FTW98FA093

NTSB accident investigation · Bell 222UT · Sandy, UT · January 12, 1998

Accident · FatalField investigationFinal report
Date
January 11, 1998, 22:50 local (Jan 12, 1998, 05:50 UTC)
Place
Sandy, UT
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N222UHBell 222UT
Weather
Instrument (IMC) · Night/dark
Status
Completed · report October 30, 1998
Report
Approved by Office Director
FAA report
19980111000249A
Case key
20399

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

flight by the pilot into known adverse weather conditions, and his failure (or inability) to maintain sufficient clearance or altitude from mountainous terrain. Related factors were: darkness, heavy snow, high winds, the pilot's perception of pressure that was induced by the conditions and events, and mountainous terrain.

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 weatherTakeoff - initial climb
Light condition - dark nightFactor
Weather condition - snowFactor
Weather condition - high windFactor
Flight into known adverse weather - intentionalPilot in commandCause
Pressure induced by conditions/eventsPilot in commandFactor
In flight collision with terrain/waterManeuvering
Terrain condition - mountainous/hillyFactor
Altitude/clearance - not maintainedPilot in commandCause

Analysis

The hospital helicopter was dispatched to transport a skier, who had been injured in an avalanche. Snow was not falling when the helicopter departed the hospital, but there were 'gusty winds and light to moderate snow' during arrival at the landing zone. The dispatcher telephoned the pilot (using a cellular phone) to advise him that hospital weather conditions had deteriorated due to a fast moving front. She said it was 'snowing really hard,' the winds were gusting to 37 knots, and visibility was less than 300 feet (she could not see a wing of the hospital on the closed circuit television monitor, and could barely distinguish the helipad). A sheriff's deputy said that the helicopter took off from the landing zone in 'blizzard conditions' and circled the landing zone, then turned north and disappeared from view. Seconds later, a deputy heard 'a slight muffled boom. . . The weather had grown steadily worse and the snow was falling very heavily.' Later, the helicopter was found where it had impacted mountainous terrain in a canyon area. Several tree tops were severed when the helicopter crashed.

Factual narrative

History of flight

On January 11, 1998, approximately 2250 mountain standard time, a Bell 222UT, N222UH, operated by Air Methods Corporation of Englewood, Colorado, was destroyed when it collided with mountainous terrain in Little Cottonwood Canyon, near Sandy, Utah. The airline transport rated pilot, registered nurse, emergency medical technician, and patient were fatally injured. Instrument meteorological conditions prevailed, and no flight plan was filed for the air medical transport flight operating under Title 14 CFR Part 135. The flight originated a few minutes before the accident.

The following is based on the Salt Lake County Sheriff's Office report, University Hospital's tape recorded radio transmissions, dispatcher log entries, and a record of the pilot's cellular telephone calls.

At 1714 on the day of the accident, the Salt Lake County Sheriff's Office was notified by Snowbird Public Safety that a cross-country skier had been injured in an avalanche. The skier's companion told deputies the accident occurred at 1630 on the western face of Pink Pine Ridge, between the White Pine and Red Pine drainages, west of Snowbird, on the canyon's south wall. Search and rescue personnel arrived and a command post was established in Little Cottonwood Canyon. A ground team was then sent in to recover the victim.

At 1718, the Salt Lake County Fire Department dispatcher called University Hospital's dispatcher, requesting that a helicopter be sent to stand by at the site. N222UH, call sign AirMed 4, was dispatched at 1726. Weather conditions precluded the helicopter from going directly to the avalanche site, so the pilot landed on a road near the command center at 1731. When it was determined that it would be several hours before the patient could be brought down to the command center, the helicopter returned to the hospital, arriving there at 1804. At that time, a new pilot came on duty.

Rescue teams reached the injured skier approximately 2100. At 2141, the Salt Lake County Sheriff's Office requested that the helicopter return to the scene. The hospital dispatcher said it was not snowing in the hospital vicinity at that time. N222UH departed the hospital at 2150, and the University of Utah Hospital Communications Center provided flight following services. According to the sheriff's report, when the helicopter arrived at the landing zone, weather conditions were "gusty winds, approximately 30 to 35 miles per hour, and light to moderate snow." The pilot called the hospital dispatcher on his cellular telephone at 2203, and advised they were on the scene.

At 2206, the hospital dispatcher telephoned the pilot and advised him that it was "snowing at the Capitol. Everything behind the Capitol is white. It [the weather system] is coming this way fast." The pilot acknowledged the information and advised the dispatcher that rescuers had not yet arrived with the patient. The dispatcher said, "If you're there too long, you might not make it back." (Hospital officials demonstrated the closed-circuit television system for this investigator. The camera, mounted on the side of the hospital, is remotely controlled by the dispatcher. Panning the camera up, Salt Lake City International Airport, about 9 miles away, could be seen as well as the state capitol building, about 3 miles away). At 2209, the hospital dispatcher telephoned the pilot again and told him, "It's snowing hard here. . .I can't see past Primary." (Hospital officials pointed out Primary Hospital to this investigator. It is located approximately 300 feet from the video camera). The pilot thanked her for the weather update.

At 2225, the pilot telephoned the dispatcher and asked, "How's it looking where you're at?" He was told it was "snowing really hard, wind is blowing at twenty-three according to our machine...oh, thirty-three, now thirty-seven." The pilot then asked the dispatcher to tune her scanner radio to frequency 124.75 mHz. He listened to a last portion of Salt Lake City International Airport's ATIS (Automatic Terminal Information Service) Information Mike, then asked that someone go to the hangar and get the covers for the helicopter in case they got stranded. The pilot said it was snowing in the canyon and that he would be able to takeoff in the next 5 or 10 minutes, but he would have to go to another hospital. The dispatcher told him she could "hardly see the helipad." The pilot said the patient had not arrived. This was the last communication the dispatcher had with the pilot.

A sheriff's deputy said the helicopter remained on the ground for 15 to 20 minutes before the patient arrived. The deputy and the pilot discussed the weather conditions, and the pilot asked what the conditions were at the mouth of Little Cottonwood Canyon "in order to determine what type of weather was on its way." They were advised that there was "rain and snow mix, and the snow was just starting to stick on the road."

At the pilot's request, the White Pine parking lot, where the command center was located, was cleared of vehicles and the patient was loaded aboard the helicopter. The deputy said that at that time, "the weather had changed slightly, in that it was snowing heavier and there was some local lightning and thunder."

The deputy said the helicopter lifted off "in a straight up fashion," then "turned towards the valley and began a slow circle" around the White Pine parking lot. The pilot said he was going to "look at his options." One observer said he heard the pilot say he was going to "grab some altitude." The deputy said the landing light was on. The helicopter circled again and appeared to be gaining altitude. It turned north (right) and disappeared from view. Seconds later, he heard "a slight muffled boom. . . The weather had grown steadily worse and the snow was falling very heavily." Another deputy said it was "blizzard conditions. It was snowing and the wind was gusting to 35 knots."

Approximately 0330, when visibility had improved, a fire was sighted on the south face of Dromedary Peak, near Little Pine, at the 8,500 foot level (about 1,500 feet above the highway). Shortly after 0700, a sheriff's helicopter found the burning wreckage of N222UH. The victims were removed later that afternoon.

Crew information

The pilot, Clifford Stanley Berg, age 48, was born on April 18, 1949. He held Airline Transport Pilot Certificate No. 528768567, dated March 4, 1990, with ratings for airplane multiengine land and rotorcraft-helicopter, type ratings in the Bell 205 and Bell 206, and commercial privileges in airplanes single engine land. He held a Flight Instructor Certificate, dated August 6, 1997, with airplane single/multiengine, rotorcraft-helicopter, and instrument airplane and instrument helicopter ratings. He also held a Ground Instructor Certificate, dated March 23, 1989, with Advanced and Instrument ratings. His first class airman medical certificate, dated February 11, 1997, contained the restriction: "Must wear corrective lenses." His last FAR 135 flight proficiency and instrument competency check was accomplished on September 29, 1997, in the Bell 222UT.

Mr. Berg was employed by Air Methods Corporation in 1990. Prior to being appointed lead pilot for the company's Salt Lake City operation, he managed their helicopter program in Rockford, Illinois, and their fixed wing program in Billings, Montana.

According to Air Methods' flight and duty time records, Mr. Berg worked 12 hour shifts, with 12 hours off, for each day in January 1998. During this 10-day time period, he had flown 2.4 hours. Records also showed that Mr. Berg had accrued 6,257 total flight hours, of which 4,871 hours were in rotorcraft and 318 hours were in the Bell 222UT.

Aircraft information

N222UH (s/n 47545), a Bell 222UT, was manufactured in 1984. It was powered by two Lycoming LTS-101-750C1 turboshaft engines (s/n LE-47026AE, left; LE

Aircraft

Registration
N222UH
Reported as
Bell 222UT
Category
Helicopter
Serial number
47545
Airframe hours
6,308
Engine
Lycoming LTS-101-750C1, 735 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Air Methods
Registered owner
Air Methods Corporation
Airworthiness certificate
Standard, Utility
Last inspection
Annual · November 3, 1997 · 72 hours before
Departed
NONE
Destination
UT21 · Salt Lake City, UT

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
48
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
6,257 total · 318 in this make and model · 6,257 as pilot in command · 42 in the last 90 days · 31 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
270° at 35 knots
Visibility
1 statute miles

Docket · 30

The files NTSB released with the investigation on June 18, 1998, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.3 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2Item 1 · .PDF · 1.4 MBSupplement CItem 2 · .PDF · 407 KBSupplement DItem 3 · .PDF · 477 KBSupplement GItem 4 · .PDF · 111 KBSupplement KItem 5 · .PDF · 411 KBSupplement NItem 6 · .PDF · 168 KBSupplement SItem 7 · .PDF · 68 KBWitness StatementItem 8 · .PDF · 49 KBWeather Reports and RecordsItem 9 · .PDF · 464 KBReports from Local Agencies - Salt Lake County Sheriff's OfficeItem 10 · .PDF · 2.1 MBReports from Parties to the Investigation - Bell Helicopter TextronItem 11 · .PDF · 411 KBStatement of Party Representatives to NTSB InvestigationItem 12 · .PDF · 90 KBToxicological ReportItem 13 · .PDF · 27 KBPhoto #1 - The accident site. Little Cottonwood Canyon can be seen in background. Note severed tree top. Main body of wreckage is in foreground.Item 14 · .PDF · 104 KBPhoto #2 - View from the accident site, looking up at top of mountain and the direction helicopter was traveling.Item 15 · .PDF · 92 KBPhoto #3 - Fallen tree trunk at accident site.Item 16 · .PDF · 90 KBPhoto #4 - Helicopter fuselage rests on right side. Note thickness of trees.Item 17 · .PDF · 103 KBPhoto #5 - Inverted helicopter tail boom.Item 18 · .PDF · 90 KBPhoto #6 - Rescuers crawl around main body of wreckage. Note extent of fire damage to the cabin area.Item 19 · .PDF · 97 KBPhoto #7 - Arrow depicts accident site, 50 minutes before accident.Item 20 · .PDF · 51 KBPhoto #8 - Arrow depicts accident site, 45 minutes before accident.Item 21 · .PDF · 52 KBPhoto #9 - Arrow depicts accident site, 40 minutes before accident.Item 22 · .PDF · 51 KBPhoto #10 - Arrow depicts accident site, 30 minutes before accident.Item 23 · .PDF · 52 KBPhoto #11 - Arrow depicts accident site, 25 minutes before accident.Item 24 · .PDF · 52 KBPhoto #12 - Arrow depicts accident site, 15 minutes before accident.Item 25 · .PDF · 52 KBPhoto #13 - Arrow depicts accident site, 10 minutes before accident.Item 26 · .PDF · 50 KBPhoto #14 - Arrow depicts accident site, 5 minutes before accident.Item 27 · .PDF · 51 KBPhoto #15 - Arrow depicts accident site, at time of accident.Item 28 · .PDF · 50 KBPhoto #16 - Arrow depicts accident site, 5 minutes after accident.Item 29 · .PDF · 49 KBPhoto #17 - Arrow depicts accident site, 10 minutes after accident.Item 30 · .PDF · 49 KB

FAA reports on this event · 1

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

Other investigations on N222UH · 1

Matched to the same aircraft by N-number and date.