · FatalField investigationFinal report
Date
April 20, 2004, 23:43 local (Apr 21, 2004, 04:43 UTC)
Place
Boonville, IN
Injuries
1 fatal, 3 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N137AEBell 206L-1
Weather
Visual (VMC) · Night/dark
Status
Completed · report June 8, 2005
Report
Approved by Office Director
Parties
Air Evac, Bell Helicopter, Senior Air Saety Investigator, FAA, Indianapolis FSDO
FAA report
20040420012859A
Case key
59097

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's inadequate planning/decision which resulted in his failure to maintain terrain clearance. Contributing factors were the pilot's inadequate preflight planning, his diverted attention, and the dark night conditions.

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 collision with terrain/waterCruise - normal
Diverted attentionPilot in commandFactor
Light condition - dark nightFactor
Preflight planning/preparation - inadequatePilot in commandCause
Altimeter setting - improperPilot in commandFactor
Altitude/clearance - not maintainedPilot in commandCause

Analysis

The helicopter collided with up sloping terrain during a night air medical flight. The accident occurred while transporting a patient from one hospital to another. Examination of the accident site and wreckage revealed the helicopter impacted the terrain in a level flight attitude. The accident site was at an abandoned strip mine located in a rural area. The area contained very few ground structures to provide reference lighting. During post accident interviews the pilot stated that he remembered picking up the patient and the next thing he remembered is the helicopter tumbling. The flight nurse and paramedic on board did not recall there being any indication of a problem prior to impact. The destination hospital is located inside the Class C airspace of the Evansville Regional Airport (EVV). The air traffic control facility at EVV closes at 2300. Between 2328 and 2339, the pilot made 12 attempts to establish contact with approach control as he approached the Class C airspace. There was a time zone change at EVV 16 days prior to the accident. Examination of the cockpit revealed the altimeter was set at 30.08 inches of mercury. The current altimeter setting was 29.77 inches of mercury. This resulted in the altimeter indicating about 310 feet higher then the actual altitude of the helicopter. The pilot who flew the helicopter prior to the accident flight reported the radar altimeter was operating erratically. This pilot and the mechanic who maintained the helicopter, both stated the accident pilot was informed of the problem. Bench testing of the radar altimeter failed to duplicate the reported erratic operation. The decision height (DH) bug on the radar altimeter was found set to 60 feet. Company policy is that the DH bug be set to 500 feet during visual night operations. Examination of the airframe, engine, and flight controls failed to reveal any mechanical failure/malfunction.

Factual narrative

History of flight

On April 20, 2004, at 2343 central daylight time, a Bell 206L-1, N137AE, operated by Air Evac Life Team as Air Evac 17, collided with the terrain during a medivac flight. The patient was fatally injured. The pilot, paramedic, and nurse, were seriously injured. The helicopter was substantially damaged. The 14 CFR Part 135 flight was operating in visual meteorological conditions and was receiving company flight following at the time of the accident. The helicopter last departed the St. Joseph's Hospital Heliport (II47), in Huntingburg, Indiana, with an intended destination of Deaconess Hospital (16IN) in Evansville, Indiana.

Air Evac 17 was based at the Davies County Airport (DCY), Washington, Indiana. At 2151, the crew was notified of a patient who needed to be transported from II47 to16IN. Air Evac 17 departed DCY about 2204 en route to II47. Air Evac 17 landed in II47 around 2223 and departed around 2325 en route to 16IN with the patient on board.

The last radio contact that Air Evac dispatch had with the flight was at 2327 when Air Evac 17 reported they had departed II47 with 4 people and 450 pounds of fuel on board.

The destination helipad, 16IN, is located within the Class C airspace surrounding the Evansville Regional Airport (EVV), Evansville, Indiana. The hours of operation of the air traffic control tower at EVV were between 0600 and 2300. The audio recording equipment was inadvertently left on after the tower closed. A recording of the approach frequency communications revealed the pilot of N137AE made 12 radio transmissions during the time period 2328 - 2339. The first four transmissions were attempts to contact the approach control. The fifth transmission was a partial transmission. This was followed by six more transmissions attempting to contact approach. The last transmission was partially unintelligible.

Following the accident, the flight crew paramedic used a cellular phone and called dispatch to inform them that they had crashed. A recording of the call was made available to the NTSB. The beginning of the recording is time stamped 2344. The paramedic stated he did not know their location and the last location he was aware of was being 8 minutes from their destination. He stated they were in a field and he could see a flashing white light on a tower that was a couple miles away.

During the cellular call, the paramedic stated he did not know what happened, but the helicopter was on its side. He later stated they just hit the ground. The paramedic informed the dispatcher that the pilot was trapped in the wreckage, the nurse was out of the wreckage by the tail of the helicopter, the patient was by the nose of the helicopter and that they were all injured. Despite his injuries which included a broken jaw, the paramedic continued talking with dispatch, the pilot, and the nurse. The paramedic asked the pilot what happened and the pilot responded that they lost altitude.

During the time that the paramedic was on the cell phone with the dispatcher, other Air Evac employees were making telephone calls getting helicopters and local authorities out to search for N137AE. At 0055, the paramedic informed the dispatcher that he could see an aircraft light that was heading toward him. At 0112, the paramedic stated that he was able to see flashing lights on an emergency vehicle in the distance. The paramedic removed a blue pen light from the shoulder of the nurse and used the light to signal the helicopters that were flying overhead searching. At 0117, they were located by another Air Evac helicopter.

One witness, who was at his residence located approximately 300 yards north of the accident site, reported that around 2330 he heard a helicopter fly overhead. He reported the helicopter sounded very loud and that the sound gradually faded away in the distance as if it was flying away. He stated that about a half hour later he heard another helicopter flying from west to east. He stated this one was not as loud as the first. He stated that shortly after hearing the second helicopter, he heard others in the area as if they were searching for something. He was not aware of the accident when he heard the helicopters.

During an interview, the flight nurse stated he remembered being about 10 minutes away from 16IN and the next thing he remembered is being on the ground outside the helicopter. He stated he does not recall any problems prior to the helicopter impacting the ground.

In a post-accident interview, the paramedic stated that he remembered picking up the patient in Huntingburg and caring for the patient during the flight. He stated the next thing he remembered is impacting the ground, getting out of the helicopter, and making the call to dispatch to get help. He stated that he does not remember the pilot indicating that there were any problems prior to impacting the ground. He stated that he recalled it being windy at the time of the accident.

In a post-accident interview, the pilot stated he recalled picking up the patient in Huntingburg and the next thing he remembered is the helicopter tumbling on the ground. He stated he remembered being trapped inside the wreckage.

The emergency medical technicians (EMT) who treated the pilot at the accident site reported that the pilot stated "Boy I screwed up." An EMT asked him what happened and the pilot reported, "I started making my turn and we started tumbling."

Personnel information

The pilot held a commercial pilot certificate with airplane single-engine land, helicopter, instrument airplane, and instrument helicopter ratings. The pilot held a second-class medical certificate dated January 23, 2004. The medical certificate contained the limitation: "Must wear corrective lenses."

The pilot reported having a total of 3,846.7 hours of flight time of which 3,592.7 hours were in helicopters. The pilot reported he had a total of 649.6 hours of flight time in Bell 206L-1 helicopters. He reported he flew 63.7 hours in the last 90 days, 38.1 hours in the last 30 days, and 0.9 hours in the last 24 hours. All of this flight time was in a Bell 206L-1. The pilot's last biennial flight review was on January 20, 2004, in a Bell 206L-1 helicopter.

The pilot completed his initial training with Air Evac in January 2001, and his Federal Aviation Regulation (FAR) 135 Airman Competency/Proficiency Check was satisfactorily completed on January 13, 2001.

In February 2002, the pilot attended a Bell 206L-1 refresher course conducted by the Bell Helicopter Training Academy. The pilot satisfactorily completed this Ground and Flight Procedures Training Course. Records were not located to indicate the date that the pilot passed a FAR 135 Airman Competency/Proficiency Check in 2002.

In January 2003, the pilot once again attended a Bell 206L-1 refresher course conducted by the Bell Helicopter Training Academy. The pilot was issued a completion certificate for the Ground portion of the training. Remarks in the training record state the pilot "... needs more flight training to achieve Bell minimum standards." There were no records located which indicated the pilot had received additional training. Records were not located to indicate the date that the pilot passed a FAR 135 Airman Competency/Proficiency Check in 2003.

On January 9, 2004, the pilot failed his FAR 135 Airman Competency/Proficiency Check. Comments in the remarks section of Federal Aviation Administration Form 8410-3 stated, "Company Part 135 check ride unsat." Comments in the pilot's Flight Training Record dated January 9, 2004 state, "Unsat maneuvers - hydraulics, hovering autos, t/r malf were not complete. Knowledge of company ops, weak." Following this check ride, the pilot was placed in an Initial Training class for requalification. On January 20, 2004, the pilot passed a FAR 135 Airman Competency/Proficiency Ch

Aircraft

Registration
N137AE
Reported as
Bell 206L-1
Category
Helicopter
Serial number
45266
Airframe hours
26,910
Engine
Allison 250-C28B, 500 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Air Evac Ems Inc, doing business as Air Evac Life Team
Registered owner
Air Evac Leasing Corp
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · April 18, 2004 · 1 hours before
Departed
HNB · Huntingburg, IN
Destination
16IN · Evansville, IN
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
42
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
January 20, 2004
Seat
Right
Flight hours
3,847 total · 650 in this make and model · 3,802 as pilot in command · 64 in the last 90 days · 38 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
210° at 12 knots, gusting 17
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 54 °F
Altimeter
29.77 inHg
Observed at
EVV, 13 nm away

Docket · 44

The files NTSB released with the investigation on April 2, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 21.5 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 456 KBPilot Interview and Crew StatementsItem 2 · .PDF · 222 KBWitness Statements and Record of InterviewsItem 3 · .PDF · 92 KBSt. Louis Sectional ChartItem 4 · .PDF · 359 KBWreckage DiagramItem 5 · .PDF · 50 KBWeather InformationItem 6 · .PDF · 235 KBIndiana State Police ReportItem 7 · .PDF · 745 KBPilot Training RecordsItem 8 · .PDF · 1.3 MBPilot Duty TimesItem 9 · .PDF · 231 KBEngine Test DataItem 10 · .PDF · 141 KBCaution/Warning Panel ExaminationItem 11 · .PDF · 1.2 MBDiamond J Instrument InspectionItem 12 · .PDF · 286 KBSkytrak InformationItem 13 · .PDF · 632 KBRadar Altimeter Procedures InformationItem 14 · .PDF · 128 KBMaintenance RecordsItem 15 · .PDF · 433 KBMinimum Equipment ListItem 16 · .PDF · 97 KBFAA Form 337 Litter MountItem 17 · .PDF · 1.9 MBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 313 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 19 · .PDF · 174 KBPhoto 1. Initial Ground ScarsItem 20 · .PDF · 606 KBPhoto 2. Search Light With Wire Strike Cutter in ForegroundItem 21 · .PDF · 328 KBPhoto 3. Wire Strike Cutter Removed From GroundItem 22 · .PDF · 623 KBPhoto 4. Search Light Ground ScarItem 23 · .PDF · 613 KBPhoto 5. One of Three Slash Marks in TerrainItem 24 · .PDF · 608 KBPhoto 6. Separated Portion of Cross TubeItem 25 · .PDF · 219 KBPhoto 7. Front of Main WreckageItem 26 · .PDF · 610 KBPhoto 8. Belly of Main WreckageItem 27 · .PDF · 609 KBPhoto 9. Rear View of Main WreckageItem 28 · .PDF · 610 KBPhoto 10. Top View of Main WreckageItem 29 · .PDF · 607 KBPhoto 11. Front View of Main WreckageItem 30 · .PDF · 591 KBPhoto 12. Yellow Main Rotor BladeItem 31 · .PDF · 618 KBPhoto 13. Red Main Rotor BladeItem 32 · .PDF · 593 KBPhoto 14. Tip of Red Main Rotor BladeItem 33 · .PDF · 273 KBPhoto 15. Main Rotor Drive ShaftItem 34 · .PDF · 622 KBPhoto 16. Tail Rotor AssemblyItem 35 · .PDF · 613 KBPhoto 17. Melted Plastic BottleItem 36 · .PDF · 598 KBPhoto 18. Burned GrassItem 37 · .PDF · 358 KBPhoto 19. Main Wreckage Up RightedItem 38 · .PDF · 625 KBPhoto 20. Paint Transfer Marks on Red Main Rotor Blade TipItem 39 · .PDF · 606 KBPhoto 21. Tail Boom AssemblyItem 40 · .PDF · 615 KBPhoto 22. Slash in Leading Edge of Left Horizontal Stabilizer (Bell Photo)Item 41 · .PDF · 112 KBPhoto 23. Skid AssemblyItem 42 · .PDF · 565 KBPhoto 24. Main Rotor BladesItem 43 · .PDF · 241 KBPhoto 25. Tail Rotor Drive ShaftItem 44 · .PDF · 153 KB

FAA reports on this event · 1

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