# NTSB ERA09IA186: Agusta A109E, N911UF, Gainesville, FL, March 6, 2009 - Type: NTSB incident investigation - Classification: Incident · Minor injuries · Incident investigation · Final report - Date: March 5, 2009, 20:10 local (Mar 6, 2009, 01:10 UTC) - Place: Gainesville, FL - Coordinates: 29.634721, -82.423889 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.6347&lon=-82.4239&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Birdstrike](https://openairdocs.org/ntsb-events/901) - Highest injury: Minor injuries - Injuries: 1 minor, 3 uninjured - Status: Completed, report December 20, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 73451 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09IA186 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73451/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73451 - Page: https://openairdocs.org/ntsb/ERA09IA186 ## Probable cause An inadvertent in-flight collision with a duck. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Object/animal/substance: animal(s)/bird(s)](https://openairdocs.org/ntsb-findings/03022045): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/03022045/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Birdstrike](https://openairdocs.org/ntsb-events/901) (defining event); cases with it: [All aircraft, 253 cases](https://openairdocs.org/ntsb-events/901/sequence.md) ## Analysis During a nighttime helicopter patient transfer, while the helicopter was descending through 800 feet at 145 knots, a duck impacted the windshield. The windshield shattered, and a number of switches and circuit breakers on the pilot’s overhead panel were broken, while others were turned off. The engine throttles were not affected. The pilot maintained control of the helicopter and landed it without further incident. Analysis of windshield fracture surfaces revealed that they were typical of overstress with bending deformations. There was no forward shielding of the overhead panel switches and throttles. ## Factual narrative On March 5, 2009, about 2010 eastern standard time, an Agusta A109E, N911UF, operated by Air Methods Corporation, as a ShandsCair medical evacuation flight, incurred minor damage from a bird strike while approaching Gainesville, Florida. The certificated airline transport pilot sustained minor injuries, while the flight nurse, flight paramedic, and trauma patient were not injured. Night visual meteorological conditions prevailed, and no flight plan had been filed for the flight between an automobile accident site in Trenton, Florida, and Shands Helistop (FA12), Gainesville, Florida. The air medical evacuation flight was conducted under the provisions of 14 Code of Federal Regulations Part 135. According to the pilot, the incident occurred when the helicopter was inbound to the hospital, about “3 minutes” from the hospital's rooftop helipad. The helicopter was descending at 145 knots through 800 feet, when the windshield “exploded.” The pilot was pelted with plexiglass and other debris. The master caution warning light started flashing, but the pilot had difficulty reading the caution warning lights as the left lens to his eyeglasses was missing. The pilot was eventually able to determine that SAS number 1 had been disengaged, and after resetting the switches, the master caution light extinguished. The pilot also noted that the instrument panel lights were off on the pilot’s side, so he reached up to the overhead panel and turned the lights back on. He then noticed that several circuit breakers and switches were broken off, and that several other switches had been moved aft, to the "off" position. The entire overhead panel was covered in blood. The pilot also determined that despite the wind noise, the helicopter was still operating normally, and he subsequently landed it at its home base, a ground helipad, without further incident. The patient was then transferred 1 mile to the hospital's emergency room by ambulance. Postflight examination of the helicopter revealed that a 2- to 3-pound duck impacted the helicopter, and came to rest inside the cabin, at the feet of one of the medical crewmembers. The impact broke off the landing light switch and turned off the navigation lights and the anti-collision light. The pilot’s instrument panel lights rheostat was rotated to the point of turning off the lights, and circuit breakers for the number 2 engine starter/generator were broken off, although the circuits remained energized. The circuit breaker for the “Outer Link” satellite tracking system was deactivated, which resulted in the ShandsCair communication center’s loss of flight tracking at 2008. Blood was also found on one of the main rotor blades. The pilot further noted that aside from electrical control switches, the power control levers were also located on the overhead panel, and that if they had moved aft, there would have been a reduction of engine power. A photograph of the overhead panel revealed that there was no forward shielding of theswitches and throttles. Shards from the shattered windshield were forwarded to the Safety Board for further examination. Plastic windshield fractures were found to be “typical of brittle overstress under primarily bending deformation.” Additional bird strike information can be found at the Federal Aviation Administration (FAA) Wildlife Mitigation web page, at: http://wildlife-mitigation.tc.faa.gov/public_html/index.html ## Aircraft - Registration: N911UF (not matched to a registry record) - Reported make and model: AGUSTA A109E - Category: Helicopter - Serial number: 11604 - Airframe hours: 2670 - Engines: Pratt & Whitney 206C 640 horsepower turbo shaft - Damage: Minor damage - Flight: Part 135 - Operator: Air Methods Corp - Registered owner: Shands Teaching Hospital And Clinics Inc - Airworthiness certificate: Standard, Normal - Departed: None, Trenton, FL - Destination: FL12, Gainesville, FL ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: minor; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 2; last flight review December 16, 2008; seat: right; flight hours: 12,850 total, 170 in this make and model, 12,500 as pilot in command, 80 in the last 90 days, 24 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 90° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 45 °F - Altimeter: 30.00 inHg - Observed at: GNV, 10 nm away ## Docket (6 files) The files NTSB released with the investigation on August 12, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73451. 3.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 530 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40332402&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Materials Laboratory Factual Report 09-025, Piece of fractured windshield (item 2, .PDF, 426 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319357&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2009-025,%20Piece%20of%20fractured%20windshield-Master.PDF - Operator Photo: Deceased Duck (item 3, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324419&FileExtension=.PDF&FileName=Operator%20Photo%3A%20Deceased%20Duck-Master.PDF - Operator Photo: Throttle Quadrant Area (item 4, .PDF, 305 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324420&FileExtension=.PDF&FileName=Operator%20Photo%3A%20Throttle%20Quadrant%20Area-Master.PDF - Operator Photo: Pilot's Windshield Area (item 5, .PDF, 406 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324421&FileExtension=.PDF&FileName=Operator%20Photo%3A%20Pilot%27s%20Windshield%20Area-Master.PDF - Operator Photo: Patient Area (item 6, .PDF, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324423&FileExtension=.PDF&FileName=Operator%20Photo%3A%20Patient%20Area-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.