# NTSB SEA05MA202: Agusta A109A II, N655GS, Edmonds, WA, September 30, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Major investigation · Final report - Date: September 29, 2005, 21:13 local (Sep 30, 2005, 04:13 UTC) - Place: Edmonds, WA - Coordinates: 47.850555, -122.375 - Nearby events: https://openairdocs.org/map.md?lat=47.8506&lon=-122.3750&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report April 25, 2007 - Report: Approved by Office Director - Parties: Airlift Northwest, NTSB, CJ Systems Aviation Group, Rolls-Royce Corporation, FAA FSDO, Agusta Aerospace Corporation - NTSB case key (mKey): 62576 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA05MA202 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62576/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=62576 - Page: https://openairdocs.org/ntsb/SEA05MA202 ## Probable cause Loss of control for an undetermined reason during maneuvering flight, which resulted in an in-flight collision with water. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - reason for occurrence undetermined (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis After dropping off a patient, the pilot and two flight nurses boarded the air ambulance helicopter for a dark night cross country flight from a hospital back to their base. A company VFR flight plan was filed. Radar data shows the helicopter departed the hospital, proceeded northbound over ocean water, following the coastline at an altitude of approximately 800 feet msl. Just prior to the loss of radar contact, the helicopter entered a left turn towards the west, away from the shoreline. No eye witnesses to the accident were located. A number of ear witnesses heard a low flying helicopter and then the sound of impact. The witnesses reported low clouds and restricted visibility in rain, mist and fog in the vicinity of the accident site. The closest aviation weather reporting station, located 5 miles northwest of the accident site, reported winds from the southwest at 6 knots, with visibilities restricted in light rain and mist, with a ceiling ranging from 200 to 800 feet. Conditions rapidly deteriorated within 30 minutes of the accident, with visibilities lowering to 1/4 miles in dense fog with ceilings at 200 feet. Plotting the helicopter's flight track on weather radar images indicates the helicopter encountered an area of light precipitation as it approached the accident site. The pilot was instrument rated and met the currency requirements for IFR flight, and the helicopter was equipped and certified for IFR flight. The pilot had been employed as an air ambulance helicopter pilot in the accident area for the past 16 years. He had 7,990 hours helicopter flight time with 4,192 hours in the accident make and model, 2,396 hours night flight time and 672 hours instrument flight time. Examination of the helicopter's maintenance records revealed no evidence of any uncorrected maintenance discrepancies. Damage observed on the recovered wreckage was consistent with the helicopter impacting the water in an uncontrolled descent. Examination of the recovered wreckage revealed no evidence suggesting mechanical malfunction or failure. However, the majority of the helicopter, including most of the flight control system and all flight instruments and avionics, was not recovered, precluding determination of the reasons for the loss of control. ## Factual narrative HISTORY OF FLIGHT On September 29, 2005, about 2113 Pacific daylight time (PDT), an Agusta A109A II helicopter, N655GS, impacted the ocean waters of Puget Sound near Edmonds, Washington. The air ambulance helicopter was destroyed and the three occupants, an airline transport pilot and two flight nurses, were killed. The helicopter was operated by CJ Systems Aviation Group of West Mifflin, Pennsylvania, under contract to Airlift Northwest of Seattle, Washington. The helicopter was on a 14 CFR Part 91 positioning flight when the accident occurred. The flight departed from Harborview Medical Center in Seattle about 2104 with an intended destination of Arlington Municipal Airport (AWO) in Arlington, Washington. Earlier in the evening, the helicopter had flown a patient from a hospital in Arlington to Harborview. The accident occurred as the helicopter was returning to its base at AWO. Visual meteorological conditions prevailed for the helicopter's departure from Harborview, and instrument meteorological conditions prevailed at the accident site. A company visual flight rules (VFR) flight plan was filed. Radar data provided by the Federal Aviation Administration (FAA) shows the helicopter departing Harborview, proceeding northbound over the water, following the coastline at an altitude of approximately 800 feet msl. As the radar track reaches an area near Edmonds called Brown's Bay, the helicopter enters a left turn towards the west, away from the shoreline. The last radar return was recorded at 2112:33 and places the helicopter at N 47:51.250 and W 122:21.520. No eye witnesses to the accident were located. A number of ear witnesses heard a low flying helicopter and then an "explosion" or loud boom. About 2122, the communications center for Northwest Airlift attempted to contact the helicopter by radio as there was another mission for the helicopter. The communications center received no response from the helicopter. A search was started, and the United States Coast Guard found debris floating in the water at N 47:51.190 and W 122:21.010 about 0130 on September 30, 2005. The body of one flight nurse was found with the floating debris. On October 7 to 10, 2005, an extensive search and recovery effort was conducted by the United States Navy employing specialized undersea search and recovery equipment. A debris field was located on the ocean floor at a depth of about 525 feet, centered at N 47:51.018 and W 122:21.901, about 2,100 feet southwest of the last radar return. During this effort, the pilot's body was located and recovered. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with a helicopter rating and commercial privileges in single engine land airplanes with an instrument airplane rating. His most recent first class medical certificate was issued on March 26, 2005, with the limitations: "Holder must wear corrective lenses for distant vision and have available for near and intermediate. Not valid for any class after March 31, 2006." The pilot had been employed as an air ambulance helicopter pilot in the Puget Sound area since 1988. He was hired by CJ Systems on May 1, 2000, when CJ Systems became the helicopter vendor to Airlift Northwest. He was previously employed in the same capacity, as an Agusta A109A pilot, by Hospital Air Transport, Inc., Airlift Northwest's previous helicopter vendor. He completed his most recent twelve month 14 CFR Part 135 checks (135.293(a), 135.293(b), and 135.299) on November 11, 2004. His most recent six month 14 CFR Part 135 instrument flight rules (IFR) proficiency check (135.297) was completed on May 20, 2005. According to information provided by CJ Systems, the pilot had accumulated a total flight time of 8,190 hours of which 7,990 hours were in helicopters with 4,192 hours in the Agusta A109A. He had accumulated 2,396 hours of night flight time and 672 hours of instrument flight time. In the previous 90 and 30 days, he had accumulated 38 and 12 hours, respectively. On January 20, 2002, the pilot was involved in an accident that occurred during a repositioning flight in an Agusta A109A II near Baring, Washington. According to the NTSB Factual Report on the accident, on the previous day, the pilot had aborted a flight due to adverse weather conditions (dark night, snow, rain and fog), and the helicopter was parked over night in an open field. The following morning, the pilot boarded the helicopter with the intention of returning it to the AWO base. Shortly after takeoff, there was a sequential loss of power in both engines, and the helicopter landed hard following an autorotation. The helicopter sustained substantial damage, and the pilot, the sole occupant, sustained serious injuries. Both engines were test run following the accident with no indication of any mechanical problems. The NTSB determined that the probable cause of the accident was "the sequential non-mechanical total loss of power in both engines 1 and 2 for undetermined reasons and the pilot's failure to maintain adequate rotor RPM to prevent a hard landing. Contributing factors were the tripped "RPM WARN" circuit breaker which disabled the engine failure and low rotor warning lights and aural warnings." Following the accident, the pilot was out of work recovering from his injuries for approximately 20 months. He returned to work in September 2003. The duty schedule for the pilots at the AWO base was 7 days on, working 12 hour shifts, followed by 7 days off. The pilots worked day shift for 7 days, had 7 days off, and then worked night shift for 7 days. The day shift was from 6:15 am to 6:15 pm, and the night shift was from 6:15 pm to 6:15 am. The accident flight occurred on the second day of the pilot's week working the night shift. On the first day of his work week, he made one 0.6-hour flight with 3 landings. The accident flight was his first flight on the second day of his work week. AIRCRAFT INFORMATION The 1984 model Agusta A109A II helicopter, S/N 7299, was powered by two 420-horsepower Rolls Royce Allison 250-C20B turbo-shaft engines, S/N CAE 834357 (#1) and CAE 834829 (#2), driving a four bladed main rotor system and a two bladed tail rotor. The helicopter was equipped and certified for IFR flight. Installed equipment included a Garmin GNS-430 GPS/Com/Nav and a factory installed autopilot. The helicopter was being maintained by the operator in accordance with an FAA Approved Inspection Program. Examination of the helicopter's maintenance records revealed that it received a 150 hour/12 month airframe inspection on September 7, 2005, at an airframe total time of 3,740.1 hours. On this date, both engines received 150 hour inspections with engine #1 at a total time of 8,832.6 and engine #2 at a total time of 6,178.0 hours. The helicopter's most recent inspection, a 25 hour/30 day inspection, was done on September 19, 2005, at an airframe total time of 3,766.5 hours, engine #1 total time of 8,859.0 hours, and engine #2 total time of 6,204.4 hours. When the accident occurred, the helicopter had been flown approximately 29 hours since this inspection. Review of the daily maintenance report sheets for the helicopter from August 1, 2005, to the date of the accident revealed no listings of any uncorrected maintenance discrepancies. According to the day shift pilot who flew the helicopter for 1.5 hours on the day of the accident and 1.5 hours on the day before the accident, he experienced no anomalies with the aircraft. The dayshift pilot mentioned that the autopilot was slow to react to some turbulence he encountered, so he turned it off and hand flew the helicopter. He stated that this was "typical, nothing unusual" for the autopilot. METEOROLOGICAL INFORMATION The National Weather Service (NWS) Surface Analysis Chart for 2000 PDT depicted a low pressure system to the north of the accident site over British Colum ## Aircraft - Registration: [N655GS](https://openairdocs.org/deregistered/N655GS-2010-05-28), registration cancelled 2010-05-28, S/N 7299, built 1984 (OpenAirDocs) - Reported make and model: Agusta A109A II - Registry model: [Agusta A109A II](https://openairdocs.org/model/agusta-a109a-ii) (registry code 0260120) (OpenAirDocs) - Registry engine: [Allison 250-C20 series](https://openairdocs.org/engine/allison-250-c20-series) (registry code 03020, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: 7299 - Airframe hours: 3794 - Engines: Rolls-Royce 250-C20B 420 horsepower turbo shaft; Rolls-Royce 250-C20B 420 horsepower turbo shaft - Damage: Destroyed - Flight: Positioning, Part 91 - Operator: CJ Systems Aviation Group - Registered owner: Ameritech Credit Corp DBA - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 1, 2005, 54 hours before - Departed: WA53, Seattle, WA - Destination: AWO, Arlington, WA - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; airline transport; airplane ratings: single-engine land; instrument ratings: helicopter, airplane; medical: class 1, with waivers/limitations; last flight review May 1, 2005; seat: right; toxicology performed; flight hours: 8,190 total, 4,192 in this make and model, 7,340 as pilot in command, 38 in the last 90 days, 12 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 220° at 6 knots - Visibility: 4 statute miles - Lowest ceiling: 400 ft broken - Temperature: 59 °F, dew point 57 °F - Altimeter: 29.81 inHg - Observed at: PAE, 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 20050929022889A](https://openairdocs.org/incident/20050929022889A), Sep 29, 2005: Agusta A109A2, Shoreline, WA, Destroyed, 3 fatal. (-23) On September 29, 2005, about 2113 pacific daylight time, an augusta A109A-2 helicopter, N655GS, impacted the ocean waters of puget sound near edmonds,… ## Docket (30 files) The files NTSB released with the investigation on February 8, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=62576. 13.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272093&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Meteorology 5 - Factual Report of Group Chairman (item 2, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40242971&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Witness Interview Summaries and Map Showing Witness Locations (item 3, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272094&FileExtension=.PDF&FileName=Witness%20Interview%20Summaries%20and%20Map%20Showing%20Witness%20Locations-Redacted.PDF - Record of Interview - Day Shift Pilot (item 4, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272095&FileExtension=.PDF&FileName=Record%20of%20Interview%20-%20Day%20Shift%20Pilot-Master.PDF - Excerpts from Edmonds Police Department Report (item 5, .PDF, 198 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411333&FileExtension=.PDF&FileName=Excerpts%20from%20Edmonds%20Police%20Department%20Report-Redacted.PDF - FAA Radar Data (item 6, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272097&FileExtension=.PDF&FileName=FAA%20Radar%20Data-Master.PDF - Airlift Northwest Dispatch Audio Tape Summary (item 7, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272098&FileExtension=.PDF&FileName=Airlift%20Northwest%20Dispatch%20Audio%20Tape%20Summary-Master.PDF - Pilot's Recent 14 CFR Part 135 Checks (item 8, .PDF, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272099&FileExtension=.PDF&FileName=Pilot%27s%20Recent%2014%20CFR%20Part%20135%20Checks-Redacted.PDF - Toxicological Report (item 9, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272100&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 339 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272101&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272102&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Image 1. Tail Boom. (item 12, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272103&FileExtension=.PDF&FileName=Image%201.%20%20Tail%20Boom.-Master.PDF - Image 2. Main rotor pylon. (item 13, .PDF, 411 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272104&FileExtension=.PDF&FileName=Image%202.%20%20Main%20rotor%20pylon.-Master.PDF - Image 3. Number 1 engine. (item 14, .PDF, 418 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272106&FileExtension=.PDF&FileName=Image%203.%20%20Number%201%20engine.-Master.PDF - Image 4. Main Rotor Blade Sections – removed from rotor head after recovery by Navy. (item 15, .PDF, 477 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272107&FileExtension=.PDF&FileName=Image%204.%20%20Main%20Rotor%20Blade%20Sections%20%E2%80%93%20removed%20from%20rotor%20head%20after%20recovery%20by%20Navy.-Master.PDF - Image 5. Roof section – upright. (item 16, .PDF, 476 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272108&FileExtension=.PDF&FileName=Image%205.%20%20Roof%20section%20%E2%80%93%20upright.-Master.PDF - Image 6. Roof section - inverted. (item 17, .PDF, 445 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272109&FileExtension=.PDF&FileName=Image%206.%20%20Roof%20section%20-%20inverted.-Master.PDF - Image 7. Number 1 engine compressor inlet. (item 18, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272110&FileExtension=.PDF&FileName=Image%207.%20%20Number%201%20engine%20compressor%20inlet.-Master.PDF - Image 8. Number 1 engine compressor inlet – close-up. (item 19, .PDF, 355 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272111&FileExtension=.PDF&FileName=Image%208.%20%20Number%201%20engine%20compressor%20inlet%20%E2%80%93%20close-up.-Master.PDF - Image 9. Number 1 engine drive shaft – engine to combining gearbox. (item 20, .PDF, 419 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272112&FileExtension=.PDF&FileName=Image%209.%20%20Number%201%20engine%20drive%20shaft%20%E2%80%93%20engine%20to%20combining%20gearbox.-Master.PDF - Image 10. Number 1 engine oil cooler blower drive shaft. (item 21, .PDF, 433 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272113&FileExtension=.PDF&FileName=Image%2010.%20%20Number%201%20engine%20oil%20cooler%20blower%20drive%20shaft.-Master.PDF - Image 11. Number 1 engine oil cooler blower drive shaft – close-up. (item 22, .PDF, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272114&FileExtension=.PDF&FileName=Image%2011.%20%20Number%201%20engine%20oil%20cooler%20blower%20drive%20shaft%20%E2%80%93%20close-up.-Master.PDF - Image 12. Number 2 engine oil cooler blower drive shaft – section. (item 23, .PDF, 403 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272115&FileExtension=.PDF&FileName=Image%2012.%20%20Number%202%20engine%20oil%20cooler%20blower%20drive%20shaft%20%E2%80%93%20section.-Master.PDF - Image 13. Number 2 engine oil cooler blower drive shaft – other section. (item 24, .PDF, 402 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272116&FileExtension=.PDF&FileName=Image%2013.%20%20Number%202%20engine%20oil%20cooler%20blower%20drive%20shaft%20%E2%80%93%20other%20section.-Master.PDF - Image 14. Number 2 engine oil cooler blower drive shaft – close-up. (item 25, .PDF, 414 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272117&FileExtension=.PDF&FileName=Image%2014.%20%20Number%202%20engine%20oil%20cooler%20blower%20drive%20shaft%20%E2%80%93%20close-up.-Master.PDF - Image 15. Blue main rotor blade. (item 26, .PDF, 485 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272118&FileExtension=.PDF&FileName=Image%2015.%20%20Blue%20main%20rotor%20blade.-Master.PDF - Image 16. Yellow main rotor blade. (item 27, .PDF, 482 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272119&FileExtension=.PDF&FileName=Image%2016.%20%20Yellow%20main%20rotor%20blade.-Master.PDF - Image 17. Red main rotor blade. (item 28, .PDF, 483 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272120&FileExtension=.PDF&FileName=Image%2017.%20%20Red%20main%20rotor%20blade.-Master.PDF - Image 18. White main rotor blade. (item 29, .PDF, 447 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272121&FileExtension=.PDF&FileName=Image%2018.%20%20White%20main%20rotor%20blade.-Master.PDF - Image 19. Miscellaneous pieces. (item 30, .PDF, 439 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272122&FileExtension=.PDF&FileName=Image%2019.%20%20Miscellaneous%20pieces.-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.