FTW98FA256

NTSB accident investigation · Eurocopter AS350BA · La Gloria, TX · June 5, 1998

Accident · FatalField investigationFinal report
Date
June 5, 1998, 05:49 local (10:49 UTC)
Place
La Gloria, TX
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N911VAEurocopter AS350BA
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 30, 2001
Report
Approved by Office Director
FAA report
19980605012429A
Case key
20424

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 continued flight into adverse weather conditions resulting in a loss of control due to spatial disorientation. Contributing factors were the dark night illumination, the lack of visual cues, the pilot's lack of total instrument time, and the pressure induced by the medical emergency to complete the medical evacuation.

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
Light condition - dark nightFactor
Weather condition - haze/smokeFactor
Flight into known adverse weather - continuedPilot in command
Visual/aural perceptionPilot in commandFactor
Pressure induced by conditions/eventsFactor
Loss of control - in flightManeuvering
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in commandCause
Lack of total instrument timePilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The 2,905-hour instrument rated commercial helicopter pilot encountered an area of limited visibility during a dark night flight over an unlit, very sparsely populated, rural area while en route to evacuate a truck driver injured in a highway accident. The helicopter crashed 19 miles west of the truck accident site, indicating that the pilot failed to recognize his intended destination and flew past it. The helicopter impacted trees and terrain in a left turn in a 85 to 95 degrees nose down attitude. The pilot had accumulated a total of 4 hours of actual and 45 hours of simulated instrument flight time, none of it within the 90 days preceding the accident. The pilot was reported to have been concerned about night flights in the area due to the lack of lights on the ground to maintain visual reference. Another helicopter pilot stated that 'at night the area west of the highway is a big black hole.' No discrepancies were found that could have prevented normal flight operations. The pilot who flew the helicopter prior to the accident flight stated that 'the aircraft flew well and responded normally.' The visibility had been severely restricted by thick smoke from fires in Mexico. No distress calls were received from the helicopter. There were no reported eyewitnesses to the accident.

Factual narrative

History of flight

On June 5, 1998, at 0549 central daylight time, a Eurocopter AS350BA medical ambulance helicopter, N911VA, was destroyed upon impact with trees and terrain near La Gloria, Texas. The instrument rated commercial pilot and two medical technicians on board the helicopter were fatally injured. The helicopter was owned by Metro Aviation of Shreveport, Louisiana, and operated by Tex-Air Helicopters of Houston, Texas. Dark night visual meteorological conditions prevailed for the 14 Code of Federal Regulations Part 91 positioning flight for which a company VFR flight plan was filed. The flight departed from a heliport near Harlingen, Texas, at 0514, with a location known as Humble Kelsey, located approximately 8 nautical miles to the northeast of La Gloria along Highway 755, as its intended destination.

The helicopter was dispatched to pick up and transport the driver of an 18-wheeler tanker truck, who had been seriously injured when he lost control of his truck while driving in reduced visibility on Highway 755. The pilot was not provided the coordinates of the truck accident site; however, he was familiar with the town of La Gloria, Texas, which he planned to use as the initial point for locating Highway 755 prior to proceeding northeast bound towards Humble Kelsey to pick up the injured truck driver. The helicopter, operating under the call sign "Air Care One," departed its home base heliport with 1 hour and 55 minutes of fuel on board. At 0529, the pilot reported to his dispatcher that the flight was en route over the Edinburg Airport, estimating arrival at the accident site in 16 minutes. In the last position report to his home base at 0539, the pilot reported that he was "5 minutes out" from his destination and announced that he was "switching to ground."

The helicopter was assigned a mode C transponder code of 5377. Air Traffic Control (ATC) radar tracked the helicopter from 05:19:56 to 05:34:15 flying on a west northwest heading from Harlingen toward La Gloria. During this time period, the helicopter's altitude remained between 700 feet and 1,100 feet MSL. Radar contact was then lost until 05:47:06 when one radar return was recorded which indicated the helicopter was at 1,800 feet, approximately 2 miles southeast of the site where it crashed. Two-way radio communication was not established between the helicopter and any ATC facility in the area. The helicopter failed to arrive at its destination and a search was initiated.

The wreckage of the helicopter was located 30 hours after the accident in a mesquite covered sparsely populated rural area of Starr County, Texas. The accident site was approximately 19.0 nautical miles west of the flight's intended destination, the truck accident location.

There were no reported eyewitnesses to the accident.

Personnel information

The 46-year old commercial pilot, who was occupying the right seat of the helicopter, had been employed by the operator since January 1998. He received his commercial pilot certificate on December 13, 1996. According to the operator, the pilot had accumulated a total of 2,950 flight hours, of which 54 hours were in the same make and model as the accident helicopter. The pilot had accumulated a total of 4 hours of actual and 45 hours of simulated instrument flight time. The pilot logged no actual or simulated instrument time in the 90 days preceding the accident. The pilot had accumulated a total of 30 hours of night flight, of which 20 hours were accumulated during the preceding 90 days.

The pilot received a helicopter instrument rating on January 5, 1998, prior to his employment with Tex-Air Helicopters. During his training in preparation for his instrument rating, the pilot received a total of 15.4 hours of ground instrument training and a total of 5.0 hours of instrument flight training prior to taking his instrument check ride. The operator of the training facility that provided the instrument training reported that the pilot failed his first instrument check ride due to deficiencies in basic instrument proficiency and ADF navigation. This check ride was 1.2 hours in duration. The pilot was provided an additional hour of remedial ground school and an additional 1.3 hours of remedial flight training. The pilot was reported to have satisfactory completed the second check ride, which was given two days after the first check ride and lasted 0.9 hours. Including the two check rides, the pilot accumulated a total of 8.4 hours of instrument flight time during this training.

Interviews of the pilot's co-workers revealed that the pilot was very concerned about night flights in the sparsely populated areas north of the Rio Grande Valley in southwest Texas due to the lack of lights on the ground to maintain visual reference. One of the other pilots told the FAA inspector that "at night the area west of the Interstate highway is a big black hole."

Aircraft information

The 1981 model helicopter, serial number 1446, had accumulated a total of 4,752.7 flight hours (1,565.0 Hobbs meter hours) at the time of the accident. The helicopter was manufactured in France and re-assembled in Grand Prairie, Texas, on February 25, 1982. The helicopter was being maintained under the manufacturer's maintenance program. The last scheduled maintenance performed on the helicopter was a 100-hour inspection, which was completed on April 17, 1998, at 4,706.2 hours, 46.5 hours prior to the accident. The aircraft logbook was recovered at the accident site. According to the operator, and as confirmed by examination of the aircraft logbook, there were no open deferred maintenance items on the helicopter at the time of the accident.

The 641-horsepower Turbomeca Arriel 1B turboshaft engine, serial number 801, was manufactured in France, on August 24, 1984. The engine had accumulated a total of 4,156.9 hours since new. The last overhaul was completed on June 16, 1994, at 2,997.8 hours. The last engine inspection was completed at 4,062.0 hours, on April 17, 1998.

The basic empty weight of the helicopter was 3,079 pounds, and the maximum gross weight was 4,630 pounds. Weight and balance calculations were performed using figures provided by the operator. The aircraft was found to be within its weight and balance limits at the time of the accident.

The pilot who flew the helicopter prior to the accident flight on the day before the accident was asked by the NTSB investigator-in-charge (IIC) to provide a statement regarding the condition of the aircraft. The pilot stated that "the aircraft flew well and responded normally." The pilot further stated that "no discrepancies were noted during the flight."

The maintenance records for the helicopter were initially reviewed by the FAA inspector who responded to the accident site. The records were later forwarded to the NTSB IIC for further examination. Review of the maintenance records for the helicopter and powerplant did not reveal any evidence of overdue inspections or uncorrected discrepancies that could have contributed to the accident.

The helicopter was equipped for night flights. Besides the on-board medical equipment installed, the following optional equipment was installed in the helicopter: a 3-axis (pitch, roll, yaw) auto pilot system, a strobe light system, a radar altimeter, an EMS lighting system, a GPS with moving map display, and an air conditioner.

Meteorological information

McAllen, Texas, located 46 nautical miles southeast (132 degrees) of the accident site, was the nearest weather reporting station to the accident site. At 0553, McAllen was reporting a broken ceiling at 1,400 feet, with a visibility of 5 statute miles. The temperature to dew point spread was reported as 1 degree.

A farm worker residing at the Diamond O Ranch, approximately 11 miles southeast of the accident site, reported that visibility on the day of the acc

Aircraft

Registration
N911VA
Reported as
Eurocopter AS350BA
Category
Helicopter
Serial number
1446
Airframe hours
4,753
Engine
Turbomeca ARRIEL 1B, 641 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Operator
Edward L. Behne, doing business as Tex-Air Helicopters Inc.
Registered owner
Metro Aviation Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 17, 1998 · 46 hours before
Departed
78TS · Harlingen, TX
Destination
NONE · La Gloria, 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
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
2,950 total · 54 in this make and model · 2,605 as pilot in command · 27 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
120° at 8 knots
Visibility
5 statute miles
Lowest ceiling
1,400 ft broken
Temperature
81 °F, dew point 79 °F
Altimeter
29.00 inHg
Observed at
MFE, 46 nm away

Docket · 86

The files NTSB released with the investigation on May 15, 2001, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Supplement AItem 1 · .PDF · 271 KBSupplement BItem 2 · .PDF · 407 KBSupplement GItem 3 · .PDF · 106 KBSupplement SItem 4 · .PDF · 72 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2Item 5 · .PDF · 606 KBMaterials Laboratory Factual ReportItem 6 · .PDF · 243 KBMaterials Laboratory Factual Report, Figure 1Item 7 · .PDF · 30 KBWitness StatementsItem 8 · .PDF · 106 KBWeather Reports & RecordsItem 9 · .PDF · 2.1 MBMaps, ChartsItem 10 · .PDF · 408 KBReports From FAA (Radar Data)Item 11 · .PDF · 256 KBReports From OperatorItem 12 · .PDF · 668 KBAirframe Manufacturer's ReportItem 13 · .PDF · 168 KBAirframe Manufacturer's Report, Photos 1 & 2Item 14 · .PDF · 43 KBAirframe Manufacturer's Report, Photos 3 & 4Item 15 · .PDF · 48 KBAirframe Manufacturer's Report, Photos 5 & 6Item 16 · .PDF · 43 KBAirframe Manufacturer's Report, Photos 7 & 8Item 17 · .PDF · 48 KBAirframe Manufacturer's Report, Photos 9 & 10Item 18 · .PDF · 50 KBAirframe Manufacturer's Report, Photos 11 & 12Item 19 · .PDF · 51 KBAirframe Manufacturer's Report, Photos 13 & 14Item 20 · .PDF · 55 KBAirframe Manufacturer's Report, Photos 15 & 16Item 21 · .PDF · 48 KBAirframe Manufacturer's Report, Photos 17 & 18Item 22 · .PDF · 28 KBAirframe Manufacturer's Report, Photos 19 & 20Item 23 · .PDF · 39 KBAirframe Manufacturer's Report, Photos 21 & 22Item 24 · .PDF · 49 KBAirframe Manufacturer's Report, Photos 23 & 24Item 25 · .PDF · 51 KBAirframe Manufacturer's Report, Photos 24 & 25Item 26 · .PDF · 45 KBAirframe Manufacturer's Report, Photos 26 & 27Item 27 · .PDF · 52 KBAirframe Manufacturer's Report, Photos 28 & 29Item 28 · .PDF · 51 KBAirframe Manufacturer's Report, Photos 30 & 31Item 29 · .PDF · 51 KBAirframe Manufacturer's Report, Photos 32 & 33Item 30 · .PDF · 48 KBAirframe Manufacturer's Report, Photos 34 & 35Item 31 · .PDF · 48 KBAirframe Manufacturer's Report, Photos 36 & 37Item 32 · .PDFEngine ReportItem 33 · .PDF · 364 KBEngine Report, Attachment A, Photo 1Item 34 · .PDF · 46 KBEngine Report, Attachment A, Photo 2Item 35 · .PDF · 43 KBEngine Report, Attachment A, Photo 3Item 36 · .PDF · 46 KBEngine Report, Attachment A, Photo 4Item 37 · .PDF · 47 KBEngine Report, Attachment A, Photo 5Item 38 · .PDF · 49 KBEngine Report, Attachment A, Photo 6Item 39 · .PDF · 45 KBEngine Report, Attachment A, Photo 7Item 40 · .PDF · 43 KBEngine Report, Attachment A, Photo 8Item 41 · .PDF · 51 KBEngine Report, Attachment A, Photo 9Item 42 · .PDF · 47 KBEngine Report, Attachment B, Photo 1Item 43 · .PDF · 42 KBEngine Report, Attachment B, Photo 2Item 44 · .PDF · 40 KBEngine Report, Attachment B, Photo 3Item 45 · .PDF · 41 KBEngine Report, Attachment B, Photo 4Item 46 · .PDF · 46 KBEngine Report, Attachment B, Photo 5Item 47 · .PDF · 43 KBEngine Report, Attachment B, Photo 6Item 48 · .PDF · 42 KBEngine Report, Attachment B, Photo 7Item 49 · .PDF · 43 KBEngine Report, Attachment B, Photo 8Item 50 · .PDF · 47 KBEngine Report, Attachment B, Photo 9Item 51 · .PDF · 43 KBEngine Report, Attachment B, Photo 10Item 52 · .PDF · 41 KBEngine Report, Attachment B, Photo 11Item 53 · .PDF · 42 KBEngine Report, Attachment B, Photo 12Item 54 · .PDF · 41 KBEngine Report, Attachment B, Photo 13Item 55 · .PDF · 43 KBEngine Report, Attachment B, Photo 14Item 56 · .PDF · 47 KBEngine Report, Attachment B, Photo 15Item 57 · .PDF · 43 KBEngine Report, Attachment B, Photo 16Item 58 · .PDF · 42 KBOther Pertinent Forms and Reports - Aircraft RecordsItem 59 · .PDF · 1.2 MBStatement of Party Representatives to NTSB InvestigationItem 60 · .PDF · 378 KB
All 86 files on NTSB’s docket

FAA reports on this event · 1

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