# NTSB FTW97FA121: MBB BO-105S, N7161J, Lena, LA, March 14, 1997 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 14, 1997, 01:45 local (07:45 UTC) - Place: Lena, LA - Coordinates: 31.460443, -92.770942 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=31.4604&lon=-92.7709&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report January 7, 1998 - Report: Approved by Office Director - NTSB case key (mKey): 20024 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW97FA121 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/20024/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=20024 - Page: https://openairdocs.org/ntsb/FTW97FA121 ## Probable cause The pilot's continued VFR flight into instrument meteorological conditions, and his subsequent loss of aircraft control due to spatial disorientation. Factors were the pilot not following company procedures and directives, the low ceiling, and the dark night light condition. ## 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 - low ceiling (contributing factor) - Loss of control - in flight, maneuvering - light condition - dark night (contributing factor) - procedures/directives - not followed, pilot in command (contributing factor) - vfr flight into imc - continued, pilot in command (cause) - spatial disorientation, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis During a dark night flight from Shreveport, Louisiana, to Lafayette, Louisiana, via Alexandria, Louisiana, the helicopter descended to 500 feet MSL due to weather, and was following Interstate 49 south over the northbound lanes. The pilot slowed the helicopter to 70 knots keeping pace with the traffic. The medical crewmember remembered 'feeling a shudder, like the shudder as the helicopter decelerates through effective translational lift.' He heard the pilot say an expletive and felt the helicopter begin to turn left. He saw sparks overhead and felt plexi glass hit him. Subsequently, the helicopter impacted the ground. During this sequence he lost visual orientation of the helicopter's position in relation to the ground. According to the company's Operations Manual, during nighttime hours, the air ambulance cross country VFR minimum ceiling is 1,000 feet and the minimum visibility is 3 miles. Any flight outside the local flying area is considered a cross-country operation. The medical crewmember reported that the ceiling was about 550 to 600 feet, and the visibility was approximately 2 miles. Examination of the helicopter did not reveal any structural or mechanical anomalies. ## Factual narrative HISTORY OF FLIGHT On March 14, 1997, approximately 0145 central standard time, a MBB BO-105S helicopter, N7161J, registered to Deutsche Financial Services Holding Corporation, and operated by Petroleum Helicopters, Inc. (PHI), under contract to Acadian Air Med Services as a Title 14 CFR Part 91 positioning flight, was destroyed following a loss of control near Lena, Louisiana. Instrument meteorological conditions prevailed, and a company VFR flight plan was filed for the dark night cross country flight. The instrument rated commercial pilot was fatally injured, and the medical crewmember was seriously injured. The dark early morning flight originated from Shreveport, Louisiana, at 0102, about 42 minutes prior to the accident, and was en route to Lafayette, Louisiana, via Alexandria, Louisiana. The medical crewmember reported the following information in an interview conducted by the investigator-in-charge. He was handling flight following with company dispatch while the pilot was talking with ATC. They had descended to 500 feet MSL due to weather, and were following Interstate 49 south over the northbound lanes. The pilot had slowed the helicopter to 70 knots and was keeping pace with the traffic. He remembered "feeling a shudder, like the shudder as the helicopter decelerates through effective translational lift." He heard the pilot say an expletive and felt the helicopter begin to turn left. He saw sparks overhead and felt plexi glass hit him. Subsequently, the helicopter impacted the ground. During this sequence he lost visual orientation of the helicopter's position in relation to the ground. After the helicopter came to a stop he jumped out and "ran into the darkness," about 30 to 40 yards. "As I turned to look behind me I realized that it was so dark that I could not see the aircraft anymore." It was not until the first car passed by that "I realized we were close to the interstate." Witnesses reported to local law enforcement officials that they were in their car traveling south along Interstate 49 when they saw the helicopter in front of them slow down. As they passed the helicopter, they could clearly see its registration number. As they continued to watch the helicopter through the back window and rear view mirrors, they observed sparks and then saw the helicopter impact the ground. They crossed over the grass median, and as they approached the helicopter, they observed the medical crewmember walking around. Another witness reported the following information to the investigator-in-charge. He was driving southbound on Interstate 49, north of Alexandria, Louisiana, when he observed a helicopter in front of him coming from the northwest and traveling southeast just above the trees. The helicopter began following the highway southbound at a slow speed. He was traveling at a speed of 75 MPH and was catching up to the helicopter. He started to slow down because he thought the helicopter was going to land. He saw a flash and then the "helicopter crashed." He originally thought that the helicopter crashed on the southbound lane; however, when he arrived at the crash site it was on the northbound side of the highway. He stated that it was a very dark night and the visibility "appeared good." PERSONNEL INFORMATION The instrument rated commercial pilot had been employed by PHI since July 30, 1984. The pilot had accumulated a total of 7,179 flight hours, of which 3,598 hours were in the BO-105 helicopter. He had also accumulated a total of 437 hours at night, of which 5 hours were in the last 30 days. On August 11, 1985, the pilot completed transition training in the BO-105 helicopter, and demonstrated proficiency in accordance with FAR 135.293 and FAR 135.299. On February 11, 1988, he successfully completed Helicopter Emergency Medical Service Pilot Training in accordance with the Petroleum Helicopters, Inc., training manual. On September 16, 1996, he completed VFR recurrent training, which included basic instrument proficiency, and demonstrated competency in the BO-105 helicopter in accordance with FAR 135.293 and FAR 135.299. AIRCRAFT INFORMATION The air medical helicopter had a total airframe time of 3,570 hours and 25 minutes at the time of the accident. The aircraft was equipped for night operations; however, it was not certified for flight into instrument meteorological conditions, nor was it equipped with an autopilot. A review of the airframe and engine records did not reveal any anomalies or uncorrected maintenance defects. An estimate of the weight of the helicopter at the time of the accident placed it within weight and balance limits. METEOROLOGICAL INFORMATION Federal Aviation Administration (FAA) records revealed the pilot of N7161J called DeRidder AFSS by telephone at 0030, and received a weather briefing for a VFR flight from Shreveport, Louisiana, to Lafayette, Louisiana via Alexandria, Louisiana. The pilot was advised VFR flight was not recommended. He was briefed that instrument meteorological conditions prevailed throughout the area and that convective sigmet 7C was in effect for Louisiana and Alabama from 30 miles north northeast of Mobile, Alabama, to 30 miles north northeast of Alexandria, Louisiana, for a line of thunderstorms 20 miles wide moving east at 30 knots. He was also briefed on a stationary cold front located mid way between Shreveport and Alexandria. The weather for Alexandria at the time of the briefing was a ceiling of 700 feet broken, visibility of 7 miles with mist. Fort Polk weather was 300 feet overcast, visibility of 4 miles with mist. The medical crewmember reported to the investigator-in-charge that the ceiling while flying over Interstate 49 was about 550 to 600 feet, and the visibility was approximately 2 miles. COMMUNICATION The pilot established radio contact with Polk approach control at 0132. At 0133, approach control advised the pilot that Alexandria was reporting a broken cloud layer at 700 feet. At 0136, the pilot informed Polk approach that he intended to request a Special VFR clearance through the Alexandria International Airport's Class D airspace upon arrival at Alexandria. At 0138, Polk approach observed on radar that N7161J was descending and asked the pilot to what altitude he would be descending. The pilot replied he was descending to 500 feet. At 0142, Polk approach attempted to issue a Special VFR clearance to the pilot; however, the pilot did not respond. There were no further radio communications from the pilot. Radar contact was lost with the helicopter at 0144, approximately 10 miles northwest of the Alexandria International Airport at an altitude of 200 feet. The elevation at the Alexandria Airport is 89 feet. The medical crewmember using the call sign "Air Med 1" established radio contact with Acadian Ambulance Service, Inc. (AASI) dispatch center for flight following at 0112. At 0114, Air Med 1 and the AASI dispatcher had a discussion on the expected weather after passing Alexandria. At 0117, Air Med 1 requested the weather at Lafayette, and the dispatcher contacted Air Med 4 (Alexandria based) for the current weather at Alexandria. At 0118, Air Med 4 reported to the dispatcher that Alexandria was currently reporting a ceiling of 600 feet, and the visibility was 6 miles; however, he advised the weather was lower than reported. At 0119, the dispatcher reported to Air Med 1 that Alexandria and most of Rapides had a ceiling of 500 to 700 feet and the visibility was 5 miles. At 0139, Air Med 1 reported to the AASI dispatch center that they were 10 minutes out of Alexandria, and they were under 500 feet following Interstate 49. The dispatcher asked Air Med 1 if they were planning on staying at Alexandria, and Air Med 1 advised that they would make that decision when they got a little closer. There were no further radio communications from Air Med 1. WRECKAGE AND IMPACT INFORMATION The ai ## Aircraft - Registration: [N7161J](https://openairdocs.org/deregistered/N7161J-1999-01-07), registration cancelled 1999-01-07, S/N S834, built 1990 (OpenAirDocs) - Reported make and model: MBB BO-105S - Registry model: [Messerschmitt-Boelkow-Blohm BO-105S](https://openairdocs.org/model/messerschmitt-boelkow-blohm-bo-105s) (registry code 5626006) (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: S 834 - Airframe hours: 3570 - Engines: Allison 250-C20B 425 horsepower turbo shaft - Damage: Destroyed - Flight: Positioning, Part 91 - Operator: Petroleum Helicopters, Inc - Registered owner: Deutsche Credit Corporation - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, February 21, 1997, 24 hours before - Departed: HLUS, SHREVEPORT, LA - Destination: LFT, LAFAYETTE, LA - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; commercial; airplane ratings: single-engine land; instrument ratings: helicopter; medical: class 2, valid medical--no waivers/lim.; seat: right; toxicology performed; flight hours: 7,179 total, 3,958 in this make and model, 76 in the last 90 days, 26 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Visibility: 2 statute miles - Lowest ceiling: 550 ft overcast ## 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 19970314003079A](https://openairdocs.org/incident/19970314003079A), Mar 14, 1997: Bolkms BO105S, Alexandria, LA, Destroyed, 1 fatal. Air ambulance returning from passenger drop off. Crashed. (-23) the pilot and EMT departed lafayette, Louisiana, and picked up a patient at eunice, Louisiana,… ## Docket (33 files) The files NTSB released with the investigation on November 24, 1997, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=20024. 12.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 1, .PDF, 620 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402283&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Redacted.PDF - Supplement A (item 2, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075578&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 3, .PDF, 382 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075579&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement G (item 4, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075580&FileExtension=.PDF&FileName=Supplement%20G-Master.PDF - Supplement K (item 5, .PDF, 463 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075581&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Supplement S (item 6, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075582&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Passenger Statement (item 7, .PDF, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402284&FileExtension=.PDF&FileName=Passenger%20Statement-Redacted.PDF - Witness Statement (item 8, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075585&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 9, .PDF, 588 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40188481&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Weather Reports and Records (item 10, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075586&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Transcript of Radio Communications (item 11, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402285&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - Report from Parties to the Investigation - Allison Engine Company (item 12, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402286&FileExtension=.PDF&FileName=Report%20from%20Parties%20to%20the%20Investigation%20-%20Allison%20Engine%20Company-Redacted.PDF - Reports from Parties to the Investigation - American Eurocopter (item 13, .PDF, 700 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402287&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20American%20Eurocopter-Redacted.PDF - Other Pertinent Forms and Reports - Company Operations Manual (item 14, .PDF, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075589&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20-%20Company%20Operations%20Manual-Master.PDF - Other Pertinent Forms and Reports - Equipment Tests (item 15, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402289&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20-%20Equipment%20Tests-Redacted.PDF - Other Pertinent Forms and Reports - Pilot Training Records (item 16, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402290&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20-%20Pilot%20Training%20Records-Redacted.PDF - Other Pertinent Forms and Reports - Spatial Disorientation Reference Material (item 17, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075592&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20-%20Spatial%20Disorientation%20Reference%20Material-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402291&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402293&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 20, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402294&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1: Aerial View of accident site. Note arcing ground scar in front of helicopter wreckage. No negative. Photo courtesy of Eurocopter. (item 21, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075596&FileExtension=.PDF&FileName=Photo%201%3A%20%20Aerial%20View%20of%20accident%20site.%20%20Note%20arcing%20ground%20scar%20in%20front%20of%20helicopter%20wreckage.%20%20No%20negative.%20%20Photo%20courtesy%20of%20Eurocopter.-Master.PDF - Photo 2: Arcing ground scar in front of helicopter. No negative. Photo courtesy of Eurocopter. (item 22, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075597&FileExtension=.PDF&FileName=Photo%202%3A%20%20Arcing%20ground%20scar%20in%20front%20of%20helicopter.%20%20No%20negative.%20%20Photo%20courtesy%20of%20Eurocopter.-Master.PDF - Photo 3: Arcing scar on the outside north-bound lane of Interstate 49. (item 23, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075598&FileExtension=.PDF&FileName=Photo%203%3A%20%20Arcing%20scar%20on%20the%20outside%20north-bound%20lane%20of%20Interstate%2049.-Master.PDF - Photo 4: Rear view of helicopter wreckage. (item 24, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075599&FileExtension=.PDF&FileName=Photo%204%3A%20%20Rear%20view%20of%20helicopter%20wreckage.-Master.PDF - Photo 5: Front view of helicopter wreckage. Note initial right skid ground scar. (item 25, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075600&FileExtension=.PDF&FileName=Photo%205%3A%20%20Front%20view%20of%20helicopter%20wreckage.%20%20Note%20initial%20right%20skid%20ground%20scar.-Master.PDF - Photo 6: View of tail boom. (item 26, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075601&FileExtension=.PDF&FileName=Photo%206%3A%20%20View%20of%20tail%20boom.-Master.PDF - Photo 7: Tail rotor still attached to vertical stabilizer. (item 27, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075602&FileExtension=.PDF&FileName=Photo%207%3A%20%20Tail%20rotor%20still%20attached%20to%20vertical%20stabilizer.-Master.PDF - Photo 8: View of instrument panel. (item 28, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075603&FileExtension=.PDF&FileName=Photo%208%3A%20%20View%20of%20instrument%20panel.-Master.PDF - Photo 9: Blue main rotor blade in tree to the left rear of helicopter. (item 29, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075604&FileExtension=.PDF&FileName=Photo%209%3A%20%20Blue%20main%20rotor%20blade%20in%20tree%20to%20the%20left%20rear%20of%20helicopter.-Master.PDF - Photo 10: Tailboom and both engines which were separated from the fuselage. (item 30, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075605&FileExtension=.PDF&FileName=Photo%2010%3A%20%20Tailboom%20and%20both%20engines%20which%20were%20separated%20from%20the%20fuselage.-Master.PDF - Photo 11: Tail rotor power output of the main transmission. (item 31, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075606&FileExtension=.PDF&FileName=Photo%2011%3A%20%20Tail%20rotor%20power%20output%20of%20the%20main%20transmission.-Master.PDF - Photo 12: Main rotor system. All blades sheared at the blade root. (item 32, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075607&FileExtension=.PDF&FileName=Photo%2012%3A%20%20Main%20rotor%20system.%20%20All%20blades%20sheared%20at%20the%20blade%20root.-Master.PDF - Photo 13: All 4 main rotor blades. No negative. Photo courtesy of Eurocopter. (item 33, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40075608&FileExtension=.PDF&FileName=Photo%2013%3A%20%20All%204%20main%20rotor%20blades.%20%20No%20negative.%20%20Photo%20courtesy%20of%20Eurocopter.-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.