# NTSB DEN05FA103: Agusta A119, N403CF, Mancos, CO, June 30, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 30, 2005, 13:57 local (19:57 UTC) - Place: Mancos, CO - Coordinates: 37.400554, -108.142219 - Nearby events: https://openairdocs.org/map.md?lat=37.4006&lon=-108.1422&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report January 31, 2007 - Report: Approved by Office Director - Parties: Pratt & Whitney Canada, Agusta Aerospace Corporation, FAA Flight Standards District Office, Honeywell - NTSB case key (mKey): 61840 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN05FA103 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61840/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=61840 - Page: https://openairdocs.org/ntsb/DEN05FA103 ## Probable cause a loss of engine power for undetermined reasons and the pilot's inability to get into autorotation prior to impacting the ground. A factor contributing to the accident was the helicopter's low altitude when power was lost. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, approach - vfr pattern - final approach - reason for occurrence undetermined (cause) - In flight collision with terrain/water, descent - uncontrolled - autorotation - not possible, pilot in command (cause) - altitude - low (contributing factor) - terrain condition - ground ## Analysis The EMS helicopter had been dispatched to medivac a logger who had been injured in a trucking accident. The pilot made a low pass, then circled around to make his landing approach. A volunteer fireman, who was standing at the landing zone (LZ) and directing the helicopter, said the temperature was "about 80 degrees [F.]," and he advised the pilot that the winds were calm. The fireman said the helicopter was about 220 feet above tree level when "it dropped straight down." He heard no unusual engine sounds and did not see the impact. The on-scene examination revealed all four main rotor blades remained attached to the rotor hub and were drooped over the wreckage. Examination of the fuel control unit (FCU) revealed a 1/16-inch gap at the mating flange between the flow (fuel bypass passage, Po) and drive (air pressure passages, Px & Py) bodies. One of four retention-bolts was backed out and the packing was partially extruded. The bolt was too short, another bolt was too long, and the other two bolts were insufficiently torqued. Additionally, the flow and drive bodies were not perfectly flat. Further examination of the FCU revealed no functional anomalies. ## Factual narrative HISTORY OF FLIGHT On June 30, 2005, at 1357 mountain daylight time, an Agusta A119 helicopter, N403CF, operated by Tri-State Care Flight, LLC, of Bullhead City, Arizona, as "Care Flight 4" and piloted by a commercial pilot, was substantially damaged when it impacted terrain while approaching to land at a landing zone (LZ), 7.5 miles northeast of Mancos, Colorado. The pilot, flight nurse, and paramedic were fatally injured. Visual meteorological conditions prevailed, and a company visual flight rules (VFR) flight plan had been filed and activated for the emergency medical service (EMS) flight being conducted under Title 14 Code of Federal Regulations (CFR) Part 91. The flight originated at Animas Airpark (5CO0), Durango, Colorado, at 1242. According to Tri-State Care Flight, the helicopter had been dispatched earlier to search for a 14-year-old drowning victim in the Animas River near Farmington, New Mexico. The helicopter crew eventually located the victim. While the helicopter was returning to Durango, it was dispatched to the Red Arrow Mines area, near Mancos, for a logger who had been injured in a trucking accident. The helicopter flew to 5CO0, where it was refueled from a company fuel truck (quantity unknown), then responded to the emergency. According to a volunteer fireman who was standing at the LZ and directing the helicopter, the pilot made a low pass, then circled around to make his landing approach. The fireman said the temperature was "about 80 degrees [F.]," and he advised the pilot that the winds were calm. The pilot acknowledged this information. The fireman, who was looking directly at the approaching helicopter, said it was about 220 feet above tree level when "it dropped straight down." He said he heard no unusual engine sounds, and he did not see the impact. The first 9-1-1 telephone call was received by Montezuma County Dispatch at 1402. The accident occurred during the hours of daylight in the Helmet Peak area, near Forest Road (FR) 567 and FR 322, 7-1/2 miles northeast of Mancos. The accident site was at an elevation of 9,731 feet msl, and at a location of 37 degrees, 23.620' north latitude, and 108 degrees, 08.320' west longitude. CREW INFORMATION The pilot, age 40, held a commercial pilot certificate with rotorcraft-helicopter and instrument-helicopter ratings, dated September 25, 1995. He also held a second class airman medical certificate, dated April 18, 2005, with no restrictions or limitations. According to Tri-State Care Flight records, the pilot had logged 2,215 total flight hours, of which 1,600 hours were as pilot-in-command, and 130 hours were in the Agusta A119. In addition, the pilot had logged 532 night hours, and 81 hours in actual instrument meteorological conditions. When he made application for his medical certificate, the pilot estimated he had accrued 2,500 total flight hours, of which 80 hours were logged in the previous 6 months. He was employed by Tri-State Care Flight as an EMS helicopter pilot on May 9, 2004. The flight nurse, age 49, was employed by Tri-State Care Flight on September 6, 2004. His most recent medical recurrency check was accomplished on May 31, 2005, and his most recent helicopter recurrency check was accomplished on May 10, 2004. The emergency medical technician-paramedic (EMT-P), age 33, was employed by Tri-State Care Flight on May 10, 2004. His most recent medical recurrency check was accomplished on May 31, 2005, and his most recent helicopter recurrency check was accomplished on May 10, 2004. AIRCRAFT INFORMATION N403CF (s/n 14009), a model A119, was manufactured by Agusta SPA. The Federal Aviation Administration issued the helicopter a standard airworthiness certificate in the normal category on July 6, 2000. The helicopter was powered by a Pratt & Whitney Canada, Inc., (hereinafter referred to as P&WC) PT6B-37A turboshaft engine (s/n PCE-PU0006), rated at 900 shaft horsepower. The helicopter has a gross weight of 2,720 kilograms (5,997 pounds), a fuel capacity of 157 gallons, and a ceiling of 15,000 feet. According to the aircraft's maintenance records, the engine was installed in the airframe on September 11, 2000, the first run-up occurred on October 6, 2000, and ground and in-flight checks were completed on December 17, 2000. The helicopter was certified as being airworthy. Additional flight checks were made on December 18, 20, 28, and 29, 2000. The first annual inspection was performed on August 2, 2001. Additional annual inspections were performed on September 17, 2003, and April 15, 2004, the latter occurring at a total time of 394.3 hours. More recently, the helicopter was maintained under an FAA approved airworthiness inspection program (AAIP), to wit: Phase A March 10, 2005 642.6 hours Phase B April 4, 2005 699.6 hours Phase C May 22, 2005 752.5 hours At the accident site, the Hobbs meter read 816.2 hours. On June 3, 2002, the fuel control unit (FCU) was removed and another FCU was installed. No reason was given. On January 2, 2003, that FCU and the fuel pump were removed and replaced with different units. Again, no reason was given. METEOROLOGICAL INFORMATION Routine Aviation Weather Reports (METARs), recorded at 1353 by the Cortez (CEZ) and Durango (DRO) ASOSs (Automated Surface Observing Systems), located 30 n.m. west-southwest and 30 n.m. southeast of the accident site, were as follows: CEZ (1353): Wind, variable at 5 knots; visibility, 10 s.m. (or greater); sky condition, clear (below 12,000 ft.); temperature, 30 degrees Celsius (C.); dew point, -4 degrees C.; altimeter setting, 30.16 inches of Mercury; remarks: precipitation discriminator, sea level pressure, 1014.2 mb. DRO (1404): Wind, variable at 5 knots, gusts to 16 knots; visibility, 10 s.m. (or greater); sky condition, clear (below 12,000 ft.); temperature, 29 degrees C.; dew point, -5 degrees C.; altimeter setting, 30.21 inches of Mercury. WRECKAGE AND IMPACT INFORMATION FAA's Northwest Mountain (ANM) Regional Operations Center (ROC) notified the National Transportation Safety Board of the accident at 1434 on June 30, and its investigator arrived on site approximately 0900 on July 1. The on-scene examination disclosed a ground scar, aligned on a magnetic heading of 106 degrees, containing skid marks and a separated left skid. The helicopter was next to and at the end of the ground scar, and was aligned on a magnetic heading of 360 degrees. All four rotor blades were still attached to the hub. The blades drooped over the wreckage. There were no contact marks on the hydraulic accumulators. The pitch link and swash plate control rods were all intact and attached. The tail boom was severed just aft of the engine and was to the right side of the helicopter. It was aligned on a magnetic heading of 265 degrees. The tail rotor separated at the gearbox, and lay to the left and next to the tail boom. Cockpit examination revealed the following instrument readings: Vertical speed: 100 fpm UP Altimeter: 9,500 feet Kollsman window: 30.22 in. Hg. Airspeed: 0 kts. Attitude indicator: Level, 20 degrees nose up HSI heading/course/needle: 110 degrees/115 degrees/centered/NAV, HDG, VERT flags exposed Magnetic compass: 349 degrees Torque: 0 RPM: 101% ITT: 0 XMSN oil temperature/pressure: 0/0 Engine oil temperature/pressure: 0/0 Fuel pressure: 22 psi Hydraulic pressure: 14/0 Voltmeter: 15 Ammeter: 0 Fuel: 4/0 Hobbs meter: 816.2 MEDICAL AND PATHOLOGICAL INFORMATION Autopsies were performed on the three crewmembers on July 1, 2005. In each case, the cause of death was attributed to "multiple fractures and internal injuries due to blunt trauma"; the manner of death was listed as "accidental." A toxicological screen revealed no carbon monoxide, cyanide, ethanol, or drugs in the pilot's blood. TESTS AND RESEARCH On behalf of NTSB, the engine was disassembled and inspected at ## Aircraft - Registration: [N403CF](https://openairdocs.org/deregistered/N403CF-2017-06-19), registration cancelled 2017-06-19, S/N 14009, built 2000 (OpenAirDocs) - Reported make and model: Agusta A119 - Registry model: [Agusta A119](https://openairdocs.org/model/agusta-a119) (registry code 0260102) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6 series](https://openairdocs.org/engine/pratt-whitney-pt6-series) (registry code 52033, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: 14009 - Airframe hours: 753 - Engines: Pratt & Whitney Canada PT6B-37A 900 horsepower turbo shaft - Damage: Substantial damage - Flight: Positioning, Part 91 - Registered owner: Tri-State Care Flight LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2005, 422 hours before - Departed: 5CO0, Durango, CO - Destination: Mancos, CO - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: fatal; commercial; instrument ratings: helicopter; medical: class 2, without waivers/limitations; seat: right; toxicology performed; flight hours: 2,215 total, 130 in this make and model, 1,600 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 25 °F - Altimeter: 30.15 inHg - Observed at: CEZ, 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 20050630012169A](https://openairdocs.org/incident/20050630012169A), Jun 30, 2005: Agusta A119, Mancos, CO, Destroyed, 3 fatal. (-23) Aircraft was observed on approach to landing zone at approximately 200 feet AGL, 9730 feet MSL, temp 20 degrees c, with suspected tail wind of… ## Docket (23 files) The files NTSB released with the investigation on November 21, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=61840. 122 MB in all. - Supplement S, Aircraft Occupant and Injured Ground Personnel (item 1, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40258429&FileExtension=.PDF&FileName=Supplement%20S,%20Aircraft%20Occupant%20and%20Injured%20Ground%20Personnel-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40258432&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Materials Laboratory Factual Report 06-020, Examination of Instruments and Annunciators (item 3, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257986&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2006-020,%20Examination%20of%20Instruments%20and%20Annunciators-Master.PDF - Record of Telephone Interview (item 4, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467356&FileExtension=.PDF&FileName=Record%20of%20Telephone%20Interview-Master.PDF - Map of Accident Area (item 5, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40258426&FileExtension=.PDF&FileName=Map%20of%20Accident%20Area-Master.PDF - Wreckage Diagram (item 6, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40258451&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Weather Report and Records (item 7, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40258427&FileExtension=.PDF&FileName=Weather%20Report%20and%20Records-Master.PDF - P&WC Final Report (Excerpts) (item 8, .PDF, 98.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269160&FileExtension=.PDF&FileName=P%26WC%20Final%20Report%20(Excerpts)-Master.PDF - Honeywell Final Report, FCU (item 9, .PDF, 7.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467357&FileExtension=.PDF&FileName=Honeywell%20Final%20Report,%20FCU-Master.PDF - Excerpts from Engine Maintenance Records (item 10, .PDF, 342 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467358&FileExtension=.PDF&FileName=Excerpts%20from%20Engine%20Maintenance%20Records-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467359&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Toxicological Report (item 12, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467360&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 01. View to the east from tree line to accident site. (item 13, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259171&FileExtension=.PDF&FileName=Photo%2001.%20View%20to%20the%20east%20from%20tree%20line%20to%20accident%20site.-Master.PDF - Photo 02. View to the west, wreckage in foreground, tree line in background. (item 14, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259172&FileExtension=.PDF&FileName=Photo%2002.%20View%20to%20the%20west,%20wreckage%20in%20foreground,%20tree%20line%20in%20background.-Master.PDF - Photo 03. First impact marks. (item 15, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259173&FileExtension=.PDF&FileName=Photo%2003.%20First%20impact%20marks.-Master.PDF - Photo 04. Separated left skid, just beyond first impact marks. (item 16, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259174&FileExtension=.PDF&FileName=Photo%2004.%20Separated%20left%20skid,%20just%20beyond%20first%20impact%20marks.-Master.PDF - Photo 05. View to the south and nose of helicopter. Note crushed nose section and rotor blades. (item 17, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259175&FileExtension=.PDF&FileName=Photo%2005.%20View%20to%20the%20south%20and%20nose%20of%20helicopter.%20Note%20crushed%20nose%20section%20and%20rotor%20blades.-Master.PDF - Photo 06. Note collapse-crush damage. (item 18, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259176&FileExtension=.PDF&FileName=Photo%2006.%20%20Note%20collapse-crush%20damage.-Master.PDF - Photo 07. Severed tail boom and tail rotor assembly. (item 19, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259177&FileExtension=.PDF&FileName=Photo%2007.%20Severed%20tail%20boom%20and%20tail%20rotor%20assembly.-Master.PDF - Photo 08. The transmission, cyclic- collective controls, and hydraulic accumulators. (item 20, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259178&FileExtension=.PDF&FileName=Photo%2008.%20The%20transmission,%20cyclic-%20collective%20controls,%20and%20hydraulic%20accumulators.-Master.PDF - Photo 09. The instrument panel. (item 21, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259179&FileExtension=.PDF&FileName=Photo%2009.%20The%20instrument%20panel.-Master.PDF - Photo 10. The overhead panel. (item 22, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259180&FileExtension=.PDF&FileName=Photo%2010.%20The%20overhead%20panel.-Master.PDF - Photo 11. Collective control. (item 23, .PDF, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40259181&FileExtension=.PDF&FileName=Photo%2011.%20Collective%20control.-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.