WPR19LA071

NTSB accident investigation · Bell 206 · Ashland, OR · January 23, 2019

Accident · FatalClass 3 · LimitedFinal report
Date
January 23, 2019, 11:43 local (19:43 UTC)
Place
Ashland, OR
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N8227JBell 206
Defining event
Maneuvering-low-alt flying: Low altitude operation/event
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Rolls Royce, Federal Aviation Administration, Bell Helicopters, Erickson Helicopters Inc
FAA report
20190123000339A
Case key
98851

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's decision to continue visual flight into deteriorating weather, which resulted in an encounter with instrument meteorological conditions and spatial disorientation leading to a loss of control.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ceiling/visibility/precip: cloudsEnvironmental issues › Conditions/weather/phenomena · Effect on personnelBell 206L-3: 1 caseAll aircraft: 108 casesProbable cause
Ceiling/visibility/precip: fogEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionBell 206L-3: 1 caseAll aircraft: 78 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBell 206L-3: 8 casesAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The purpose of the flight was for the pilot to accrue flight-time to fulfill annual flight-time insurance requirements. Radar data indicate that, after departure, the pilot flew the helicopter generally to the south of the departure airport, where the helicopter made various low-level maneuvers and then began to follow a highway northward. The helicopter made several turns during the final two minutes of recorded radar data before the last recorded data point, which was near to the accident site. Examination of the wreckage found no evidence of any engine or airframe anomalies that may have contributed to the accident. At the time of the accident, weather forecasts and advisories for the accident area predicted areas of instrument meteorological conditions (IMC) and mountain obscuration and various cameras in the area captured images of low ceilings, fog, and obscuration. There was no record the pilot obtained a preflight weather briefing on the day of the accident. Had he obtained such a briefing, he likely would have been aware of the possibility of encountering below minimum weather conditions for helicopter operations. The circumstances of the accident are consistent with the pilot encountering IMC, subsequently becoming spatially disoriented, and losing control of the helicopter.

Factual narrative

On January 23, 2019, at 1143 Pacific standard time, a Bell 206L-3, N8227J, was substantially damaged when it was involved in an accident near Ashland, Oregon. The pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 flight. The pilot was operating out of Medford Airport (MFR), Medford, Oregon, with the purpose of amassing flight-time to fulfill the operator’s annual flight-time requirements. On the day prior, he had flown the accident helicopter on two different flights totaling five hours of flight time. A review of the preliminary radar data provided by the Federal Aviation Administration disclosed that in the 1.5 hours following departure, the helicopter maneuvered in the local area west of Ashland making numerous turns. Thereafter the helicopter continued south over the Siskiyou Summit and after making various low-level maneuvers, followed Interstate 5 (I-5) toward Hilt, Oregon. Around 1120 the helicopter began to head north and made several turns and slow maneuvers. At 1141, the helicopter continued north and adjoined the I-5 for about 1.5 minutes. At 1142:50 the radar track showed that the helicopter then made several turns until heading east. The last radar return at 1143:30 was located in the immediate vicinity of the accident site and oriented about 600 ft east of the interstate at an elevation of about 4,100 ft. Toxicology testing performed at the FAA Forensic Sciences Laboratory identified Acetaminophen, Salicylate and Pramoxine in urine samples. An autopsy of the pilot was performed by the Jackson County Office of the State Medical Examiner, Central Point, Oregon. The cause of death was listed as severe blunt trauma due to a helicopter crash. The pilot completed a risk assessment form prior to the flight and determined it to be “low risk.” He marked the following on the form: visibility greater than 1 mile during the day, which was in the “low risk” category; icing was forecast but that the current weather indicates that conditions changed, which was a “medium risk” category; and that the ceiling was forecast and currently greater than 500 ft, which was the “low risk” category. Investigation found no evidence that the pilot obtained a weather briefing. The pilot’s papers on his kneeboard contained written notes consistent with the Medford Meteorological Terminal Air Report (METAR) issued at 0853. It was consistent with noting the freezing level at 7,000 to 11,000 ft, and broken cloud layers at 1,200 and 2,100 ft with an overcast layer at 5,000 ft. An employee of the operator who responded to the accident, stated that at 1400 he drove south on I-5 toward the accident (between mile marker #5 and #6). He reported that the fog was dense starting at mile marker #2 with less than 50 yards visibility. He additionally observed that the clouds/fog were coming over the summit at what seemed to be a very fast pace with the summit completely obscured. A ski resort located approximately5.5 nm west of the accident site had several webcams installed that captured the weather conditions immediately surrounding the time of the accident. The webcam images depicted snow covering the surface with obscured sky conditions with fog. The accident site was located south of the cold front in the warm air side of the front and immediately north of the high-pressure ridge in an area with a weak pressure gradient. The surrounding station models on the surface analysis chart depicted calm to light southwesterly winds of 10 knots or less, overcast cloud cover, with temperatures in the upper 30’s to low 40’s degrees Fahrenheit (F), with temperature-dew point spreads of 4º F or less. Several stations northwest of the accident site over the western Cascades reported light continuous snow and rain. The 12-hour Low-Level Significant Weather Prognostic Chart that depicted the expected general flight categories: cloud conditions, freezing level, and turbulence that was current at the time of the accident and valid until 1600. The chart depicted an area of instrument flight rule (IFR) conditions over northern California, western Oregon and Washington. The freezing level was depicted at approximately 8,000 ft over the Ashland area and implied the potential for icing in-clouds above that level. Graphic Forecast for Aviation (GFA) and AIRMETs forecasts indicated that mountain obscuration and IFR conditions were expected over the area. The GFA “aviation surface forecast” image depicted visibility restrictions less than a mile during the period with AIRMET Sierra for IFR conditions over the area from 1000 and expanding at 1300 over the accident area. The GFA “cloud cover forecast” also expected overcast clouds with bases at 3,500 ft lowering to 3,000 ft msl during the period with tops from 12,000 ft to 8,000 ft over the area, with AIRMET Sierra current for mountain obscuration conditions. According to the operator, the pilot had amassed about 84 hours in the year proceeding the accident during 39 flights. During that time, 55.6 hours were in the accident helicopter (20 flights). The accident site was located in the dense trees about 9 nautical miles (nm) southeast of Ashland, Oregon. In character, the terrain was composed of mature Douglas-Fir and Ponderosa Pines trees between 100-150 feet in height. The wreckage was found distributed over a 100 ft distance with no discernable flight path direction. The main rotor blades were both attached to the hub and the hub was attached to the mast. Both blades were severed chordwise approximately 5-7 feet outboard of the hub. Both tail rotor blades exhibited chordwise bending consistent with impact forces. Postaccident engine and airframe examinations revealed no mechanical failures or malfunctions that would have precluded normal operation.

Aircraft

Registration
N8227J
Reported as
Bell 206 (L3)
Category
Helicopter
Serial number
51313
Built
1989
Airframe hours
5,088
Engine
Rolls Royce M250-C30P, 650 horsepower, turbo shaft
Damage
Substantial damage
Flight
Other work use · Part 91
Operator
Erickson Helicopters Inc
Registered owner
HeliFleet LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 14, 2018 · 6 hours before
Departed
OR99 · Medford, OR
Destination
OR99 · Medford, OR
Flight plan
Company VFR
Airport
OR99 · Rogue Valley Medical Center
Equipment
Satellite tracking device, ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
69
Injuries
Fatal
Certificate
Airline transport
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Seat
Right
Restraint
4-point
Toxicology
Performed
Flight hours
18,011 total · 4,458 in this make and model · 13,897 as pilot in command · 29 in the last 90 days · 15 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
4 statute miles
Lowest ceiling
900 ft overcast
Temperature
45 °F, dew point 39 °F
Altimeter
30.50 inHg
Observed at
KMFR, 23 nm away

Docket · 7

The files NTSB released with the investigation on May 12, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.