# NTSB NYC99FA140: Sikorsky S-76A, N2743E, Jackson, KY, June 15, 1999 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 14, 1999, 22:08 local (Jun 15, 1999, 02:08 UTC) - Place: Jackson, KY - Coordinates: 37.549636, -83.369407 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.5496&lon=-83.3694&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report July 10, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 46619 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC99FA140 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/46619/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=46619 - Page: https://openairdocs.org/ntsb/NYC99FA140 ## Probable cause the failure of the PIC to adequately supervise the SIC, and maintain a positive climb. Factors were the fog and dark night. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - weather condition - fog (contributing factor) - light condition - dark night (contributing factor) - procedures/directives - not followed, pilot in command - climb - not maintained, pilot in command (cause) - supervision - inadequate, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - rising ## Analysis The S-76A departed on a positioning flight with two pilots and two medical personnel onboard. Night instrument meteorological conditions prevailed with prevailing visibility less than 1/4 mile. The departure airport was 1,381 feet MSL. After becoming airborne, as it passed through 1,600 feet, the helicopter entered a descending left turn which terminated on the side of a hill, about 1,000 feet elevation. The CVR recorded the pilot calling out the descending turn to the co-pilot who was flying, but the co-pilot did not acknowledge the pilot's call. Additionally, the pilot did not take control of the helicopter from the co-pilot, and he did not acknowledge the co-pilot's comment about a possible gyro failure, or answer the co-pilots question about the pilot taking control of the helicopter. No evidence a pre-existing failure or malfunction was found with the helicopter. According to the company operations manual, the minimum visibility for an instrument departure was 1/4 mile. Both pilots had failed upgrades in the preceding year, but had passed their respective 6 month IFR checks with no problems noted. ## Factual narrative HISTORY OF FLIGHT On June 14, 1999, at 2208 Eastern Daylight Time, a Sikorsky S-76A, N2743E, operated by Petroleum Helicopters Incorporated (PHI), was destroyed when it collided with terrain in Jackson, Kentucky. The two certificated commercial pilots and two medical personnel were fatally injured. Instrument meteorological conditions prevailed for the positioning flight, which had departed from Julian Carroll Airport (JKL), Jackson, Kentucky, and was destined for University of Kentucky heliport (37KY), Lexington, Kentucky. The flight was conducted on an instrument flight rules (IFR) flight plan under 14 CFR Part 91. The flight crew was on the fourth day of a seven-day rotation when the accident occurred. They had logged on duty at 1100. According to records recovered at the accident site, the helicopter departed 37KY at 1356, and arrived at JKL at 1426. While at JKL, the pilots and medical crew had access to a lounge area for rest. While on the ground, the helicopter was serviced with 35 gallons of Jet-A with prist. According to the airport manager, the pilots refueled the helicopter. The pilots had a computer with a direct user access terminal system (DUATS) in their flight lounge, which had been used to check weather and file flight plans. According to records from the Federal Aviation Administration (FAA), the pilot-in-command (PIC) accessed DUATS three times prior to the accident flight. The first time occurred at 1912, when the pilot requested an abbreviated weather briefing for the State of Kentucky. He specifically requested aviation routine weather reports (METAR) and aerodrome forecasts (TAF). Included was the data on Lexington, Kentucky (LEX) and JKL. The second contact occurred at 2005. The pilot filed an IFR flight plan for a direct flight from JKL to the LEX VOR. He did not request any weather data. The third contact occurred at 2121. Again, the pilot requested an abbreviated weather briefing for the State of Kentucky. He specifically requested METARs, and TAFs. The JKL weather included winds calm, visibility 1/2 mile, sky obscured, vertical visibility 100 feet, weather fog, temperature and dewpoint 18 C. The LEX weather was visibility 10 miles, sky clear below 12,000 feet, temperature 24 C, and dewpoint 18 C. The airport manager observed the flight crew walk to the helicopter. He reported that visibility was reduced by fog and he could not recognize the pilots, but only saw vague shapes as they boarded the helicopter. At 2154:31, the flight crew checked the JKL automated surface observation system (ASOS). The helicopter was equipped with a cockpit voice recorder (CVR). According to the CVR transcript, the weather recorded by the CVR was: "...Carroll airport Jackson Kentucky. automated weather observation, zero one five four zulu, visibility less than one quarter, fog, sky condition overcast two hundred, temperature one eight Celsius, dewpoint one eight Celsius, altimeter three zero zero six, remarks density altitude one thousand niner hundred...." Following the weather, which was played through several times, the flight crew proceeded to prepare for an instrument departure. No comments were recorded about the visibility being less than 1/4 mile. The flight crew made initial radio contact with Indianapolis Air Traffic Control Center, Hazard Radar (AZQ), and at 2159:51, AZQ transmitted, "november ah seven two seven four three echo, you're cleared ah to lexington from julian carroll as filed, climb and maintain four thousand, squawk four two six two, contact indy center on this frequency on departure, and clearance is void if not off by zero two...one zero if not off by zero two one zero then advise center no later than one five of intentions." This was acknowledged and read back by the flight crew. A certified weather observer at the National Weather Service facility at JKL observed the takeoff and reported: "...When they rolled onto the runway I walked out to watch them takeoff. At the runway/taxiway intersection, they turned left for runway 19 and pulled up into a hover about 20 feet above the runway. They then proceeded down runway 19. I lost them in the fog about halfway between the taxi/runway intersection and the end of the runway. As a certified weather observer I concur with the ASOS visibility of [less than] <1/4 mile. I estimate that the visibility was about 1/8 of a mile or slightly more...." At 2205:51, the CVR recorded the pilot-in-command (PIC) transmitting on UNICOM frequency, "...we'll be a uh... south departure right turn we, be uh west out of the area." The airport manager acknowledged this. At 2206:18, the CVR recorded the second-in-command (SIC) on interphone, "I'm gonna lift to a hover, and we'll un get sixty knots before we get solid in it I guess. Try to keep it within the lights down here." The PIC acknowledged this. At 2206:51, the PIC stated, "airspeed's alive, positive rate of climb.", and the PIC subsequently said, "your at thirty [knots]", and then "heading one nine zero." This was followed by the PIC stating, "I'm gonna kill the landing....[lights]." The SIC acknowledged this. At 2207:22, the CVR recorded the PIC on interphone, "and you're at eighty... wanna hold eighty. Or Vbroc [Velocity best rate of climb] rather." The SIC acknowledged this. At 2207:32, the PIC transmitted, "indy center sikorsky ah two seven four three echo we're ah passing one thousand six hundred for four thousand." AZQ replied, "november two seven four three echo indy center roger, and ah understand climbing to four thousand say altitude leaving.", to which the PIC replied, "one thousand six hundred for ah four thousand." This transmission was acknowledged by AZQ. At 2207:51, the PIC was heard to say, "go ahead and stay on your heading.", after which two unidentified intercom transmissions were recorded, "alright.", and then, "its ok, you got five hours." At 2208:03, the PIC stated, "ok your in a right hand turn and descending." There was no acknowledgement from the SIC. At 2208:05, the SIC stated, "ok I think my gyro just quit." There was no acknowledgement from the PIC. At 2208:10, the SIC asked, "you have the controls?" There was no acknowledgement from the PIC. At 2208:11, the PIC stated, "you're in a left hand turn and descending...turn turn back and level level us off. There was no acknowledgement from the SIC. At 2208:16, the CVR recorded an increase in ambient noise level through the microphone-summing amplifier. At 2208:18, the PIC stated, "right hand turn.....right hand turn." There was no acknowledgement from the SIC. At 2208:24, the CVR recorded the initial sound of impact and ceased operation. A witness located near the accident site reported: "The sky was foggy...I heard a helicopter coming, it sounded different than normal. I was outside and tried to see it but did not see any lights. Next the sound shifted as it went behind the hill. I then heard a pop in the distance. I knew what happened and jumped in my jeep to go and call 911. It was about 30 to 45 seconds into my trip, about 1/8 of a mile I saw the explosion to my left. I continued and called 911." In a follow-up interview conducted by a FAA Inspector, the witness explained the helicopter sounded different because it was at a lower than normal altitude. The accident occurred during the hours of darkness at 37 degrees, 33.945 minutes north latitude, and 83 degrees, 17.462 minutes west longitude. PERSONNEL INFORMATION Pilot-In-Command The PIC held a commercial pilot certificate with rotorcraft-helicopter and instrument helicopter ratings. He was last issued a second class airman medical certificate on January 2, 1999, with a limitation to carry corrective lenses for near vision. According to employment records from PHI, the pilot had received his initial rotorcraft flight training in the US Army, an ## Aircraft - Registration: [N2743E](https://openairdocs.org/deregistered/N2743E-2003-05-13), registration cancelled 2003-05-13, S/N 760155, built 1981 (OpenAirDocs) - Reported make and model: Sikorsky S-76A - Registry model: [Sikorsky S-76A](https://openairdocs.org/model/sikorsky-s-76a) (registry code 8143006) (OpenAirDocs) - Registry engine: [Allison 250 SER 250HP](https://openairdocs.org/engine/allison-250-ser-250hp) (registry code 03002, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 760155 - Airframe hours: 10721 - Engines: Allison 250 C30S 650 horsepower turbo shaft - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: Petroleum Helicopters - Registered owner: Petroleum Helicopters - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, June 4, 1999, 24 hours before - Departed: JKL, JACKSON, KY - Destination: 37KY, LEXINGTON, KY - Flight plan: IFR - Airport: JKL, Julian Carroll, runway 19, 4,400 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; commercial; instrument ratings: helicopter; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 6,859 total, 2,319 in this make and model, 5,373 as pilot in command, 110 in the last 90 days, 40 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: calm - Visibility: 0.25 statute miles - Lowest ceiling: 200 ft overcast - Temperature: 64 °F, dew point 64 °F - Altimeter: 30.00 inHg - Observed at: JKL, 2 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 19990614007009A](https://openairdocs.org/incident/19990614007009A), Jun 14, 1999: Skrsky S76A, Jackson, KY, Destroyed, 4 fatal. (.4)The S-76A departed on a positioning flight with two pilots and two medical personnel onboard. Night instrument meteorological conditions prevailed with… ## Docket (32 files) The files NTSB released with the investigation on May 18, 2000, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=46619. 18.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 1, .PDF, 622 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405665&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Redacted.PDF - Supplement C (item 2, .PDF, 467 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121713&FileExtension=.PDF&FileName=Supplement%20C-Master.PDF - Supplement D (item 3, .PDF, 548 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121714&FileExtension=.PDF&FileName=Supplement%20D-Master.PDF - Supplement E (item 4, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405666&FileExtension=.PDF&FileName=Supplement%20E-Redacted.PDF - Supplement G (item 5, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121716&FileExtension=.PDF&FileName=Supplement%20G-Master.PDF - Supplement S (item 6, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121717&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Witness Statements and Summaries of Interviews (item 7, .PDF, 461 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405667&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Summaries%20of%20Interviews-Redacted.PDF - Cockpit Voice Recorder - Factual Report of Group Chairman (item 8, .PDF, 679 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405668&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - Materials Laboratory Factual Report (item 9, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405669&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report-Redacted.PDF - Sikorsky Aircraft Co. Sound Analysis Factual Report (item 10, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405670&FileExtension=.PDF&FileName=Sikorsky%20Aircraft%20Co.%20Sound%20Analysis%20Factual%20Report-Redacted.PDF - FAA ATC Transcripts and Controller Statements (item 11, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405671&FileExtension=.PDF&FileName=FAA%20ATC%20Transcripts%20and%20Controller%20Statements-Redacted.PDF - DUATS Connections (3) (item 12, .PDF, 942 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405672&FileExtension=.PDF&FileName=DUATS%20Connections%20(3)-Redacted.PDF - METARS - Jackson, Kentucky (item 13, .PDF, 314 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121724&FileExtension=.PDF&FileName=METARS%20-%20Jackson,%20Kentucky-Master.PDF - Radar Data - Source Code (item 14, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121725&FileExtension=.PDF&FileName=Radar%20Data%20-%20Source%20Code-Master.PDF - Radar Data - Flight Track (item 15, .PDF, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121726&FileExtension=.PDF&FileName=Radar%20Data%20-%20Flight%20Track-Master.PDF - Flight Crew Duty Times (item 16, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405673&FileExtension=.PDF&FileName=Flight%20Crew%20Duty%20Times-Redacted.PDF - Flight Time Sheet - Recovered At Accident Site (item 17, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121728&FileExtension=.PDF&FileName=Flight%20Time%20Sheet%20-%20Recovered%20At%20Accident%20Site-Master.PDF - GPS Factual Report of Examination (item 18, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405674&FileExtension=.PDF&FileName=GPS%20Factual%20Report%20of%20Examination-Redacted.PDF - Checkrides - Ernest Jones (item 19, .PDF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405675&FileExtension=.PDF&FileName=Checkrides%20-%20Ernest%20Jones-Redacted.PDF - Checkrides - Donald Greene (item 20, .PDF, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405676&FileExtension=.PDF&FileName=Checkrides%20-%20Donald%20Greene-Redacted.PDF - Exerpts From PHI Operations Manual (item 21, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121732&FileExtension=.PDF&FileName=Exerpts%20From%20PHI%20Operations%20Manual-Master.PDF - Correspondence from PHI (item 22, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405677&FileExtension=.PDF&FileName=Correspondence%20from%20PHI-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 23, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405678&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 24, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405679&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Reports (item 25, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405680&FileExtension=.PDF&FileName=Toxicological%20Reports-Redacted.PDF - Aerial View of Accident Site - Looking In Direction of Flight (item 26, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121737&FileExtension=.PDF&FileName=Aerial%20View%20of%20Accident%20Site%20-%20Looking%20In%20Direction%20of%20Flight-Master.PDF - Arrow Points To Entrance Into Trees Made By Helicopter (item 27, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121738&FileExtension=.PDF&FileName=Arrow%20Points%20To%20Entrance%20Into%20Trees%20Made%20By%20Helicopter-Master.PDF - Main Wreckage On Side Of Hill (item 28, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121739&FileExtension=.PDF&FileName=Main%20Wreckage%20On%20Side%20Of%20Hill-Master.PDF - Main Rotor Head (item 29, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121740&FileExtension=.PDF&FileName=Main%20Rotor%20Head-Master.PDF - Debris Field On Side Of Hill (item 30, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121741&FileExtension=.PDF&FileName=Debris%20Field%20On%20Side%20Of%20Hill-Master.PDF - Left Engine Air Intake (item 31, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121742&FileExtension=.PDF&FileName=Left%20Engine%20Air%20Intake-Master.PDF - Right Engine Air Intake (item 32, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40121743&FileExtension=.PDF&FileName=Right%20Engine%20Air%20Intake-Master.PDF From the NTSB's public API. 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