FTW03FA082

NTSB accident investigation · Agusta A-109-K2 · Salt Lake City, UT · January 11, 2003

Accident · FatalField investigationFinal report
Date
January 10, 2003, 20:50 local (Jan 11, 2003, 03:50 UTC)
Place
Salt Lake City, UT
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N601RXAgusta A-109-K2
Weather
Instrument (IMC) · Night/dark
Status
Completed · report March 30, 2004
Report
Approved by Office Director
Parties
Federal Aviation Administration, IHC Life Flight, Turbomeca Engine Corporation, Agusta Aerospace Corporation
FAA report
20030110000089A
Case key
56318

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 delayed remedial action and continued flight into known adverse weather conditions which resulted in his failure to maintain clearance with the ground. Contributing factors were the prevailing fog, and the pressure to complete the mission induced by the pilot in command as a result of the air ambulance operation.

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 encounter with weatherManeuvering
Weather condition - fogFactor
Flight into known adverse weather - continuedPilot in commandCause
Pressure induced by conditions/eventsPilot in commandFactor
Remedial action - delayedPilot in commandCause
In flight collision with terrain/waterManeuvering
Remedial action - delayedPilot in commandCause
Clearance - not maintainedPilot in commandCause
Terrain condition - ground

Analysis

While maneuvering low to the ground during night conditions, the air ambulance helicopter encountered fog and poor weather conditions, and impacted the terrain. Shortly after departing from its hospital base, the helicopter was cleared by air traffic control to proceed through a major airport's airspace to respond to a medical emergency. After crossing through the airspace, the pilot elected to abort the mission; however, he was instructed by air traffic control to hold and wait for clearance through the airspace due to landing traffic at the airport. After holding for approximately 10 minutes, the pilot stated, "I'm basically inadvertent IMC at this time and declaring emergency...I'm currently on a heading one five zero." Examination of the accident site revealed the helicopter impacted the terrain on a heading of 150 degrees, became airborne for approximately 1/4 mile, then impacted the terrain and came to rest upright in a grassy field. According to documents provided by the operator, the pilot had accumulated a total of 311 simulated instrument flight time, and 3 hours of actual instrument flight time. Examination of the helicopter revealed no evidence of an in-flight control or system malfunction prior to the initial impact. Prior to the accident helicopter's departure from the hospital base, another air ambulance company helicopter attempted the same mission; however, aborted the mission due to fog and deteriorating weather conditions.

Factual narrative

History of flight

On January 10, 2003, approximately 2050 mountain standard time, an Agusta A-109-K2 twin-engine helicopter, N601RX, operated as Life Flight 6, was destroyed when it impacted terrain while attempting to maneuver in dense fog near the Salt Lake City International Airport (SLC), near Salt Lake City, Utah. The instrument-rated commercial pilot and the flight paramedic were fatally injured, and the flight nurse was seriously injured. The helicopter was owned and operated by IHC (Intermountain Health Care) Health Services, Inc., of Salt Lake City, and doing business as (d.b.a.) IHC Life Flight. Night instrument meteorological conditions (IMC) prevailed for the 14 Code of Federal Regulations Part 91 flight, for which a company visual flight rules (VFR) flight plan was filed. The flight originated at the LDS Hospital, Salt Lake City, at 2032, and was destined for Wendover, Utah, to pick up a patient who had been injured in an auto accident.

According to Air Methods (another Salt Lake City air ambulance company), dispatch records, and a written statement provided by the Air Methods pilot, at 1949, a call was received from Tooele County, Utah, police dispatch requesting a helicopter to stand by for a possible medical response flight. Approximately 5 minutes later, an Air Methods flight was dispatched from the University of Utah Medical Center, Salt Lake City, for the medical emergency flight to Wendover. After departure, the Air Methods pilot contacted the SLC air traffic control tower (ATCT) and requested an "I-80 transition low-level west bound to Wendover." SLC ATCT instructed the Air Methods pilot to hold east of SLC due to landing traffic. The pilot held at 700-feet agl from approximately 2010 to 2019 while monitoring the ATCT and the automatic terminal information system (ATIS) frequencies. The pilot stated the weather "drastically changed from 2 miles visibility to 1/16th SM (statute miles) FG (fog)." Approximately 2019, ATCT cleared the pilot to transition over SLC; however, due to the deteriorating weather, the pilot elected to abort the flight and return to the University of Utah Medical Center.

Approximately 2030, the Air Methods flight terminated at the University helipad. After completing the shutdown and post flight procedures, the pilot returned to the Air Methods dispatch facility at the medical center. As the pilot walked into dispatch, he heard dispatch personnel and his crew discussing that Life Flight was attempting the flight. The pilot then contacted the Life Flight 6 pilot on the dispatch radio and reported that he just aborted the same mission because the visibility had reduced to 1/16 mile. The Life Flight 6 pilot stated he was going to try to get over the fog and get to Wendover.

Between 2017 and 2056, the following communications excerpts were recorded by Life Flight dispatch personnel (LFD), Tooele dispatch (TD), and the Life Flight 6 pilot (LF6). It should be noted that recorded times may vary between Air Methods dispatch and Life Flight dispatch due to time disparities between the facilities.

Approximately 2017, Tooele County dispatch and Life Flight Communication Center:

LFD: Life Flight [dispatcher]

TD: Hello this is [dispatcher] from Tooele County

LFD: Hey

TD: Are you guys able to fly

LFD: Auh, I can check, we can sure give it a try

TD: Well, Air Med can't, so I don't know if you could

LFD: Oh, well

TD: Is it the same

LFD: Let me check with my pilot...

Approximately 2018, Life Flight 6 pilot and Life Flight Communication Center:

LF6: Life Flight [pilot]

LFD: [Pilot] this is [dispatcher]

LF6: Hi [dispatcher]

LFD: This is [dispatcher], will you check weather for Wendover marker 22, mile marker 22

LF6: You think there is a weather reporting service right at mile marker 22

LFD: Well, yea, that's what I'm thinking (laughter), well, how about out west, can you fly out west

LF6: I can see out west, all I got really is Wendover itself and it says 10 miles and I'll look back in Salt Lake again, got Salt Lake and they gotten really bad there right there in the valley 1/16th of a mile

LFD: Ok, so this is a, um, you could probably look at mile marker 22 as closer to Wendover, so

LF6: Is it

LFD: Just yes or no

LF6: Well, it's one of those things; I can give it a shot.

LFD: Ok

LF6: I can't make promises

LFD: Alright, I can tell them we will give it a shot and there are no guarantees

LF6: Is this a go

LFD: Yes, let's plan on going, why don't you go get ready and I will call the dispatch back, and I will call dispatch back...

Approximately 2022, Tooele County and Life Flight Communication Center:

LFD: Hi, this is [dispatcher] at Life Flight

TD: Dispatch [dispatcher]

LFD: Yea, you know what, we are going to give it a try

TD: Ok

LFD: It looks like Wendover is clear enough to get into it; it's just going to be between here and there that could be iffy. They're going to lift to see how far they can get.

TD: Ok

LFD: But I can't really guarantee anything, so...

TD: That's ok

LFD: Tell me what you got

Approximately 2044, Life Flight Communications Center and Life Flight 6 pilot:

LF6: We are on the west side of the airport. Air Med got sent out for this same damn thing and then they called us to go out. Air Med turned around for low visibility so they go shopping for another helicopter and we're turning around at the west side airport. You know it what's their determination, you know

LFD: I understand, unfortunately that happens all day long a lot of the dispatch center do it, but so I understand that you are turning back twenty

LF6: I mean they need help, I mean when they need help, it's not you know like they call to just hi themselves anyway, there's a ton of air traffic out here so we'll wait to cross back over the airport.

LFD: Alright, were you able to get a hold of anyone the Wendover ambulance on the ground

LF6: We talked with them but we haven't make contact with them to tell them that we are turning around

LFD: Ok, no problem, I can tell Tooele Dispatch and let them know

LF6: Ok, that would be great

According to the communication transcript provided by the SLC ATCT, at 2031, the Life Flight pilot contacted SLC ATCT for a departure clearance from the LDS Hospital. Approximately 2033, the Life Flight pilot was cleared to proceed toward SLC via the signatory letter of agreement (LOA) and enter the Class B airspace. At 2033, the pilot advised ATCT that he was attempting to "climb out of it" and requested clearance to 7,000 or 8,000 feet. Life Flight 6 was cleared for the ascent and to remain to the east of SLC. At 2035, ATCT inquired how high did Life Flight 6 want to fly to obtain VFR. Life Flight 6 pilot reported that he attempted to climb; however, he would lose VFR and requested not to do that, but to transition through the SLC airspace "to see if it clears up any better for us." ATCT advised the pilot the visibility was 1/16th of a mile and to proceed inbound via the LOA and remain east of SLC. At 2037, ATCT asked the pilot, "based on [his] flight conditions" if could he continue westbound, and the pilot responded, "I'd like to give it a try if I could."

At 2039, Life Flight 6 was cleared westbound and to maintain VFR at or below 5,000 feet. At 2041, Life Flight 6 pilot stated he was on the west side of the airfield, and requested to head back to the east; however, he could hold over there. At 2044, the pilot asked ATCT whether he was cleared back to the east. ATCT informed the pilot that she could not let him go east until he could see other aircraft on final approach to runway 34R or have a "hole large enough to get [Life Flight 6] back to the east side."

At 2049:51, Life Flight 6 pilot reported to ATCT, "I'm basically inadvertent IMC at this time and declaring emergency." At 2051:03, ATCT asked the pilot whether he had runway 34L in sight, the pilot res

Aircraft

Registration
N601RX
Reported as
Agusta A-109-K2
Category
Helicopter
Serial number
10017
Airframe hours
3,545.4
Engines
Turbomeca Arriel 1K1, 720 horsepower, turbo shaftTurbomeca Arriel 1K1, 720 horsepower, turbo shaft
Damage
Destroyed
Flight
Positioning · Part 91
Registered owner
IHC Health Services Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 9, 2003 · 1.6 hours before
Departed
Salt Lake City, UT
Destination
Wendover, UT
Flight plan
Company VFR
Airport
SLC · Salt Lake City Intl

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
47
Injuries
Fatal
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
September 30, 2002
Seat
Right
Toxicology
Performed
Flight hours
3,846 total · 124 in this make and model

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
350° at 6 knots
Visibility
0.13 statute miles
Lowest ceiling
200 ft indefinitevv
Temperature
34 °F, dew point 34 °F
Altimeter
30.10 inHg
Observed at
KSLC, 1 nm away

Docket · 43

The files NTSB released with the investigation on January 30, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.1 MB in all.

Photo 01: Initial Ground ScarItem 1 · .PDF · 234 KBPhoto 02: Landing Gear Ground ScarItem 2 · .PDF · 306 KBPhoto 03: Front View of WreckageItem 3 · .PDF · 279 KBPhoto 04: Left Side View of WreckageItem 4 · .PDF · 267 KBPhoto 05: Rear View of WreckageItem 5 · .PDF · 238 KBPhoto 06: Right Side View of WreckageItem 6 · .PDF · 251 KBPhoto 07: Right Side View of WreckageItem 7 · .PDF · 283 KBPhoto 08: Front View of Wreckage (provided by Agusta)Item 8 · .PDF · 687 KBPhoto 09: Left Side View of CockpitItem 9 · .PDF · 339 KBPhoto 10: View of Aft Cabin (provided by Agusta)Item 10 · .PDF · 673 KBPhoto 11: Bottom View of Fuselage (provided by Agusta)Item 11 · .PDF · 606 KBPhoto 12: Right Side Instrument PanelItem 12 · .PDF · 381 KBPhoto 13: Tail Rotor Assembly (provided by Agusta)Item 13 · .PDF · 749 KBPhoto 14: Left Horizontal Stabilizer (provided by Agusta)Item 14 · .PDF · 690 KBPhoto 15: Section of Left Horizontal Stabilizer at Initial ImpactItem 15 · .PDF · 401 KBPhoto 16: Section of Tail Rotor BladeItem 16 · .PDF · 539 KBPhoto 17: Engine 1 Main DriveshaftItem 17 · .PDF · 294 KBPhoto 18: Engine 2 Main DriveshaftItem 18 · .PDF · 289 KBPhoto 19: Separated Tail Rotor DriveshaftItem 19 · .PDF · 254 KBAir Methods StatementsItem 20 · .PDF · 256 KBLife Flight Witness StatementItem 21 · .PDF · 58 KBWitness StatementItem 22 · .PDF · 47 KBNOAA StatementItem 23 · .PDF · 38 KBAccident Site Witness StatementsItem 24 · .PDF · 110 KBATC StatementsItem 25 · .PDF · 324 KBWreckage DiagramsItem 26 · .PDF · 81 KBWeather InformationItem 27 · .PDF · 88 KBSLC Tower Ops. Supervisor Position ATC TranscriptItem 28 · .PDF · 210 KBSLC Local Control East Position ATC TranscriptItem 29 · .PDF · 186 KBSLC Local Control Center Position ATC TranscriptItem 30 · .PDF · 68 KBLife Flight Communication Center TranscriptItem 31 · .PDF · 122 KBAir Methods Dispatch InformationItem 32 · .PDF · 63 KBRadar InformationItem 33 · .PDF · 185 KBFAA Record of Telephone ConversationItem 34 · .PDF · 36 KBAgusta ReportItem 35 · .PDF · 629 KBPilot InformationItem 36 · .PDF · 1.3 MB25-hour Maintenance InspectionItem 37 · .PDF · 135 KBMaintenance Status ReportItem 38 · .PDF · 1.7 MBUnscheduled Maintenance InspectionItem 39 · .PDF · 140 KBLife Flight/SLC Letter of AgreementItem 40 · .PDF · 120 KBStatement of Party Representatives to NTSB InvestigationItem 41 · .PDF · 341 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 42 · .PDF · 68 KBToxicological ReportItem 43 · .PDF · 53 KB

FAA reports on this event · 1

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