# NTSB SEA95FA214: Agusta A109A II, N1WC, Winslow, WA, September 11, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 11, 1995, 05:30 local (12:30 UTC) - Place: Winslow, WA - Coordinates: 47.639442, -122.530853 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.6394&lon=-122.5309&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report April 29, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 42067 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA95FA214 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/42067/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=42067 - Page: https://openairdocs.org/ntsb/SEA95FA214 ## Probable cause the pilot failed to maintain sufficient altitude/clearance above the surface of water, while flying over calm water conditions at night. Factors relating to the accident were: darkness, low ceiling, fog, glassy (calm) water conditions, and the lack of visual cues for visual perception of altitude. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, cruise - light condition - dark night (contributing factor) - weather condition - low ceiling (contributing factor) - weather condition - fog (contributing factor) - terrain condition - water,glassy (contributing factor) - visual/aural perception, pilot in command (contributing factor) - visual illusion, pilot in command (contributing factor) - altitude/clearance - not maintained, pilot in command (cause) ## Analysis The helicopter pilot took off at night on a positioning flight for an emergency medical service (EMS) operation. There were reports of a low overcast layer varying from 1,000 feet above ground level to the surface. The majority of the witnesses reported that the helicopter was flying low as it traveled over the ground and continued over water toward a nearby island. Subsequently, the helicopter collided with the water and sank. Several of the witnesses reported that the engine sounded normal until the helicopter crashed. Some witnesses reported a 'popping' sound or a 'laboring' sound from the engines; however, after the engines were recovered at a later date, no evidence of a preimpact mechanical failure or malfunction was found. Local residents reported that the water condition at the time of the accident was 'calm' or 'glassy.' Several small pieces of the fuselage and main rotor blades were found floating on the surface of the water. Examination revealed that 3 of the main rotor blades had separated approximately three feet out from the attach points. The fourth blade separated approximately seven feet out from the attach point; however, the blade was bent and cracked chordwise approximately three feet out from the attach point. Using side scan sonar, wreckage was found over a distance of approximately 600 feet. The landing gear was found in the extended position, and the engine power levers were found in the flight position. Also, torsional evidence was found on the tail rotor driveshaft. ## Factual narrative HISTORY OF FLIGHT On September 11, 1995, at 0530 Pacific daylight time, an Agusta A109A II, N1WC, registered to Signet Leasing and operated by Hospital Air Transport as a 14 CFR Part 91 positioning flight, collided with the water approximately one mile off the shoreline of Bainbridge Island, near Winslow, Washington. Visual and instrument meteorological conditions prevailed at the time and a company visual flight rules flight plan was filed. The helicopter sank in approximately 750 feet of water and was destroyed. The commercial pilot and two flight nurses were fatally injured. The helicopter had departed from Boeing Field, Seattle, Washington, at 0526, and was en route to pick up a woman in labor on Bainbridge Island to transport her to a hospital in Seattle. At approximately 0500, an individual from the Bainbridge Fire Department reported that he heard over his radio that the Bainbridge Island Fire Department was dispatched to a woman in labor. Approximately 10 minutes later, he heard a call go out to Airlift Northwest to check on their availability. At 0526, the air traffic controller, on duty at Boeing tower, reported that the pilot notified the tower that he (the pilot) was at "pad two" for departure westbound. The controller cleared the pilot for takeoff to the west. The controller reported that he notified the pilot that the wind was from 40 degrees at six knots, and the altimeter was 30.15" Hg. The controller stated that the takeoff appeared normal and that there was no further contact with Boeing tower. At 0540, the dispatcher from Airlift Northwest called the tower and reported that they had not had any communications with the pilot. The controller then checked with Seattle Tracon, who also reported that they had had no contact with the pilot. Statements prepared by EMT/firefighter personnel on Bainbridge Island, reported that they had heard the helicopter approaching the island. One individual reported that the engines and the rotors sounded normal before a sudden "boom" followed by complete silence was heard. Two other individuals reported hearing the helicopter approach, as it normally does from the east, and then there was a loud "thump" or "muffled explosion" heard. At 0538, the Bainbridge Island Police Department was notified by a citizen who stated that they heard what sounded like "a boat hit something in the water." The Bainbridge Fire and Police were dispatched for a possible water rescue outside of Eagle Harbor. Rescue personnel reported that as they were leaving the docks, they notified the crew of the outgoing 0535 ferry boat of the water rescue. The responding individual on the ferry boat reported that they were half-way across the channel, and that they did not observe anything unusual. The individuals on the rescue boat reported that as they were heading out of the harbor, the water was glassy calm, and that they could see across the Puget Sound to the east at Seattle. As the search continued, the fog began to settle closer to the surface. During the search, the rescue teams were notified that an Airlift Northwest helicopter was overdue. The search continued and at approximately 0640, the outgoing 0620 ferry boat notified the Coast Guard of the possible crash site. It was reported that there was a strong odor of fuel and an oil slick was present, along with floating debris on the water surface. Search personnel responded to the site and recovered the bodies of the two flight nurses and assisted in retrieving the floating debris. Excerpts from witness statements from individuals located on Bainbridge Island reported: "Was awakened by approaching helicopter, then heard a muffled explosion. Did not hear any unusual power changes to believe engine trouble prior to impact. The weather at the time was haze or light fog. I could see no horizon looking ESE toward Duwamish Head (west Seattle, Elliott Bay) or west Seattle." "Was awakened by the familiar sound of a helicopter coming from Seattle toward Bainbridge Island. The sound became louder, which is typical of the helicopters I've heard before. I estimated hearing the sound for only a few seconds before I heard a very distinct collision sound. It was fairly loud, not an explosion, but rather like a car hitting a tree. The engine sound disappeared simultaneously with the collision. The water was flat calm, no waves at all. It was quite foggy, not very light yet, and my vision was very limited. I estimate I could see several hundred yards (maybe a half mile or so), but could not see the lights from Seattle." "Heard loud engine noise followed by a "whump" sound typical of a boat hull hitting a wave. Then all was silent. Went to window. The morning was still dark and a thick cloud ceiling hung about 300-500 feet over the water. I recall seeing lights of downtown Seattle, of the Duwamish Head and of Yeomalt Point (northeast of Winslow, Bainbridge Island) under the overcast. The sound heard prior to the impact was not the typical beat of the Airlift Northwest helicopter, but rather a louder, harsher "popping" sound lasting about two seconds. The noise continued until the sound of the hull striking the water." "Heard the helicopter coming for 2 or 3 minutes. It was running perfectly at high rpm with no change whatsoever in rpm. Then there was a significant "pop" - not an explosion - and then silence. The weather was foggy that morning." Excerpts of witness statements from individuals located near Seattle reported: "Something wrong with the sound. Assumed flying low because of the overcast or fog." "Heard aircraft directly overhead approximately 150-200 feet above ground level. Engine did not sound intermittent. When I saw it, it was 50 feet above ground level over Puget Sound. Watched with binoculars and saw anti-collision lights, strobes working and helicopter was straight and level, then it disappeared. No explosion or erratic attitude. Presumed it was controlled flight into water. Fog was at 200 feet above ground level. Helicopter was under it. It was dark and water very smooth." "Heard loud, deep roar that seemed laboring while moving very slowly. Very loud after passing over the house at a very low level. Didn't sound like other helicopters that flew over the house. Weather was foggy." "Helicopter at or about 500 feet above water level and fast and low. Base of overcast at 1,000 feet. Helicopter exhibited no obvious problems. The engine sounded fine and exterior lights were on." "Heard helicopter and looked out window. Helicopter was approximately 340 feet above ground level flying full speed NNW. Watched until over Alki Point lighthouse (west Seattle). Helicopter was descending slightly to about 300 feet. Observed medical helicopters before and this sounded 100% normal with no mechanical problem." "Heard helicopter approach and sounded lower than any previous heard before. Shook the house. Ground fog at time of the flight and visibility was less than 1,000 feet." PERSONNEL INFORMATION At the time of the accident, the pilot held a commercial pilot's certificate with rotorcraft and rotorcraft instrument ratings. The pilot's total flight time was estimated at 3,056 hours, with 51 total flight hours in the Agusta A109A. Flight records provided by personnel from Hospital Air Transport, indicated that the pilot had been an Aeromedical Evacuation/Maintenance Test Pilot for the Army military service until he was retired from active service. The pilot's records indicate that the last military flight was dated July 1993. There was no flight time reported until the pilot was hired by Hospital Air Transport on July 1, 1995. The pilot was qualified as pilot-in-command in the Agusta A109A on July 21, 1995, after completing 15 hours of flight time, which included eight hours for instrument proficiency. Duri ## Aircraft - Registration: [N1WC](https://openairdocs.org/deregistered/N1WC-1996-02-27), registration cancelled 1996-02-27, S/N 7278 (OpenAirDocs) - Reported make and model: Agusta A109A II - Registry model: [Agusta AGUSTA A109](https://openairdocs.org/model/agusta-agusta-a109) (registry code 0260109) (OpenAirDocs) - Category: Helicopter - Serial number: 7278 - Airframe hours: 3909 - Engines: Allison 250 C20B 420 horsepower turbo shaft - Damage: Destroyed - Flight: Positioning, Part 91 - Operator: Hospital Air Transport, doing business as Airlift Norwest - Registered owner: Signet Leasing - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 10, 1995, 1 hours before - Departed: BFI, SEATTLE, WA - Destination: WA - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; commercial; instrument ratings: helicopter; medical: class 1, valid medical--w/ waivers/lim; seat: right; flight hours: 3,056 total, 51 in this make and model, 51 in the last 90 days, 19 in the last 30 days ## Weather - Conditions: Night/dark - Wind: 10° at 5 knots - Temperature: 57 °F, dew point 55 °F - Altimeter: 30.00 inHg - Observed at: BFI, 9 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 19950911028339A](https://openairdocs.org/incident/19950911028339A), Sep 11, 1995: Agusta A109A2, Winslow, WA, Destroyed, 3 fatal. All indications the rotor craft was inadvertently flow into the water at cruise. Dense fog dark night factors. ## Docket (34 files) The files NTSB released with the investigation on April 11, 1997, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=42067. 8.1 MB in all. - Supplement C (item 1, .PDF, 389 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065625&FileExtension=.PDF&FileName=Supplement%20C-Master.PDF - Supplement D (item 2, .PDF, 487 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065626&FileExtension=.PDF&FileName=Supplement%20D-Master.PDF - Supplement I (item 3, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065627&FileExtension=.PDF&FileName=Supplement%20I-Master.PDF - Supplement S (item 4, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065628&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Supplement U (item 5, .PDF, 369 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065629&FileExtension=.PDF&FileName=Supplement%20U-Master.PDF - Map of Accident Site Location, Wreckage Diagrams (item 6, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065630&FileExtension=.PDF&FileName=Map%20of%20Accident%20Site%20Location,%20%20Wreckage%20Diagrams-Master.PDF - ATC Statements (item 7, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402161&FileExtension=.PDF&FileName=ATC%20Statements-Redacted.PDF - Witness Statements (item 8, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402166&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Flight Path Chart (item 9, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402162&FileExtension=.PDF&FileName=Flight%20Path%20Chart-Redacted.PDF - NTSB Metallurgist's Factual Report (item 10, .PDF, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402163&FileExtension=.PDF&FileName=NTSB%20Metallurgist%27s%20Factual%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 355 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402164&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402165&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. View of main rotor assembly during recovery. (item 13, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065637&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20main%20rotor%20assembly%20during%20recovery.-Master.PDF - Photo 2. View of main rotor assembly above water level. Upper deck and engines still attached before it broke away. (item 14, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065638&FileExtension=.PDF&FileName=Photo%202.%20%20View%20of%20main%20rotor%20assembly%20above%20water%20level.%20%20Upper%20deck%20and%20engines%20still%20attached%20before%20it%20broke%20away.-Master.PDF - Photo 3. View of tail boom with tail rotor attached. Additionally damaged during recovery. (item 15, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065639&FileExtension=.PDF&FileName=Photo%203.%20%20View%20of%20tail%20boom%20with%20tail%20rotor%20attached.%20%20Additionally%20damaged%20during%20recovery.-Master.PDF - Photo 4. View of top side of upper deck. (item 16, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065640&FileExtension=.PDF&FileName=Photo%204.%20%20View%20of%20top%20side%20of%20upper%20deck.-Master.PDF - Photo 5. View of bottom side of upper deck. (item 17, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065641&FileExtension=.PDF&FileName=Photo%205.%20%20View%20of%20%20bottom%20side%20of%20upper%20deck.-Master.PDF - Photo 6. View of belly sections of fuselage. View aft facing forward. (Floating Debris) (item 18, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065642&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20%20belly%20sections%20of%20fuselage.%20%20View%20aft%20facing%20forward.%20%20(Floating%20Debris)-Master.PDF - Photo 7. View of interior cabin upper deck. (item 19, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065643&FileExtension=.PDF&FileName=Photo%207.%20%20View%20of%20interior%20cabin%20upper%20deck.-Master.PDF - Photo 8. View of pilot's cyclic control and rudder pedals. (Floating Debris) (item 20, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065644&FileExtension=.PDF&FileName=Photo%208.%20%20View%20of%20pilot%27s%20cyclic%20control%20and%20rudder%20pedals.%20%20(Floating%20Debris)-Master.PDF - Photo 9. View of engine power levers in flight position. (item 21, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065645&FileExtension=.PDF&FileName=Photo%209.%20%20View%20of%20engine%20power%20levers%20in%20flight%20position.-Master.PDF - Photo 10. View of landing gear lever in up position. (item 22, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065646&FileExtension=.PDF&FileName=Photo%2010.%20%20View%20of%20landing%20gear%20lever%20in%20up%20position.-Master.PDF - Photo 11. View of main landing gear found in the extended position. (item 23, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065647&FileExtension=.PDF&FileName=Photo%2011.%20%20View%20of%20main%20landing%20gear%20found%20in%20the%20extended%20position.-Master.PDF - Photo 12. View of the nose landing gear found in the extended position. (item 24, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065648&FileExtension=.PDF&FileName=Photo%2012.%20%20View%20of%20the%20nose%20landing%20gear%20found%20in%20the%20extended%20position.-Master.PDF - Photo 13. Right side view of the tailboom. (item 25, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065649&FileExtension=.PDF&FileName=Photo%2013.%20%20Right%20side%20view%20of%20the%20tailboom.-Master.PDF - Photo 14. Left side view of tailboom. (item 26, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065650&FileExtension=.PDF&FileName=Photo%2014.%20%20Left%20side%20view%20of%20tailboom.-Master.PDF - Photo 15. View of tail rotor drive shaft. (item 27, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065651&FileExtension=.PDF&FileName=Photo%2015.%20%20View%20of%20tail%20rotor%20drive%20shaft.-Master.PDF - Photo 16. View of tail rotor. (item 28, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065652&FileExtension=.PDF&FileName=Photo%2016.%20%20View%20of%20tail%20rotor.-Master.PDF - Photo 17. View of main rotor blades and damage. (Floating Debris) (item 29, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065653&FileExtension=.PDF&FileName=Photo%2017.%20%20View%20of%20main%20rotor%20blades%20and%20damage.%20%20(Floating%20Debris)-Master.PDF - Photo 18. Side view of main rotor blades. (item 30, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065654&FileExtension=.PDF&FileName=Photo%2018.%20%20Side%20view%20of%20main%20rotor%20blades.-Master.PDF - Photo 19. View of main rotor blades viewed from the blade tips, inboard. (Floating Debris) (item 31, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065655&FileExtension=.PDF&FileName=Photo%2019.%20%20View%20of%20main%20rotor%20blades%20viewed%20from%20the%20blade%20tips,%20inboard.%20%20(Floating%20Debris)-Master.PDF - Photo 20. View of main rotor assembly with broken main rotor blades in place. (item 32, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065656&FileExtension=.PDF&FileName=Photo%2020.%20%20View%20of%20main%20rotor%20assembly%20with%20broken%20main%20rotor%20blades%20in%20place.-Master.PDF - Photo 21. View of main rotor blades layed in place to the main rotor assembly. (item 33, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065657&FileExtension=.PDF&FileName=Photo%2021.%20%20View%20of%20main%20rotor%20blades%20layed%20in%20place%20to%20the%20main%20rotor%20assembly.-Master.PDF - Photo 22. View of main rotor assembly with inboard sections of the main rotor blades still attached. (item 34, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40065658&FileExtension=.PDF&FileName=Photo%2022.%20%20View%20of%20main%20rotor%20assembly%20with%20inboard%20sections%20of%20the%20main%20rotor%20blades%20still%20attached.-Master.PDF From the NTSB's public API. 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