# NTSB FTW00FA091: Eurocopter BO105S-CBS-5, N335T, Dalhart, TX, March 10, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 10, 2000, 06:05 local (12:05 UTC) - Place: Dalhart, TX - Coordinates: 36.060668, -102.509307 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.0607&lon=-102.5093&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report April 19, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 48771 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW00FA091 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/48771/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=48771 - Page: https://openairdocs.org/ntsb/FTW00FA091 ## Probable cause The pilot's failure to maintain control of the helicopter as a result of his continued flight into known adverse weather conditions. Factors were the dark night light condition, fog, low ceiling, and the pilot's lack of total instrument flight time. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - flight into known adverse weather - performed, pilot in command (cause) - weather condition - low ceiling (contributing factor) - weather condition - fog (contributing factor) - light condition - dark night (contributing factor) - lack of total instrument time, pilot in command (contributing factor) - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - open field ## Analysis During dark night conditions, the helicopter was en route from its hospital base to another hospital to pick up a medical patient for transport back to the base hospital, when the pilot landed the helicopter 15 miles south of the destination hospital due to fog. The patient was transported via ambulance to the helicopter. After the patient was transferred to the helicopter, witnesses reported that the helicopter departed, with its lights on, and headed toward the south at an altitude between 10 and 75 feet agl. They reported the visibility as poor, about 1/4 mile, a very low ceiling, and extremely dense fog. One witness stated that it appeared as if the helicopter was 'trying to stay close to the ground and not get up into the heavy fog.' Examination of the accident site revealed that the helicopter impacted in a near 45 degree nose low attitude and the wreckage encompassed an area measuring 262 feet by 75 feet. A weather study revealed that the accident site was in area of low ceilings and fog, which was expanding to the south and west. According to documents provided by the operator, the pilot had accumulated a total of 44 simulated instrument flight hours and 1 hour of actual instrument flight experience. Examination of the helicopter revealed no evidence of an in-flight control or system malfunction, and examination of the engines revealed evidence of operation at the time of impact. ## Factual narrative HISTORY OF FLIGHT On March 10, 2000, at 0605 central standard time, an Mbb, BO105S-CBS-5 helicopter, N335T, was destroyed when it impacted terrain while maneuvering near Dalhart, Texas. The helicopter was registered to General Electric Capital Corporation, of Englewood, Colorado, and operated by Temsco Helicopters, Inc., Ketchikan, Alaska, under contract to Northwest Texas Healthcare System Hospital (Northwest Texas Hospital), of Amarillo, Texas. The instrument rated commercial pilot, two medical crew members, and the medical patient sustained fatal injuries. Dark night instrument meteorological conditions prevailed and a company flight plan was filed for the 14 Code of Federal Regulations Part 135 air medical transport flight. The flight originated from a farm field 15 miles south of Boise City, Oklahoma, at 0600 and was destined for the Northwest Texas Hospital. According to dispatch personnel at the Northwest Texas Hospital, the helicopter departed Northwest Texas Hospital at 0355 and was destined for a hospital in Boise City. The purpose of the flight was to transfer a patient from the hospital in Boise City to the Northwest Texas Hospital. At 0506, the pilot reported that he landed the helicopter approximately 15 miles south of the Boise City hospital along the east side of Highway 385 due to fog. He stated that he would wait for the patient to be transported to his location and then return to the Northwest Texas Hospital. At 0557, the emergency medical technician (EMT), who was aboard the ambulance, transferred the patient to the helicopter. The EMT stated that he observed the helicopter depart to the south with all the lights on, paralleling Highway 385 approximately 30-50 feet agl. The EMT added that the visibility on the ground was 1/4 mile with a "very low ceiling," and "it seemed like [the helicopter] was trying to stay close to the ground and not get up into the heavy fog." According to the ambulance driver, he watched the helicopter liftoff and fly southbound over the road at an altitude of 50-75 feet agl. He stated that he followed the helicopter as it paralleled the road for approximately 1.5 minutes, and it was flying in "extremely dense fog." He then turned northbound and the helicopter disappeared from his view. He added that he also observed ice forming on the ambulance's mirrors and antennas. The Boise City Sheriff stated that he and his wife were driving north on Highway 385 and they observed the helicopter lift off of the ground with its lights on. He reported that the helicopter flew south paralleling the east side of Highway 385, approximately 10-20 feet above the ground. The Sheriff added that there was patchy fog in the area and approximately 1/4-inch of ice had formed on his vehicle's antenna while driving in the area. There were no witnesses to the accident. PERSONNEL INFORMATION The FAA issued the pilot a commercial certificate on December 22, 1992. According to records provided by Temsco Helicopters Inc., the pilot was initially qualified in the BO-105 on January 29, 1998. A pilot qualification form, which was provided by Temsco Helicopters Inc., dated December 16, 1999, revealed that the pilot had accumulated a total of 3,585 flight hours, of which 3,500 hours were in helicopters, and 90 hours were in the BO-105. Additionally, the form revealed that the pilot had accumulated 44 hours of simulated instrument time and 1 hour of actual instrument time. The pilot successfully completed his most recent recurrent ground and flight training on January 6, 1999. According to the grade sheet for the flight portion of the recurrent training (FAA Form 8410-3), the pilot received a satisfactory rating for flight by reference to instruments. According to the Pilot/Operator Aircraft Accident Report (NTSB FORM 6120.1/2), which was completed by Temsco Helicopters Inc., the pilot had accumulated a total of 3,630 flight hours of which 3,580 were in rotorcraft, and 107 hours were in the BO-105. Additionally, the pilot held a second class medical certificate dated February 1, 2000. The two medical crewmembers, a paramedic and a flight nurse, were based at the Northwest Texas Hospital. AIRCRAFT INFORMATION The 1994-model helicopter was powered by two 420-horsepower Allison 250-C20B turboshaft engines. The helicopter was equipped with a four-bladed main rotor system and a two-bladed tail rotor. The helicopter underwent its most recent annual inspection on January 16, 2000, and as of March 8, 2000, had accumulated a total of 565.2 hours. The engines underwent their most recent 100-hour inspections on January 16, 2000, at which time the left engine had accumulated a total of 360.7 hours, and the right engine had accumulated a total of 497.4 hours. Additionally, the helicopter was equipped for IFR operations. METEOROLOGICAL INFORMATION The area forecast for Oklahoma and Northwestern Texas was issued on March 10, 2000, at 0445, and was valid on March 10, 2000, until 1700. The forecast for Oklahoma (panhandle and western third) was broken to scattered clouds at 3,000 feet agl and broken clouds at 12,000 feet agl. Light rain showers and isolated thunderstorms were also forecast. The forecast for Northwestern Texas (panhandle) was for broken clouds at 12,000 feet agl, isolated rain showers, and isolated thunderstorms. There were no AIRMETs, SIGMETs, or Convective SIGMETs in effect for the time and area of the accident. At 0551, the weather observation facility at Dalhart, Texas, (located 28 miles south of the accident site) reported scattered clouds at 10,000 feet, a broken ceiling at 20,000 feet, visibility 15 miles, wind from 350 degrees at 6 knots, temperature 36 degrees Fahrenheit, dew point 32 degrees Fahrenheit, and an altimeter setting of 29.97 inches of mercury. At 0650, Dalhart reported scattered clouds at 15,000 feet, visibility 15 miles, wind from 330 degrees at 8 knots, temperature 32 degrees Fahrenheit, dewpoint 30 degrees Fahrenheit, and an altimeter setting of 29.98 inches of Mercury. At 0750, Dalhart reported a ceiling of 200 feet broken and 15,000 feet overcast, visibility 1 mile in mist, wind from 360 degrees at 10 knots, temperature 32 degrees Fahrenheit, dewpoint 29 degrees Fahrenheit, altimeter 29.97 inches of mercury, and the remarks sections reported visibility higher to the south-southwest. At 0750, Dalhart also issued a corrected report which stated that there was a broken ceiling at 100 feet and overcast cloud layer at 15,000 feet, visibility .25 miles in freezing fog and mist, wind from 360 degrees at 10 knots, temperature 32 degrees Fahrenheit, dewpoint 29 degrees Fahrenheit, altimeter setting 29.99 inches of Mercury, and the remarks section reported visibility higher to the south-southwest. According to Geostationary Operational Environmental Satellite (GOES) 8 data, between 0545 and 0645 radiative temperatures increased in value and area, near the accident location. GOES images revealed that the temperature changed between +2 and +10 degrees Celcius. Values between +2 and +5 degrees Celcius indicate the presence of liquid stratiform clouds and fog. According to the U.S. Naval Observatory, sunrise occurred at 0707. WRECKAGE AND IMPACT INFORMATION The accident site was located on the west side of Highway 385, approximately 0.8 mile southwest of the departure site. The location of the wreckage was recorded by a GPS receiver at north 036 degrees 28.37 minutes latitude and west 102 degrees 32.50 minutes longitude. The entire accident site, including ground impressions and aircraft components, encompassed an area measuring 262 feet by 75 feet. The ground at the accident site was charred and sooted. The energy path was oriented along a measured magnetic heading of 240 degrees. Ground impressions at the initial impact point were consistent with both skids and slash marks from the main rotor blades. A por ## Aircraft - Registration: [N335T](https://openairdocs.org/deregistered/N335T-2009-04-09), registration cancelled 2009-04-09, S/N S898, built 1994 (OpenAirDocs) - Reported make and model: Eurocopter BO105S-CBS-5 (BO105S-CBS) - Registry model: [Eurocopter Deutschland BO105SCBS-5](https://openairdocs.org/model/eurocopter-deutschland-bo105scbs-5) (registry code 8680981) (OpenAirDocs) - Registry engine: [Allison 250-C20 series](https://openairdocs.org/engine/allison-250-c20-series) (registry code 03020, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: S898 - Airframe hours: 570 - Engines: Allison 250-C20B 420 horsepower turbo shaft - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Operator: Temsco Helicopters Inc., doing business as Northwest Texas Hospital - Registered owner: General Electric Capital Corp. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 16, 2000, 50 hours before - Destination: NONE, AMARILLO, TX - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; commercial; airplane ratings: single-engine land; instrument ratings: helicopter; medical: class 2, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 3,630 total, 107 in this make and model, 3,550 as pilot in command, 77 in the last 90 days, 17 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Visibility: 0.25 statute miles - Lowest ceiling: 100 ft broken ## 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 20000310007469A](https://openairdocs.org/incident/20000310007469A), Mar 10, 2000: Dallhart, TX, No damage. (-23) On March 10, 2000, at 0605 CST, a Eurocopter BO105SCBS-5 helicopter, N335T, was destroyed when it impacted terrain while maneuvering near dalhart, Texas.… ## Docket (37 files) The files NTSB released with the investigation on March 13, 2001, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=48771. 10.1 MB in all. - Supplement S (item 1, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134479&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - NTSB Factual Report (Meteorology) (item 2, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405691&FileExtension=.PDF&FileName=NTSB%20Factual%20Report%20(Meteorology)-Redacted.PDF - NTSB Factual Report (Meteorology), Map 1 (item 3, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134481&FileExtension=.PDF&FileName=NTSB%20Factual%20Report%20(Meteorology),%20Map%201-Master.PDF - NTSB Factual Report (Meteorology), Map 2 (item 4, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134482&FileExtension=.PDF&FileName=NTSB%20Factual%20Report%20(Meteorology),%20Map%202-Master.PDF - NTSB Factual Report (Meteorology), Chart (item 5, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134483&FileExtension=.PDF&FileName=NTSB%20Factual%20Report%20(Meteorology),%20Chart-Master.PDF - NTSB Factual Report (Meteorology), Chart (item 6, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134484&FileExtension=.PDF&FileName=NTSB%20Factual%20Report%20(Meteorology),%20Chart-Master.PDF - NTSB Factual Report (Meteorology), Chart (item 7, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134485&FileExtension=.PDF&FileName=NTSB%20Factual%20Report%20(Meteorology),%20Chart-Master.PDF - NTSB Factual Report (Meteorology), Chart (item 8, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134486&FileExtension=.PDF&FileName=NTSB%20Factual%20Report%20(Meteorology),%20Chart-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 9, .PDF, 530 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405692&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Redacted.PDF - Witness Statements (item 10, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405693&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Wreckage Diagram (item 11, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134489&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Wreckage Map (item 12, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134490&FileExtension=.PDF&FileName=Wreckage%20Map-Master.PDF - Reports from Party to the Investigation (Rolls-Royce Allison) (item 13, .PDF, 388 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405696&FileExtension=.PDF&FileName=Reports%20from%20Party%20to%20the%20Investigation%20(Rolls-Royce%20Allison)-Redacted.PDF - Report From Party to the Investigation (Rolls-Royce Allison), Photo 1 (item 14, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134492&FileExtension=.PDF&FileName=Report%20From%20Party%20to%20the%20Investigation%20(Rolls-Royce%20Allison),%20Photo%201-Master.PDF - Report From Party to the Investigation (Rolls-Royce Allison), Photo 2 (item 15, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134493&FileExtension=.PDF&FileName=Report%20From%20Party%20to%20the%20Investigation%20(Rolls-Royce%20Allison),%20Photo%202-Master.PDF - Report From Party to the Investigation (Rolls-Royce Allison), Photo 3 (item 16, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134494&FileExtension=.PDF&FileName=Report%20From%20Party%20to%20the%20Investigation%20(Rolls-Royce%20Allison),%20Photo%203-Master.PDF - Report From Party to the Investigation (Rolls-Royce Allison), Photo 4 (item 17, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134495&FileExtension=.PDF&FileName=Report%20From%20Party%20to%20the%20Investigation%20(Rolls-Royce%20Allison),%20Photo%204-Master.PDF - Report From Party to the Investigation (Rolls-Royce Allison), Photo 5 (item 18, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134496&FileExtension=.PDF&FileName=Report%20From%20Party%20to%20the%20Investigation%20(Rolls-Royce%20Allison),%20Photo%205-Master.PDF - Report From Party to the Investigation (Rolls-Royce Allison), Photo 6 (item 19, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134497&FileExtension=.PDF&FileName=Report%20From%20Party%20to%20the%20Investigation%20(Rolls-Royce%20Allison),%20Photo%206-Master.PDF - Dispatch Records from Northwest Texas Hospital (item 20, .PDF, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405698&FileExtension=.PDF&FileName=Dispatch%20Records%20from%20Northwest%20Texas%20Hospital-Redacted.PDF - Pilot Records (item 21, .PDF, 966 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405699&FileExtension=.PDF&FileName=Pilot%20Records-Redacted.PDF - Excerpts from Airframe and Engine Records (item 22, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405700&FileExtension=.PDF&FileName=Excerpts%20from%20Airframe%20and%20Engine%20Records-Redacted.PDF - Excerpt from Tempsco Helicopters, Inc., Operational Procedures Manual (item 23, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134501&FileExtension=.PDF&FileName=Excerpt%20from%20Tempsco%20Helicopters,%20Inc.,%20Operational%20Procedures%20Manual-Master.PDF - Other Weather Data (item 24, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134502&FileExtension=.PDF&FileName=Other%20Weather%20Data-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 25, .PDF, 428 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405701&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 26, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405702&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 27, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405703&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1: View of Accident Site from Initial Impact Point (item 28, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134506&FileExtension=.PDF&FileName=Photo%201%3A%20%20View%20of%20Accident%20Site%20from%20Initial%20Impact%20Point-Master.PDF - Photo 2: View of Accident Site from Initial Impact Point. Arrow Points to Initial Ground Scar Consistent With a Skid. (item 29, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134507&FileExtension=.PDF&FileName=Photo%202%3A%20%20View%20of%20Accident%20Site%20from%20Initial%20Impact%20Point.%20%20Arrow%20Points%20to%20Initial%20Ground%20Scar%20Consistent%20With%20a%20Skid.-Master.PDF - Photo 3: View of Portion of Left Skid Shoe in Initial Impact Crater. (item 30, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134508&FileExtension=.PDF&FileName=Photo%203%3A%20%20View%20of%20Portion%20of%20Left%20Skid%20Shoe%20in%20Initial%20Impact%20Crater.-Master.PDF - Photo 4: View of Section of Separated Tail Boom. Note Tail Rotor Drive Shaft and Bending Deformation Consistent With Rotation. (item 31, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134509&FileExtension=.PDF&FileName=Photo%204%3A%20%20View%20of%20Section%20of%20Separated%20Tail%20Boom.%20%20Note%20Tail%20Rotor%20Drive%20Shaft%20and%20Bending%20Deformation%20Consistent%20With%20Rotation.%20%20-Master.PDF - Photo 5: View of Separated Tail Boom. Note Main Wreckage in Background. (item 32, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134510&FileExtension=.PDF&FileName=Photo%205%3A%20%20View%20of%20Separated%20Tail%20Boom.%20%20Note%20Main%20Wreckage%20in%20Background.-Master.PDF - Photo 6: View of Separated Tail Rotor Blades and Section of Tail Boom. (item 33, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134511&FileExtension=.PDF&FileName=Photo%206%3A%20%20View%20of%20Separated%20Tail%20Rotor%20Blades%20and%20Section%20of%20Tail%20Boom.-Master.PDF - Photo 7: View of Main Wreckage. Includes Main Rotor Head, Transmission and Engines. (item 34, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134512&FileExtension=.PDF&FileName=Photo%207%3A%20%20View%20of%20Main%20Wreckage.%20%20Includes%20Main%20Rotor%20Head,%20Transmission%20and%20Engines.%20%20-Master.PDF - Photo 8: A Close-Up View of the Main Rotor Head. (item 35, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134513&FileExtension=.PDF&FileName=Photo%208%3A%20%20A%20Close-Up%20View%20of%20the%20Main%20Rotor%20Head.-Master.PDF - Photo 9: View of One of the Separated Main Rotor Blades. (item 36, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134514&FileExtension=.PDF&FileName=Photo%209%3A%20%20View%20of%20One%20of%20the%20Separated%20Main%20Rotor%20Blades.-Master.PDF - Photo 10: View of Another Separated Main Rotor Blade. (item 37, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40134515&FileExtension=.PDF&FileName=Photo%2010%3A%20%20View%20of%20Another%20Separated%20Main%20Rotor%20Blade.%20%20-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.