# NTSB NYC06MA005: Augusta 109E, N7YL, Smethport, PA, October 8, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Major investigation · Final report - Date: October 7, 2005, 23:42 local (Oct 8, 2005, 03:42 UTC) - Place: Smethport, PA - Coordinates: 41.754722, -78.553886 - Nearby events: https://openairdocs.org/map.md?lat=41.7547&lon=-78.5539&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 20, 2007 - Report: Approved by Office Director - Parties: FAA/FSDO, CJ Systems Aviation, Turbomeca USA, Augusta - NTSB case key (mKey): 62626 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC06MA005 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62626/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=62626 - Page: https://openairdocs.org/ntsb/NYC06MA005 ## Probable cause The pilot's failure to maintain aircraft control. Factors in the accident were, night instrument meteorological conditions, pilot workload, and improper air traffic control procedures by the approach controller. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - iaf to faf/outer marker (ifr) - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - weather condition - clouds - light condition - dark night - communications/information/atc - improper, atc personnel(artcc) (cause) - excessive workload (task overload), pilot in command - In flight collision with object, approach - iaf to faf/outer marker (ifr) - object - tree(s) ## Analysis The single-pilot helicopter was flying under instrument flight rules in night instrument meteorological conditions. The controller instructed the pilot to fly heading 340 degrees to intercept the localizer course for an instrument landing system approach. At that time, the helicopter was about 1.5 miles from the localizer centerline, headed 095 degrees, about 150 knots groundspeed. Consequently, the helicopter flew through and ended up well east of the 322-degree localizer course. During the resulting 135-degree turn to rejoin the final approach course, the pilot was issued an approach clearance, but told to "maintain 4,000." The helicopter's track approached the runway centerline, and then turned sharply away from, and to the right of the inbound course. The track showed an approximate heading of 100 degrees, when the radar target disappeared. During the 1 minute and 10 seconds following the pilot's acknowledgement of the 4,000-foot altitude assignment, the helicopter descended only 300 feet, slowed to approximately 65 knots groundspeed, and turned 140 degrees right of course. At the point where the helicopter re-intercepted the localizer, the autopilot was capable of capturing the localizer, but incapable of capturing the glideslope. If altitude hold remained engaged at that point of the flight, and the pilot reduced collective to initiate a descent, the autopilot would adjust pitch in an effort to maintain the selected altitude. Similar scenarios in helicopters and flight simulators have resulted in unusual attitudes and zero airspeed descents to the ground. The pilot had accrued 9,616 total hours of flight experience. He had 100 total hours of instrument flight experience; of which 10 hours was simulated instrument flight experience. Examination of the wreckage revealed no mechanical anomalies. Examination of voice communication tapes revealed that the controller used non-standard approach clearance procedures, did not comply with requirements for weather dissemination, and did not comply with the appropriate intercept angle of 45 degrees for helicopters as prescribed in Federal Aviation Administration orders. ## Factual narrative HISTORY OF FLIGHT On October 7, 2005, at 2342 eastern daylight time, an Agusta 109E, N7YL, operated by CJ Systems Aviation Group Inc., was destroyed when it impacted trees and terrain in Smethport, Pennsylvania, while performing an instrument approach to Bradford Regional Airport (BFD), Bradford, Pennsylvania. The certificated commercial pilot was fatally injured. Night instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight that originated from Kane Community Hospital (PA91), Kane, Pennsylvania, at 2324. The positioning flight was conducted under 14 CFR Part 91. In an interview, a mission flight nurse stated that he and another nurse were onboard the helicopter during a positioning flight from their base in Harborcreek, Pennsylvania, to Kane Community Hospital. Upon arrival at the hospital, he and the other nurse deplaned to prepare a patient for transport to Pittsburgh, Pennsylvania, while the helicopter departed for Bradford Airport to refuel. Examination of radar and voice communication data provided by the Federal Aviation Administration (FAA) revealed that the helicopter departed Kane Hospital helipad and tracked the Copter GPS 246 Departure procedure course. The pilot contacted air traffic control (ATC), at 2324:47, stated that he had departed the hospital, and was "VFR to uh Bradford three thousand two hundred climbing to five." Over the next 4 minutes, the pilot requested the instrument landing system (ILS) runway 32 approach to Bradford Regional Airport, and he and the controller discussed whether the helicopter would be vectored to the final approach course or if the full approach procedure would be flown. The controller stated, "say your heading I've got you heading the wrong way for Bradford." The pilot replied that he was heading 246 degrees, which was prescribed in the procedure, but the controller questioned the response. The pilot reaffirmed his intention to fly to Bradford, and the controller assigned a 040-degree heading. The pilot acknowledged the instructions; the helicopter then reversed direction, and assumed a northeasterly track. About 3 minutes later, the controller stated, "fly heading of zero eight five radar vectors runway three two I-L-S." The pilot acknowledged the radio call, and the helicopter assumed an easterly track. At 2339:01, the controller stated, "seven yankee lima fly heading of three four zero join the localizer report established please." At that time, the helicopter was at 5,000 feet, on an easterly track, about 1 mile west of the runway extended centerline, about 150 knots groundspeed. The pilot acknowledged the instructions. The radar track depicted the helicopter on an easterly heading as it flew through the 322-degree final approach course, about 4 miles outside of the outer marker. At 2340:03, the controller advised the pilot that the helicopter was "on the right side of the I-L-S," and the pilot acknowledged the call. At 2341:09, the controller asked if the pilot was established on the ILS. The pilot responded that he was "recapturing." The controller then asked if the pilot had said "affirmative," and the pilot replied "affirmative." At 0341:19, the controller transmitted, "Lifeguard seven yankee lima roger cleared I-L-S three two uh runway at Bradford uh maintain four thousand feet and uh report cancellation on this frequency..." The pilot read back the clearance at 0341:33. There were no further transmissions from the helicopter. When the pilot replied "recapturing" the controller insisted the pilot respond "affirmative," which the pilot subsequently did. At the time the controller advised that the helicopter was right of the localizer course, the radar track depicted the helicopter about midway through a left turn to about a 310-degree heading, at 5,000 feet, and about 1 mile east of the runway centerline. The helicopter's track approached the localizer course centerline, and then turned sharply away from, and to the right of the inbound course. The radar target showed an approximate track of 100 degrees, when the target disappeared. During the 1 minute and 10 seconds following the pilot's acknowledgement of the 4,000-foot altitude assignment, the helicopter descended only 300 feet, slowed to approximately 65 knots groundspeed, and turned 140 degrees right of course. The final three plots of the radar track showed a sharp left turn back towards the localizer course, and an approximate ground speed of 55 knots. The last radar plot was approximately over the crash site at 4,300 feet, about 1 mile east of the extended runway centerline, and 4 miles from the airport. In an interview, a witness that lived approximately 1 mile from the crash site said that he did not see the helicopter, but heard it pass overhead. He said he was familiar with the sound, as he had lived close to the final approach course for runway 32 for many years. The witness said the sound was louder than usual, and he felt the helicopter was closer to his home and lower than usual. The witness described the sound as smooth and continuous, with no change in aircraft noise. After the helicopter over flew his position, he heard the sound of an explosion. On October 8, 2005, the FAA generated an alert notice at 0101, and a ground search for the helicopter began in the early morning hours of October 8, 2005. A search by air was not conducted due to weather. The helicopter wreckage was found on October 9, 2005, and was examined at the site on October 10, 2005. The accident occurred during the hours of darkness approximately 40 degrees, 53 minutes north latitude, and 78 degrees, 06 minutes west longitude. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for rotorcraft helicopter and instrument helicopter. The commercial certificate was issued February 10, 1979, and the instrument rating was added June 18, 1997. His most recent FAA second-class medical certificate was issued on October 19, 2004, and he reported 9,616 total hours of flight experience on that date. The pilot's logbook was not recovered; however, some flight times were extracted from company records. In the 90 days prior to the accident, the pilot logged 56 hours, all of which was in the Augusta 109E. In this time period, he logged 25 hours of flight experience at night, 3 hours of simulated instrument experience, and 3 hours of actual instrument flight experience. The company reported that the pilot had 110 total hours of instrument flight experience, and estimated that of this 70 hours were simulated instrument flight experience, and 40 hours were actual instrument flight experience. Later, the company reported that the pilot had accrued 100 hours of instrument flying experience, 10 hours of which was simulated. AIRCRAFT INFORMATION The helicopter was manufactured in 2001, and had accrued 1,905 total airframe hours. It was maintained under an Approved Aircraft Inspection Program (AAIP), and its most recent inspection was completed August 5, 2005. The helicopter was equipped with an Integrated Flight Control System (IFCS). The system provided attitude automatic stabilization and automatic path control. Both stabilization and automatic path computation were actuated through the helipilot (autopilot) system and the flight director system. A review of maintenance records revealed numerous entries related to autopilot malfunctions and failures. The malfunctions included erratic command bars on pilot and copilot displays, and uncommanded pitch and roll oscillations that occurred during preflight checks and also in flight. Over a 2-year span, 10 autopilot computers were changed on the accident helicopter due to their exposure to "high vibration levels." A service bulletin (109EP-51) was released February 9, 2005, to address the vibration issues with the installa ## Aircraft - Registration: [N7YL](https://openairdocs.org/deregistered/N7YL-2013-05-10), registration cancelled 2013-05-10, S/N 11502, built 2001 (OpenAirDocs) - Reported make and model: Augusta 109E - Registry model: [Agusta A109E](https://openairdocs.org/model/agusta-a109e) (registry code 0260101) (OpenAirDocs) - Registry engine: [Turbomeca ARRIUS-2K1](https://openairdocs.org/engine/turbomeca-arrius-2k1) (registry code 60055, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 11502 - Airframe hours: 1905 - Engines: Turbomeca Arrius 2K1 675 horsepower turbo shaft; Turbomeca Arrius 2K1 675 horsepower turbo shaft - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Registered owner: CJ Systems Incorporated - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, August 1, 2005, 124 hours before - Departed: PA91, Kane, PA - Destination: BFD, Bradford, PA - Flight plan: IFR - Airport: BFD, Bradford Regional, runway 32, 6,499 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: fatal; commercial; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review June 1, 2005; seat: right; toxicology performed; flight hours: 9,616 total, 300 in this make and model, 56 in the last 90 days, 11 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 10° at 8 knots - Visibility: 2.5 statute miles - Lowest ceiling: 600 ft overcast - Temperature: 50 °F, dew point 48 °F - Altimeter: 29.86 inHg - Observed at: BFD, 4 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 20051007027709A](https://openairdocs.org/incident/20051007027709A), Oct 7, 2005: Agusta A109E, Smethport, PA, Destroyed, 1 fatal. (-23) Further investigation by this office revealed that on October 7, 2005, at 2342 eastern daylight time, an augusta 109E, N7YL, operated by cj systems… ## Other investigations on N7YL (1) 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. - [NTSB NYC03LA110](https://openairdocs.org/ntsb/NYC03LA110), May 15, 2003: Agusta A109E (N7YL), Harbor Creek, PA, substantial damage. Probable cause: The pilot's improper preflight inspection, during which he failed to remove a flashlight from the tailboom strake. A factor was the pilot's attention be diverted by a mechanic during the preflight… ## Docket (16 files) The files NTSB released with the investigation on December 7, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=62626. 29.3 MB in all. - Meteorology 5 - Factual Report of Group Chairman (item 1, .PDF, 930 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40240353&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 348 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274844&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Company Interviews (item 3, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274281&FileExtension=.PDF&FileName=Company%20Interviews-Master.PDF - FAA Avionics Summary (item 4, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274282&FileExtension=.PDF&FileName=FAA%20Avionics%20Summary-Master.PDF - FAA Maintenance Summary (item 5, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274283&FileExtension=.PDF&FileName=FAA%20Maintenance%20Summary-Master.PDF - FSF Helicopter Safety Article (item 6, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274284&FileExtension=.PDF&FileName=FSF%20Helicopter%20Safety%20Article-Master.PDF - FAA safo (item 7, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274285&FileExtension=.PDF&FileName=FAA%20SAFO-Master.PDF - Agusta Comment on SAFO (item 8, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274286&FileExtension=.PDF&FileName=Agusta%20Comment%20on%20SAFO-Master.PDF - Autopilot Parts Shipped for N7YL (item 9, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274288&FileExtension=.PDF&FileName=Autopilot%20Parts%20Shipped%20for%20N7YL-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274800&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - CJ Systems Antenna Information (item 11, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381114&FileExtension=.PDF&FileName=CJ%20Systems%20Antenna%20Information-Redacted.PDF - Toxicological Report (item 12, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40276931&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - ATC 3 - Factual Report of Group Chairman (item 13, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274839&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274850&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - ATC 3 - Attachment 1 ATC Training Materials (item 15, .PDF, 24.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274951&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%201%20%20ATC%20Training%20Materials-Master.PDF - Augusta Flight Simulation Summary (item 16, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40280896&FileExtension=.PDF&FileName=Augusta%20Flight%20Simulation%20Summary-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.