# NTSB NYC05MA039: Eurocopter Deutschland EC 135 P2, N136LN, Oxon Hill, MD, January 11, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Major investigation · Final report - Date: January 10, 2005, 23:11 local (Jan 11, 2005, 04:11 UTC) - Place: Oxon Hill, MD - Coordinates: 38.783611, -77.019165 - Nearby events: https://openairdocs.org/map.md?lat=38.7836&lon=-77.0192&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report December 20, 2007 - Report: Approved by Office Director - Parties: Pratt & Whitney, FAA/FSDO, American Eurocopter LLC, Air Methods - Safety recommendations: Yes - NTSB case key (mKey): 60835 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC05MA039 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60835/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60835 - Page: https://openairdocs.org/ntsb/NYC05MA039 ## Probable cause The pilot's failure to identify and arrest the helicopter's descent, which resulted in controlled flight into terrain. Contributing to the accident were the dark night conditions, limited outside visual references, and the lack of an operable radar altimeter in the helicopter. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, cruise - psychological condition, pilot in command (contributing factor) - descent - continued, pilot in command (cause) - terrain condition - water - light condition - dark night (contributing factor) ## Analysis The Safety Board's full brief is available at http://ntsb.gov/Publictn/publictn.htm. The Aviation Accident Brief number is NTSB/AAB-07/04. On January 10, 2005, about 2311 eastern standard time, a Eurocopter Deutschland GmbH EC-135 P2 helicopter, N136LN, operated by LifeNet, Inc., as Life Evac 2, crashed into the Potomac River during low-altitude cruise flight near Oxon Hill, Maryland. The certificated commercial pilot and the flight paramedic were killed, and the flight nurse received serious injuries. The helicopter was destroyed. The positioning flight was conducted under the provisions of 14 Code of Federal Regulations Part 91 and visual flight rules with a company flight plan filed. Night visual meteorological conditions prevailed at the time of the accident. ## Factual narrative The Safety Board's full brief is available at http://ntsb.gov/Publictn/publictn.htm. The Aviation Accident Brief number is NTSB/AAB-07/04. HISTORY OF FLIGHT On January 10, 2005, about 2311 eastern standard time, [1] a Eurocopter Deutschland GmbH EC-135 P2 helicopter, N136LN, operated by LifeNet, Inc., as Life Evac 2, crashed into the Potomac River during low-altitude cruise flight near Oxon Hill, Maryland. The certificated commercial pilot and the flight paramedic were killed, and the flight nurse received serious injuries. The helicopter was destroyed. The positioning flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91 and visual flight rules (VFR) with a company flight plan filed. Night visual meteorological conditions prevailed at the time of the accident. The flight originated at the Washington Hospital Center Helipad (DC08), Washington, D.C., about 2304, and was en route to Stafford Regional Airport (RMN), Stafford, Virginia. Global positioning system (GPS) data for the flight [2] showed that the helicopter proceeded toward the Federal Aviation Administration's (FAA) published helicopter route 1. [3] According to FAA air traffic control (ATC) transcripts, the pilot contacted the local controller at Ronald Reagan Washington National Airport (DCA), Washington, D.C., at 2305:47 and stated, "washington tower life evac two . . . sir we're at uh medstar like to go out to uh r f k route one then to route four south." The local controller responded, "life evac two (unintelligible) bravo airspace altimeter three zero two five." The pilot responded, "roger understand cleared as requested." Examination of FAA ATC radar data showed that the helicopter intercepted a segment of published helicopter route 1, followed it southwest to intercept helicopter route 4, and then flew southbound along the Potomac River toward Woodrow Wilson Bridge. As the helicopter flew over the river toward Woodrow Wilson Bridge, its Mode C transponder reported that its altitude varied from 0 to 100 feet. [4] When the helicopter was about 0.5 nautical mile (nm) north of the bridge, its reported Mode C altitude was 200 feet. At 2311:20, the pilot reported to the local controller, "life evac two is at the Woodrow Wilson [Bridge]," and the controller responded, "life evac two washington tower traffic on a ten mile final is a seven [sic] an airbus." [5] At 2311:30, the pilot responded, "roger we have him in sight and will be out of his way," and the controller stated, "life evac two maintain visual separation from traffic." ATC radar data showed that, at the time of the pilot's response, the helicopter was about 0.25 nm north of the Woodrow Wilson Bridge at an altitude of about 200 feet. The pilot made no further radio communications. According to the flight nurse, who was seated in the helicopter's left front copilot's seat, the pilot maneuvered the helicopter to cross the bridge midspan. The flight nurse stated that the helicopter appeared to be at the same or higher altitude than the lights he saw on some construction cranes near the Woodrow Wilson Bridge. He stated that he "called the lights" on both sides of the river to the pilot and that the pilot acknowledged him. According to a Maryland Department of State Police report, the flight nurse also stated that there was a "commercial airplane coming into [DCA], and the pilot . . . made a change in his flightpath and started to descend." [6] According to ATC radar data, at 2311:39, the helicopter had crossed over the Woodrow Wilson Bridge and was just south of the bridge with a ground track of about 180 degrees and an altitude of about 200 feet. Four seconds later, the helicopter had a ground track of about 190 degrees and an altitude of about 100 feet. The helicopter's last recorded position at 2311:48 showed a ground track of about 200 degrees and an altitude of about 0 feet. According to ATC radar data, at the time of the helicopter's last radar return, the northbound Airbus that the local controller previously mentioned was about 2.2 nm south of the helicopter's position at an altitude of about 1,700 feet. According to the flight nurse, after the helicopter flew over the southern half of the Woodrow Wilson Bridge, the next thing he recalled was being submerged in water with his seatbelt on and his helmet off. He stated that the helicopter's master caution lights and panel segment lights did not illuminate and that he did not hear any audio alarms sound before the crash. He stated that the pilot did not execute any evasive maneuvers or communicate any difficulties, either verbally or nonverbally. According to witnesses in vehicles on the Woodrow Wilson Bridge, the helicopter crossed over the bridge before it descended and then impacted the water. None of the witnesses reported seeing the helicopter impact any objects before its descent. The wreckage was located in the Potomac River about 0.5 nm south of the Woodrow Wilson Bridge. At 2314:46 (about 3 minutes after the helicopter crashed), the DCA local controller stated, "life evac two frequency change approved." The controller received no reply and made no further attempts to contact the flight. The Maryland State Police later notified the controller of the crash. PERSONNEL INFORMATION The pilot, age 56, was hired by LifeNet in June 2004. He held a commercial pilot certificate with ratings for airplane single- and multi-engine land, rotorcraft helicopter, and instrument helicopter. His most recent FAA second-class airman medical certificate was issued on May 28, 2004. On his application for the medical certificate, he reported 1,500 hours total civilian flight experience, 30 hours of which were accumulated in the previous 6 months. [7] A review of company records showed that, in the 90 days, 30 days, and 24 hours before the accident, the pilot flew 42 hours, 12 hours, and 1 hour, respectively, and performed a total of 71 night landings. According to LifeNet's training records, during the pilot's first few weeks of employment, the company provided 12 hours of basic indoctrination training, as well as 20 hours of initial ground training and 7.8 hours of flight training in the Messchersmitt Bolkal Blohm BK-117 helicopter. The training records indicated that the pilot completed the initial pilot-testing requirements of 14 CFR 135.293 and the pilot-in-command flight check required by 14 CFR 135.299 on July 8, 2004, in the BK-117. The company subsequently provided the pilot 18 hours of transition ground training and 5.8 hours of transition flight training for the EC-135, and the pilot completed the initial testing and flight-check requirements in the EC-135 on October 3, 2004. During his employment with LifeNet, the pilot accumulated 51.5 flight hours in the BK-117 and 40.8 flight hours in the EC-135. According to LifeNet's assistant chief pilot, when the pilot applied for employment, he reported that he had been retired since 1997 but that he was current for Part 135 operations and had passed Part 135 flight checks in a Bell 206 helicopter in February 2004 and in a BK-117 in April 2004. The assistant chief pilot stated that, according to the pilot's interview and resume, he had been a military pilot in the U.S. Army from 1968 to 1971 and had accumulated about 2,400 military flight hours in helicopters, including about 350 hours of night flying and about 70 hours of instrument flying. From 1971 to his retirement in 1997, the pilot worked for a corporation in both nonflying and flying positions. During his 26-year corporate employment, the pilot accumulated 400 hours total flight experience in Agusta 109 and Sikorsky S76 helicopters and about 300 total civilian flight hours in fixed-wing airplanes. The resume that the pilot submitted to LifeNet did not list his most recent employer, which was another Part 135 helicopter operator that had terminated his employment after about 2 weeks. According to the ch ## Aircraft - Registration: [N136LN](https://openairdocs.org/deregistered/N136LN-2008-12-11), registration cancelled 2008-12-11, S/N 0336, built 2004 (OpenAirDocs) - Reported make and model: Eurocopter Deutschland EC 135 P2 - Registry model: [Eurocopter Deutschland EC 135 P2](https://openairdocs.org/model/eurocopter-deutschland-ec-135-p2) (registry code 5620027) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PW206B series](https://openairdocs.org/engine/pratt-whitney-canada-pw206b-series) (registry code 52135, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 0336 - Airframe hours: 166 - Engines: Pratt & Whitney 206B 431 horsepower turbo shaft; Pratt & Whitney 206B 431 horsepower turbo shaft - Damage: Destroyed - Flight: Positioning, Part 91 - Operator: Life Net Inc., doing business as Life Evac - Registered owner: Wells Fargo Bank Northwest NA Trustee - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, December 1, 2004, 36 hours before - Departed: DC08, Washington, DC - Destination: RMN, Stafford, VA - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review February 1, 2004; seat: left; toxicology performed; flight hours: 2,841 total, 40 in this make and model, 9 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 13,000 ft broken - Temperature: 45 °F, dew point 36 °F - Altimeter: 30.25 inHg - Observed at: DCA, 5 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 20050110007249A](https://openairdocs.org/incident/20050110007249A), Jan 10, 2005: Urocop EC135P2, Oxon Hill, MD, Destroyed, 2 fatal. (-23) After dropping off medivac patient flight was returning to stafford county airport. On board was pilot, [privacy data omitted], paramedic, [privacy data… ## Docket (45 files) The files NTSB released with the investigation on December 6, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60835. 12.2 MB in all. - Witness Statement 1 (item 1, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275797&FileExtension=.PDF&FileName=Witness%20Statement%201-Redacted.PDF - Witness Statement 2 (item 2, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275798&FileExtension=.PDF&FileName=Witness%20Statement%202-Redacted.PDF - Flight Nurse Interview (item 3, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275801&FileExtension=.PDF&FileName=Flight%20Nurse%20Interview-Redacted.PDF - Flight Nurse statement to MSP (item 4, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243691&FileExtension=.PDF&FileName=Flight%20Nurse%20statement%20to%20MSP-Redacted.PDF - Interview 1 of Flight Crew from Previous Night Flight (item 5, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275799&FileExtension=.PDF&FileName=Interview%201%20of%20Flight%20Crew%20from%20Previous%20Night%20Flight-Redacted.PDF - Interview 2 of Flight Crew from Previous Night Flight (item 6, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275800&FileExtension=.PDF&FileName=Interview%202%20of%20Flight%20Crew%20from%20Previous%20Night%20Flight-Redacted.PDF - Operator Statement (referencing pilot flight time) (item 7, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243694&FileExtension=.PDF&FileName=Operator%20Statement%20(referencing%20pilot%20flight%20time)-Redacted.PDF - Pilot Resume (item 8, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243692&FileExtension=.PDF&FileName=Pilot%20Resume-Redacted.PDF - Pilot (LifeNet) Flight Logs (item 9, .PDF, 238 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273144&FileExtension=.PDF&FileName=Pilot%20(LifeNet)%20Flight%20Logs-Master.PDF - Pilot Training Records (Lifenet) (item 10, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275803&FileExtension=.PDF&FileName=Pilot%20Training%20Records%20(Lifenet)-Redacted.PDF - Previous Employer Interview (item 11, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40265086&FileExtension=.PDF&FileName=Previous%20Employer%20Interview-Redacted.PDF - GPS Plot (item 12, .PDF, 684 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243749&FileExtension=.PDF&FileName=GPS%20Plot-Master.PDF - ATC 3 - Factual Report of Group Chairman (item 13, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234780&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - ATC 3 - Attachment 1 FAA Accident Package (item 14, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275807&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%201%20FAA%20Accident%20Package-Redacted.PDF - ATC 3 - Attachment 2 Determination of No Hazard to Air Navigation (item 15, .PDF, 280 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234233&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%202%20Determination%20of%20No%20Hazard%20to%20Air%20Navigation-Master.PDF - ATC 3 - Attachment 3 Candler flight 666 radar data (item 16, .TXT, 4 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234239&FileExtension=.txt&FileName=ATC%203%20-%20Attachment%203%20Candler%20flight%20666%20radar%20data-Master.txt - ATC 3 - Attachment 4 LifeFlight 2 radar data (item 17, .TXT, 3 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40234240&FileExtension=.txt&FileName=ATC%203%20-%20Attachment%204%20LifeFlight%202%20radar%20data-Master.txt - Meteorology 5 - Factual Report of Weather Specialist (item 18, .PDF, 449 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40233087&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Weather%20Specialist-Master.PDF - Structures 7 - Factual Report of Group Chairman (Appx A was never received from MD State Police) (item 19, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243165&FileExtension=.PDF&FileName=Structures%207%20-%20Factual%20Report%20of%20Group%20Chairman%20(Appx%20A%20was%20never%20received%20from%20MD%20State%20Police)-Master.PDF - EEC Examination Data (item 20, .XLS, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243738&FileExtension=.xls&FileName=EEC%20Examination%20Data-Master.xls - Photo 1 - View from main wreckage impact point (looking back toward bridge) (item 21, .PDF, 491 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244110&FileExtension=.PDF&FileName=Photo%201%20-%20View%20from%20main%20wreckage%20impact%20point%20(looking%20back%20toward%20bridge)-Master.PDF - Photo 2 - Taken at radar data point south of the bridge (looking to the left) (item 22, .PDF, 536 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244111&FileExtension=.PDF&FileName=Photo%202%20-%20Taken%20at%20radar%20data%20point%20south%20of%20the%20bridge%20(looking%20to%20the%20left)-Master.PDF - Photo 3 - Taken at radar data point south of the bridge (looking to the right) (item 23, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244112&FileExtension=.PDF&FileName=Photo%203%20-%20Taken%20at%20radar%20data%20point%20south%20of%20the%20bridge%20(looking%20to%20the%20right)-Master.PDF - Photo 4 - Helicopter during recovery from the barge. (item 24, .PDF, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244113&FileExtension=.PDF&FileName=Photo%204%20-%20Helicopter%20during%20recovery%20from%20the%20barge.-Master.PDF - Photo 5 - View of helicopter from front (item 25, .PDF, 356 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244115&FileExtension=.PDF&FileName=Photo%205%20-%20View%20of%20helicopter%20from%20front-Master.PDF - Photo 6 - Fuselage reconstruction (looking at helicopter left side) (item 26, .PDF, 420 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244131&FileExtension=.PDF&FileName=Photo%206%20-%20Fuselage%20reconstruction%20(looking%20at%20helicopter%20left%20side)-Master.PDF - Performance Memo (item 27, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275806&FileExtension=.PDF&FileName=Performance%20Memo-Redacted.PDF - Performance Memo 2 (item 28, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274387&FileExtension=.PDF&FileName=Performance%20Memo%202-Master.PDF - Performance Plot 1 (item 29, .PDF, 393 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244459&FileExtension=.PDF&FileName=Performance%20Plot%201-Master.PDF - Performance Plot 2 (item 30, .PDF, 244 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244460&FileExtension=.PDF&FileName=Performance%20Plot%202-Master.PDF - Performance Plot 3 (item 31, .PDF, 382 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244461&FileExtension=.PDF&FileName=Performance%20Plot%203-Master.PDF - Performance Plot 4 (item 32, .PDF, 411 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244463&FileExtension=.PDF&FileName=Performance%20Plot%204-Master.PDF - Performance Plot 5 (item 33, .PDF, 396 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244464&FileExtension=.PDF&FileName=Performance%20Plot%205-Master.PDF - Performance Plot 6 (item 34, .PDF, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244465&FileExtension=.PDF&FileName=Performance%20Plot%206-Master.PDF - Description of Traffic Camera Images (item 35, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243723&FileExtension=.PDF&FileName=Description%20of%20Traffic%20Camera%20Images-Master.PDF - Traffic Camera Image 1 of 4 (item 36, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243650&FileExtension=.PDF&FileName=Traffic%20Camera%20Image%201%20of%204-Master.PDF - Traffic Camera Image 2 of 4 (item 37, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243651&FileExtension=.PDF&FileName=Traffic%20Camera%20Image%202%20of%204-Master.PDF - Traffic Camera Image 3 of 4 (item 38, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243652&FileExtension=.PDF&FileName=Traffic%20Camera%20Image%203%20of%204-Master.PDF - Traffic Camera Image 4 of 4 (item 39, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243653&FileExtension=.PDF&FileName=Traffic%20Camera%20Image%204%20of%204-Master.PDF - Lunar Illumination Prediction (source: Solar Luminar Almanac Prediction v.1.4) (item 40, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243751&FileExtension=.PDF&FileName=Lunar%20Illumination%20Prediction%20(source%3A%20Solar%20Luminar%20Almanac%20Prediction%20v.1.4)-Master.PDF - Toxicological Report (item 41, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275802&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Maryland State Police Report (item 42, .PDF, 516 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274912&FileExtension=.PDF&FileName=Maryland%20State%20Police%20Report-Redacted.PDF - MSP Observation (item 43, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40243791&FileExtension=.PDF&FileName=MSP%20Observation-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 44, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275805&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 45, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275804&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF From the NTSB's public API. 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