# NTSB IAD97FA032: Mbb BO-105CBS, N90750, Penn Yan, NY, December 13, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 12, 1996, 21:13 local (Dec 13, 1996, 02:13 UTC) - Place: Penn Yan, NY - Coordinates: 42.590034, -77.14981 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.5900&lon=-77.1498&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report July 31, 1998 - Report: Approved by Office Director - NTSB case key (mKey): 28125 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD97FA032 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28125/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=28125 - Page: https://openairdocs.org/ntsb/IAD97FA032 ## Probable cause the pilot's failure to maintain altitude/clearance from the terrain. Factors relating to the accident were: the pilot's diverted attention to the GPS, darkness, low ceiling, rising terrain, and high wind condition. ## Analysis The pilot landed the helicopter in an open field for a medical evacuation. He had planned to fly to a hospital about 40 miles northwest. After takeoff, the pilot radioed the company dispatcher that he was airborne, and to standby for time and distance to the destination. The distance would be obtained from a GPS located on the rear of the helicopter's center console. About 2 minutes later, the helicopter crashed in a secluded wooded area on rising terrain about 1.1 miles northwest of the departure point. Witnesses reported that the cloud cover and the isolated area made a dark night with no discernable horizon. Winds were reported as strong and gusty from the south/southeast. The topography surrounding the area included rising terrain, with peaks at 2,700 feet msl. The helicopter had departed an airport with an elevation of 814 feet msl. The pick-up point was 1,540 feet msl, and the accident site was 1,740 feet msl. Cloud cover in the area was at 1,900 to 2,000 feet msl. ## Factual narrative HISTORY OF FLIGHT On December 12, 1996, approximately 2113 eastern standard time, a Messerschmitt-Bolkow-Blohm (MBB) BO-105CBS, N90750, was destroyed following a collision with the terrain west of Penn Yan, New York. The certificated commercial pilot, paramedic, and the patient received fatal injuries. The helicopter was owned by RTS Helicopter Services Corporation, Montvale, New Jersey; leased by EMS Air Services of New York, Inc., and operated by Mercy Flight Central, Inc., Canandaigua, New York. Night visual meteorological conditions existed and no flight plan was filed for the medical evacuation flight conducted under 14 CFR Part 135. The initial request for the medical evacuation of an injured hunter was received at Mercy Flight Central Dispatcher, at 2029. The helicopter departed from the Canandaigua Airport, at 2039, and landed on a field, in the town of Jerusalem, New York, at 2059. The pilot had planned to take the injured hunter to a hospital in Rochester, New York, approximately 40 miles northwest. Witnesses that helped load the injured hunter, stated that the helicopter took off towards the south/southeast and made a turn to the west. Witnesses stated that the cloud cover and the isolated area, made it a dark night with no discernable horizon. The pilot radioed the Mercy Flight Central Dispatcher, at 2111, and stated that he was "airborne, and standby for the time and distance (to the destination)." Approximately 2113, initial phone calls were received at the local Fire Department concerning a fire and explosion in a secluded wooded area, approximately 1 mile from the location where the helicopter departed. The accident occurred during the hours of night, approximately 42 degrees 39.18 minutes north latitude, and 77 degrees 14.07 minutes west longitude. PERSONNEL INFORMATION The pilot held a Commercial Pilot Certificate with ratings for rotorcraft-helicopter, instrument helicopter, and a Private Pilot Certificate for airplane single engine land. He also held a Flight Instructor Certificate for rotorcraft-helicopter. His most recent Federal Aviation Administration Second Class Medical Certificate was issued on June 1, 1996. A Mercy Flight Pilot History sheet, dated November 4, 1996, indicated that the pilot transitioned to the BO-105 in April, 1996. The block marked Pilot-In-Command (PIC) Experience for the BO-105 was filled in as follows: 70 Total Hours, 70 hours Total Last 12 Months, 20 hours Total Last 90 Days, 0 hours Total Instrument, and 30 hours Total Night. The Airman Competency/Proficiency Check FAR 135, FAA Form 8410-3, indicated that the pilot was given and passed the FAR 135 Check flight in the BO-105 on April 5, 1996. The pilot's flight time in the BO-105 from September 12, 1996, to December 11, 1996, was compiled by the Director of Operations. His totals showed: September 12, 1996, through October 12, 1996, 8.3 hours day/6.3 hours night; October 13, 1996, through November 12, 1996, 3.3 hours day/8.3 hours night; November 13, 1996, through December 11, 1996; 1.1 hour day/4.3 hours night. The pilot's total PIC time for all makes and models flown was 4,450 hours. The pilot's Duty Time Records for November 1996, and December 1996, indicated that the pilot rotated from a daytime(0700 to 1900) schedule to a nighttime (1900 to 0700) schedule, with days off in between. Mid November, the pilot started a night shift beginning the night of November 19, 1996, and ended it the morning of November 24, 1996. A day shift began the morning of November 29, 1996, and ended the evening of December 3, 1996. The pilot started a night shift the evening of December 9, 1996, and was on it the night of the accident. METEOROLOGICAL INFORMATION The Penn Yan Airport's Automated Surface Observation System, which was in the test stage at the time of the accident, recorded the ceiling as 1,000 feet, variable 700 feet; visibility 10 miles; winds 150 degrees magnetic at 15 knots with gusts at 20 knots. Witnesses reported strong gusty winds from the south/southeast when the helicopter departed. WRECKAGE AND IMPACT INFORMATION The helicopter wreckage was located in a secluded wooded hilly area, approximately 1.1 miles north/northwest of the field where the helicopter departed. The elevation of the terrain in the crash area was 1,740 feet msl, and the patient pickup field had an elevation of 1,540 feet msl. A post crash fire consumed a large portion of the wreckage. Examination and documentation of the wreckage site was accomplished on December 13 and 14, 1996. All major components of the helicopter were accounted for at the scene. Remoteness of the crash site and inclement weather hampered the wreckage recovery until December 15, 1996, when the wreckage was taken to the Mercy Flight hangar at the Canandaigua Airport. The debris field was oriented on a heading of 347 degrees magnetic, and was 224 feet long from the initial tree contact to the main fuselage wreckage. Smaller parts of debris were found beyond the main wreckage, but the main fuselage, main rotor blades, tail section, and engines were located together. The main fuselage and cockpit were fragmented by impact forces and burnt by post crash fire. Flight control continuity could not be accomplished. The engines were severely damaged, and both main magnesium gearbox casings were consumed by fire. The shafting to both engines were intact, but unable to rotate. The engines were shipped to the Allison Engine Company, Indianapolis, Indiana, for further examination. Non burnt segments of the main rotor blades, including leading edge lead, blade skin, trailing edge skin were found scattered throughout initial debris field leading to the main wreckage. The four main rotor blades were found attached to the main hub, splintered and burnt in the post crash fire. The initial tree impact scars were observed at the top of a 50 foot tree. Broken tree limbs and cut branches were progressively lower on the trees in the direction of the main wreckage. Approximately 188 feet beyond the initial tree impact, a 17 foot high tree in the middle of the debris path was uprooted and lying on its side, pointing in the direction of the main wreckage. A piece of metal was embedded in a 15 foot high tree, approximately 130 feet from the initial tree contact point. The tail boom and tail rotor were separated from the main fuselage and showed signs of rotational damage. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by Cynthia B. Hoeflinger, M.D., Ph.D., Deputy Medical Examiner, County of Monroe, Office of the Medical Examiner, Rochester, New York, on December 13, 1996. The toxicological testing report from the FAA toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, and the Office of the Chief Medical Examiner, was negative for drugs and alcohol for the pilot. TESTS AND RESEARCH Examination of the engines at the Allison Engine Company occurred on February 18, 1997. No evidence of pre-impact failure was found. Mechanical integrity of the compressor and power turbine shafting systems was confirmed. Both engines exhibited heavy rubbing in the power turbine section, where both 3rd and 4th stage turbine wheels made contact with the 4th stage turbine nozzle. ADDITIONAL INFORMATION The company's Operations Specifications addressed weather for flights in two segments, locally and cross country, which were color coded for the separate locals. The requirements necessary to launch for flights was based on weather, and got more stringent as the weather deteriorated. Visual flight rules (VFR) conditions was color coded as green. Below VFR conditions, but, above the Instrument Flight Rules (IFR) was classified as yellow. Below IFR minimums, the color code was red. The night of the accident the weather was classified as yellow/yellow, for the local area and cross country, which required the weather to be checked by ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, climb - to cruise - light condition - dark night (contributing factor) - weather condition - low ceiling (contributing factor) - weather condition - high wind (contributing factor) - terrain condition - rising (contributing factor) - altitude/clearance - not maintained, pilot in command (cause) - diverted attention, pilot in command (contributing factor) ## Aircraft - Registration: [N90750](https://openairdocs.org/deregistered/N90750-2013-03-18), registration cancelled 2013-03-18, S/N S-154, built 1974 (OpenAirDocs) - Reported make and model: Mbb BO-105CBS - Registry model: [Messerschmitt-Boelkow-Blohm-Gm BO-105C](https://openairdocs.org/model/messerschmitt-boelkow-blohm-gm-bo-105c) (registry code 5626005) (OpenAirDocs) - Registry engine: [Allison 250 SER 400HP](https://openairdocs.org/engine/allison-250-ser-400hp) (registry code 03013, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: S-154 - Airframe hours: 11036 - Engines: Allison 250-C20B 420 horsepower turbo shaft - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Operator: Ems Air Services Of New York, doing business as Mercy Flight Central - Registered owner: American Aircraft Equity, Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 30, 1996, 25 hours before - Departed: NONE, JERSUSALEM, NY - Destination: NONE, ROCHESTER, NY ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; military, commercial; instrument ratings: helicopter; medical: class 2, valid medical--no waivers/lim.; seat: right; toxicology performed; flight hours: 4,450 total, 70 in this make and model, 3,850 as pilot in command, 18 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 150° at 13 knots, gusting 19 - Temperature: 45 °F, dew point 41 °F - Altimeter: 30.00 inHg - Observed at: PEO, 10 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 19961213039319A](https://openairdocs.org/incident/19961213039319A), Dec 13, 1996: Bolkms BO105C, Penn Yan, NY, Destroyed, 3 fatal. Helicopter crashed and burned in remote area while medivac rescue injured hunter. Flash, fireball. ## Docket (21 files) The files NTSB released with the investigation on July 7, 1998, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=28125. 3.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 1, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402172&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Redacted.PDF - Supplement C (item 2, .PDF, 409 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089808&FileExtension=.PDF&FileName=Supplement%20C-Master.PDF - Supplement D (item 3, .PDF, 522 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089809&FileExtension=.PDF&FileName=Supplement%20D-Master.PDF - Supplement S (item 4, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089810&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Local Area Map/Topographic Depiction/Wreckage Diagram (item 5, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089812&FileExtension=.PDF&FileName=Local%20Area%20Map%2FTopographic%20Depiction%2FWreckage%20Diagram-Master.PDF - Local Weather/Depiction Chart for Local Winds (item 6, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089819&FileExtension=.PDF&FileName=Local%20Weather%2FDepiction%20Chart%20for%20Local%20Winds-Master.PDF - Mercy Flight Central, Inc. Dispatch Information log (item 7, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089813&FileExtension=.PDF&FileName=Mercy%20Flight%20Central,%20Inc.%20Dispatch%20Information%20log-Master.PDF - Pilot History/Airman Competency Check/Flight Time Last 90 Days/Duty Time Record (item 8, .PDF, 323 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402173&FileExtension=.PDF&FileName=Pilot%20History%2FAirman%20Competency%20Check%2FFlight%20Time%20Last%2090%20Days%2FDuty%20Time%20Record-Redacted.PDF - Yates County Sheriff's Department Witness Statement (item 9, .PDF, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402174&FileExtension=.PDF&FileName=Yates%20County%20Sheriff%27s%20Department%20Witness%20Statement-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402175&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402176&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Toxicological Report (item 12, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402177&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo #1 View of wreckage path leading toward main wreckage, approximately 347 heading. (item 13, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089799&FileExtension=.PDF&FileName=Photo%20%231%20View%20of%20wreckage%20path%20leading%20toward%20main%20wreckage,%20approximately%20347%20heading.-Master.PDF - Photo #2 Side view of main wreckage with engine and main rotor blade hub in center of picture. (item 14, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089800&FileExtension=.PDF&FileName=Photo%20%232%20Side%20view%20of%20main%20wreckage%20with%20engine%20and%20main%20rotor%20blade%20hub%20in%20center%20of%20picture.-Master.PDF - Photo #3 View of main rotor blades + hub with destruction caused by post crash fire. (item 15, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089801&FileExtension=.PDF&FileName=Photo%20%233%20View%20of%20main%20rotor%20blades%20%2B%20hub%20with%20destruction%20caused%20by%20post%20crash%20fire.-Master.PDF - Photo #4 Piece of tail boom located in trees + separated from main wreckage stack. (item 16, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089802&FileExtension=.PDF&FileName=Photo%20%234%20Piece%20of%20tail%20boom%20located%20in%20trees%20%2B%20separated%20from%20main%20wreckage%20stack.-Master.PDF - Photo #5 Tail boom laid on hangar floor to see scopion effect. (item 17, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089803&FileExtension=.PDF&FileName=Photo%20%235%20Tail%20boom%20laid%20on%20hangar%20floor%20to%20see%20scopion%20effect.-Master.PDF - Photo #6 Top view of main rotor blades as they lay on hangar floor. (item 18, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089804&FileExtension=.PDF&FileName=Photo%20%236%20Top%20view%20of%20main%20rotor%20blades%20as%20they%20lay%20on%20hangar%20floor.-Master.PDF - Photo #7 Overview of main rotor blades laying on hangar floor. (item 19, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089805&FileExtension=.PDF&FileName=Photo%20%237%20Overview%20of%20main%20rotor%20blades%20laying%20on%20hangar%20floor.-Master.PDF - Photo #8 Bottom view of main rotor blades (item 20, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089806&FileExtension=.PDF&FileName=Photo%20%238%20Bottom%20view%20of%20main%20rotor%20blades-Master.PDF - Photo #9 Overview of bottom of main rotor blades (item 21, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40089807&FileExtension=.PDF&FileName=Photo%20%239%20Overview%20of%20bottom%20of%20main%20rotor%20blades-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.