LAX03MA292

NTSB accident investigation · Aerospatiale AS350BA · GrandCanyonWest, AZ · September 20, 2003

Accident · FatalClass 1 · MajorFinal report
Date
September 20, 2003, 12:38 local (19:38 UTC)
Place
GrandCanyonWest, AZ
Injuries
7 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N270SHAerospatiale AS350BA
Weather
Visual (VMC) · Day
Status
Completed · report November 14, 2007
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Parties
Federal Aviation Administration, American Eurocopter, Sundance Helicopters, Inc., Honeywell
Safety recommendations
Yes
FAA report
20030920037859A
Case key
57969

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 disregard of safe flying procedures and misjudgment of the helicopter's proximity to terrain, which resulted in an in-flight collision with a canyon wall. Contributing to the accident was the failure of Sundance Helicopters and the Federal Aviation Administration to provide adequate surveillance of Sundance's air tour operations in Descent Canyon.

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 collision with terrain/waterManeuvering
In-flight planning/decision - poorPilot in commandFactor
Terrain condition - mountainous/hilly
Clearance - not maintainedPilot in commandCause
Procedure inadequatePilot in commandCause
Low altitude flight/maneuver - intentionalPilot in commandCause
Inadequate surveillance of operationCompany/operator mgmtFactor
Inadequate surveillance of operationFaa(organization)Factor

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Brief number is NTSB/AAB-07/03.

On September 20, 2003, about 1238 mountain standard time, an Aerospatiale AS350BA helicopter, N270SH, operated by Sundance Helicopters, Inc., crashed into a canyon wall while maneuvering through Descent Canyon, about 1.5 nautical miles east of Grand Canyon West Airport (1G4) in Arizona. The pilot and all six passengers on board were killed, and the helicopter was destroyed by impact forces and postcrash fire. The air tour sightseeing flight was operated under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed for the flight, which was operated under visual flight rules on a company flight plan. The helicopter was transporting passengers from a helipad at 1G4 (helipad elevation 4,775 feet mean sea level [msl]) near the upper rim of the Grand Canyon to a helipad designated "the Beach" (elevation 1,300 msl) located next to the Colorado River at the floor of the Grand Canyon.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Brief number is NTSB/AAB-07/03.

On September 20, 2003, about 1238 mountain standard time, an Aerospatiale AS350BA helicopter, N270SH, operated by Sundance Helicopters, Inc., crashed into a canyon wall while maneuvering through Descent Canyon, about 1.5 nautical miles east of Grand Canyon West Airport (1G4) in Arizona. The pilot and all six passengers on board were killed, and the helicopter was destroyed by impact forces and postcrash fire. The air tour sightseeing flight was operated under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed for the flight, which was operated under visual flight rules on a company flight plan. The helicopter was transporting passengers from a helipad at 1G4 (helipad elevation 4,775 feet mean sea level [msl]) near the upper rim of the Grand Canyon to a helipad designated "the Beach" (elevation 1,300 msl) located next to the Colorado River at the floor of the Grand Canyon.

The director of operations estimated that each flight from 1G4 to the Beach helipad lasted about 3.5 minutes. These flights were part of an advertised tour package in which Sundance pilots flew passengers through Descent Canyon, dropped them off at the Beach helipad for a scenic boat ride on the Colorado River, then picked them up at the Beach helipad later in the day for a return flight to 1G4 through another scenic canyon.

The accident flight was the pilot's 11th flight through Descent Canyon that day. The helicopter lifted off from 1G4 about 1237 and flew to the rim of Descent Canyon. The Sundance tour coordinator and a loader for Papillon Grand Canyon Helicopters at 1G4 stated that they observed the accident helicopter hover at the rim of Descent Canyon for about 30 to 45 seconds before beginning a level descent. There were no known witnesses or air traffic control radar data to provide information on the accident flight's progress inside the canyon after it descended out of view of the witnesses at 1G4.

The main wreckage was located on a canyon wall ledge about 400 feet beyond a near-vertical canyon wall that showed evidence of gouging consistent with a main rotor blade strike.

Aircraft

Registration
N270SH
Reported as
Aerospatiale AS350BA
Category
Helicopter
Serial number
1864
Airframe hours
10,892
Engine
Lycoming LTS101-600A3A, 650 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Registered owner
Sundance Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 3, 2003 · 95 hours before
Departed
1G4 · GrandCanyonWest, AZ
Destination
NONE · Descent Canyon, AZ
Flight plan
Company VFR
Airport
1G4 · Grand Canyon West

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
44
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
July 1, 2003
Seat
Right
Toxicology
Performed
Flight hours
7,857 total · 2,350 in this make and model · 7,762 as pilot in command · 228 in the last 90 days · 86 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 4 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 21 °F
Altimeter
29.95 inHg
Observed at
IGM, 44 nm away

Docket · 87

The files NTSB released with the investigation on October 25, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 105 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 389 KBOperations - Factual Report of Group ChairmanItem 2 · .PDF · 332 KBOperations - Attachment A - Operations Specifications, Sundance Helicopters (SH)Item 3 · .PDF · 1.3 MBOperations - Attachment B - Sundance Helicopters, Inc., Part 135 Operations ManualItem 4 · .PDF · 7.1 MBOperations - Attachment C - Sundance Helicopters FAA approved Training Program for Part 135 OperationsItem 5 · .PDF · 4.4 MBOperations - Attachment D - Sundance Helicopters Operations Memorandum, October 10, 2000, Grand Canyon West ProceduresItem 6 · .PDF · 215 KBOperations - Attachment E - Training Curriculum, Sundance HelicoptersItem 7 · .PDF · 434 KBOperations - Addendum F - LAS FSDO Grand Canyon National Park Special Flight Rules Area (GCNP SFRA) Procedures ManualItem 8 · .PDF · 3.6 MBOperations - Attachment G - Operations Memorandum, February 19, 2001, Operations at Grand Canyon WestItem 9 · .PDF · 37 KBOperations - Attachment H - Operations Memorandum, June 15, 2000, Jack stall and AirspeedItem 10 · .PDF · 132 KBOperations - Attachment I - Emergency Procedures, 350 BA Flight ManualItem 11 · .PDF · 338 KBOperations - Attachment J - Operations Memorandum, October 1, 2000, 1G4 Operations [deleted]Item 12 · .PDF · 8 KBOperations - Attachment K - Topo maps, 1G4, Descent Canyon Tour Route in Effect & Revised RouteItem 13 · .PDF · 7.4 MBOperations - Attachment L - Sundance Helicopters, Pilot Flight Duty RecordItem 14 · .PDF · 762 KBOperations - Attachment M - Records for Mr. Mezaki, provided by SH relative to Pilot Records Improvement Act of 1996Item 15 · .PDF · 597 KBOperations - Attachment N.1 - Sundance Helicopters Aircraft Weight and Balance: estimated for N270SH for time of the accidentItem 16 · .PDF · 46 KBOperations - Attachment N.2 - Sundance Helicopters Aircraft Weight and Balance: SH's filed weight and balance records for N270SHItem 17 · .PDF · 178 KBOperations - Attachment O - Sundance Helicopters, Fuel Sample Log, dated 9/20/03Item 18 · .PDF · 44 KBOperations - Attachment P - 1G4 Passenger Manifest, 9/20/03 and sheet sketching locations of passengers on the accident flight provided by Ms. Springgate-HillItem 19 · .PDF · 123 KBOperations - Attachment Q - Sundance Helicopters, Minimum Equipment List, AS-350Item 20 · .PDF · 1.5 MBOperations - Attachment R - Passenger Briefing Cards in English, German and Japanese - "Hotloads"Item 21 · .PDF · 518 KBOperations - Attachment S - Secondary file for Accident pilot regarding dangerous flight on June 1, 2001Item 22 · .PDF · 3.8 MBOperations - Attachment T - Air Vegas Passenger/Cargo Manifest Forms, Passenger Information and Correspondence between NTSB and SHItem 23 · .PDF · 501 KBOperations - Attachment U - Sequence of flights and SH flight numbers and down and up timesItem 24 · .PDF · 65 KBOperations - Attachment V - Sundance Helicopters - Training Program records for accident pilotItem 25 · .PDF · 2.8 MBOperations - Attachment W - Weather Report, Las Vegas 9/20/2003Item 26 · .PDF · 43 KBOperations - Attachment X - Tour-related brochures for Sundance Helicopters and Air Vegas AirlinesItem 27 · .PDF · 1.2 MBOperations - Attachment Y - Interview Summary Statement of John Sullivan - CEO of Sundance HelicoptersItem 28 · .PDF · 94 KBOperations - Attachment Z - Letter from NTSB Ops. Group Chairman to Ms. Roxanne Velez dated January 29, 2004Item 29 · .PDF · 71 KBOperations - Attachment AA - Email from SH, Tom Schaus to NTSB Ops. Group Chairman regarding suspension of Mr. MezakiItem 30 · .PDF · 43 KBOperations - Attachment BB - Statement of SH employee Paul Kirschel regarding maintenanceItem 31 · .PDF · 74 KBOperations - Attachment CC - DOD Capability Survey of Sundance Helicopters, Inc., October 28, 2003Item 32 · .PDF · 1.1 MBOperations - Attachment DD - Accident pilot's logbook entries, May 27, 2001, through October 1, 2001Item 33 · .PDF · 4.3 MBOperations - Attachment EE - FAA Information AirNav.Com, "1G4 Grand Canyon West Airport, Peach Springs, Arizona, USA"Item 34 · .PDF · 132 KBOperations - Attachment FF - Witness SummariesItem 35 · .PDF · 154 KBOperations - Attachment GG - Memo from AFS-1 to AAI-1 in response to NTSB IIC's information request, May 18, 2004Item 36 · .PDF · 86 KBOperations - Attachment HH - National Flight Standards Work Program Guidelines FAA Order 1800.56A August 7, 2000; Order 1800.56A Chg 1 March 15, 2001; Order 1800.56B Sept 14, 2001; Order 1800.56C Sept 13, 2002; Order 1800.56D Sept 17, 2003Item 37 · .PDF · 5.1 MBOperations - Attachment II - Email TR Proven, FAA IIC, showing example of FAA’s tabulated data of Sundance’s flight activity, dated September 29, 2003Item 38 · .PDF · 84 KBOperations - Attachment JJ - Email from NTSB IIC to FAA POI, regarding PTRS, dated October 2, 2003Item 39 · .PDF · 24 KBOperations - Attachment KK - Statement of FAA POI, dated October 1, 2003Item 40 · .PDF · 88 KBOperations - Attachment LL - Statement of FAA APOI, dated September 26, 2003Item 41 · .PDF · 66 KBOperations - Attachment MM - TOPS program brochure, extract received from Sundance, September 2003Item 42 · .PDF · 337 KBOperations - Attachment NN - TOPS program directive, received from Sundance, dated April 30, 1996Item 43 · .PDF · 371 KBOperations - Attachment OO - Sundance Operations memo regarding Jack Stall and Airspeed, dated June 15, 2000Item 44 · .PDF · 45 KBOperations - Attachment PP - Sundance Chief Pilot memo regarding diving into Descent Canyon and TOPS standards, dated February 19, 2001Item 45 · .PDF · 35 KBOperations - Attachment QQ - TOPS Operational Safety Audit for Sundance, dated July 16, 2003Item 46 · .PDF · 308 KBOperations - Attachment RR - TOPS audit form for Sundance, dated July 16, 2003Item 47 · .PDF · 847 KBOperations - Attachment SS - Email from B. Fahnestock, Sundance Director of Maintenance, to NTSB Airworthiness Group Chair Deforge, dated September 29, 2003.Item 48 · .PDF · 13 KBOperations - Attachment TT - Descent Canyon Flight FrequencyItem 49 · .PDF · 24 KBOperations, Memo Documentation of Descent Canyon Topography and Impact Signatures w/photosItem 50 · .PDF · 927 KBOperations, Memo Attachment 1, Documentation Flight VideoItem 51 · .PDF · 8 KBOperations, Memo Attachment 2, Documentation PhotographsItem 52 · .PDF · 18 KBOperations, Memo Attachment 3, Documentation GPS Track PlotItem 53 · .PDF · 844 KBAirworthiness - Factual Report of Group ChairmanItem 54 · .PDF · 10 photos · 1.2 MBAirworthiness - Factual Report, Attachment 1. Honeywell Engine Teardown ReportItem 55 · .PDF · 112 photos · 27.8 MBHoneywell Engine Proprietary ReleaseItem 56 · .PDF · 23 KBPassenger Interview Group Factual ReportItem 57 · .PDF · 73 KBPassenger Interview Group Attachment 1Item 58 · .PDF · 879 KBPassenger Interview Group Attachment 2Item 59 · .PDF · 123 KBServo Transparency StudyItem 60 · .PDF · 4.2 MB
All 87 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.