FTW04FA097

NTSB accident investigation · Bell 407 · Pyote, TX · March 21, 2004

Accident · FatalField investigationFinal report
Date
March 21, 2004, 02:16 local (08:16 UTC)
Place
Pyote, TX
Injuries
4 fatal, 1 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N502MTBell 407
Weather
Instrument (IMC) · Night/dark
Status
Completed · report January 26, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration - FSDO, Med-Trans Corporation, Federal Aviation Administration - ASW 112, Rolls-Royce Corporation, Bell Helicopter Textron
FAA report
20040321003219A
Case key
58927

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 inadvertent encounter with adverse weather, which resulted in the pilot failing to maintain terrain clearance. Contributing factors were the dark night conditions, the pilot's inadequate preflight preparation and planning, and the pressure to complete the mission induced by the pilot as a result of the nature of the EMS mission.

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 weatherCruise - normal
Light condition - dark nightFactor
Preflight planning/preparation - inadequatePilot in commandFactor
Flight into adverse weather - inadvertentPilot in commandCause
Pressure induced by conditions/eventsPilot in commandFactor
Weather condition - gustsFactor
Weather condition - sand/dust stormFactor
Weather condition - turbulence,convection inducedFactor
In flight collision with terrain/waterManeuvering - turn to reverse direction
Clearance - not maintainedPilot in commandCause

Analysis

While maneuvering during dark night conditions, an emergency medical services helicopter impacted the terrain near Pyote, Texas, after encountering a gust front that produced localized blowing dust and moderate to severe turbulence. The pilot did not obtain any formal preflight weather briefing before departure or en route. No flight dispatch services were used for the flight. No evidence was found to indicate that the pilot obtained any preflight weather briefing before departure or en route. Radar data depicted the helicopter traveling in a north-northeasterly direct route toward the destination after departing from a hospital. Approximately 34 minutes after departure, the helicopter executed a right turn to the east. About that time, the pilot contacted the company dispatch and began a position report, stating, "...hold on a [minute] dispatch, [approximately 14 seconds later] look at, gimme something to look at." There were no further communications from the helicopter. Radar data indicated that the helicopter continued in a right turn back to the north. Examination of the accident site revealed the helicopter impacted the terrain on a southerly heading in the opposite direction of the destination, consistent with the helicopter turning around again. Examination of the helicopter revealed no evidence of an in-flight control or system malfunction before the initial impact. According to documents provided by the operator, the pilot had accumulated a total of 86 flight hours as pilot-in-command of the accident helicopter make and model and a total of 4,209 rotorcraft flight hours. Reported weather conditions at the time of the accident and near the accident site included strong winds, moderate to severe turbulence, and unstable atmosphere that supported thunderstorm activity.

Factual narrative

History of flight

On March 21, 2004, approximately 0216 central standard time, a Bell 407 air ambulance helicopter, N502MT, was destroyed when it impacted terrain while maneuvering in reduced visibility conditions near Pyote, Texas. The instrument-rated commercial pilot, a flight paramedic, an infant patient, and a passenger sustained fatal injuries, and a flight nurse sustained serious injuries. The single-engine helicopter was owned and operated by Med-Trans Corporation (MTC), of Bismarck, North Dakota, and doing business as CareStar, Odessa, Texas. Night instrument meteorological conditions (IMC) prevailed throughout the area for the Title 14 Code of Regulations Part 135 on-demand air ambulance flight for which a company visual flight rules (VFR) flight plan was filed. The flight originated from the Big Bend Regional Medical Center, near Alpine, Texas, approximately 0139 to transfer the patient to the University Medical Center (UMC), near Lubbock, Texas.

According to MTC personnel, the pilot reported for duty approximately 2000, March 20, 2004, at the base hangar at the Odessa-Schlemeyer Field (ODO), near Odessa, Texas, and was relieving the base chief pilot. Approximately 2200, the base chief pilot informed the accident pilot via a telephone call that there was weather in the area and to be careful on any possible flights. He advised the accident pilot to move the helicopter into the hangar due to weather, and that there was a pending pediatric flight.

At 2330, the medical staff requested, through dispatch personnel that an infant patient be transfered from Alpine to Lubbock. At 2342, the MTC pilot departed the base hangar and arrived at the Medical Center Hospital (MCH) in Odessa to pick up the flight nurse and paramedic for the flight to Alpine. A review of the MCH dispatch log revealed that at 2346, the following transmission from dispatch was recorded, "[CareStar], Adv yellow weather status, pilot checked weather, will take run." At 2352, the flight departed MCH en route to the Big Bend Regional Medical Center, and arrived at 0044 (March 21, 2005).

Approximately 0135, the patient and passenger boarded the helicopter. At 0139, the flight departed Big Bend Regional Medical Center en route to Lubbock (Lubbock is approximately 220 miles north-northeast of Alpine). A review of the radar data depicted the helicopter heading in a north-northeasterly direction after departure from Alpine. At 0155, the pilot contacted the MCH dispatch and gave the following position report, "[N] 30.51.50, [W] 103.23.56, ETA 1 hr. 28 min, 740 [pounds of] fuel."

At 0213, approximately 1 mile south of the accident site, the helicopter executed a turn to the north, and then a turn back to the northeast. At 0215, the radar data depicted the helicopter turned to the east and then turned 270 degrees back to the north. Approximately the same time the helicopter executed the turn to the east, the pilot contacted the MCH dispatch and began a position report, when he stated, "...hold on a [minute] dispatch, [approximately 14 seconds later] look at, gimmie something to look at." There were no further communications from the helicopter. The last radar position of the helicopter was recorded at 0216:13, at 31 degrees 24 minutes 08 seconds north latitude and 103 degrees 07 minutes 31 seconds west longitude, at an altitude of 5,900 feet msl, approximately 1,200 feet north of the accident site.

At 0323, the MCH dispatch facility notified the Texas Department of Public Safety (DPS) of a possible missing helicopter. Due to weather in the Odessa area, the DPS helicopter could not initiate a search until approximately 0600. At 0619, DPS helicopter rescue personnel located the helicopter wreckage approximately 6 miles south of Pyote. The geographical coordinates of the helicopter wreckage were north latitude 31 degrees 23.944 minutes by west longitude 103 degrees 07.554 minutes at an elevation of approximately 2,480 feet msl. (It should be noted that the communications transcripts and radar data times are off by up to 4 minutes at some points, and the time noted in this report is from the radar data.)

Several attempts to obtain a statement from the flight nurse were unsuccessful.

Personnel information

The pilot held a commercial helicopter certificate issued on February 18, 1999, with an instrument helicopter rating, which was issued October 4, 1999. The pilot held a certified flight instructor certificate with rotorcraft and instrument rotorcraft ratings. In addition, the pilot held an airline transport pilot certificate with a rating for multi-engine land airplanes. The pilot was issued a second-class medical certificate on March 3, 2004, with the limitation, "Holder shall possess glasses that correct for the near vision."

According to the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2), the operator reported the pilot accumulated 17,307 total flight hours, and 4,209 hours total rotorcraft flight time. The pilot accumulated 1,747 hours of night flight time, 130 hours of actual instrument flight time, and 87 hours of simulated instrument time; however, it was unknown how many night and instrument hours were in rotorcraft operations. According to the pilot's resume, as of October 1, 2003, the pilot had accumulated 13,032 total hours in aerial application flight operations, of which 1,200 hours were in rotorcraft. The pilot's logbook was not provided to investigators during the investigation.

The operator provided the pilot's duty time records to the National Transportation Safety Board Investigator-In-Charge (NTSB IIC). As of March 19, 2004, the pilot accumulated 86 flight hours as pilot-in-command in the Bell 407. The pilot accumulated 60.6, 39.2, and 25.4 flight hours in the last 90, 60, and 30 days, respectively. According to the operator's "Record of Flight Training," the pilot accumulated 4.4 flight hours of new hire training, which covered, "Normal and Emergency Procedure Training, Night Flight [and] Approaches." The 4.4 hours of new hire training consisted of 3 hours of day flight, 0.2 hours of simulated instrument conditions (under a view limiting hood), and 1.2 hours of night flight.

On November 11, 2003, the pilot satisfactorily completed his Federal Aviation Regulations Part 135 Airman Competency/Proficiency Check in the Bell 407 helicopter. According to the remarks, the pilot successfully completed the "Initial new hire" check ride.

According to the company's "Pilot Interview" form, question 14 asked, "How many times have you been Inadvertent IMC? How did you react? How do you avoid Inadvertent IMC?" The pilot answered the first question, "No" and did not answer the last two questions.

Company information

Med-Trans Corporation was issued an operating certificate by the Federal Aviation Administration (FAA) in 1995, to conduct on-demand air taxi operations under the provisions of Title 14 CFR Part 135. At the time of the accident, MTC had air ambulance operations in the states of Tennessee, Kentucky, South Carolina, Texas, Arizona, California, South Dakota, North Dakota, and Nebraska. The corporate headquarters was located in Bismarck, the Director of Maintenance was located in Bismarck, the Director of Operations was located in Tucson, Arizona, and the Chief Pilot was located in Johnson City, Tennessee. The Part 135 operating certificate was managed by the FAA Flight Standards District Office in Scottsdale, Arizona. The FAA approved company operation specifications did not allow flights to be conducted in IMC.

Aircraft information

The red and white accident helicopter (serial number 53549) was configured for the transport of medical patients with two seats in the cockpit, one rear-facing seat aft of the pilot's seat, two forward-facing seats, and one medical bed. The helicopter was powered by one 650-horsepower Rolls Royce Corporation turbo-shaft engine (se

Aircraft

Registration
N502MT
Reported as
Bell 407
Category
Helicopter
Serial number
53549
Airframe hours
452.4
Engine
Rolls-Royce 250-C47B, 650 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 135
Registered owner
Med-Trans Corporation
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · February 28, 2004 · 48.4 hours before
Departed
Alpine, TX
Destination
Lubbock, 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
46
Injuries
Fatal
Certificates
Flight instructor, Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
November 11, 2003
Seat
Right
Toxicology
Performed
Flight hours
17,307 total · 66 in this make and model · 66 in the last 90 days · 26 in the last 30 days

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
10° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 59 °F
Altimeter
30.32 inHg
Observed at
PEQ, 19 nm away

Docket · 39

The files NTSB released with the investigation on April 26, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.7 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 239 KBMeteorology 5 - Factual Report of Group ChairmanItem 2 · .PDF · 1.1 MBDispatch LogItem 3 · .PDF · 126 KBWitness StatementItem 4 · .PDF · 38 KBDispatch Witness Statement - PakcykItem 5 · .PDF · 58 KBDispatch Witness Statement - HolmanItem 6 · .PDF · 105 KBNurse at Alpine Witness StatementItem 7 · .PDF · 58 KBWitness Statement - WebsterItem 8 · .PDF · 81 KBRadar InformationItem 9 · .PDF · 39 KBDPS Wreckage DiagramItem 10 · .PDF · 581 KBBell Helicopter ReportItem 11 · .PDF · 268 KBExcerpts of Rolls Royce ReportItem 12 · .PDF · 909 KBPilot Part 135 CheckrideItem 13 · .PDF · 70 KBPilot Training RecordItem 14 · .PDF · 39 KBPilot InterviewItem 15 · .PDF · 85 KBExcerpts of Company Operations SpecificationsItem 16 · .PDF · 83 KBExcerpts of Company Training ManualItem 17 · .PDF · 66 KBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 77 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 19 · .PDF · 45 KBToxicological ReportItem 20 · .PDF · 53 KBPhoto #1 - View of Accident SiteItem 21 · .PDF · 289 KBPhoto #2 - Initial Impact AreaItem 22 · .PDF · 421 KBPhoto #3 - Initial Impact AreaItem 23 · .PDF · 287 KBPhoto #4 - View of Engine and Main WreckageItem 24 · .PDF · 426 KBPhoto #5 - View of Main WreckageItem 25 · .PDF · 299 KBPhoto #6 - View of Main WreckageItem 26 · .PDF · 289 KBPhoto # 7 - View of Main WreckageItem 27 · .PDF · 343 KBPhoto # 8 - View of Main WreckageItem 28 · .PDF · 237 KBPhoto # 9 - View of Main WreckageItem 29 · .PDF · 300 KBPhoto #10 - View of Main WreckageItem 30 · .PDF · 344 KBPhoto #11 - View of Main WreckageItem 31 · .PDF · 258 KBPhoto #12 - View of RotorheadItem 32 · .PDF · 304 KBPhoto #13 - View of Landing Gear SkidsItem 33 · .PDF · 298 KBPhoto #14 - View of Fuselage StructureItem 34 · .PDF · 298 KBPhoto #15 - View of Tail RotorItem 35 · .PDF · 525 KBPhoto #16 - Main Drive ShaftItem 36 · .PDF · 355 KBPhoto #17 - View of Fractured Engine to Aircraft Tail Rotor Short ShaftItem 37 · .PDF · 475 KBPhoto #18 - View of EngineItem 38 · .PDF · 558 KBPhoto #19 - View of CompressorItem 39 · .PDF · 317 KB

FAA reports on this event · 1

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