# NTSB FTW04FA097: Bell 407, N502MT, Pyote, TX, March 21, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 21, 2004, 02:16 local (08:16 UTC) - Place: Pyote, TX - Coordinates: 31.398889, -103.125556 - Nearby events: https://openairdocs.org/map.md?lat=31.3989&lon=-103.1256&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal, 1 serious - 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 - NTSB case key (mKey): 58927 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW04FA097 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58927/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58927 - Page: https://openairdocs.org/ntsb/FTW04FA097 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - normal - light condition - dark night (contributing factor) - preflight planning/preparation - inadequate, pilot in command (contributing factor) - flight into adverse weather - inadvertent, pilot in command (cause) - pressure induced by conditions/events, pilot in command (contributing factor) - weather condition - gusts (contributing factor) - weather condition - sand/dust storm (contributing factor) - weather condition - turbulence,convection induced (contributing factor) - In flight collision with terrain/water, maneuvering - turn to reverse direction - clearance - not maintained, pilot in command (cause) ## 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](https://openairdocs.org/deregistered/N502MT-2006-09-12), registration cancelled 2006-09-12, S/N 53549, built 2003 (OpenAirDocs) - Reported make and model: Bell 407 - Registry model: [Bell 407](https://openairdocs.org/model/bell-407) (registry code 1182206) (OpenAirDocs) - Registry engine: [Rolls-Royce 250-C47B](https://openairdocs.org/engine/rolls-royce-250-c47b) (registry code 54585, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 53549 - Airframe hours: 452.4 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: fatal; 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 ## 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 20040321003219A](https://openairdocs.org/incident/20040321003219A), Mar 21, 2004: Bell 407, Destroyed, 4 fatal. (-23) The flight departed from big bend regional medical center near alpine, TX at approximately 0143 on 03/21/04 for an air ambulance flight to lubbock, TX.… ## Docket (39 files) The files NTSB released with the investigation on April 26, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58927. 10.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406658&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Meteorology 5 - Factual Report of Group Chairman (item 2, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40236433&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Dispatch Log (item 3, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406659&FileExtension=.PDF&FileName=Dispatch%20Log-Redacted.PDF - Witness Statement (item 4, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229729&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Dispatch Witness Statement - Pakcyk (item 5, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406660&FileExtension=.PDF&FileName=Dispatch%20Witness%20Statement%20-%20Pakcyk-Redacted.PDF - Dispatch Witness Statement - Holman (item 6, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229731&FileExtension=.PDF&FileName=Dispatch%20Witness%20Statement%20-%20Holman-Master.PDF - Nurse at Alpine Witness Statement (item 7, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406661&FileExtension=.PDF&FileName=Nurse%20at%20Alpine%20Witness%20Statement-Redacted.PDF - Witness Statement - Webster (item 8, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229733&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Webster-Master.PDF - Radar Information (item 9, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229734&FileExtension=.PDF&FileName=Radar%20Information-Master.PDF - DPS Wreckage Diagram (item 10, .PDF, 581 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229735&FileExtension=.PDF&FileName=DPS%20Wreckage%20Diagram-Master.PDF - Bell Helicopter Report (item 11, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229736&FileExtension=.PDF&FileName=Bell%20Helicopter%20Report-Master.PDF - Excerpts of Rolls Royce Report (item 12, .PDF, 909 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229737&FileExtension=.PDF&FileName=Excerpts%20of%20Rolls%20Royce%20Report-Master.PDF - Pilot Part 135 Checkride (item 13, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406662&FileExtension=.PDF&FileName=Pilot%20Part%20135%20Checkride-Redacted.PDF - Pilot Training Record (item 14, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229759&FileExtension=.PDF&FileName=Pilot%20Training%20Record-Master.PDF - Pilot Interview (item 15, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229760&FileExtension=.PDF&FileName=Pilot%20Interview-Master.PDF - Excerpts of Company Operations Specifications (item 16, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229761&FileExtension=.PDF&FileName=Excerpts%20of%20Company%20Operations%20Specifications-Master.PDF - Excerpts of Company Training Manual (item 17, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229762&FileExtension=.PDF&FileName=Excerpts%20of%20Company%20Training%20Manual-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406663&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406664&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 20, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406665&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo #1 - View of Accident Site (item 21, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229766&FileExtension=.PDF&FileName=Photo%20%231%20-%20View%20of%20Accident%20Site-Master.PDF - Photo #2 - Initial Impact Area (item 22, .PDF, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229767&FileExtension=.PDF&FileName=Photo%20%232%20-%20Initial%20Impact%20Area-Master.PDF - Photo #3 - Initial Impact Area (item 23, .PDF, 287 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229771&FileExtension=.PDF&FileName=Photo%20%233%20-%20Initial%20Impact%20Area-Master.PDF - Photo #4 - View of Engine and Main Wreckage (item 24, .PDF, 426 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229773&FileExtension=.PDF&FileName=Photo%20%234%20-%20View%20of%20Engine%20and%20Main%20Wreckage-Master.PDF - Photo #5 - View of Main Wreckage (item 25, .PDF, 299 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229774&FileExtension=.PDF&FileName=Photo%20%235%20-%20View%20of%20Main%20Wreckage-Master.PDF - Photo #6 - View of Main Wreckage (item 26, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229775&FileExtension=.PDF&FileName=Photo%20%236%20-%20View%20of%20Main%20Wreckage-Master.PDF - Photo # 7 - View of Main Wreckage (item 27, .PDF, 343 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229776&FileExtension=.PDF&FileName=Photo%20%23%207%20-%20View%20of%20Main%20Wreckage-Master.PDF - Photo # 8 - View of Main Wreckage (item 28, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229777&FileExtension=.PDF&FileName=Photo%20%23%208%20-%20View%20of%20Main%20Wreckage-Master.PDF - Photo # 9 - View of Main Wreckage (item 29, .PDF, 300 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229778&FileExtension=.PDF&FileName=Photo%20%23%209%20-%20View%20of%20Main%20Wreckage-Master.PDF - Photo #10 - View of Main Wreckage (item 30, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229779&FileExtension=.PDF&FileName=Photo%20%2310%20-%20View%20of%20Main%20Wreckage-Master.PDF - Photo #11 - View of Main Wreckage (item 31, .PDF, 258 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229780&FileExtension=.PDF&FileName=Photo%20%2311%20-%20View%20of%20Main%20Wreckage-Master.PDF - Photo #12 - View of Rotorhead (item 32, .PDF, 304 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229782&FileExtension=.PDF&FileName=Photo%20%2312%20-%20View%20of%20Rotorhead-Master.PDF - Photo #13 - View of Landing Gear Skids (item 33, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229791&FileExtension=.PDF&FileName=Photo%20%2313%20-%20View%20of%20Landing%20Gear%20Skids-Master.PDF - Photo #14 - View of Fuselage Structure (item 34, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229784&FileExtension=.PDF&FileName=Photo%20%2314%20-%20View%20of%20Fuselage%20Structure-Master.PDF - Photo #15 - View of Tail Rotor (item 35, .PDF, 525 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229785&FileExtension=.PDF&FileName=Photo%20%2315%20-%20View%20of%20Tail%20Rotor-Master.PDF - Photo #16 - Main Drive Shaft (item 36, .PDF, 355 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229786&FileExtension=.PDF&FileName=Photo%20%2316%20-%20Main%20Drive%20Shaft-Master.PDF - Photo #17 - View of Fractured Engine to Aircraft Tail Rotor Short Shaft (item 37, .PDF, 475 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229787&FileExtension=.PDF&FileName=Photo%20%2317%20-%20View%20of%20Fractured%20Engine%20to%20Aircraft%20Tail%20Rotor%20Short%20Shaft-Master.PDF - Photo #18 - View of Engine (item 38, .PDF, 558 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229788&FileExtension=.PDF&FileName=Photo%20%2318%20-%20View%20of%20Engine-Master.PDF - Photo #19 - View of Compressor (item 39, .PDF, 317 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229789&FileExtension=.PDF&FileName=Photo%20%2319%20-%20View%20of%20Compressor-Master.PDF From the NTSB's public API. 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