# NTSB FTW03FA082: Agusta A-109-K2, N601RX, Salt Lake City, UT, January 11, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 10, 2003, 20:50 local (Jan 11, 2003, 03:50 UTC) - Place: Salt Lake City, UT - Coordinates: 40.767776, -112.01139 - Nearby events: https://openairdocs.org/map.md?lat=40.7678&lon=-112.0114&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report March 30, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration, IHC Life Flight, Turbomeca Engine Corporation, Agusta Aerospace Corporation - NTSB case key (mKey): 56318 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW03FA082 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56318/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56318 - Page: https://openairdocs.org/ntsb/FTW03FA082 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, maneuvering - weather condition - fog (contributing factor) - flight into known adverse weather - continued, pilot in command (cause) - pressure induced by conditions/events, pilot in command (contributing factor) - remedial action - delayed, pilot in command (cause) - In flight collision with terrain/water, maneuvering - remedial action - delayed, pilot in command (cause) - clearance - not maintained, pilot in command (cause) - 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](https://openairdocs.org/deregistered/N601RX-2003-09-04), registration cancelled 2003-09-04, S/N 10017 (OpenAirDocs) - Reported make and model: Agusta A-109-K2 - Registry model: [Agusta S P A A109K2](https://openairdocs.org/model/agusta-s-p-a-a109k2) (registry code 0260502) (OpenAirDocs) - Category: Helicopter - Serial number: 10017 - Airframe hours: 3545.4 - Engines: Turbomeca Arriel 1K1 720 horsepower turbo shaft; Turbomeca 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: fatal; 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 ## 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 20030110000089A](https://openairdocs.org/incident/20030110000089A), Jan 10, 2003: Agusta A109K2, Salt Lake City, UT, Substantial damage, 2 fatal. (-23) On January 10, 2003, a lifeflight helicopter #6, an Agusta A-109-K29, N601RX, was dispatch to an auto accident west of Salt Lake City, Utah, near the… ## Docket (43 files) The files NTSB released with the investigation on January 30, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56318. 14.1 MB in all. - Photo 01: Initial Ground Scar (item 1, .PDF, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204111&FileExtension=.PDF&FileName=Photo%2001%3A%20%20Initial%20Ground%20Scar-Master.PDF - Photo 02: Landing Gear Ground Scar (item 2, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204112&FileExtension=.PDF&FileName=Photo%2002%3A%20%20Landing%20Gear%20Ground%20Scar-Master.PDF - Photo 03: Front View of Wreckage (item 3, .PDF, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204113&FileExtension=.PDF&FileName=Photo%2003%3A%20%20Front%20View%20of%20Wreckage-Master.PDF - Photo 04: Left Side View of Wreckage (item 4, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204114&FileExtension=.PDF&FileName=Photo%2004%3A%20Left%20Side%20View%20of%20Wreckage-Master.PDF - Photo 05: Rear View of Wreckage (item 5, .PDF, 238 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204115&FileExtension=.PDF&FileName=Photo%2005%3A%20Rear%20View%20of%20Wreckage-Master.PDF - Photo 06: Right Side View of Wreckage (item 6, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204116&FileExtension=.PDF&FileName=Photo%2006%3A%20Right%20Side%20View%20of%20Wreckage-Master.PDF - Photo 07: Right Side View of Wreckage (item 7, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204117&FileExtension=.PDF&FileName=Photo%2007%3A%20Right%20Side%20View%20of%20Wreckage-Master.PDF - Photo 08: Front View of Wreckage (provided by Agusta) (item 8, .PDF, 687 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204118&FileExtension=.PDF&FileName=Photo%2008%3A%20Front%20View%20of%20Wreckage%20(provided%20by%20Agusta)-Master.PDF - Photo 09: Left Side View of Cockpit (item 9, .PDF, 339 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204119&FileExtension=.PDF&FileName=Photo%2009%3A%20Left%20Side%20View%20of%20Cockpit-Master.PDF - Photo 10: View of Aft Cabin (provided by Agusta) (item 10, .PDF, 673 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204120&FileExtension=.PDF&FileName=Photo%2010%3A%20View%20of%20Aft%20Cabin%20(provided%20by%20Agusta)-Master.PDF - Photo 11: Bottom View of Fuselage (provided by Agusta) (item 11, .PDF, 606 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204121&FileExtension=.PDF&FileName=Photo%2011%3A%20Bottom%20View%20of%20Fuselage%20(provided%20by%20Agusta)-Master.PDF - Photo 12: Right Side Instrument Panel (item 12, .PDF, 381 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204122&FileExtension=.PDF&FileName=Photo%2012%3A%20Right%20Side%20Instrument%20Panel-Master.PDF - Photo 13: Tail Rotor Assembly (provided by Agusta) (item 13, .PDF, 749 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204123&FileExtension=.PDF&FileName=Photo%2013%3A%20Tail%20Rotor%20Assembly%20(provided%20by%20Agusta)-Master.PDF - Photo 14: Left Horizontal Stabilizer (provided by Agusta) (item 14, .PDF, 690 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204124&FileExtension=.PDF&FileName=Photo%2014%3A%20Left%20Horizontal%20Stabilizer%20(provided%20by%20Agusta)-Master.PDF - Photo 15: Section of Left Horizontal Stabilizer at Initial Impact (item 15, .PDF, 401 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204125&FileExtension=.PDF&FileName=Photo%2015%3A%20Section%20of%20Left%20Horizontal%20Stabilizer%20at%20Initial%20Impact-Master.PDF - Photo 16: Section of Tail Rotor Blade (item 16, .PDF, 539 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204126&FileExtension=.PDF&FileName=Photo%2016%3A%20Section%20of%20Tail%20Rotor%20Blade-Master.PDF - Photo 17: Engine 1 Main Driveshaft (item 17, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204127&FileExtension=.PDF&FileName=Photo%2017%3A%20Engine%201%20Main%20Driveshaft-Master.PDF - Photo 18: Engine 2 Main Driveshaft (item 18, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204128&FileExtension=.PDF&FileName=Photo%2018%3A%20Engine%202%20Main%20Driveshaft-Master.PDF - Photo 19: Separated Tail Rotor Driveshaft (item 19, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204130&FileExtension=.PDF&FileName=Photo%2019%3A%20Separated%20Tail%20Rotor%20Driveshaft-Master.PDF - Air Methods Statements (item 20, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399598&FileExtension=.PDF&FileName=Air%20Methods%20Statements-Redacted.PDF - Life Flight Witness Statement (item 21, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399607&FileExtension=.PDF&FileName=Life%20Flight%20Witness%20Statement-Redacted.PDF - Witness Statement (item 22, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399608&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - NOAA Statement (item 23, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204134&FileExtension=.PDF&FileName=NOAA%20Statement-Master.PDF - Accident Site Witness Statements (item 24, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399609&FileExtension=.PDF&FileName=Accident%20Site%20Witness%20Statements-Redacted.PDF - ATC Statements (item 25, .PDF, 324 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399612&FileExtension=.PDF&FileName=ATC%20Statements-Redacted.PDF - Wreckage Diagrams (item 26, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204138&FileExtension=.PDF&FileName=Wreckage%20Diagrams-Master.PDF - Weather Information (item 27, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204139&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - SLC Tower Ops. Supervisor Position ATC Transcript (item 28, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438783&FileExtension=.PDF&FileName=SLC%20Tower%20Ops.%20Supervisor%20Position%20ATC%20Transcript-Redacted.PDF - SLC Local Control East Position ATC Transcript (item 29, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438784&FileExtension=.PDF&FileName=SLC%20Local%20Control%20East%20Position%20ATC%20Transcript-Redacted.PDF - SLC Local Control Center Position ATC Transcript (item 30, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438785&FileExtension=.PDF&FileName=SLC%20Local%20Control%20Center%20Position%20ATC%20Transcript-Redacted.PDF - Life Flight Communication Center Transcript (item 31, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204144&FileExtension=.PDF&FileName=Life%20Flight%20Communication%20Center%20Transcript-Master.PDF - Air Methods Dispatch Information (item 32, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204145&FileExtension=.PDF&FileName=Air%20Methods%20Dispatch%20Information-Master.PDF - Radar Information (item 33, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204146&FileExtension=.PDF&FileName=Radar%20Information-Master.PDF - FAA Record of Telephone Conversation (item 34, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399613&FileExtension=.PDF&FileName=FAA%20Record%20of%20Telephone%20Conversation-Redacted.PDF - Agusta Report (item 35, .PDF, 629 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204148&FileExtension=.PDF&FileName=Agusta%20Report-Master.PDF - Pilot Information (item 36, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438786&FileExtension=.PDF&FileName=Pilot%20Information-Redacted.PDF - 25-hour Maintenance Inspection (item 37, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399617&FileExtension=.PDF&FileName=25-hour%20Maintenance%20Inspection-Redacted.PDF - Maintenance Status Report (item 38, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204151&FileExtension=.PDF&FileName=Maintenance%20Status%20Report-Master.PDF - Unscheduled Maintenance Inspection (item 39, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399618&FileExtension=.PDF&FileName=Unscheduled%20Maintenance%20Inspection-Redacted.PDF - Life Flight/SLC Letter of Agreement (item 40, .PDF, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399619&FileExtension=.PDF&FileName=Life%20Flight%2FSLC%20Letter%20of%20Agreement-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 41, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399620&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 42, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399621&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 43, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204156&FileExtension=.PDF&FileName=Toxicological%20Report-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.