DFW08FA062

NTSB accident investigation · Eurocopter France AS350B2 · S. Padre Island, TX · February 6, 2008

Accident · FatalField investigationFinal report
Date
February 5, 2008, 20:54 local (Feb 6, 2008, 02:54 UTC)
Place
S. Padre Island, TX
Injuries
3 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N911VAEurocopter France AS350B2
Defining event
Maneuvering: VFR encounter with IMC
Weather
Visual (VMC) · Night/dark
Status
Completed · report January 15, 2009
Report
Approved by Office Director
Parties
FAA San Antonio FSDO, Metro Aviation, Inc., FAA AAI-100, American Eurocopter, Turbomeca USA
FAA report
20080205833449A
Case key
67469

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

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Probable cause

The pilot's failure to maintain aircraft control resulting in the helicopter impacting the water. Factors contributing to the accident were the pilot's inadvertent flight into instrument meteorological conditions, the low ceiling, dark night conditions, and the pilot's lack of recent instrument flying experience.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedEurocopter France AS350B2: 3 casesAll aircraft: 1,269 casesProbable cause
Ceiling/visibility/precip: below VFR minimaEnvironmental issues › Conditions/weather/phenomena · Effect on operationEurocopter France AS350B2: 2 casesAll aircraft: 184 casesProbable cause
Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeEurocopter France AS350B2: 1 caseAll aircraft: 190 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeEurocopter France AS350B2: 1 caseAll aircraft: 448 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The EMS helicopter departed in dark night visual meteorological conditions en route to pick up a patient. The helicopter approached the intended landing zone from the west and reported to approach control that he had the landing zone in sight when he was at 1,000 feet above ground level and approximately 4 miles west of the landing zone. Shortly after that, the helicopter began a left turn approximately two miles to the west of the landing zone, followed by a tighter radius right turn. Several radio recordings from the flight nurse onboard the helicopter were heard to transmit the following: "uh i got lights here...follow the uh the lights out...ok follow the lights out...we're in the clouds again we're gonna abort transport patient by ground." The last radar position was at an altitude of 1,000 feet. Several witnesses saw the lights of the helicopter fall almost straight down, and the helicopter wreckage exhibited damage consistent with a high speed, port side, inverted impact with water. No anomalies were noted with the airframe, systems, and engine. A review of the pilot's experience showed that his most recent actual instrument experience was in 1997 when he completed an instrument competency check in a single-engine airplane. The only instrument experience in a helicopter entered in the pilot's logbook within the past ten years was two entries of simulated instrument time of 0.8 hours in December, 2005. and 0.2 hours in September, 2007.

Factual narrative

History of flight

On February 5, 2008, at 2054 central standard time, a Eurocopter France AS350B2 emergency medical service (EMS) helicopter, N911VA, operated by Metro Aviation, Inc., Shreveport, Louisiana, and was registered to Harlingen Comm Emergency Care Foundation, Inc., doing business as Valley Air Care, Harlingen, Texas, impacted the Laguna Madre near South Padre Island, Texas. The helicopter was destroyed. The airline transport pilot, flight nurse, and flight paramedic sustained fatal injuries. Visual meteorological conditions prevailed, and a company flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 flight. The helicopter departed the Valley Baptist Medical Center Heliport (49TX), Harlingen, Texas, at 2040 and was en route to pick up a patient at an emergency landing zone in the parking lot of the South Padre Island Convention Center at South Padre Island, Texas.

The flight to the emergency landing zone at South Padre Island from 49TX was 26.7 miles on a magnetic course of 88 degrees. The accident helicopter was equipped with a Global Positioning System (GPS) flight tracking system referred to as OuterLink. According to the OuterLink system, the helicopter powered up for flight at 2037:09 and departed the 49TX helipad at 2040:35. At 2041:12, the pilot using the call sign Air Care One, contacted the controlling Federal Aviation Administration (FAA) air traffic control facility, Valley Approach Control, located in the Corpus Christi Air Traffic Control Tower, Corpus Christi, Texas, and initiated visual flight rules (VFR) flight following for the flight to the destination landing zone. At 2052:24, the pilot told Valley Approach Control "...air care one has the landing zone in sight we're out of nine hundred for landing padre island."

Beginning at 2053, the flight nurse on board made several transmissions on the MedCom radio. At 2053:01, he said, "uh i got lights here," then "(unintelligible) follow the uh the lights out," followed by "ok follow the lights out," and at 2053:23, he said "(unintelligible) we're in the clouds again we're gonna abort transport patient by ground."

Valley Approach Control's radar system recorded a radar hit every 5 seconds. The first radar contacts with the helicopter began at 2040:38 as it departed the 49TX helipad. The radar data showed the helicopter was generally eastbound until it was about 2 miles west of the intended destination and then made a left turn back westbound followed by a tighter radius right turn.

Emergency responders waiting for the helicopter at the emergency landing zone saw the helicopter go down and immediately notified the 911-call center. An immediate search began, and search and rescue teams located the wreckage at 2320, about 2.4 miles west of the destination landing zone.

According to several witnesses located near the destination landing zone, they saw the lights of the helicopter fly eastbound toward the landing zone and then make a left turn westbound. One of those witnesses remembers seeing the lights on the helicopter go almost straight down and shortly afterward heard the sounds of impact.

Another witness staying in an RV camping area about 500 feet from the destination landing zone had watched several times before when medical helicopters came in to meet the ground ambulance and saw the lights of the accident helicopter fly toward the convention center parking lot, but it did not descend as it normally did. The helicopter then made a left turn and headed back to the west. Shortly after the helicopter departed to the west, she saw lights spiraling down, and shortly after that, she heard the sounds of impact.

Another witness was standing in a parking lot behind a restaurant approximately one mile south of the intended landing zone. He was watching the accident helicopter approach the island from the west when it made a turn back to the west and appeared to not be descending to land. He recalled that there were clouds above and it was windy, but the visibility was good.

Personnel information

The pilot, age 55, held an airline transport pilot certificate dated April 3, 2003, with ratings in airplane single-engine land, rotorcraft helicopter, and with commercial privileges in airplane multi-engine land, and airplane single-engine sea. He was issued a second class airman medical certificate on December 11, 2007. The medical certificate contained the limitation "must wear corrective lenses."

Metro Aviation, Inc., initially hired the pilot as an EMS helicopter pilot at the Harlingen base, in December 2005, and he worked in that position until April of 2006. They rehired the pilot for the same position in September 2007. At the time of the accident, the pilot had logged 16,896 total hours; with a total of 11,518 hours in helicopters, 1,100 of which in the make and model of the accident helicopter, 18 hours of which were in the past 90 days, and 7 hours within the past 90 days at night. Metro Aviation, Inc. records showed that the pilot had no previous experience with night vision goggles (NVG) and he had not previously been trained in the use of NVGs.

The pilot's logbook shows he had logged a total of 115 hours of actual instrument flying experience and 46 hours of simulated instrument experience. In 1997, the pilot logged 3.1 hours of actual instrument experience in a single-engine airplane during an instrument competency check. In 2003, the pilot logged 9.5 hours of simulated instrument experience when he completed training and a practical test for his airline transport pilot rating for single-engine land airplanes. The only instrument experience in a helicopter entered in the pilot's logbook within the past ten years was two entries of simulated instrument experience for Part 135 training and testing of 0.8 hours in December, 2005. and 0.2 hours in September, 2007.

According to the pilot's logbook, he had a general pattern of employment of flying EMS helicopters during the winter months and agricultural airplanes during seasonal months. His pilot logbook showed he began flying AS350 helicopters at the Harlingen EMS base for Tex-Air Helicopters, Inc. a different Part 135 air carrier beginning in 1998. His logbook showed he had accumulated a total of 1,780 hours in EMS operations within the past twenty years.

The pilot's most recent Part 135.293 competency check, and Part 135.299 line check was completed with a satisfactory rating in all tested areas on September 12, 2007. A Metro Aviation, Inc., check airman conducted the flight check in daylight hours in a Eurocopter France AS350B2 helicopter.

According to company records, the pilot had seven consecutive days off ending on January 25, 2008, and would have been scheduled for another seven day rest period beginning at 0700, on the morning of February 8, 2008. He had been on the day shift (0645 to 1815) from January 25th through the 31st, 2008, and on February 1, 2008, he had started a seven-day period of duty for the night shift (1800 to 0700).

Aircraft information

The accident helicopter was a Eurocopter France AS350B2 model, S/N 2588, that had been converted from a Eurocopter AS350BA at the American Eurocopter facility, Grand Prairie, Texas, in June of 2007. The airframe had accumulated 10,307.3 hours total time at the time of the accident, with an engine total time of 218.8 (engine S/N 19124).

The helicopter was configured with a right pilot seat, a swivel medical seat on the right side behind the pilot, and a medic jump seat on the center aft bulkhead. A stretcher extended from the left front cabin aft, with a Plexiglas shield to separate the patient from the pilot.

The accident helicopter was equipped for NVG operations.

Meteorological information

National Weather Service (NWS) Surface Analysis for February 6, 2008, at 2100, showed a cold front just west of the accident site, which had moved well to th

Aircraft

Registration
N911VA
Reported as
Eurocopter France AS350B2
Category
Helicopter
Serial number
2588
Airframe hours
10,307
Engine
Turbomeca Arriel 1D1, 732 horsepower, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Metro Aviation, Inc.
Registered owner
Harlingen Comm Emergency Care Foundation Inc DBA
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 22, 2008 · 9 hours before
Departed
49TX · Harlingen, TX
Destination
S. Padre Island, TX
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
55
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 11, 2007
Seat
Right
Toxicology
Performed
Flight hours
16,896 total · 1,100 in this make and model · 16,420 as pilot in command · 18 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
310° at 8 knots
Visibility
8 statute miles
Lowest ceiling
1,400 ft overcast
Temperature
73 °F, dew point 70 °F
Altimeter
29.80 inHg
Observed at
KPIL, 7 nm away

Docket · 28

The files NTSB released with the investigation on January 14, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.0 MB in all.

NTSB Form 6120.1 Metro AvnItem 1 · .PDF · 569 KBHelicopter Accident ChecklistItem 2 · .PDF · 2.2 MBTranscript of ATC communicationsItem 3 · .PDF · 28 KBTranscript of MedCom dispatch recordingItem 4 · .PDF · 22 KBMap 1 Summary of ATC Radar HitsItem 5 · .PDF · 485 KBMap 2 GPS OuterLink Position ReportsItem 6 · .PDF · 643 KBMap 3 SPI Convention Center - view from Google EarthItem 7 · .PDF · 83 KBStatement of Party Representatives to NTSB InvestigationItem 8 · .PDF · 76 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 9 · .PDF · 169 KBOperations 2 - Attachment 1 Selected OpSpecsItem 10 · .PDF · 668 KBOperations 2 - Attachment 2 (Manual - Ops Control)Item 11 · .PDF · 29 KBOperations 2 - Attachment 3 (Manual - Wx & HEMS Minima)Item 12 · .PDF · 41 KBOperations 2 - Attachment 4 (Risk Assessment Tool)Item 13 · .PDF · 234 KBOperations 2 - Attachment 5 (Flight Briefing Form and Weather Data)Item 14 · .PDF · 548 KBOperations 2 - Attachment 6 (Instrument Proficiency Memo)Item 15 · .PDF · 14 KBATC 3 - Attachment 1 - Spread sheet of Radar repliesItem 16 · .PDF · 17 KBWitness 4 - Attachment 1 (Witness Interviews)Item 17 · .PDF · 38 KBWitness 4 - Attachment 2 (USCG Helo Pilot)Item 18 · .PDF · 34 KBMeteorology 5 - Attachment 1 (Weather Summary)Item 19 · .PDF · 1.1 MBMeteorology 5 - Attachment 2 (Sunrise & Sunset Data)Item 20 · .PDF · 19 KBPowerplants 8 - Attachment 1 (Engine Exam)Item 21 · .PDF · 123 KBSystems 9 - Attachment 1 (Component Exam)Item 22 · .PDF · 127 KBGPS 17 - Factual Report of Group ChairmanItem 23 · .PDF · 3.3 MBPhoto 1 (Precrash Photo)Item 24 · .PDF · 421 KBPhoto 2 (Wreckage in water)Item 25 · .PDF · 486 KBPhoto 3 (Initial recovery from water)Item 26 · .PDF · 616 KBToxicological ReportItem 27 · .PDF · 130 KBReports from Federal Agencies (USCG Station SAR Log - Case 391572)Item 28 · .PDF · 1.8 MB

FAA reports on this event · 1

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